Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM FLEXERIL

Facility

$69.50

Service Code	CPT 80369 90
Hospital Charge Code	900911448
Hospital Revenue Code	301
Min. Negotiated Rate	$38.22
Max. Negotiated Rate	$55.60
Rate for Payer: Cash Price	$31.28
Rate for Payer: Cigna of CA HMO/PPO	$55.60
Rate for Payer: Health Smart Auto/Commercial	$41.70
Rate for Payer: LLUH Dept of Risk Management WC	$38.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.12

HC SOM FLEXERIL

Facility

$69.50

Service Code	CPT 80369 90
Hospital Charge Code	900911448
Hospital Revenue Code	301
Min. Negotiated Rate	$38.22
Max. Negotiated Rate	$52.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.70
Rate for Payer: Aetna of CA Government/Medicare	$41.70
Rate for Payer: Cash Price	$31.28
Rate for Payer: Health Smart Auto/Commercial	$41.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.70
Rate for Payer: LLUH Dept of Risk Management WC	$38.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.12

HC SOM FLEXERIL

Facility

$69.50

Service Code	CPT 80369
Hospital Charge Code	900911448
Hospital Revenue Code	301
Min. Negotiated Rate	$38.22
Max. Negotiated Rate	$52.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.70
Rate for Payer: Aetna of CA Government/Medicare	$41.70
Rate for Payer: Cash Price	$31.28
Rate for Payer: Health Smart Auto/Commercial	$41.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.70
Rate for Payer: LLUH Dept of Risk Management WC	$38.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.12

HC SOM FLEXERIL

Facility

$69.50

Service Code	CPT 80369
Hospital Charge Code	900911448
Hospital Revenue Code	301
Min. Negotiated Rate	$38.22
Max. Negotiated Rate	$55.60
Rate for Payer: Cash Price	$31.28
Rate for Payer: Cigna of CA HMO/PPO	$55.60
Rate for Payer: Health Smart Auto/Commercial	$41.70
Rate for Payer: LLUH Dept of Risk Management WC	$38.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.12

HC SOM FLT3 D835 INTERP

Facility

$162.50

Service Code	CPT 87077 90
Hospital Charge Code	900914513
Hospital Revenue Code	300
Min. Negotiated Rate	$89.38
Max. Negotiated Rate	$121.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$97.50
Rate for Payer: Aetna of CA Government/Medicare	$97.50
Rate for Payer: Cash Price	$73.13
Rate for Payer: Health Smart Auto/Commercial	$97.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$97.50
Rate for Payer: LLUH Dept of Risk Management WC	$89.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.88

HC SOM FLT3 D835 INTERP

Facility

$162.50

Service Code	CPT 87077
Hospital Charge Code	900914513
Hospital Revenue Code	309
Min. Negotiated Rate	$89.38
Max. Negotiated Rate	$130.00
Rate for Payer: Cash Price	$73.13
Rate for Payer: Cigna of CA HMO/PPO	$130.00
Rate for Payer: Health Smart Auto/Commercial	$97.50
Rate for Payer: LLUH Dept of Risk Management WC	$89.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.88

HC SOM FLT3 D835 INTERP

Facility

$162.50

Service Code	CPT 87077 90
Hospital Charge Code	900914513
Hospital Revenue Code	300
Min. Negotiated Rate	$89.38
Max. Negotiated Rate	$130.00
Rate for Payer: Cash Price	$73.13
Rate for Payer: Cigna of CA HMO/PPO	$130.00
Rate for Payer: Health Smart Auto/Commercial	$97.50
Rate for Payer: LLUH Dept of Risk Management WC	$89.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.88

HC SOM FLT3 D835 INTERP

Facility

$162.50

Service Code	CPT 87077
Hospital Charge Code	900914513
Hospital Revenue Code	309
Min. Negotiated Rate	$89.38
Max. Negotiated Rate	$121.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$97.50
Rate for Payer: Aetna of CA Government/Medicare	$97.50
Rate for Payer: Cash Price	$73.13
Rate for Payer: Health Smart Auto/Commercial	$97.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$97.50
Rate for Payer: LLUH Dept of Risk Management WC	$89.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.88

HC SOM FLT 3 & D835 VARIANT DET

Facility

$165.00

Service Code	CPT 81245 90
Hospital Charge Code	900912984
Hospital Revenue Code	300
Min. Negotiated Rate	$90.75
Max. Negotiated Rate	$132.00
Rate for Payer: Cash Price	$74.25
Rate for Payer: Cigna of CA HMO/PPO	$132.00
Rate for Payer: Health Smart Auto/Commercial	$99.00
Rate for Payer: LLUH Dept of Risk Management WC	$90.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$123.75

HC SOM FLT 3 & D835 VARIANT DET

Facility

$165.00

Service Code	CPT 81245
Hospital Charge Code	900912984
Hospital Revenue Code	309
Min. Negotiated Rate	$90.75
Max. Negotiated Rate	$123.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$99.00
Rate for Payer: Aetna of CA Government/Medicare	$99.00
Rate for Payer: Cash Price	$74.25
Rate for Payer: Health Smart Auto/Commercial	$99.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$99.00
Rate for Payer: LLUH Dept of Risk Management WC	$90.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$123.75

HC SOM FLT 3 & D835 VARIANT DET

Facility

$165.00

Service Code	CPT 81245 90
Hospital Charge Code	900912984
Hospital Revenue Code	300
Min. Negotiated Rate	$90.75
Max. Negotiated Rate	$123.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$99.00
Rate for Payer: Aetna of CA Government/Medicare	$99.00
Rate for Payer: Cash Price	$74.25
Rate for Payer: Health Smart Auto/Commercial	$99.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$99.00
Rate for Payer: LLUH Dept of Risk Management WC	$90.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$123.75

HC SOM FLT 3 & D835 VARIANT DET

Facility

$165.00

Service Code	CPT 81245
Hospital Charge Code	900912984
Hospital Revenue Code	309
Min. Negotiated Rate	$90.75
Max. Negotiated Rate	$132.00
Rate for Payer: Cash Price	$74.25
Rate for Payer: Cigna of CA HMO/PPO	$132.00
Rate for Payer: Health Smart Auto/Commercial	$99.00
Rate for Payer: LLUH Dept of Risk Management WC	$90.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$123.75

HC SOM FLUORIDE BLOOD

Facility

$247.70

Service Code	CPT 82735 90
Hospital Charge Code	900911276
Hospital Revenue Code	301
Min. Negotiated Rate	$136.24
Max. Negotiated Rate	$185.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$148.62
Rate for Payer: Aetna of CA Government/Medicare	$148.62
Rate for Payer: Cash Price	$111.47
Rate for Payer: Health Smart Auto/Commercial	$148.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$148.62
Rate for Payer: LLUH Dept of Risk Management WC	$136.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$185.78

HC SOM FLUORIDE BLOOD

Facility

$247.70

Service Code	CPT 82735
Hospital Charge Code	900911276
Hospital Revenue Code	301
Min. Negotiated Rate	$136.24
Max. Negotiated Rate	$198.16
Rate for Payer: Cash Price	$111.47
Rate for Payer: Cigna of CA HMO/PPO	$198.16
Rate for Payer: Health Smart Auto/Commercial	$148.62
Rate for Payer: LLUH Dept of Risk Management WC	$136.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$185.78

HC SOM FLUORIDE BLOOD

Facility

$247.70

Service Code	CPT 82735 90
Hospital Charge Code	900911276
Hospital Revenue Code	301
Min. Negotiated Rate	$136.24
Max. Negotiated Rate	$198.16
Rate for Payer: Cash Price	$111.47
Rate for Payer: Cigna of CA HMO/PPO	$198.16
Rate for Payer: Health Smart Auto/Commercial	$148.62
Rate for Payer: LLUH Dept of Risk Management WC	$136.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$185.78

HC SOM FLUORIDE BLOOD

Facility

$247.70

Service Code	CPT 82735
Hospital Charge Code	900911276
Hospital Revenue Code	301
Min. Negotiated Rate	$136.24
Max. Negotiated Rate	$185.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$148.62
Rate for Payer: Aetna of CA Government/Medicare	$148.62
Rate for Payer: Cash Price	$111.47
Rate for Payer: Health Smart Auto/Commercial	$148.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$148.62
Rate for Payer: LLUH Dept of Risk Management WC	$136.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$185.78

HC SOM FLUOXETINE

Facility

$55.00

Service Code	CPT 80299 90
Hospital Charge Code	900911433
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 FLUOXETINE

Facility

$55.00

Service Code	CPT 80299
Hospital Charge Code	900911433
Hospital Revenue Code	301
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$41.25
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Cash Price	$24.75
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: 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 FLUOXETINE

Facility

$55.00

Service Code	CPT 80299
Hospital Charge Code	900911433
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 FLUOXETINE

Facility

$55.00

Service Code	CPT 80299 90
Hospital Charge Code	900911433
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 FLUPHENAZINE

Facility

$85.63

Service Code	CPT 80342 90
Hospital Charge Code	900911432
Hospital Revenue Code	301
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$68.50
Rate for Payer: Cash Price	$38.53
Rate for Payer: Cigna of CA HMO/PPO	$68.50
Rate for Payer: Health Smart Auto/Commercial	$51.38
Rate for Payer: LLUH Dept of Risk Management WC	$47.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.22

HC SOM FLUPHENAZINE

Facility

$85.63

Service Code	CPT 80342
Hospital Charge Code	900911432
Hospital Revenue Code	301
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$64.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.38
Rate for Payer: Aetna of CA Government/Medicare	$51.38
Rate for Payer: Cash Price	$38.53
Rate for Payer: Health Smart Auto/Commercial	$51.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.38
Rate for Payer: LLUH Dept of Risk Management WC	$47.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.22

HC SOM FLUPHENAZINE

Facility

$85.63

Service Code	CPT 80342
Hospital Charge Code	900911432
Hospital Revenue Code	301
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$68.50
Rate for Payer: Cash Price	$38.53
Rate for Payer: Cigna of CA HMO/PPO	$68.50
Rate for Payer: Health Smart Auto/Commercial	$51.38
Rate for Payer: LLUH Dept of Risk Management WC	$47.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.22

HC SOM FLUPHENAZINE

Facility

$85.63

Service Code	CPT 80342 90
Hospital Charge Code	900911432
Hospital Revenue Code	301
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$64.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.38
Rate for Payer: Aetna of CA Government/Medicare	$51.38
Rate for Payer: Cash Price	$38.53
Rate for Payer: Health Smart Auto/Commercial	$51.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.38
Rate for Payer: LLUH Dept of Risk Management WC	$47.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$64.22

HC SOM FLURAZEPAM (DALMANE) LEVEL

Facility

$25.00

Service Code	CPT 80346
Hospital Charge Code	900911084
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna of CA HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

Know your out-of-pocket cost for care.

All Charges