Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM COMPLEMENT C1Q

Facility

$25.00

Service Code	CPT 86160
Hospital Charge Code	900911109
Hospital Revenue Code	302
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 COMPLEMENT C1Q

Facility

$25.00

Service Code	CPT 86160 90
Hospital Charge Code	900911109
Hospital Revenue Code	302
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 COMPLEMENT C1Q BINDING

Facility

$86.00

Service Code	CPT 86332
Hospital Charge Code	900911097
Hospital Revenue Code	302
Min. Negotiated Rate	$47.30
Max. Negotiated Rate	$64.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.60
Rate for Payer: Aetna of CA Government/Medicare	$51.60
Rate for Payer: Cash Price	$38.70
Rate for Payer: Health Smart Auto/Commercial	$51.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.60
Rate for Payer: LLUH Dept of Risk Management WC	$47.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.50

HC SOM COMPLEMENT C1Q BINDING

Facility

$86.00

Service Code	CPT 86332
Hospital Charge Code	900911097
Hospital Revenue Code	302
Min. Negotiated Rate	$47.30
Max. Negotiated Rate	$68.80
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna of CA HMO/PPO	$68.80
Rate for Payer: Health Smart Auto/Commercial	$51.60
Rate for Payer: LLUH Dept of Risk Management WC	$47.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.50

HC SOM COMPLEMENT C1Q BINDING

Facility

$86.00

Service Code	CPT 86332 90
Hospital Charge Code	900911097
Hospital Revenue Code	302
Min. Negotiated Rate	$47.30
Max. Negotiated Rate	$68.80
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna of CA HMO/PPO	$68.80
Rate for Payer: Health Smart Auto/Commercial	$51.60
Rate for Payer: LLUH Dept of Risk Management WC	$47.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.50

HC SOM COMPLEMENT C1Q BINDING

Facility

$86.00

Service Code	CPT 86332 90
Hospital Charge Code	900911097
Hospital Revenue Code	302
Min. Negotiated Rate	$47.30
Max. Negotiated Rate	$64.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.60
Rate for Payer: Aetna of CA Government/Medicare	$51.60
Rate for Payer: Cash Price	$38.70
Rate for Payer: Health Smart Auto/Commercial	$51.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.60
Rate for Payer: LLUH Dept of Risk Management WC	$47.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.50

HC SOM COMPLEMENT C-2

Facility

$50.00

Service Code	CPT 86161 90
Hospital Charge Code	900911110
Hospital Revenue Code	302
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna of CA HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM COMPLEMENT C-2

Facility

$50.00

Service Code	CPT 86161 90
Hospital Charge Code	900911110
Hospital Revenue Code	302
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM COMPLEMENT C-2

Facility

$50.00

Service Code	CPT 86161
Hospital Charge Code	900911110
Hospital Revenue Code	302
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM COMPLEMENT C-2

Facility

$50.00

Service Code	CPT 86161
Hospital Charge Code	900911110
Hospital Revenue Code	302
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna of CA HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM COMPLEMENT C-5

Facility

$45.00

Service Code	CPT 86160
Hospital Charge Code	900911042
Hospital Revenue Code	302
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Cigna of CA HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

HC SOM COMPLEMENT C-5

Facility

$45.00

Service Code	CPT 86160
Hospital Charge Code	900911042
Hospital Revenue Code	302
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

HC SOM COMPLEMENT C-5

Facility

$45.00

Service Code	CPT 86160 90
Hospital Charge Code	900911042
Hospital Revenue Code	302
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Cigna of CA HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

HC SOM COMPLEMENT C-5

Facility

$45.00

Service Code	CPT 86160 90
Hospital Charge Code	900911042
Hospital Revenue Code	302
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

HC SOM CONF HC DRUG ABUSE SUR 12, U

Facility

$150.00

Service Code	CPT 80307 90
Hospital Charge Code	900912913
Hospital Revenue Code	301
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$120.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna of CA HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.50

HC SOM CONF HC DRUG ABUSE SUR 12, U

Facility

$150.00

Service Code	CPT 80307
Hospital Charge Code	900912913
Hospital Revenue Code	301
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$120.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna of CA HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.50

HC SOM CONF HC DRUG ABUSE SUR 12, U

Facility

$150.00

Service Code	CPT 80307 90
Hospital Charge Code	900912913
Hospital Revenue Code	301
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.00
Rate for Payer: Aetna of CA Government/Medicare	$90.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.50

HC SOM CONF HC DRUG ABUSE SUR 12, U

Facility

$150.00

Service Code	CPT 80307
Hospital Charge Code	900912913
Hospital Revenue Code	301
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.00
Rate for Payer: Aetna of CA Government/Medicare	$90.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.50

HC SOM COPPER LIVER TISSUE

Facility

$65.00

Service Code	CPT 82525 90
Hospital Charge Code	900911029
Hospital Revenue Code	301
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$48.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.00
Rate for Payer: Aetna of CA Government/Medicare	$39.00
Rate for Payer: Cash Price	$29.25
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.75

HC SOM COPPER LIVER TISSUE

Facility

$65.00

Service Code	CPT 82525
Hospital Charge Code	900911029
Hospital Revenue Code	301
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$48.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.00
Rate for Payer: Aetna of CA Government/Medicare	$39.00
Rate for Payer: Cash Price	$29.25
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.75

HC SOM COPPER LIVER TISSUE

Facility

$65.00

Service Code	CPT 82525 90
Hospital Charge Code	900911029
Hospital Revenue Code	301
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$52.00
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cigna of CA HMO/PPO	$52.00
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.75

HC SOM COPPER LIVER TISSUE

Facility

$65.00

Service Code	CPT 82525
Hospital Charge Code	900911029
Hospital Revenue Code	301
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$52.00
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cigna of CA HMO/PPO	$52.00
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.75

HC SOM COPPER SERUM

Facility

$14.32

Service Code	CPT 82525
Hospital Charge Code	900911099
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$10.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.59
Rate for Payer: Aetna of CA Government/Medicare	$8.59
Rate for Payer: Cash Price	$6.44
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.74

HC SOM COPPER SERUM

Facility

$14.32

Service Code	CPT 82525
Hospital Charge Code	900911099
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$11.46
Rate for Payer: Cash Price	$6.44
Rate for Payer: Cigna of CA HMO/PPO	$11.46
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.74

HC SOM COPPER SERUM

Facility

$14.32

Service Code	CPT 82525 90
Hospital Charge Code	900911099
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$10.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.59
Rate for Payer: Aetna of CA Government/Medicare	$8.59
Rate for Payer: Cash Price	$6.44
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.74

Know your out-of-pocket cost for care.

All Charges