Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM CLONAZEPAM (CLONOPIN)

Facility

$30.00

Service Code	CPT 80346
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 80346
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

HC SOM CLONAZEPAM (CLONOPIN)

Facility

$30.00

Service Code	CPT G0480 90
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

HC SOM CLONAZEPAM (CLONOPIN)

Facility

$30.00

Service Code	CPT G0480 90
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 CLOZAPINE LEVEL

Facility

$31.59

Service Code	CPT 80159 90
Hospital Charge Code	900911438
Hospital Revenue Code	301
Min. Negotiated Rate	$17.37
Max. Negotiated Rate	$23.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.95
Rate for Payer: Aetna of CA Government/Medicare	$18.95
Rate for Payer: Cash Price	$14.22
Rate for Payer: Health Smart Auto/Commercial	$18.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.95
Rate for Payer: LLUH Dept of Risk Management WC	$17.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.69

HC SOM CLOZAPINE LEVEL

Facility

$31.59

Service Code	CPT 80159 90
Hospital Charge Code	900911438
Hospital Revenue Code	301
Min. Negotiated Rate	$17.37
Max. Negotiated Rate	$25.27
Rate for Payer: Cash Price	$14.22
Rate for Payer: Cigna of CA HMO/PPO	$25.27
Rate for Payer: Health Smart Auto/Commercial	$18.95
Rate for Payer: LLUH Dept of Risk Management WC	$17.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.69

HC SOM CLOZAPINE LEVEL

Facility

$31.59

Service Code	CPT 80159
Hospital Charge Code	900911438
Hospital Revenue Code	301
Min. Negotiated Rate	$17.37
Max. Negotiated Rate	$23.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.95
Rate for Payer: Aetna of CA Government/Medicare	$18.95
Rate for Payer: Cash Price	$14.22
Rate for Payer: Health Smart Auto/Commercial	$18.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.95
Rate for Payer: LLUH Dept of Risk Management WC	$17.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.69

HC SOM CLOZAPINE LEVEL

Facility

$31.59

Service Code	CPT 80159
Hospital Charge Code	900911438
Hospital Revenue Code	301
Min. Negotiated Rate	$17.37
Max. Negotiated Rate	$25.27
Rate for Payer: Cash Price	$14.22
Rate for Payer: Cigna of CA HMO/PPO	$25.27
Rate for Payer: Health Smart Auto/Commercial	$18.95
Rate for Payer: LLUH Dept of Risk Management WC	$17.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.69

HC SOM CMV PCR NON-BLOOD

Facility

$55.00

Service Code	CPT 87496 90
Hospital Charge Code	900912519
Hospital Revenue Code	306
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$44.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Cigna of CA HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.25

HC SOM CMV PCR NON-BLOOD

Facility

$55.00

Service Code	CPT 87496
Hospital Charge Code	900912519
Hospital Revenue Code	306
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$44.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Cigna of CA HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.25

HC SOM CMV PCR NON-BLOOD

Facility

$55.00

Service Code	CPT 87496 90
Hospital Charge Code	900912519
Hospital Revenue Code	306
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$41.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.00
Rate for Payer: Aetna of CA Government/Medicare	$33.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.25

HC SOM CMV PCR NON-BLOOD

Facility

$55.00

Service Code	CPT 87496
Hospital Charge Code	900912519
Hospital Revenue Code	306
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$41.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.00
Rate for Payer: Aetna of CA Government/Medicare	$33.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.25

HC SOM CMVQU 87497

Facility

$333.90

Service Code	CPT 87497 90
Hospital Charge Code	900915269
Hospital Revenue Code	306
Min. Negotiated Rate	$183.64
Max. Negotiated Rate	$250.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$200.34
Rate for Payer: Aetna of CA Government/Medicare	$200.34
Rate for Payer: Cash Price	$150.26
Rate for Payer: Health Smart Auto/Commercial	$200.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$200.34
Rate for Payer: LLUH Dept of Risk Management WC	$183.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.42

HC SOM CMVQU 87497

Facility

$333.90

Service Code	CPT 87497 90
Hospital Charge Code	900915269
Hospital Revenue Code	306
Min. Negotiated Rate	$183.64
Max. Negotiated Rate	$267.12
Rate for Payer: Cash Price	$150.26
Rate for Payer: Cigna of CA HMO/PPO	$267.12
Rate for Payer: Health Smart Auto/Commercial	$200.34
Rate for Payer: LLUH Dept of Risk Management WC	$183.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.42

HC SOM CMVQU 87497

Facility

$333.90

Service Code	CPT 87497
Hospital Charge Code	900915269
Hospital Revenue Code	306
Min. Negotiated Rate	$183.64
Max. Negotiated Rate	$250.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$200.34
Rate for Payer: Aetna of CA Government/Medicare	$200.34
Rate for Payer: Cash Price	$150.26
Rate for Payer: Health Smart Auto/Commercial	$200.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$200.34
Rate for Payer: LLUH Dept of Risk Management WC	$183.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.42

HC SOM CMVQU 87497

Facility

$333.90

Service Code	CPT 87497
Hospital Charge Code	900915269
Hospital Revenue Code	306
Min. Negotiated Rate	$183.64
Max. Negotiated Rate	$267.12
Rate for Payer: Cash Price	$150.26
Rate for Payer: Cigna of CA HMO/PPO	$267.12
Rate for Payer: Health Smart Auto/Commercial	$200.34
Rate for Payer: LLUH Dept of Risk Management WC	$183.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.42

HC SOM COAG FACTOR VIII ASSAY

Facility

$75.32

Service Code	CPT 85240
Hospital Charge Code	900913969
Hospital Revenue Code	305
Min. Negotiated Rate	$41.43
Max. Negotiated Rate	$60.26
Rate for Payer: Cash Price	$33.89
Rate for Payer: Cigna of CA HMO/PPO	$60.26
Rate for Payer: Health Smart Auto/Commercial	$45.19
Rate for Payer: LLUH Dept of Risk Management WC	$41.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.49

HC SOM COAG FACTOR VIII ASSAY

Facility

$75.32

Service Code	CPT 85240 90
Hospital Charge Code	900913969
Hospital Revenue Code	305
Min. Negotiated Rate	$41.43
Max. Negotiated Rate	$60.26
Rate for Payer: Cash Price	$33.89
Rate for Payer: Cigna of CA HMO/PPO	$60.26
Rate for Payer: Health Smart Auto/Commercial	$45.19
Rate for Payer: LLUH Dept of Risk Management WC	$41.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.49

HC SOM COAG FACTOR VIII ASSAY

Facility

$75.32

Service Code	CPT 85240 90
Hospital Charge Code	900913969
Hospital Revenue Code	305
Min. Negotiated Rate	$41.43
Max. Negotiated Rate	$56.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.19
Rate for Payer: Aetna of CA Government/Medicare	$45.19
Rate for Payer: Cash Price	$33.89
Rate for Payer: Health Smart Auto/Commercial	$45.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.19
Rate for Payer: LLUH Dept of Risk Management WC	$41.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.49

HC SOM COAG FACTOR VIII ASSAY

Facility

$75.32

Service Code	CPT 85240
Hospital Charge Code	900913969
Hospital Revenue Code	305
Min. Negotiated Rate	$41.43
Max. Negotiated Rate	$56.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.19
Rate for Payer: Aetna of CA Government/Medicare	$45.19
Rate for Payer: Cash Price	$33.89
Rate for Payer: Health Smart Auto/Commercial	$45.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.19
Rate for Payer: LLUH Dept of Risk Management WC	$41.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.49

HC SOM COAG FVIII INHIB SCREEN

Facility

$222.45

Service Code	CPT 85335
Hospital Charge Code	900913971
Hospital Revenue Code	305
Min. Negotiated Rate	$122.35
Max. Negotiated Rate	$166.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$133.47
Rate for Payer: Aetna of CA Government/Medicare	$133.47
Rate for Payer: Cash Price	$100.10
Rate for Payer: Health Smart Auto/Commercial	$133.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$133.47
Rate for Payer: LLUH Dept of Risk Management WC	$122.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$166.84

HC SOM COAG FVIII INHIB SCREEN

Facility

$222.45

Service Code	CPT 85335
Hospital Charge Code	900913971
Hospital Revenue Code	305
Min. Negotiated Rate	$122.35
Max. Negotiated Rate	$177.96
Rate for Payer: Cash Price	$100.10
Rate for Payer: Cigna of CA HMO/PPO	$177.96
Rate for Payer: Health Smart Auto/Commercial	$133.47
Rate for Payer: LLUH Dept of Risk Management WC	$122.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$166.84

HC SOM COAG FVIII INHIB SCREEN

Facility

$222.45

Service Code	CPT 85335 90
Hospital Charge Code	900913971
Hospital Revenue Code	305
Min. Negotiated Rate	$122.35
Max. Negotiated Rate	$177.96
Rate for Payer: Cash Price	$100.10
Rate for Payer: Cigna of CA HMO/PPO	$177.96
Rate for Payer: Health Smart Auto/Commercial	$133.47
Rate for Payer: LLUH Dept of Risk Management WC	$122.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$166.84

HC SOM COAG FVIII INHIB SCREEN

Facility

$222.45

Service Code	CPT 85335 90
Hospital Charge Code	900913971
Hospital Revenue Code	305
Min. Negotiated Rate	$122.35
Max. Negotiated Rate	$166.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$133.47
Rate for Payer: Aetna of CA Government/Medicare	$133.47
Rate for Payer: Cash Price	$100.10
Rate for Payer: Health Smart Auto/Commercial	$133.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$133.47
Rate for Payer: LLUH Dept of Risk Management WC	$122.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$166.84

HC SOM COCCI AB IGG CSF BY CF

Facility

$12.00

Service Code	CPT 86635 90
Hospital Charge Code	900911338
Hospital Revenue Code	302
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.00

Know your out-of-pocket cost for care.

All Charges