Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM AMINO ACID QUANT UR RANDOM

Facility

$100.00

Service Code	CPT 82139
Hospital Charge Code	900911210
Hospital Revenue Code	301
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$80.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna of CA HMO/PPO	$80.00
Rate for Payer: Health Smart Auto/Commercial	$60.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.00

HC SOM AMINO ACID QUANT UR RANDOM

Facility

$100.00

Service Code	CPT 82139 90
Hospital Charge Code	900911210
Hospital Revenue Code	301
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$80.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna of CA HMO/PPO	$80.00
Rate for Payer: Health Smart Auto/Commercial	$60.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.00

HC SOM AMINO ACIDS PLASMA

Facility

$75.00

Service Code	CPT 82139
Hospital Charge Code	900910486
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Cigna of CA HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM AMINO ACIDS PLASMA

Facility

$75.00

Service Code	CPT 82139 90
Hospital Charge Code	900910486
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Cigna of CA HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM AMINO ACIDS PLASMA

Facility

$75.00

Service Code	CPT 82139 90
Hospital Charge Code	900910486
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$56.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM AMINO ACIDS PLASMA

Facility

$75.00

Service Code	CPT 82139
Hospital Charge Code	900910486
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$56.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM AMIODARONE

Facility

$30.00

Service Code	CPT 80151
Hospital Charge Code	900911286
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM AMIODARONE

Facility

$30.00

Service Code	CPT 80151 90
Hospital Charge Code	900911286
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM AMIODARONE

Facility

$30.00

Service Code	CPT 80151 90
Hospital Charge Code	900911286
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM AMIODARONE

Facility

$30.00

Service Code	CPT 80151
Hospital Charge Code	900911286
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM AMITRIPTYLINE LEVEL

Facility

$234.83

Service Code	CPT G0480
Hospital Charge Code	900912504
Hospital Revenue Code	301
Min. Negotiated Rate	$129.16
Max. Negotiated Rate	$176.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$140.90
Rate for Payer: Aetna of CA Government/Medicare	$140.90
Rate for Payer: Cash Price	$105.67
Rate for Payer: Health Smart Auto/Commercial	$140.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$140.90
Rate for Payer: LLUH Dept of Risk Management WC	$129.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$176.12

HC SOM AMITRIPTYLINE LEVEL

Facility

$234.83

Service Code	CPT G0480
Hospital Charge Code	900912504
Hospital Revenue Code	301
Min. Negotiated Rate	$129.16
Max. Negotiated Rate	$187.86
Rate for Payer: Cash Price	$105.67
Rate for Payer: Cigna of CA HMO/PPO	$187.86
Rate for Payer: Health Smart Auto/Commercial	$140.90
Rate for Payer: LLUH Dept of Risk Management WC	$129.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$176.12

HC SOM AMITRIPTYLINE LEVEL

Facility

$234.83

Service Code	CPT 80335
Hospital Charge Code	900912504
Hospital Revenue Code	301
Min. Negotiated Rate	$129.16
Max. Negotiated Rate	$187.86
Rate for Payer: Cash Price	$105.67
Rate for Payer: Cigna of CA HMO/PPO	$187.86
Rate for Payer: Health Smart Auto/Commercial	$140.90
Rate for Payer: LLUH Dept of Risk Management WC	$129.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$176.12

HC SOM AMITRIPTYLINE LEVEL

Facility

$234.83

Service Code	CPT G0480 90
Hospital Charge Code	900912504
Hospital Revenue Code	301
Min. Negotiated Rate	$129.16
Max. Negotiated Rate	$176.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$140.90
Rate for Payer: Aetna of CA Government/Medicare	$140.90
Rate for Payer: Cash Price	$105.67
Rate for Payer: Health Smart Auto/Commercial	$140.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$140.90
Rate for Payer: LLUH Dept of Risk Management WC	$129.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$176.12

HC SOM AMITRIPTYLINE LEVEL

Facility

$234.83

Service Code	CPT 80335
Hospital Charge Code	900912504
Hospital Revenue Code	301
Min. Negotiated Rate	$129.16
Max. Negotiated Rate	$176.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$140.90
Rate for Payer: Aetna of CA Government/Medicare	$140.90
Rate for Payer: Cash Price	$105.67
Rate for Payer: Health Smart Auto/Commercial	$140.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$140.90
Rate for Payer: LLUH Dept of Risk Management WC	$129.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$176.12

HC SOM AMITRIPTYLINE LEVEL

Facility

$234.83

Service Code	CPT G0480 90
Hospital Charge Code	900912504
Hospital Revenue Code	301
Min. Negotiated Rate	$129.16
Max. Negotiated Rate	$187.86
Rate for Payer: Cash Price	$105.67
Rate for Payer: Cigna of CA HMO/PPO	$187.86
Rate for Payer: Health Smart Auto/Commercial	$140.90
Rate for Payer: LLUH Dept of Risk Management WC	$129.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$176.12

HC SOM AMOBARBITAL

Facility

$272.21

Service Code	CPT 80345
Hospital Charge Code	900910550
Hospital Revenue Code	301
Min. Negotiated Rate	$149.72
Max. Negotiated Rate	$217.77
Rate for Payer: Cash Price	$122.49
Rate for Payer: Cigna of CA HMO/PPO	$217.77
Rate for Payer: Health Smart Auto/Commercial	$163.33
Rate for Payer: LLUH Dept of Risk Management WC	$149.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$204.16

HC SOM AMOBARBITAL

Facility

$272.21

Service Code	CPT G0480 90
Hospital Charge Code	900910550
Hospital Revenue Code	301
Min. Negotiated Rate	$149.72
Max. Negotiated Rate	$204.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$163.33
Rate for Payer: Aetna of CA Government/Medicare	$163.33
Rate for Payer: Cash Price	$122.49
Rate for Payer: Health Smart Auto/Commercial	$163.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$163.33
Rate for Payer: LLUH Dept of Risk Management WC	$149.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$204.16

HC SOM AMOBARBITAL

Facility

$272.21

Service Code	CPT G0480
Hospital Charge Code	900910550
Hospital Revenue Code	301
Min. Negotiated Rate	$149.72
Max. Negotiated Rate	$217.77
Rate for Payer: Cash Price	$122.49
Rate for Payer: Cigna of CA HMO/PPO	$217.77
Rate for Payer: Health Smart Auto/Commercial	$163.33
Rate for Payer: LLUH Dept of Risk Management WC	$149.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$204.16

HC SOM AMOBARBITAL

Facility

$272.21

Service Code	CPT 80345
Hospital Charge Code	900910550
Hospital Revenue Code	301
Min. Negotiated Rate	$149.72
Max. Negotiated Rate	$204.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$163.33
Rate for Payer: Aetna of CA Government/Medicare	$163.33
Rate for Payer: Cash Price	$122.49
Rate for Payer: Health Smart Auto/Commercial	$163.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$163.33
Rate for Payer: LLUH Dept of Risk Management WC	$149.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$204.16

HC SOM AMOBARBITAL

Facility

$272.21

Service Code	CPT G0480 90
Hospital Charge Code	900910550
Hospital Revenue Code	301
Min. Negotiated Rate	$149.72
Max. Negotiated Rate	$217.77
Rate for Payer: Cash Price	$122.49
Rate for Payer: Cigna of CA HMO/PPO	$217.77
Rate for Payer: Health Smart Auto/Commercial	$163.33
Rate for Payer: LLUH Dept of Risk Management WC	$149.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$204.16

HC SOM AMOBARBITAL

Facility

$272.21

Service Code	CPT G0480
Hospital Charge Code	900910550
Hospital Revenue Code	301
Min. Negotiated Rate	$149.72
Max. Negotiated Rate	$204.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$163.33
Rate for Payer: Aetna of CA Government/Medicare	$163.33
Rate for Payer: Cash Price	$122.49
Rate for Payer: Health Smart Auto/Commercial	$163.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$163.33
Rate for Payer: LLUH Dept of Risk Management WC	$149.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$204.16

HC SOM AMOXAPINE

Facility

$65.46

Service Code	CPT 80335
Hospital Charge Code	900911071
Hospital Revenue Code	301
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$52.37
Rate for Payer: Cash Price	$29.46
Rate for Payer: Cigna of CA HMO/PPO	$52.37
Rate for Payer: Health Smart Auto/Commercial	$39.28
Rate for Payer: LLUH Dept of Risk Management WC	$36.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.10

HC SOM AMOXAPINE

Facility

$65.46

Service Code	CPT 80335 90
Hospital Charge Code	900911071
Hospital Revenue Code	301
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$49.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.28
Rate for Payer: Aetna of CA Government/Medicare	$39.28
Rate for Payer: Cash Price	$29.46
Rate for Payer: Health Smart Auto/Commercial	$39.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.28
Rate for Payer: LLUH Dept of Risk Management WC	$36.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.10

HC SOM AMOXAPINE

Facility

$65.46

Service Code	CPT 80335
Hospital Charge Code	900911071
Hospital Revenue Code	301
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$49.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.28
Rate for Payer: Aetna of CA Government/Medicare	$39.28
Rate for Payer: Cash Price	$29.46
Rate for Payer: Health Smart Auto/Commercial	$39.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.28
Rate for Payer: LLUH Dept of Risk Management WC	$36.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.10

Know your out-of-pocket cost for care.

All Charges