Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM FLURAZEPAM (DALMANE) LEVEL

Facility

$25.00

Service Code	CPT 80346 90
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

HC SOM FLURAZEPAM (DALMANE) LEVEL

Facility

$25.00

Service Code	CPT G0480
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

HC SOM FLURAZEPAM (DALMANE) LEVEL

Facility

$25.00

Service Code	CPT G0480
Hospital Charge Code	900911084
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM FLURAZEPAM (DALMANE) LEVEL

Facility

$25.00

Service Code	CPT 80346 90
Hospital Charge Code	900911084
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

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	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM FMIS 83520

Facility

$177.73

Service Code	CPT 83520 90
Hospital Charge Code	900914924
Hospital Revenue Code	301
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$142.18
Rate for Payer: Cash Price	$79.98
Rate for Payer: Cigna of CA HMO/PPO	$142.18
Rate for Payer: Health Smart Auto/Commercial	$106.64
Rate for Payer: LLUH Dept of Risk Management WC	$97.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$133.30

HC SOM FMIS 83520

Facility

$177.73

Service Code	CPT 83520
Hospital Charge Code	900914924
Hospital Revenue Code	301
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$142.18
Rate for Payer: Cash Price	$79.98
Rate for Payer: Cigna of CA HMO/PPO	$142.18
Rate for Payer: Health Smart Auto/Commercial	$106.64
Rate for Payer: LLUH Dept of Risk Management WC	$97.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$133.30

HC SOM FMIS 83520

Facility

$177.73

Service Code	CPT 83520
Hospital Charge Code	900914924
Hospital Revenue Code	301
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$133.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$106.64
Rate for Payer: Aetna of CA Government/Medicare	$106.64
Rate for Payer: Cash Price	$79.98
Rate for Payer: Health Smart Auto/Commercial	$106.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$106.64
Rate for Payer: LLUH Dept of Risk Management WC	$97.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$133.30

HC SOM FMIS 83520

Facility

$177.73

Service Code	CPT 83520 90
Hospital Charge Code	900914924
Hospital Revenue Code	301
Min. Negotiated Rate	$97.75
Max. Negotiated Rate	$133.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$106.64
Rate for Payer: Aetna of CA Government/Medicare	$106.64
Rate for Payer: Cash Price	$79.98
Rate for Payer: Health Smart Auto/Commercial	$106.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$106.64
Rate for Payer: LLUH Dept of Risk Management WC	$97.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$133.30

HC SOM FNTSM

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914870
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Cigna of CA HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM

Facility

$175.00

Service Code	CPT 82542 90
Hospital Charge Code	900914870
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Cigna of CA HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914870
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$131.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM

Facility

$175.00

Service Code	CPT 82542 90
Hospital Charge Code	900914870
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$131.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM 82492A

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914868
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Cigna of CA HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM 82492A

Facility

$175.00

Service Code	CPT 82542 90
Hospital Charge Code	900914868
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$131.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM 82492A

Facility

$175.00

Service Code	CPT 82542 90
Hospital Charge Code	900914868
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Cigna of CA HMO/PPO	$140.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM 82492A

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914868
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$131.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM 82492B

Facility

$175.00

Service Code	CPT 82542 90
Hospital Charge Code	900914869
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$131.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM 82492B

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914869
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Cigna of CA HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM 82492B

Facility

$175.00

Service Code	CPT 82542 90
Hospital Charge Code	900914869
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Cigna of CA HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FNTSM 82492B

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914869
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$131.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM FOLATE, RBC

Facility

$52.50

Service Code	CPT 82747
Hospital Charge Code	900913862
Hospital Revenue Code	301
Min. Negotiated Rate	$28.88
Max. Negotiated Rate	$39.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.50
Rate for Payer: Aetna of CA Government/Medicare	$31.50
Rate for Payer: Cash Price	$23.63
Rate for Payer: Health Smart Auto/Commercial	$31.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.50
Rate for Payer: LLUH Dept of Risk Management WC	$28.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.38

HC SOM FOLATE, RBC

Facility

$52.50

Service Code	CPT 82747
Hospital Charge Code	900913862
Hospital Revenue Code	301
Min. Negotiated Rate	$28.88
Max. Negotiated Rate	$42.00
Rate for Payer: Cash Price	$23.63
Rate for Payer: Cigna of CA HMO/PPO	$42.00
Rate for Payer: Health Smart Auto/Commercial	$31.50
Rate for Payer: LLUH Dept of Risk Management WC	$28.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.38

HC SOM FOLATE, RBC

Facility

$52.50

Service Code	CPT 82747 90
Hospital Charge Code	900913862
Hospital Revenue Code	301
Min. Negotiated Rate	$28.88
Max. Negotiated Rate	$39.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.50
Rate for Payer: Aetna of CA Government/Medicare	$31.50
Rate for Payer: Cash Price	$23.63
Rate for Payer: Health Smart Auto/Commercial	$31.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.50
Rate for Payer: LLUH Dept of Risk Management WC	$28.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.38

HC SOM FOLATE, RBC

Facility

$52.50

Service Code	CPT 82747 90
Hospital Charge Code	900913862
Hospital Revenue Code	301
Min. Negotiated Rate	$28.88
Max. Negotiated Rate	$42.00
Rate for Payer: Cash Price	$23.63
Rate for Payer: Cigna of CA HMO/PPO	$42.00
Rate for Payer: Health Smart Auto/Commercial	$31.50
Rate for Payer: LLUH Dept of Risk Management WC	$28.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$39.38

Know your out-of-pocket cost for care.

All Charges