Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM CHROMOSOMES CHORIONIC VILLUS

Facility

$400.00

Service Code	CPT 88291 TC
Hospital Charge Code	900912549
Hospital Revenue Code	310
Min. Negotiated Rate	$220.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$240.00
Rate for Payer: Aetna of CA Government/Medicare	$240.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Health Smart Auto/Commercial	$240.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$240.00
Rate for Payer: LLUH Dept of Risk Management WC	$220.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$300.00

HC SOM CHROMOSOMES CHORIONIC VILLUS

Facility

$400.00

Service Code	CPT 88291
Hospital Charge Code	900912549
Hospital Revenue Code	310
Min. Negotiated Rate	$220.00
Max. Negotiated Rate	$320.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna of CA HMO/PPO	$320.00
Rate for Payer: Health Smart Auto/Commercial	$240.00
Rate for Payer: LLUH Dept of Risk Management WC	$220.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$300.00

HC SOM CHROMOSOMES CHORIONIC VILLUS

Facility

$400.00

Service Code	CPT 88291 TC
Hospital Charge Code	900912549
Hospital Revenue Code	310
Min. Negotiated Rate	$220.00
Max. Negotiated Rate	$320.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna of CA HMO/PPO	$320.00
Rate for Payer: Health Smart Auto/Commercial	$240.00
Rate for Payer: LLUH Dept of Risk Management WC	$220.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$300.00

HC SOM CHROMOSOMES LYMPHOID

Facility

$36.56

Service Code	CPT 88291
Hospital Charge Code	900912548
Hospital Revenue Code	310
Min. Negotiated Rate	$20.11
Max. Negotiated Rate	$29.25
Rate for Payer: Cash Price	$16.45
Rate for Payer: Cigna of CA HMO/PPO	$29.25
Rate for Payer: Health Smart Auto/Commercial	$21.94
Rate for Payer: LLUH Dept of Risk Management WC	$20.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.42

HC SOM CHROMOSOMES LYMPHOID

Facility

$36.56

Service Code	CPT 88291
Hospital Charge Code	900912548
Hospital Revenue Code	310
Min. Negotiated Rate	$20.11
Max. Negotiated Rate	$27.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.94
Rate for Payer: Aetna of CA Government/Medicare	$21.94
Rate for Payer: Cash Price	$16.45
Rate for Payer: Health Smart Auto/Commercial	$21.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.94
Rate for Payer: LLUH Dept of Risk Management WC	$20.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.42

HC SOM CHROMOSOMES SKIN BIOPSY

Facility

$276.95

Service Code	CPT 88291
Hospital Charge Code	900912547
Hospital Revenue Code	310
Min. Negotiated Rate	$152.32
Max. Negotiated Rate	$221.56
Rate for Payer: Cash Price	$124.63
Rate for Payer: Cigna of CA HMO/PPO	$221.56
Rate for Payer: Health Smart Auto/Commercial	$166.17
Rate for Payer: LLUH Dept of Risk Management WC	$152.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$207.71

HC SOM CHROMOSOMES SKIN BIOPSY

Facility

$276.95

Service Code	CPT 88291
Hospital Charge Code	900912547
Hospital Revenue Code	310
Min. Negotiated Rate	$152.32
Max. Negotiated Rate	$207.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$166.17
Rate for Payer: Aetna of CA Government/Medicare	$166.17
Rate for Payer: Cash Price	$124.63
Rate for Payer: Health Smart Auto/Commercial	$166.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$166.17
Rate for Payer: LLUH Dept of Risk Management WC	$152.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$207.71

HC SOM CHRONIC URTICARIA INDEX

Facility

$160.00

Service Code	CPT 86343
Hospital Charge Code	900912840
Hospital Revenue Code	302
Min. Negotiated Rate	$88.00
Max. Negotiated Rate	$128.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna of CA HMO/PPO	$128.00
Rate for Payer: Health Smart Auto/Commercial	$96.00
Rate for Payer: LLUH Dept of Risk Management WC	$88.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.00

HC SOM CHRONIC URTICARIA INDEX

Facility

$160.00

Service Code	CPT 86343 90
Hospital Charge Code	900912840
Hospital Revenue Code	302
Min. Negotiated Rate	$88.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$96.00
Rate for Payer: Aetna of CA Government/Medicare	$96.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Health Smart Auto/Commercial	$96.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$96.00
Rate for Payer: LLUH Dept of Risk Management WC	$88.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.00

HC SOM CHRONIC URTICARIA INDEX

Facility

$160.00

Service Code	CPT 86343 90
Hospital Charge Code	900912840
Hospital Revenue Code	302
Min. Negotiated Rate	$88.00
Max. Negotiated Rate	$128.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna of CA HMO/PPO	$128.00
Rate for Payer: Health Smart Auto/Commercial	$96.00
Rate for Payer: LLUH Dept of Risk Management WC	$88.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.00

HC SOM CHRONIC URTICARIA INDEX

Facility

$160.00

Service Code	CPT 86343
Hospital Charge Code	900912840
Hospital Revenue Code	302
Min. Negotiated Rate	$88.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$96.00
Rate for Payer: Aetna of CA Government/Medicare	$96.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Health Smart Auto/Commercial	$96.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$96.00
Rate for Payer: LLUH Dept of Risk Management WC	$88.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.00

HC SOM CIRC TUMOR PROS FLOW

Facility

$325.24

Service Code	CPT 86152 90
Hospital Charge Code	900914391
Hospital Revenue Code	301
Min. Negotiated Rate	$178.88
Max. Negotiated Rate	$260.19
Rate for Payer: Cash Price	$146.36
Rate for Payer: Cigna of CA HMO/PPO	$260.19
Rate for Payer: Health Smart Auto/Commercial	$195.14
Rate for Payer: LLUH Dept of Risk Management WC	$178.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.93

HC SOM CIRC TUMOR PROS FLOW

Facility

$325.24

Service Code	CPT 86152 90
Hospital Charge Code	900914391
Hospital Revenue Code	301
Min. Negotiated Rate	$178.88
Max. Negotiated Rate	$243.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$195.14
Rate for Payer: Aetna of CA Government/Medicare	$195.14
Rate for Payer: Cash Price	$146.36
Rate for Payer: Health Smart Auto/Commercial	$195.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$195.14
Rate for Payer: LLUH Dept of Risk Management WC	$178.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.93

HC SOM CIRC TUMOR PROS FLOW

Facility

$325.24

Service Code	CPT 86152
Hospital Charge Code	900914391
Hospital Revenue Code	309
Min. Negotiated Rate	$178.88
Max. Negotiated Rate	$260.19
Rate for Payer: Cash Price	$146.36
Rate for Payer: Cigna of CA HMO/PPO	$260.19
Rate for Payer: Health Smart Auto/Commercial	$195.14
Rate for Payer: LLUH Dept of Risk Management WC	$178.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.93

HC SOM CIRC TUMOR PROS FLOW

Facility

$325.24

Service Code	CPT 86152
Hospital Charge Code	900914391
Hospital Revenue Code	309
Min. Negotiated Rate	$178.88
Max. Negotiated Rate	$243.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$195.14
Rate for Payer: Aetna of CA Government/Medicare	$195.14
Rate for Payer: Cash Price	$146.36
Rate for Payer: Health Smart Auto/Commercial	$195.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$195.14
Rate for Payer: LLUH Dept of Risk Management WC	$178.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.93

HC SOM CIRC TUMOR PROS MARK

Facility

$325.24

Service Code	CPT 86153
Hospital Charge Code	900914392
Hospital Revenue Code	309
Min. Negotiated Rate	$178.88
Max. Negotiated Rate	$260.19
Rate for Payer: Cash Price	$146.36
Rate for Payer: Cigna of CA HMO/PPO	$260.19
Rate for Payer: Health Smart Auto/Commercial	$195.14
Rate for Payer: LLUH Dept of Risk Management WC	$178.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.93

HC SOM CIRC TUMOR PROS MARK

Facility

$325.24

Service Code	CPT 86153 90
Hospital Charge Code	900914392
Hospital Revenue Code	301
Min. Negotiated Rate	$178.88
Max. Negotiated Rate	$260.19
Rate for Payer: Cash Price	$146.36
Rate for Payer: Cigna of CA HMO/PPO	$260.19
Rate for Payer: Health Smart Auto/Commercial	$195.14
Rate for Payer: LLUH Dept of Risk Management WC	$178.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.93

HC SOM CIRC TUMOR PROS MARK

Facility

$325.24

Service Code	CPT 86153 90
Hospital Charge Code	900914392
Hospital Revenue Code	301
Min. Negotiated Rate	$178.88
Max. Negotiated Rate	$243.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$195.14
Rate for Payer: Aetna of CA Government/Medicare	$195.14
Rate for Payer: Cash Price	$146.36
Rate for Payer: Health Smart Auto/Commercial	$195.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$195.14
Rate for Payer: LLUH Dept of Risk Management WC	$178.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.93

HC SOM CIRC TUMOR PROS MARK

Facility

$325.24

Service Code	CPT 86153
Hospital Charge Code	900914392
Hospital Revenue Code	309
Min. Negotiated Rate	$178.88
Max. Negotiated Rate	$243.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$195.14
Rate for Payer: Aetna of CA Government/Medicare	$195.14
Rate for Payer: Cash Price	$146.36
Rate for Payer: Health Smart Auto/Commercial	$195.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$195.14
Rate for Payer: LLUH Dept of Risk Management WC	$178.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.93

HC SOM CITRIC ACID URINE

Facility

$20.00

Service Code	CPT 82507
Hospital Charge Code	900911053
Hospital Revenue Code	301
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 CITRIC ACID URINE

Facility

$20.00

Service Code	CPT 82507 90
Hospital Charge Code	900911053
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Cash Price	$9.00
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: 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 CITRIC ACID URINE

Facility

$20.00

Service Code	CPT 82507 90
Hospital Charge Code	900911053
Hospital Revenue Code	301
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 CITRIC ACID URINE

Facility

$20.00

Service Code	CPT 82507
Hospital Charge Code	900911053
Hospital Revenue Code	301
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 CLONAZEPAM (CLONOPIN)

Facility

$30.00

Service Code	CPT G0480
Hospital Charge Code	900911228
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 CLONAZEPAM (CLONOPIN)

Facility

$30.00

Service Code	CPT G0480
Hospital Charge Code	900911228
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

Know your out-of-pocket cost for care.

All Charges