Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM ESTRIOL

Facility

$202.56

Service Code	CPT 82677
Hospital Charge Code	900911036
Hospital Revenue Code	301
Min. Negotiated Rate	$111.41
Max. Negotiated Rate	$162.05
Rate for Payer: Cash Price	$91.15
Rate for Payer: Cigna of CA HMO/PPO	$162.05
Rate for Payer: Health Smart Auto/Commercial	$121.54
Rate for Payer: LLUH Dept of Risk Management WC	$111.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$151.92

HC SOM ESTRONE

Facility

$20.00

Service Code	CPT 82679
Hospital Charge Code	900911482
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 ESTRONE

Facility

$20.00

Service Code	CPT 82679 90
Hospital Charge Code	900911482
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 ESTRONE

Facility

$20.00

Service Code	CPT 82679
Hospital Charge Code	900911482
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 ESTRONE

Facility

$20.00

Service Code	CPT 82679 90
Hospital Charge Code	900911482
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 ETHANOL, U

Facility

$49.90

Service Code	CPT G0480 90
Hospital Charge Code	900912919
Hospital Revenue Code	301
Min. Negotiated Rate	$27.44
Max. Negotiated Rate	$39.92
Rate for Payer: Cash Price	$22.46
Rate for Payer: Cigna of CA HMO/PPO	$39.92
Rate for Payer: Health Smart Auto/Commercial	$29.94
Rate for Payer: LLUH Dept of Risk Management WC	$27.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.42

HC SOM ETHANOL, U

Facility

$49.90

Service Code	CPT G0480 90
Hospital Charge Code	900912919
Hospital Revenue Code	301
Min. Negotiated Rate	$27.44
Max. Negotiated Rate	$37.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.94
Rate for Payer: Aetna of CA Government/Medicare	$29.94
Rate for Payer: Cash Price	$22.46
Rate for Payer: Health Smart Auto/Commercial	$29.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.94
Rate for Payer: LLUH Dept of Risk Management WC	$27.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.42

HC SOM ETHANOL, U

Facility

$49.90

Service Code	CPT 80320
Hospital Charge Code	900912919
Hospital Revenue Code	301
Min. Negotiated Rate	$27.44
Max. Negotiated Rate	$37.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.94
Rate for Payer: Aetna of CA Government/Medicare	$29.94
Rate for Payer: Cash Price	$22.46
Rate for Payer: Health Smart Auto/Commercial	$29.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.94
Rate for Payer: LLUH Dept of Risk Management WC	$27.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.42

HC SOM ETHANOL, U

Facility

$49.90

Service Code	CPT G0480
Hospital Charge Code	900912919
Hospital Revenue Code	301
Min. Negotiated Rate	$27.44
Max. Negotiated Rate	$37.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.94
Rate for Payer: Aetna of CA Government/Medicare	$29.94
Rate for Payer: Cash Price	$22.46
Rate for Payer: Health Smart Auto/Commercial	$29.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.94
Rate for Payer: LLUH Dept of Risk Management WC	$27.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.42

HC SOM ETHANOL, U

Facility

$49.90

Service Code	CPT G0480
Hospital Charge Code	900912919
Hospital Revenue Code	301
Min. Negotiated Rate	$27.44
Max. Negotiated Rate	$39.92
Rate for Payer: Cash Price	$22.46
Rate for Payer: Cigna of CA HMO/PPO	$39.92
Rate for Payer: Health Smart Auto/Commercial	$29.94
Rate for Payer: LLUH Dept of Risk Management WC	$27.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.42

HC SOM ETHANOL, U

Facility

$49.90

Service Code	CPT 80320
Hospital Charge Code	900912919
Hospital Revenue Code	301
Min. Negotiated Rate	$27.44
Max. Negotiated Rate	$39.92
Rate for Payer: Cash Price	$22.46
Rate for Payer: Cigna of CA HMO/PPO	$39.92
Rate for Payer: Health Smart Auto/Commercial	$29.94
Rate for Payer: LLUH Dept of Risk Management WC	$27.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.42

HC SOM ETHCHLORVINYL (PLACIDYL)

Facility

$45.00

Service Code	CPT 80307
Hospital Charge Code	900910427
Hospital Revenue Code	301
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 ETHCHLORVINYL (PLACIDYL)

Facility

$45.00

Service Code	CPT 80307 90
Hospital Charge Code	900910427
Hospital Revenue Code	301
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 ETHCHLORVINYL (PLACIDYL)

Facility

$45.00

Service Code	CPT 80307 90
Hospital Charge Code	900910427
Hospital Revenue Code	301
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 ETHCHLORVINYL (PLACIDYL)

Facility

$45.00

Service Code	CPT 80307
Hospital Charge Code	900910427
Hospital Revenue Code	301
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 ETHOSUXIMIDE (ZARONTIN)

Facility

$35.00

Service Code	CPT 80168
Hospital Charge Code	900910338
Hospital Revenue Code	301
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 ETHOSUXIMIDE (ZARONTIN)

Facility

$35.00

Service Code	CPT 80168 90
Hospital Charge Code	900910338
Hospital Revenue Code	301
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 ETHOSUXIMIDE (ZARONTIN)

Facility

$35.00

Service Code	CPT 80168 90
Hospital Charge Code	900910338
Hospital Revenue Code	301
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 ETHOSUXIMIDE (ZARONTIN)

Facility

$35.00

Service Code	CPT 80168
Hospital Charge Code	900910338
Hospital Revenue Code	301
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 EVEROLIMUS B

Facility

$41.42

Service Code	CPT 80169
Hospital Charge Code	900913810
Hospital Revenue Code	301
Min. Negotiated Rate	$22.78
Max. Negotiated Rate	$33.14
Rate for Payer: Cash Price	$18.64
Rate for Payer: Cigna of CA HMO/PPO	$33.14
Rate for Payer: Health Smart Auto/Commercial	$24.85
Rate for Payer: LLUH Dept of Risk Management WC	$22.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.06

HC SOM EVEROLIMUS B

Facility

$41.42

Service Code	CPT 80169 90
Hospital Charge Code	900913810
Hospital Revenue Code	301
Min. Negotiated Rate	$22.78
Max. Negotiated Rate	$33.14
Rate for Payer: Cash Price	$18.64
Rate for Payer: Cigna of CA HMO/PPO	$33.14
Rate for Payer: Health Smart Auto/Commercial	$24.85
Rate for Payer: LLUH Dept of Risk Management WC	$22.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.06

HC SOM EVEROLIMUS B

Facility

$41.42

Service Code	CPT 80169
Hospital Charge Code	900913810
Hospital Revenue Code	301
Min. Negotiated Rate	$22.78
Max. Negotiated Rate	$31.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.85
Rate for Payer: Aetna of CA Government/Medicare	$24.85
Rate for Payer: Cash Price	$18.64
Rate for Payer: Health Smart Auto/Commercial	$24.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.85
Rate for Payer: LLUH Dept of Risk Management WC	$22.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.06

HC SOM EVEROLIMUS B

Facility

$41.42

Service Code	CPT 80169 90
Hospital Charge Code	900913810
Hospital Revenue Code	301
Min. Negotiated Rate	$22.78
Max. Negotiated Rate	$31.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.85
Rate for Payer: Aetna of CA Government/Medicare	$24.85
Rate for Payer: Cash Price	$18.64
Rate for Payer: Health Smart Auto/Commercial	$24.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.85
Rate for Payer: LLUH Dept of Risk Management WC	$22.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$31.06

HC SOM FANBF 86038

Facility

$75.00

Service Code	CPT 86038
Hospital Charge Code	900914925
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$56.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM FANBF 86038

Facility

$75.00

Service Code	CPT 86038 90
Hospital Charge Code	900914925
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$56.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

Know your out-of-pocket cost for care.

All Charges