Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$108.80
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna of CA HMO/PPO	$108.80
Rate for Payer: Health Smart Auto/Commercial	$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	$108.80
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna of CA HMO/PPO	$108.80
Rate for Payer: Health Smart Auto/Commercial	$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 FHBG 87912

Facility

$375.00

Service Code	CPT 87912
Hospital Charge Code	900914883
Hospital Revenue Code	306
Min. Negotiated Rate	$206.25
Max. Negotiated Rate	$300.00
Rate for Payer: Cash Price	$168.75
Rate for Payer: Cigna of CA HMO/PPO	$300.00
Rate for Payer: Health Smart Auto/Commercial	$225.00
Rate for Payer: LLUH Dept of Risk Management WC	$206.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$281.25

HC SOM FHBG 87912

Facility

$375.00

Service Code	CPT 87912
Hospital Charge Code	900914883
Hospital Revenue Code	306
Min. Negotiated Rate	$206.25
Max. Negotiated Rate	$281.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$225.00
Rate for Payer: Aetna of CA Government/Medicare	$225.00
Rate for Payer: Cash Price	$168.75
Rate for Payer: Health Smart Auto/Commercial	$225.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$225.00
Rate for Payer: LLUH Dept of Risk Management WC	$206.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$281.25

HC SOM FHBG 87912

Facility

$375.00

Service Code	CPT 87912 90
Hospital Charge Code	900914883
Hospital Revenue Code	306
Min. Negotiated Rate	$206.25
Max. Negotiated Rate	$300.00
Rate for Payer: Cash Price	$168.75
Rate for Payer: Cigna of CA HMO/PPO	$300.00
Rate for Payer: Health Smart Auto/Commercial	$225.00
Rate for Payer: LLUH Dept of Risk Management WC	$206.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$281.25

HC SOM FHBG 87912

Facility

$375.00

Service Code	CPT 87912 90
Hospital Charge Code	900914883
Hospital Revenue Code	306
Min. Negotiated Rate	$206.25
Max. Negotiated Rate	$281.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$225.00
Rate for Payer: Aetna of CA Government/Medicare	$225.00
Rate for Payer: Cash Price	$168.75
Rate for Payer: Health Smart Auto/Commercial	$225.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$225.00
Rate for Payer: LLUH Dept of Risk Management WC	$206.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$281.25

HC SOM FIAIA 82397

Facility

$186.25

Service Code	CPT 82397 90
Hospital Charge Code	900915258
Hospital Revenue Code	301
Min. Negotiated Rate	$102.44
Max. Negotiated Rate	$139.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$111.75
Rate for Payer: Aetna of CA Government/Medicare	$111.75
Rate for Payer: Cash Price	$83.81
Rate for Payer: Health Smart Auto/Commercial	$111.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$111.75
Rate for Payer: LLUH Dept of Risk Management WC	$102.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$139.69

HC SOM FIAIA 82397

Facility

$186.25

Service Code	CPT 82397 90
Hospital Charge Code	900915258
Hospital Revenue Code	301
Min. Negotiated Rate	$102.44
Max. Negotiated Rate	$149.00
Rate for Payer: Cash Price	$83.81
Rate for Payer: Cigna of CA HMO/PPO	$149.00
Rate for Payer: Health Smart Auto/Commercial	$111.75
Rate for Payer: LLUH Dept of Risk Management WC	$102.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$139.69

HC SOM FIAIA 82397

Facility

$186.25

Service Code	CPT 82397
Hospital Charge Code	900915258
Hospital Revenue Code	301
Min. Negotiated Rate	$102.44
Max. Negotiated Rate	$149.00
Rate for Payer: Cash Price	$83.81
Rate for Payer: Cigna of CA HMO/PPO	$149.00
Rate for Payer: Health Smart Auto/Commercial	$111.75
Rate for Payer: LLUH Dept of Risk Management WC	$102.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$139.69

HC SOM FIAIA 82397

Facility

$186.25

Service Code	CPT 82397
Hospital Charge Code	900915258
Hospital Revenue Code	301
Min. Negotiated Rate	$102.44
Max. Negotiated Rate	$139.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$111.75
Rate for Payer: Aetna of CA Government/Medicare	$111.75
Rate for Payer: Cash Price	$83.81
Rate for Payer: Health Smart Auto/Commercial	$111.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$111.75
Rate for Payer: LLUH Dept of Risk Management WC	$102.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$139.69

HC SOM FIDQL 86331

Facility

$59.00

Service Code	CPT 86331 90
Hospital Charge Code	900914249
Hospital Revenue Code	302
Min. Negotiated Rate	$32.45
Max. Negotiated Rate	$44.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.40
Rate for Payer: Aetna of CA Government/Medicare	$35.40
Rate for Payer: Cash Price	$26.55
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.40
Rate for Payer: LLUH Dept of Risk Management WC	$32.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.25

HC SOM FIDQL 86331

Facility

$59.00

Service Code	CPT 86331
Hospital Charge Code	900914249
Hospital Revenue Code	302
Min. Negotiated Rate	$32.45
Max. Negotiated Rate	$44.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.40
Rate for Payer: Aetna of CA Government/Medicare	$35.40
Rate for Payer: Cash Price	$26.55
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.40
Rate for Payer: LLUH Dept of Risk Management WC	$32.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.25

HC SOM FIDQL 86331

Facility

$59.00

Service Code	CPT 86331
Hospital Charge Code	900914249
Hospital Revenue Code	302
Min. Negotiated Rate	$32.45
Max. Negotiated Rate	$47.20
Rate for Payer: Cash Price	$26.55
Rate for Payer: Cigna of CA HMO/PPO	$47.20
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: LLUH Dept of Risk Management WC	$32.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.25

HC SOM FIDQL 86331

Facility

$59.00

Service Code	CPT 86331 90
Hospital Charge Code	900914249
Hospital Revenue Code	302
Min. Negotiated Rate	$32.45
Max. Negotiated Rate	$47.20
Rate for Payer: Cash Price	$26.55
Rate for Payer: Cigna of CA HMO/PPO	$47.20
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: LLUH Dept of Risk Management WC	$32.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.25

HC SOM FISH AML LOCUS ANOMALIES

Facility

$350.00

Service Code	CPT 88291 90
Hospital Charge Code	900912611
Hospital Revenue Code	310
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$210.00
Rate for Payer: Aetna of CA Government/Medicare	$210.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$262.50

HC SOM FISH AML LOCUS ANOMALIES

Facility

$350.00

Service Code	CPT 88291
Hospital Charge Code	900912611
Hospital Revenue Code	310
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna of CA HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$262.50

HC SOM FISH AML LOCUS ANOMALIES

Facility

$350.00

Service Code	CPT 88291 90
Hospital Charge Code	900912611
Hospital Revenue Code	310
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna of CA HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$262.50

HC SOM FISH AML LOCUS ANOMALIES

Facility

$350.00

Service Code	CPT 88291
Hospital Charge Code	900912611
Hospital Revenue Code	310
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$210.00
Rate for Payer: Aetna of CA Government/Medicare	$210.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$262.50

HC SOM FISH B ALL

Facility

$170.30

Service Code	CPT 88291 90
Hospital Charge Code	900912609
Hospital Revenue Code	310
Min. Negotiated Rate	$93.66
Max. Negotiated Rate	$127.72
Rate for Payer: Health Smart Auto/Commercial	$102.18
Rate for Payer: Cash Price	$76.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$102.18
Rate for Payer: Aetna of CA Government/Medicare	$102.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$102.18
Rate for Payer: LLUH Dept of Risk Management WC	$93.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$127.72

HC SOM FISH B ALL

Facility

$170.30

Service Code	CPT 88291
Hospital Charge Code	900912609
Hospital Revenue Code	310
Min. Negotiated Rate	$93.66
Max. Negotiated Rate	$127.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$102.18
Rate for Payer: Aetna of CA Government/Medicare	$102.18
Rate for Payer: Cash Price	$76.64
Rate for Payer: Health Smart Auto/Commercial	$102.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$102.18
Rate for Payer: LLUH Dept of Risk Management WC	$93.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$127.72

HC SOM FISH B ALL

Facility

$170.30

Service Code	CPT 88291 90
Hospital Charge Code	900912609
Hospital Revenue Code	310
Min. Negotiated Rate	$93.66
Max. Negotiated Rate	$136.24
Rate for Payer: Cash Price	$76.64
Rate for Payer: Cigna of CA HMO/PPO	$136.24
Rate for Payer: Health Smart Auto/Commercial	$102.18
Rate for Payer: LLUH Dept of Risk Management WC	$93.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$127.72

HC SOM FISH B ALL

Facility

$170.30

Service Code	CPT 88291
Hospital Charge Code	900912609
Hospital Revenue Code	310
Min. Negotiated Rate	$93.66
Max. Negotiated Rate	$136.24
Rate for Payer: Cash Price	$76.64
Rate for Payer: Cigna of CA HMO/PPO	$136.24
Rate for Payer: Health Smart Auto/Commercial	$102.18
Rate for Payer: LLUH Dept of Risk Management WC	$93.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$127.72

HC SOM FISH DIGEORGE VELO-CARDIO-FACL

Facility

$200.00

Service Code	CPT 88291 90
Hospital Charge Code	900910684
Hospital Revenue Code	310
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$120.00
Rate for Payer: Aetna of CA Government/Medicare	$120.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$150.00

HC SOM FISH DIGEORGE VELO-CARDIO-FACL

Facility

$200.00

Service Code	CPT 88291
Hospital Charge Code	900910684
Hospital Revenue Code	310
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cigna of CA HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$150.00

HC SOM FISH DIGEORGE VELO-CARDIO-FACL

Facility

$200.00

Service Code	CPT 88291 90
Hospital Charge Code	900910684
Hospital Revenue Code	310
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cigna of CA HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$150.00

Know your out-of-pocket cost for care.

All Charges