Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM CYSTIC FIBROSIS DNA

Facility

$168.38

Service Code	CPT 81220
Hospital Charge Code	900911481
Hospital Revenue Code	301
Min. Negotiated Rate	$92.61
Max. Negotiated Rate	$126.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$101.03
Rate for Payer: Aetna of CA Government/Medicare	$101.03
Rate for Payer: Cash Price	$75.77
Rate for Payer: Health Smart Auto/Commercial	$101.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$101.03
Rate for Payer: LLUH Dept of Risk Management WC	$92.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$126.28

HC SOM DCP 83951

Facility

$90.00

Service Code	CPT 83951
Hospital Charge Code	900914920
Hospital Revenue Code	305
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.00
Rate for Payer: Aetna of CA Government/Medicare	$54.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.50

HC SOM DCP 83951

Facility

$90.00

Service Code	CPT 83951 90
Hospital Charge Code	900914920
Hospital Revenue Code	305
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna of CA HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.50

HC SOM DCP 83951

Facility

$90.00

Service Code	CPT 83951 90
Hospital Charge Code	900914920
Hospital Revenue Code	305
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.00
Rate for Payer: Aetna of CA Government/Medicare	$54.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.50

HC SOM DCP 83951

Facility

$90.00

Service Code	CPT 83951
Hospital Charge Code	900914920
Hospital Revenue Code	305
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna of CA HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.50

HC SOM DENGUE FEVER AB IGG

Facility

$89.10

Service Code	CPT 86790
Hospital Charge Code	900911637
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$66.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.46
Rate for Payer: Aetna of CA Government/Medicare	$53.46
Rate for Payer: Cash Price	$40.10
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.82

HC SOM DENGUE FEVER AB IGG

Facility

$89.10

Service Code	CPT 86790
Hospital Charge Code	900911637
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$71.28
Rate for Payer: Cash Price	$40.10
Rate for Payer: Cigna of CA HMO/PPO	$71.28
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.82

HC SOM DENGUE FEVER AB IGG

Facility

$89.10

Service Code	CPT 86790 90
Hospital Charge Code	900911637
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$66.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.46
Rate for Payer: Aetna of CA Government/Medicare	$53.46
Rate for Payer: Cash Price	$40.10
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.82

HC SOM DENGUE FEVER AB IGG

Facility

$89.10

Service Code	CPT 86790 90
Hospital Charge Code	900911637
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$71.28
Rate for Payer: Cash Price	$40.10
Rate for Payer: Cigna of CA HMO/PPO	$71.28
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.82

HC SOM DENGUE FEVER AB IGM

Facility

$89.10

Service Code	CPT 86790
Hospital Charge Code	900912614
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$71.28
Rate for Payer: Cash Price	$40.10
Rate for Payer: Cigna of CA HMO/PPO	$71.28
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.82

HC SOM DENGUE FEVER AB IGM

Facility

$89.10

Service Code	CPT 86790 90
Hospital Charge Code	900912614
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$66.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.46
Rate for Payer: Aetna of CA Government/Medicare	$53.46
Rate for Payer: Cash Price	$40.10
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.82

HC SOM DENGUE FEVER AB IGM

Facility

$89.10

Service Code	CPT 86790 90
Hospital Charge Code	900912614
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$71.28
Rate for Payer: Cash Price	$40.10
Rate for Payer: Cigna of CA HMO/PPO	$71.28
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.82

HC SOM DENGUE FEVER AB IGM

Facility

$89.10

Service Code	CPT 86790
Hospital Charge Code	900912614
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$66.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.46
Rate for Payer: Aetna of CA Government/Medicare	$53.46
Rate for Payer: Cash Price	$40.10
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.82

HC SOM DESMOGLEIN 1

Facility

$55.00

Service Code	CPT 83516 90
Hospital Charge Code	900914423
Hospital Revenue Code	301
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 DESMOGLEIN 1

Facility

$55.00

Service Code	CPT 83516
Hospital Charge Code	900914423
Hospital Revenue Code	301
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 DESMOGLEIN 1

Facility

$55.00

Service Code	CPT 83516 90
Hospital Charge Code	900914423
Hospital Revenue Code	301
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 DESMOGLEIN 1

Facility

$55.00

Service Code	CPT 83516
Hospital Charge Code	900914423
Hospital Revenue Code	301
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 DESYREL (TRAZODONE)

Facility

$70.25

Service Code	CPT 80338 90
Hospital Charge Code	900911223
Hospital Revenue Code	301
Min. Negotiated Rate	$38.64
Max. Negotiated Rate	$56.20
Rate for Payer: Cash Price	$31.61
Rate for Payer: Cigna of CA HMO/PPO	$56.20
Rate for Payer: Health Smart Auto/Commercial	$42.15
Rate for Payer: LLUH Dept of Risk Management WC	$38.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.69

HC SOM DESYREL (TRAZODONE)

Facility

$70.25

Service Code	CPT 80338
Hospital Charge Code	900911223
Hospital Revenue Code	301
Min. Negotiated Rate	$38.64
Max. Negotiated Rate	$56.20
Rate for Payer: Cash Price	$31.61
Rate for Payer: Cigna of CA HMO/PPO	$56.20
Rate for Payer: Health Smart Auto/Commercial	$42.15
Rate for Payer: LLUH Dept of Risk Management WC	$38.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.69

HC SOM DESYREL (TRAZODONE)

Facility

$70.25

Service Code	CPT 80338
Hospital Charge Code	900911223
Hospital Revenue Code	301
Min. Negotiated Rate	$38.64
Max. Negotiated Rate	$52.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.15
Rate for Payer: Aetna of CA Government/Medicare	$42.15
Rate for Payer: Cash Price	$31.61
Rate for Payer: Health Smart Auto/Commercial	$42.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.15
Rate for Payer: LLUH Dept of Risk Management WC	$38.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.69

HC SOM DESYREL (TRAZODONE)

Facility

$70.25

Service Code	CPT 80338 90
Hospital Charge Code	900911223
Hospital Revenue Code	301
Min. Negotiated Rate	$38.64
Max. Negotiated Rate	$52.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.15
Rate for Payer: Aetna of CA Government/Medicare	$42.15
Rate for Payer: Cash Price	$31.61
Rate for Payer: Health Smart Auto/Commercial	$42.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.15
Rate for Payer: LLUH Dept of Risk Management WC	$38.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.69

HC SOM DHEA

Facility

$18.58

Service Code	CPT 82626
Hospital Charge Code	900911115
Hospital Revenue Code	302
Min. Negotiated Rate	$10.22
Max. Negotiated Rate	$14.86
Rate for Payer: Cash Price	$8.36
Rate for Payer: Cigna of CA HMO/PPO	$14.86
Rate for Payer: Health Smart Auto/Commercial	$11.15
Rate for Payer: LLUH Dept of Risk Management WC	$10.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.94

HC SOM DHEA

Facility

$18.58

Service Code	CPT 82626 90
Hospital Charge Code	900911115
Hospital Revenue Code	302
Min. Negotiated Rate	$10.22
Max. Negotiated Rate	$13.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.15
Rate for Payer: Aetna of CA Government/Medicare	$11.15
Rate for Payer: Cash Price	$8.36
Rate for Payer: Health Smart Auto/Commercial	$11.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.15
Rate for Payer: LLUH Dept of Risk Management WC	$10.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.94

HC SOM DHEA

Facility

$18.58

Service Code	CPT 82626 90
Hospital Charge Code	900911115
Hospital Revenue Code	302
Min. Negotiated Rate	$10.22
Max. Negotiated Rate	$14.86
Rate for Payer: Cash Price	$8.36
Rate for Payer: Cigna of CA HMO/PPO	$14.86
Rate for Payer: Health Smart Auto/Commercial	$11.15
Rate for Payer: LLUH Dept of Risk Management WC	$10.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.94

HC SOM DHEA

Facility

$18.58

Service Code	CPT 82626
Hospital Charge Code	900911115
Hospital Revenue Code	302
Min. Negotiated Rate	$10.22
Max. Negotiated Rate	$13.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.15
Rate for Payer: Aetna of CA Government/Medicare	$11.15
Rate for Payer: Cash Price	$8.36
Rate for Payer: Health Smart Auto/Commercial	$11.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.15
Rate for Payer: LLUH Dept of Risk Management WC	$10.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.94

Know your out-of-pocket cost for care.

All Charges