Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM FBP1 88291

Facility

$71.15

Service Code	CPT 88291 90
Hospital Charge Code	900914873
Hospital Revenue Code	310
Min. Negotiated Rate	$39.13
Max. Negotiated Rate	$56.92
Rate for Payer: Cash Price	$32.02
Rate for Payer: Cigna of CA HMO/PPO	$56.92
Rate for Payer: Health Smart Auto/Commercial	$42.69
Rate for Payer: LLUH Dept of Risk Management WC	$39.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.36

HC SOM FCFQN 86171

Facility

$67.00

Service Code	CPT 86171
Hospital Charge Code	900914248
Hospital Revenue Code	302
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$50.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.20
Rate for Payer: Aetna of CA Government/Medicare	$40.20
Rate for Payer: Cash Price	$30.15
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.25

HC SOM FCFQN 86171

Facility

$67.00

Service Code	CPT 86171 90
Hospital Charge Code	900914248
Hospital Revenue Code	302
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$50.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.20
Rate for Payer: Aetna of CA Government/Medicare	$40.20
Rate for Payer: Cash Price	$30.15
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.25

HC SOM FCFQN 86171

Facility

$67.00

Service Code	CPT 86171
Hospital Charge Code	900914248
Hospital Revenue Code	302
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$53.60
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: Cash Price	$30.15
Rate for Payer: Cigna of CA HMO/PPO	$53.60
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.25

HC SOM FCFQN 86171

Facility

$67.00

Service Code	CPT 86171 90
Hospital Charge Code	900914248
Hospital Revenue Code	302
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$53.60
Rate for Payer: Cash Price	$30.15
Rate for Payer: Cigna of CA HMO/PPO	$53.60
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.25

HC SOM FDSAC 82657

Facility

$168.92

Service Code	CPT 82657 90
Hospital Charge Code	900914885
Hospital Revenue Code	301
Min. Negotiated Rate	$92.91
Max. Negotiated Rate	$135.14
Rate for Payer: Cash Price	$76.01
Rate for Payer: Cigna of CA HMO/PPO	$135.14
Rate for Payer: Health Smart Auto/Commercial	$101.35
Rate for Payer: LLUH Dept of Risk Management WC	$92.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$126.69

HC SOM FDSAC 82657

Facility

$168.92

Service Code	CPT 82657 90
Hospital Charge Code	900914885
Hospital Revenue Code	301
Min. Negotiated Rate	$92.91
Max. Negotiated Rate	$126.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$101.35
Rate for Payer: Aetna of CA Government/Medicare	$101.35
Rate for Payer: Cash Price	$76.01
Rate for Payer: Health Smart Auto/Commercial	$101.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$101.35
Rate for Payer: LLUH Dept of Risk Management WC	$92.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$126.69

HC SOM FDSAC 82657

Facility

$168.92

Service Code	CPT 82657
Hospital Charge Code	900914885
Hospital Revenue Code	301
Min. Negotiated Rate	$92.91
Max. Negotiated Rate	$126.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$101.35
Rate for Payer: Aetna of CA Government/Medicare	$101.35
Rate for Payer: Cash Price	$76.01
Rate for Payer: Health Smart Auto/Commercial	$101.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$101.35
Rate for Payer: LLUH Dept of Risk Management WC	$92.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$126.69

HC SOM FDSAC 82657

Facility

$168.92

Service Code	CPT 82657
Hospital Charge Code	900914885
Hospital Revenue Code	301
Min. Negotiated Rate	$92.91
Max. Negotiated Rate	$135.14
Rate for Payer: Cash Price	$76.01
Rate for Payer: Cigna of CA HMO/PPO	$135.14
Rate for Payer: Health Smart Auto/Commercial	$101.35
Rate for Payer: LLUH Dept of Risk Management WC	$92.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$126.69

HC SOM FEAGR 86682

Facility

$52.57

Service Code	CPT 86682 90
Hospital Charge Code	900914927
Hospital Revenue Code	302
Min. Negotiated Rate	$28.91
Max. Negotiated Rate	$39.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.54
Rate for Payer: Aetna of CA Government/Medicare	$31.54
Rate for Payer: Cash Price	$23.66
Rate for Payer: Health Smart Auto/Commercial	$31.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.54
Rate for Payer: LLUH Dept of Risk Management WC	$28.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.43

HC SOM FEAGR 86682

Facility

$52.57

Service Code	CPT 86682
Hospital Charge Code	900914927
Hospital Revenue Code	302
Min. Negotiated Rate	$28.91
Max. Negotiated Rate	$42.06
Rate for Payer: Cash Price	$23.66
Rate for Payer: Cigna of CA HMO/PPO	$42.06
Rate for Payer: Health Smart Auto/Commercial	$31.54
Rate for Payer: LLUH Dept of Risk Management WC	$28.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.43

HC SOM FEAGR 86682

Facility

$52.57

Service Code	CPT 86682
Hospital Charge Code	900914927
Hospital Revenue Code	302
Min. Negotiated Rate	$28.91
Max. Negotiated Rate	$39.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.54
Rate for Payer: Aetna of CA Government/Medicare	$31.54
Rate for Payer: Cash Price	$23.66
Rate for Payer: Health Smart Auto/Commercial	$31.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.54
Rate for Payer: LLUH Dept of Risk Management WC	$28.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.43

HC SOM FEAGR 86682

Facility

$52.57

Service Code	CPT 86682 90
Hospital Charge Code	900914927
Hospital Revenue Code	302
Min. Negotiated Rate	$28.91
Max. Negotiated Rate	$42.06
Rate for Payer: Cash Price	$23.66
Rate for Payer: Cigna of CA HMO/PPO	$42.06
Rate for Payer: Health Smart Auto/Commercial	$31.54
Rate for Payer: LLUH Dept of Risk Management WC	$28.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.43

HC SOM FELBAMATE S

Facility

$21.17

Service Code	CPT 80167 90
Hospital Charge Code	900914198
Hospital Revenue Code	301
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$16.94
Rate for Payer: Cash Price	$9.53
Rate for Payer: Cigna of CA HMO/PPO	$16.94
Rate for Payer: Health Smart Auto/Commercial	$12.70
Rate for Payer: LLUH Dept of Risk Management WC	$11.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.88

HC SOM FELBAMATE S

Facility

$21.17

Service Code	CPT 80167
Hospital Charge Code	900914198
Hospital Revenue Code	301
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$16.94
Rate for Payer: Cash Price	$9.53
Rate for Payer: Cigna of CA HMO/PPO	$16.94
Rate for Payer: Health Smart Auto/Commercial	$12.70
Rate for Payer: LLUH Dept of Risk Management WC	$11.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.88

HC SOM FELBAMATE S

Facility

$21.17

Service Code	CPT 80167 90
Hospital Charge Code	900914198
Hospital Revenue Code	301
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$15.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.70
Rate for Payer: Aetna of CA Government/Medicare	$12.70
Rate for Payer: Cash Price	$9.53
Rate for Payer: Health Smart Auto/Commercial	$12.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.70
Rate for Payer: LLUH Dept of Risk Management WC	$11.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.88

HC SOM FELBAMATE S

Facility

$21.17

Service Code	CPT 80167
Hospital Charge Code	900914198
Hospital Revenue Code	301
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$15.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.70
Rate for Payer: Aetna of CA Government/Medicare	$12.70
Rate for Payer: Cash Price	$9.53
Rate for Payer: Health Smart Auto/Commercial	$12.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.70
Rate for Payer: LLUH Dept of Risk Management WC	$11.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.88

HC SOM FENTU

Facility

$45.00

Service Code	CPT 80354
Hospital Charge Code	900915270
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 FENTU

Facility

$45.00

Service Code	CPT G0480 90
Hospital Charge Code	900915270
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 FENTU

Facility

$45.00

Service Code	CPT 80354
Hospital Charge Code	900915270
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 FENTU

Facility

$45.00

Service Code	CPT G0480
Hospital Charge Code	900915270
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 FENTU

Facility

$45.00

Service Code	CPT G0480 90
Hospital Charge Code	900915270
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 FENTU

Facility

$45.00

Service Code	CPT G0480
Hospital Charge Code	900915270
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 FESC 83789

Facility

$136.00

Service Code	CPT 83789 90
Hospital Charge Code	900914814
Hospital Revenue Code	300
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$81.60
Rate for Payer: Aetna of CA Government/Medicare	$81.60
Rate for Payer: Cash Price	$61.20
Rate for Payer: Health Smart Auto/Commercial	$81.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$81.60
Rate for Payer: LLUH Dept of Risk Management WC	$74.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$102.00

HC SOM FESC 83789

Facility

$136.00

Service Code	CPT 83789
Hospital Charge Code	900914814
Hospital Revenue Code	301
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$81.60
Rate for Payer: Aetna of CA Government/Medicare	$81.60
Rate for Payer: Cash Price	$61.20
Rate for Payer: Health Smart Auto/Commercial	$81.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$81.60
Rate for Payer: LLUH Dept of Risk Management WC	$74.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$102.00

Know your out-of-pocket cost for care.

All Charges