Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM JC VIRUS BY PCR

Facility

$65.00

Service Code	CPT 87798 90
Hospital Charge Code	900912607
Hospital Revenue Code	306
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$48.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.00
Rate for Payer: Aetna of CA Government/Medicare	$39.00
Rate for Payer: Cash Price	$29.25
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.75

HC SOM JC VIRUS BY PCR

Facility

$65.00

Service Code	CPT 87798
Hospital Charge Code	900912607
Hospital Revenue Code	306
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$52.00
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cigna of CA HMO/PPO	$52.00
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.75

HC SOM KAPPA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521 90
Hospital Charge Code	900910385
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$11.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.45
Rate for Payer: Aetna of CA Government/Medicare	$9.45
Rate for Payer: Cash Price	$7.09
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.81

HC SOM KAPPA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521 90
Hospital Charge Code	900910385
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$12.60
Rate for Payer: Cash Price	$7.09
Rate for Payer: Cigna of CA HMO/PPO	$12.60
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.81

HC SOM KAPPA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521
Hospital Charge Code	900910385
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$12.60
Rate for Payer: Cash Price	$7.09
Rate for Payer: Cigna of CA HMO/PPO	$12.60
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.81

HC SOM KAPPA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521
Hospital Charge Code	900910385
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$11.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.45
Rate for Payer: Aetna of CA Government/Medicare	$9.45
Rate for Payer: Cash Price	$7.09
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.81

HC SOM KPNRP 87798

Facility

$157.95

Service Code	CPT 87798
Hospital Charge Code	900915274
Hospital Revenue Code	301
Min. Negotiated Rate	$86.87
Max. Negotiated Rate	$126.36
Rate for Payer: Cash Price	$71.08
Rate for Payer: Cigna of CA HMO/PPO	$126.36
Rate for Payer: Health Smart Auto/Commercial	$94.77
Rate for Payer: LLUH Dept of Risk Management WC	$86.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$118.46

HC SOM KPNRP 87798

Facility

$157.95

Service Code	CPT 87798 90
Hospital Charge Code	900915274
Hospital Revenue Code	301
Min. Negotiated Rate	$86.87
Max. Negotiated Rate	$126.36
Rate for Payer: Cash Price	$71.08
Rate for Payer: Cigna of CA HMO/PPO	$126.36
Rate for Payer: Health Smart Auto/Commercial	$94.77
Rate for Payer: LLUH Dept of Risk Management WC	$86.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$118.46

HC SOM KPNRP 87798

Facility

$157.95

Service Code	CPT 87798 90
Hospital Charge Code	900915274
Hospital Revenue Code	301
Min. Negotiated Rate	$86.87
Max. Negotiated Rate	$118.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$94.77
Rate for Payer: Aetna of CA Government/Medicare	$94.77
Rate for Payer: Cash Price	$71.08
Rate for Payer: Health Smart Auto/Commercial	$94.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$94.77
Rate for Payer: LLUH Dept of Risk Management WC	$86.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$118.46

HC SOM KPNRP 87798

Facility

$157.95

Service Code	CPT 87798
Hospital Charge Code	900915274
Hospital Revenue Code	301
Min. Negotiated Rate	$86.87
Max. Negotiated Rate	$118.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$94.77
Rate for Payer: Aetna of CA Government/Medicare	$94.77
Rate for Payer: Cash Price	$71.08
Rate for Payer: Health Smart Auto/Commercial	$94.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$94.77
Rate for Payer: LLUH Dept of Risk Management WC	$86.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$118.46

HC SOM LAMBDA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521 90
Hospital Charge Code	900910386
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$11.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.45
Rate for Payer: Aetna of CA Government/Medicare	$9.45
Rate for Payer: Cash Price	$7.09
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.81

HC SOM LAMBDA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521
Hospital Charge Code	900910386
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$12.60
Rate for Payer: Cash Price	$7.09
Rate for Payer: Cigna of CA HMO/PPO	$12.60
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.81

HC SOM LAMBDA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521
Hospital Charge Code	900910386
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$11.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.45
Rate for Payer: Aetna of CA Government/Medicare	$9.45
Rate for Payer: Cash Price	$7.09
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.81

HC SOM LAMBDA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521 90
Hospital Charge Code	900910386
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$12.60
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: Cash Price	$7.09
Rate for Payer: Cigna of CA HMO/PPO	$12.60
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.81

HC SOM LAMICTAL (LAMOTRIGINE)

Facility

$14.32

Service Code	CPT 80175 90
Hospital Charge Code	900910411
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$10.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.59
Rate for Payer: Aetna of CA Government/Medicare	$8.59
Rate for Payer: Cash Price	$6.44
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.74

HC SOM LAMICTAL (LAMOTRIGINE)

Facility

$14.32

Service Code	CPT 80175
Hospital Charge Code	900910411
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$11.46
Rate for Payer: Cash Price	$6.44
Rate for Payer: Cigna of CA HMO/PPO	$11.46
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.74

HC SOM LAMICTAL (LAMOTRIGINE)

Facility

$14.32

Service Code	CPT 80175
Hospital Charge Code	900910411
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$10.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.59
Rate for Payer: Aetna of CA Government/Medicare	$8.59
Rate for Payer: Cash Price	$6.44
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.74

HC SOM LAMICTAL (LAMOTRIGINE)

Facility

$14.32

Service Code	CPT 80175 90
Hospital Charge Code	900910411
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$11.46
Rate for Payer: Cash Price	$6.44
Rate for Payer: Cigna of CA HMO/PPO	$11.46
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.74

HC SOM LASIX

Facility

$119.28

Service Code	CPT 80299
Hospital Charge Code	900911247
Hospital Revenue Code	301
Min. Negotiated Rate	$65.60
Max. Negotiated Rate	$95.42
Rate for Payer: Cash Price	$53.68
Rate for Payer: Cigna of CA HMO/PPO	$95.42
Rate for Payer: Health Smart Auto/Commercial	$71.57
Rate for Payer: LLUH Dept of Risk Management WC	$65.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.46

HC SOM LASIX

Facility

$119.28

Service Code	CPT 80299
Hospital Charge Code	900911247
Hospital Revenue Code	301
Min. Negotiated Rate	$65.60
Max. Negotiated Rate	$89.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.57
Rate for Payer: Aetna of CA Government/Medicare	$71.57
Rate for Payer: Cash Price	$53.68
Rate for Payer: Health Smart Auto/Commercial	$71.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.57
Rate for Payer: LLUH Dept of Risk Management WC	$65.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.46

HC SOM LASIX

Facility

$119.28

Service Code	CPT 80299 90
Hospital Charge Code	900911247
Hospital Revenue Code	301
Min. Negotiated Rate	$65.60
Max. Negotiated Rate	$89.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.57
Rate for Payer: Aetna of CA Government/Medicare	$71.57
Rate for Payer: Cash Price	$53.68
Rate for Payer: Health Smart Auto/Commercial	$71.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.57
Rate for Payer: LLUH Dept of Risk Management WC	$65.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.46

HC SOM LASIX

Facility

$119.28

Service Code	CPT 80299 90
Hospital Charge Code	900911247
Hospital Revenue Code	301
Min. Negotiated Rate	$65.60
Max. Negotiated Rate	$95.42
Rate for Payer: Cash Price	$53.68
Rate for Payer: Cigna of CA HMO/PPO	$95.42
Rate for Payer: Health Smart Auto/Commercial	$71.57
Rate for Payer: LLUH Dept of Risk Management WC	$65.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.46

HC SOM LD ACTIVITY TOTAL

Facility

$11.23

Service Code	CPT 83615 90
Hospital Charge Code	900912823
Hospital Revenue Code	301
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$8.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.74
Rate for Payer: Aetna of CA Government/Medicare	$6.74
Rate for Payer: Cash Price	$5.05
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.42

HC SOM LD ACTIVITY TOTAL

Facility

$11.23

Service Code	CPT 83615
Hospital Charge Code	900912823
Hospital Revenue Code	301
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$5.05
Rate for Payer: Cigna of CA HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.42

HC SOM LD ACTIVITY TOTAL

Facility

$11.23

Service Code	CPT 83615 90
Hospital Charge Code	900912823
Hospital Revenue Code	301
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$5.05
Rate for Payer: Cigna of CA HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.42

Know your out-of-pocket cost for care.

All Charges