Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM HYPOGLYCEMIC AGENT SCREEN

Facility

$90.00

Service Code	CPT 80377 90
Hospital Charge Code	900912528
Hospital Revenue Code	301
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna of CA HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.50

HC SOM HYPOGLYCEMIC AGENT SCREEN

Facility

$90.00

Service Code	CPT 80377
Hospital Charge Code	900912528
Hospital Revenue Code	301
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.00
Rate for Payer: Aetna of CA Government/Medicare	$54.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.50

HC SOM IA2 AB

Facility

$55.00

Service Code	CPT 86341 90
Hospital Charge Code	900914354
Hospital Revenue Code	302
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 IA2 AB

Facility

$55.00

Service Code	CPT 86341
Hospital Charge Code	900914354
Hospital Revenue Code	302
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 IA2 AB

Facility

$55.00

Service Code	CPT 86341
Hospital Charge Code	900914354
Hospital Revenue Code	302
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 IA2 AB

Facility

$55.00

Service Code	CPT 86341 90
Hospital Charge Code	900914354
Hospital Revenue Code	302
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 IGA SUBCLASSES IGA 1

Facility

$66.00

Service Code	CPT 82787 90
Hospital Charge Code	900912703
Hospital Revenue Code	301
Min. Negotiated Rate	$36.30
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.60
Rate for Payer: Aetna of CA Government/Medicare	$39.60
Rate for Payer: Cash Price	$29.70
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.50

HC SOM IGA SUBCLASSES IGA 1

Facility

$66.00

Service Code	CPT 82787
Hospital Charge Code	900912703
Hospital Revenue Code	301
Min. Negotiated Rate	$36.30
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.60
Rate for Payer: Aetna of CA Government/Medicare	$39.60
Rate for Payer: Cash Price	$29.70
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.50

HC SOM IGA SUBCLASSES IGA 1

Facility

$66.00

Service Code	CPT 82787 90
Hospital Charge Code	900912703
Hospital Revenue Code	301
Min. Negotiated Rate	$36.30
Max. Negotiated Rate	$52.80
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna of CA HMO/PPO	$52.80
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.50

HC SOM IGA SUBCLASSES IGA 1

Facility

$66.00

Service Code	CPT 82787
Hospital Charge Code	900912703
Hospital Revenue Code	301
Min. Negotiated Rate	$36.30
Max. Negotiated Rate	$52.80
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna of CA HMO/PPO	$52.80
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.50

HC SOM IGA SUBCLASSES IGA 2

Facility

$67.00

Service Code	CPT 82787 90
Hospital Charge Code	900912704
Hospital Revenue Code	301
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 IGA SUBCLASSES IGA 2

Facility

$67.00

Service Code	CPT 82787 90
Hospital Charge Code	900912704
Hospital Revenue Code	301
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 IGA SUBCLASSES IGA 2

Facility

$67.00

Service Code	CPT 82787
Hospital Charge Code	900912704
Hospital Revenue Code	301
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 IGA SUBCLASSES IGA 2

Facility

$67.00

Service Code	CPT 82787
Hospital Charge Code	900912704
Hospital Revenue Code	301
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 IGA SUBCLASSES TOTAL IGA

Facility

$67.00

Service Code	CPT 82784 90
Hospital Charge Code	900912705
Hospital Revenue Code	301
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 IGA SUBCLASSES TOTAL IGA

Facility

$67.00

Service Code	CPT 82784
Hospital Charge Code	900912705
Hospital Revenue Code	301
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 IGA SUBCLASSES TOTAL IGA

Facility

$67.00

Service Code	CPT 82784
Hospital Charge Code	900912705
Hospital Revenue Code	301
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 IGA SUBCLASSES TOTAL IGA

Facility

$67.00

Service Code	CPT 82784 90
Hospital Charge Code	900912705
Hospital Revenue Code	301
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 IGF-BP3

Facility

$17.27

Service Code	CPT 83520
Hospital Charge Code	900911428
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$12.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.36
Rate for Payer: Aetna of CA Government/Medicare	$10.36
Rate for Payer: Cash Price	$7.77
Rate for Payer: Health Smart Auto/Commercial	$10.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.36
Rate for Payer: LLUH Dept of Risk Management WC	$9.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.95

HC SOM IGF-BP3

Facility

$17.27

Service Code	CPT 83520 90
Hospital Charge Code	900911428
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$12.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.36
Rate for Payer: Aetna of CA Government/Medicare	$10.36
Rate for Payer: Cash Price	$7.77
Rate for Payer: Health Smart Auto/Commercial	$10.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.36
Rate for Payer: LLUH Dept of Risk Management WC	$9.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.95

HC SOM IGF-BP3

Facility

$17.27

Service Code	CPT 83520 90
Hospital Charge Code	900911428
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$13.82
Rate for Payer: Cash Price	$7.77
Rate for Payer: Cigna of CA HMO/PPO	$13.82
Rate for Payer: Health Smart Auto/Commercial	$10.36
Rate for Payer: LLUH Dept of Risk Management WC	$9.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.95

HC SOM IGF-BP3

Facility

$17.27

Service Code	CPT 83520
Hospital Charge Code	900911428
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$13.82
Rate for Payer: Cash Price	$7.77
Rate for Payer: Cigna of CA HMO/PPO	$13.82
Rate for Payer: Health Smart Auto/Commercial	$10.36
Rate for Payer: LLUH Dept of Risk Management WC	$9.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.95

HC SOM IGG FRAC. TOTAL IGG

Facility

$6.00

Service Code	CPT 82784 90
Hospital Charge Code	900912808
Hospital Revenue Code	302
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

HC SOM IGG FRAC. TOTAL IGG

Facility

$6.00

Service Code	CPT 82784 90
Hospital Charge Code	900912808
Hospital Revenue Code	302
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

HC SOM IGG FRAC. TOTAL IGG

Facility

$6.00

Service Code	CPT 82784
Hospital Charge Code	900912808
Hospital Revenue Code	302
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

Know your out-of-pocket cost for care.

All Charges