Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM DIAZEPAM (VALIUM)

Facility

$266.68

Service Code	CPT G0480 90
Hospital Charge Code	900911088
Hospital Revenue Code	301
Min. Negotiated Rate	$146.67
Max. Negotiated Rate	$213.34
Rate for Payer: Cash Price	$120.01
Rate for Payer: Cigna of CA HMO/PPO	$213.34
Rate for Payer: Health Smart Auto/Commercial	$160.01
Rate for Payer: LLUH Dept of Risk Management WC	$146.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$200.01

HC SOM DIAZEPAM (VALIUM)

Facility

$266.68

Service Code	CPT 80346
Hospital Charge Code	900911088
Hospital Revenue Code	301
Min. Negotiated Rate	$146.67
Max. Negotiated Rate	$200.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$160.01
Rate for Payer: Aetna of CA Government/Medicare	$160.01
Rate for Payer: Cash Price	$120.01
Rate for Payer: Health Smart Auto/Commercial	$160.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$160.01
Rate for Payer: LLUH Dept of Risk Management WC	$146.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$200.01

HC SOM DIAZEPAM (VALIUM)

Facility

$266.68

Service Code	CPT G0480 90
Hospital Charge Code	900911088
Hospital Revenue Code	301
Min. Negotiated Rate	$146.67
Max. Negotiated Rate	$200.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$160.01
Rate for Payer: Aetna of CA Government/Medicare	$160.01
Rate for Payer: Cash Price	$120.01
Rate for Payer: Health Smart Auto/Commercial	$160.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$160.01
Rate for Payer: LLUH Dept of Risk Management WC	$146.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$200.01

HC SOM DIAZEPAM (VALIUM)

Facility

$266.68

Service Code	CPT 80346
Hospital Charge Code	900911088
Hospital Revenue Code	301
Min. Negotiated Rate	$146.67
Max. Negotiated Rate	$213.34
Rate for Payer: Cash Price	$120.01
Rate for Payer: Cigna of CA HMO/PPO	$213.34
Rate for Payer: Health Smart Auto/Commercial	$160.01
Rate for Payer: LLUH Dept of Risk Management WC	$146.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$200.01

HC SOM DIAZEPAM (VALIUM)

Facility

$266.68

Service Code	CPT G0480
Hospital Charge Code	900911088
Hospital Revenue Code	301
Min. Negotiated Rate	$146.67
Max. Negotiated Rate	$213.34
Rate for Payer: Cash Price	$120.01
Rate for Payer: Cigna of CA HMO/PPO	$213.34
Rate for Payer: Health Smart Auto/Commercial	$160.01
Rate for Payer: LLUH Dept of Risk Management WC	$146.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$200.01

HC SOM DIAZEPAM (VALIUM)

Facility

$266.68

Service Code	CPT G0480
Hospital Charge Code	900911088
Hospital Revenue Code	301
Min. Negotiated Rate	$146.67
Max. Negotiated Rate	$200.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$160.01
Rate for Payer: Aetna of CA Government/Medicare	$160.01
Rate for Payer: Cash Price	$120.01
Rate for Payer: Health Smart Auto/Commercial	$160.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$160.01
Rate for Payer: LLUH Dept of Risk Management WC	$146.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$200.01

HC SOM DIHYDROTESTERONE

Facility

$41.00

Service Code	CPT 82642
Hospital Charge Code	900911013
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$30.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.60
Rate for Payer: Aetna of CA Government/Medicare	$24.60
Rate for Payer: Cash Price	$18.45
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.75

HC SOM DIHYDROTESTERONE

Facility

$41.00

Service Code	CPT G0480
Hospital Charge Code	900911013
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$32.80
Rate for Payer: Cash Price	$18.45
Rate for Payer: Cigna of CA HMO/PPO	$32.80
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.75

HC SOM DIHYDROTESTERONE

Facility

$41.00

Service Code	CPT 82642
Hospital Charge Code	900911013
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$32.80
Rate for Payer: Cash Price	$18.45
Rate for Payer: Cigna of CA HMO/PPO	$32.80
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.75

HC SOM DIHYDROTESTERONE

Facility

$41.00

Service Code	CPT G0480 90
Hospital Charge Code	900911013
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$30.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.60
Rate for Payer: Aetna of CA Government/Medicare	$24.60
Rate for Payer: Cash Price	$18.45
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.75

HC SOM DIHYDROTESTERONE

Facility

$41.00

Service Code	CPT G0480 90
Hospital Charge Code	900911013
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$32.80
Rate for Payer: Cash Price	$18.45
Rate for Payer: Cigna of CA HMO/PPO	$32.80
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.75

HC SOM DIHYDROTESTERONE

Facility

$41.00

Service Code	CPT G0480
Hospital Charge Code	900911013
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$30.75
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: Cash Price	$18.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.60
Rate for Payer: Aetna of CA Government/Medicare	$24.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.75

HC SOM DILANTIN FREE

Facility

$20.00

Service Code	CPT 80186
Hospital Charge Code	900911414
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 DILANTIN FREE

Facility

$20.00

Service Code	CPT 80186 90
Hospital Charge Code	900911414
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 DILANTIN FREE

Facility

$20.00

Service Code	CPT 80186
Hospital Charge Code	900911414
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 DILANTIN FREE

Facility

$20.00

Service Code	CPT 80186 90
Hospital Charge Code	900911414
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 DILANTIN LV FREE PHENY TOT

Facility

$20.00

Service Code	CPT 80185
Hospital Charge Code	900912809
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 DILANTIN LV FREE PHENY TOT

Facility

$20.00

Service Code	CPT 80185 90
Hospital Charge Code	900912809
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 DILANTIN LV FREE PHENY TOT

Facility

$20.00

Service Code	CPT 80185
Hospital Charge Code	900912809
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 DILANTIN LV FREE PHENY TOT

Facility

$20.00

Service Code	CPT 80185 90
Hospital Charge Code	900912809
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 DIPHTHERIA ANTITOXOID (ELISA)

Facility

$35.00

Service Code	CPT 86317 90
Hospital Charge Code	900911755
Hospital Revenue Code	302
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$26.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.00
Rate for Payer: Aetna of CA Government/Medicare	$21.00
Rate for Payer: Cash Price	$15.75
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.25

HC SOM DIPHTHERIA ANTITOXOID (ELISA)

Facility

$35.00

Service Code	CPT 86317 90
Hospital Charge Code	900911755
Hospital Revenue Code	302
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$28.00
Rate for Payer: Cash Price	$15.75
Rate for Payer: Cigna of CA HMO/PPO	$28.00
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.25

HC SOM DIPHTHERIA ANTITOXOID (ELISA)

Facility

$35.00

Service Code	CPT 86317
Hospital Charge Code	900911755
Hospital Revenue Code	302
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$26.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.00
Rate for Payer: Aetna of CA Government/Medicare	$21.00
Rate for Payer: Cash Price	$15.75
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.25

HC SOM DIPHTHERIA ANTITOXOID (ELISA)

Facility

$35.00

Service Code	CPT 86317
Hospital Charge Code	900911755
Hospital Revenue Code	302
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$28.00
Rate for Payer: Cash Price	$15.75
Rate for Payer: Cigna of CA HMO/PPO	$28.00
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.25

HC SOM DNA EXTRACTION

Facility

$203.61

Service Code	CPT 81401 90
Hospital Charge Code	900910721
Hospital Revenue Code	301
Min. Negotiated Rate	$111.99
Max. Negotiated Rate	$152.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$122.17
Rate for Payer: Aetna of CA Government/Medicare	$122.17
Rate for Payer: Cash Price	$91.62
Rate for Payer: Health Smart Auto/Commercial	$122.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$122.17
Rate for Payer: LLUH Dept of Risk Management WC	$111.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$152.71

Know your out-of-pocket cost for care.

All Charges