Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM ARSENIC URINE QUANT

Facility

$25.00

Service Code	CPT 82175 90
Hospital Charge Code	900911289
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM ARSENIC URINE QUANT

Facility

$25.00

Service Code	CPT 82175 90
Hospital Charge Code	900911289
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna of CA HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM ARSENIC URINE QUANT

Facility

$25.00

Service Code	CPT 82175
Hospital Charge Code	900911289
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna of CA HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM ARSENIC URINE QUANT

Facility

$25.00

Service Code	CPT 82175
Hospital Charge Code	900911289
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM ARYLSULFATASE A, URINE

Facility

$125.00

Service Code	CPT 84311 90
Hospital Charge Code	900910723
Hospital Revenue Code	301
Min. Negotiated Rate	$68.75
Max. Negotiated Rate	$100.00
Rate for Payer: Cash Price	$56.25
Rate for Payer: Cigna of CA HMO/PPO	$100.00
Rate for Payer: Health Smart Auto/Commercial	$75.00
Rate for Payer: LLUH Dept of Risk Management WC	$68.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$93.75

HC SOM ARYLSULFATASE A, URINE

Facility

$125.00

Service Code	CPT 84311
Hospital Charge Code	900910723
Hospital Revenue Code	301
Min. Negotiated Rate	$68.75
Max. Negotiated Rate	$93.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.00
Rate for Payer: Aetna of CA Government/Medicare	$75.00
Rate for Payer: Cash Price	$56.25
Rate for Payer: Health Smart Auto/Commercial	$75.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.00
Rate for Payer: LLUH Dept of Risk Management WC	$68.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$93.75

HC SOM ARYLSULFATASE A, URINE

Facility

$125.00

Service Code	CPT 84311 90
Hospital Charge Code	900910723
Hospital Revenue Code	301
Min. Negotiated Rate	$68.75
Max. Negotiated Rate	$93.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.00
Rate for Payer: Aetna of CA Government/Medicare	$75.00
Rate for Payer: Cash Price	$56.25
Rate for Payer: Health Smart Auto/Commercial	$75.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.00
Rate for Payer: LLUH Dept of Risk Management WC	$68.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$93.75

HC SOM ARYLSULFATASE A, URINE

Facility

$125.00

Service Code	CPT 84311
Hospital Charge Code	900910723
Hospital Revenue Code	301
Min. Negotiated Rate	$68.75
Max. Negotiated Rate	$100.00
Rate for Payer: Cash Price	$56.25
Rate for Payer: Cigna of CA HMO/PPO	$100.00
Rate for Payer: Health Smart Auto/Commercial	$75.00
Rate for Payer: LLUH Dept of Risk Management WC	$68.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$93.75

HC SOM ASPERGILLUS(GALACT)ANTIGEN

Facility

$20.00

Service Code	CPT 87305
Hospital Charge Code	900912574
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna of CA HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC SOM ASPERGILLUS(GALACT)ANTIGEN

Facility

$20.00

Service Code	CPT 87305 90
Hospital Charge Code	900912574
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC SOM ASPERGILLUS(GALACT)ANTIGEN

Facility

$20.00

Service Code	CPT 87305 90
Hospital Charge Code	900912574
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna of CA HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC SOM ASPERGILLUS(GALACT)ANTIGEN

Facility

$20.00

Service Code	CPT 87305
Hospital Charge Code	900912574
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC SOM ATIVAN

Facility

$73.59

Service Code	CPT 80346
Hospital Charge Code	900911456
Hospital Revenue Code	301
Min. Negotiated Rate	$40.47
Max. Negotiated Rate	$58.87
Rate for Payer: Cash Price	$33.12
Rate for Payer: Cigna of CA HMO/PPO	$58.87
Rate for Payer: Health Smart Auto/Commercial	$44.15
Rate for Payer: LLUH Dept of Risk Management WC	$40.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.19

HC SOM ATIVAN

Facility

$73.59

Service Code	CPT G0480
Hospital Charge Code	900911456
Hospital Revenue Code	301
Min. Negotiated Rate	$40.47
Max. Negotiated Rate	$58.87
Rate for Payer: Cash Price	$33.12
Rate for Payer: Cigna of CA HMO/PPO	$58.87
Rate for Payer: Health Smart Auto/Commercial	$44.15
Rate for Payer: LLUH Dept of Risk Management WC	$40.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.19

HC SOM ATIVAN

Facility

$73.59

Service Code	CPT G0480
Hospital Charge Code	900911456
Hospital Revenue Code	301
Min. Negotiated Rate	$40.47
Max. Negotiated Rate	$55.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.15
Rate for Payer: Aetna of CA Government/Medicare	$44.15
Rate for Payer: Cash Price	$33.12
Rate for Payer: Health Smart Auto/Commercial	$44.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.15
Rate for Payer: LLUH Dept of Risk Management WC	$40.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.19

HC SOM ATIVAN

Facility

$73.59

Service Code	CPT G0480 90
Hospital Charge Code	900911456
Hospital Revenue Code	301
Min. Negotiated Rate	$40.47
Max. Negotiated Rate	$55.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.15
Rate for Payer: Aetna of CA Government/Medicare	$44.15
Rate for Payer: Cash Price	$33.12
Rate for Payer: Health Smart Auto/Commercial	$44.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.15
Rate for Payer: LLUH Dept of Risk Management WC	$40.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.19

HC SOM ATIVAN

Facility

$73.59

Service Code	CPT 80346
Hospital Charge Code	900911456
Hospital Revenue Code	301
Min. Negotiated Rate	$40.47
Max. Negotiated Rate	$55.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.15
Rate for Payer: Aetna of CA Government/Medicare	$44.15
Rate for Payer: Cash Price	$33.12
Rate for Payer: Health Smart Auto/Commercial	$44.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.15
Rate for Payer: LLUH Dept of Risk Management WC	$40.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.19

HC SOM ATIVAN

Facility

$73.59

Service Code	CPT G0480 90
Hospital Charge Code	900911456
Hospital Revenue Code	301
Min. Negotiated Rate	$40.47
Max. Negotiated Rate	$58.87
Rate for Payer: Cash Price	$33.12
Rate for Payer: Cigna of CA HMO/PPO	$58.87
Rate for Payer: Health Smart Auto/Commercial	$44.15
Rate for Payer: LLUH Dept of Risk Management WC	$40.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.19

HC SOM BACLOFEN 83789

Facility

$319.00

Service Code	CPT 83789
Hospital Charge Code	900915259
Hospital Revenue Code	301
Min. Negotiated Rate	$175.45
Max. Negotiated Rate	$239.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$191.40
Rate for Payer: Aetna of CA Government/Medicare	$191.40
Rate for Payer: Cash Price	$143.55
Rate for Payer: Health Smart Auto/Commercial	$191.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$191.40
Rate for Payer: LLUH Dept of Risk Management WC	$175.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$239.25

HC SOM BACLOFEN 83789

Facility

$319.00

Service Code	CPT 83789 90
Hospital Charge Code	900915259
Hospital Revenue Code	301
Min. Negotiated Rate	$175.45
Max. Negotiated Rate	$255.20
Rate for Payer: Health Smart Auto/Commercial	$191.40
Rate for Payer: Cash Price	$143.55
Rate for Payer: Cigna of CA HMO/PPO	$255.20
Rate for Payer: LLUH Dept of Risk Management WC	$175.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$239.25

HC SOM BACLOFEN 83789

Facility

$319.00

Service Code	CPT 83789 90
Hospital Charge Code	900915259
Hospital Revenue Code	301
Min. Negotiated Rate	$175.45
Max. Negotiated Rate	$239.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$191.40
Rate for Payer: Aetna of CA Government/Medicare	$191.40
Rate for Payer: Cash Price	$143.55
Rate for Payer: Health Smart Auto/Commercial	$191.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$191.40
Rate for Payer: LLUH Dept of Risk Management WC	$175.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$239.25

HC SOM BACLOFEN 83789

Facility

$319.00

Service Code	CPT 83789
Hospital Charge Code	900915259
Hospital Revenue Code	301
Min. Negotiated Rate	$175.45
Max. Negotiated Rate	$255.20
Rate for Payer: Cash Price	$143.55
Rate for Payer: Cigna of CA HMO/PPO	$255.20
Rate for Payer: Health Smart Auto/Commercial	$191.40
Rate for Payer: LLUH Dept of Risk Management WC	$175.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$239.25

HC SOM BARBITURATE CONFIRM, U

Facility

$61.25

Service Code	CPT G0480 90
Hospital Charge Code	900912916
Hospital Revenue Code	301
Min. Negotiated Rate	$33.69
Max. Negotiated Rate	$45.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.75
Rate for Payer: Aetna of CA Government/Medicare	$36.75
Rate for Payer: Cash Price	$27.56
Rate for Payer: Health Smart Auto/Commercial	$36.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.75
Rate for Payer: LLUH Dept of Risk Management WC	$33.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.94

HC SOM BARBITURATE CONFIRM, U

Facility

$61.25

Service Code	CPT G0480
Hospital Charge Code	900912916
Hospital Revenue Code	301
Min. Negotiated Rate	$33.69
Max. Negotiated Rate	$49.00
Rate for Payer: Cash Price	$27.56
Rate for Payer: Cigna of CA HMO/PPO	$49.00
Rate for Payer: Health Smart Auto/Commercial	$36.75
Rate for Payer: LLUH Dept of Risk Management WC	$33.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.94

HC SOM BARBITURATE CONFIRM, U

Facility

$61.25

Service Code	CPT 80345
Hospital Charge Code	900912916
Hospital Revenue Code	301
Min. Negotiated Rate	$33.69
Max. Negotiated Rate	$49.00
Rate for Payer: Cash Price	$27.56
Rate for Payer: Cigna of CA HMO/PPO	$49.00
Rate for Payer: Health Smart Auto/Commercial	$36.75
Rate for Payer: LLUH Dept of Risk Management WC	$33.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.94

Know your out-of-pocket cost for care.

All Charges