Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM NICOTINE

Facility

$20.35

Service Code	CPT 80323
Hospital Charge Code	900910769
Hospital Revenue Code	301
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$15.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.21
Rate for Payer: Aetna of CA Government/Medicare	$12.21
Rate for Payer: Cash Price	$9.16
Rate for Payer: Health Smart Auto/Commercial	$12.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.21
Rate for Payer: LLUH Dept of Risk Management WC	$11.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.26

HC SOM NICOTINE

Facility

$20.35

Service Code	CPT 80323
Hospital Charge Code	900910769
Hospital Revenue Code	301
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$16.28
Rate for Payer: Cash Price	$9.16
Rate for Payer: Cigna of CA HMO/PPO	$16.28
Rate for Payer: Health Smart Auto/Commercial	$12.21
Rate for Payer: LLUH Dept of Risk Management WC	$11.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.26

HC SOM NICOTINE

Facility

$20.35

Service Code	CPT G0480 90
Hospital Charge Code	900910769
Hospital Revenue Code	301
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$15.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.21
Rate for Payer: Aetna of CA Government/Medicare	$12.21
Rate for Payer: Cash Price	$9.16
Rate for Payer: Health Smart Auto/Commercial	$12.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.21
Rate for Payer: LLUH Dept of Risk Management WC	$11.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.26

HC SOM NITROGEN STOOL

Facility

$388.30

Service Code	CPT 84999 90
Hospital Charge Code	900911229
Hospital Revenue Code	301
Min. Negotiated Rate	$213.56
Max. Negotiated Rate	$310.64
Rate for Payer: Cash Price	$174.74
Rate for Payer: Cigna of CA HMO/PPO	$310.64
Rate for Payer: Health Smart Auto/Commercial	$232.98
Rate for Payer: LLUH Dept of Risk Management WC	$213.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$291.22

HC SOM NITROGEN STOOL

Facility

$388.30

Service Code	CPT 84999
Hospital Charge Code	900911229
Hospital Revenue Code	301
Min. Negotiated Rate	$213.56
Max. Negotiated Rate	$310.64
Rate for Payer: Cash Price	$174.74
Rate for Payer: Cigna of CA HMO/PPO	$310.64
Rate for Payer: Health Smart Auto/Commercial	$232.98
Rate for Payer: LLUH Dept of Risk Management WC	$213.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$291.22

HC SOM NITROGEN STOOL

Facility

$388.30

Service Code	CPT 84999 90
Hospital Charge Code	900911229
Hospital Revenue Code	301
Min. Negotiated Rate	$213.56
Max. Negotiated Rate	$291.22
Rate for Payer: Health Smart Auto/Commercial	$232.98
Rate for Payer: Cash Price	$174.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$232.98
Rate for Payer: Aetna of CA Government/Medicare	$232.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$232.98
Rate for Payer: LLUH Dept of Risk Management WC	$213.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$291.22

HC SOM NITROGEN STOOL

Facility

$388.30

Service Code	CPT 84999
Hospital Charge Code	900911229
Hospital Revenue Code	301
Min. Negotiated Rate	$213.56
Max. Negotiated Rate	$291.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$232.98
Rate for Payer: Aetna of CA Government/Medicare	$232.98
Rate for Payer: Cash Price	$174.74
Rate for Payer: Health Smart Auto/Commercial	$232.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$232.98
Rate for Payer: LLUH Dept of Risk Management WC	$213.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$291.22

HC SOM NMHIN 83789

Facility

$162.45

Service Code	CPT 83789 90
Hospital Charge Code	900914806
Hospital Revenue Code	300
Min. Negotiated Rate	$89.35
Max. Negotiated Rate	$129.96
Rate for Payer: Cash Price	$73.10
Rate for Payer: Cigna of CA HMO/PPO	$129.96
Rate for Payer: Health Smart Auto/Commercial	$97.47
Rate for Payer: LLUH Dept of Risk Management WC	$89.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.84

HC SOM NMHIN 83789

Facility

$162.45

Service Code	CPT 83789
Hospital Charge Code	900914806
Hospital Revenue Code	301
Min. Negotiated Rate	$89.35
Max. Negotiated Rate	$129.96
Rate for Payer: Cash Price	$73.10
Rate for Payer: Cigna of CA HMO/PPO	$129.96
Rate for Payer: Health Smart Auto/Commercial	$97.47
Rate for Payer: LLUH Dept of Risk Management WC	$89.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.84

HC SOM NMHIN 83789

Facility

$162.45

Service Code	CPT 83789
Hospital Charge Code	900914806
Hospital Revenue Code	301
Min. Negotiated Rate	$89.35
Max. Negotiated Rate	$121.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$97.47
Rate for Payer: Aetna of CA Government/Medicare	$97.47
Rate for Payer: Cash Price	$73.10
Rate for Payer: Health Smart Auto/Commercial	$97.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$97.47
Rate for Payer: LLUH Dept of Risk Management WC	$89.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.84

HC SOM NMHIN 83789

Facility

$162.45

Service Code	CPT 83789 90
Hospital Charge Code	900914806
Hospital Revenue Code	300
Min. Negotiated Rate	$89.35
Max. Negotiated Rate	$121.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$97.47
Rate for Payer: Aetna of CA Government/Medicare	$97.47
Rate for Payer: Cash Price	$73.10
Rate for Payer: Health Smart Auto/Commercial	$97.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$97.47
Rate for Payer: LLUH Dept of Risk Management WC	$89.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.84

HC SOM NMO EVAL W/REFLEX, SERUM

Facility

$467.90

Service Code	CPT 83520
Hospital Charge Code	900912998
Hospital Revenue Code	301
Min. Negotiated Rate	$257.34
Max. Negotiated Rate	$350.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$280.74
Rate for Payer: Aetna of CA Government/Medicare	$280.74
Rate for Payer: Cash Price	$210.56
Rate for Payer: Health Smart Auto/Commercial	$280.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$280.74
Rate for Payer: LLUH Dept of Risk Management WC	$257.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$350.92

HC SOM NMO EVAL W/REFLEX, SERUM

Facility

$467.90

Service Code	CPT 83520 90
Hospital Charge Code	900912998
Hospital Revenue Code	301
Min. Negotiated Rate	$257.34
Max. Negotiated Rate	$374.32
Rate for Payer: Cash Price	$210.56
Rate for Payer: Cigna of CA HMO/PPO	$374.32
Rate for Payer: Health Smart Auto/Commercial	$280.74
Rate for Payer: LLUH Dept of Risk Management WC	$257.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$350.92

HC SOM NMO EVAL W/REFLEX, SERUM

Facility

$467.90

Service Code	CPT 83520 90
Hospital Charge Code	900912998
Hospital Revenue Code	301
Min. Negotiated Rate	$257.34
Max. Negotiated Rate	$350.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$280.74
Rate for Payer: Aetna of CA Government/Medicare	$280.74
Rate for Payer: Cash Price	$210.56
Rate for Payer: Health Smart Auto/Commercial	$280.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$280.74
Rate for Payer: LLUH Dept of Risk Management WC	$257.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$350.92

HC SOM NMO EVAL W/REFLEX, SERUM

Facility

$467.90

Service Code	CPT 83520
Hospital Charge Code	900912998
Hospital Revenue Code	301
Min. Negotiated Rate	$257.34
Max. Negotiated Rate	$374.32
Rate for Payer: Cash Price	$210.56
Rate for Payer: Cigna of CA HMO/PPO	$374.32
Rate for Payer: Health Smart Auto/Commercial	$280.74
Rate for Payer: LLUH Dept of Risk Management WC	$257.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$350.92

HC SOMN NC05 CSF P-5-P 82491

Facility

$185.00

Service Code	CPT 82542
Hospital Charge Code	900914867
Hospital Revenue Code	301
Min. Negotiated Rate	$101.75
Max. Negotiated Rate	$138.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$111.00
Rate for Payer: Aetna of CA Government/Medicare	$111.00
Rate for Payer: Cash Price	$83.25
Rate for Payer: Health Smart Auto/Commercial	$111.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$111.00
Rate for Payer: LLUH Dept of Risk Management WC	$101.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$138.75

HC SOMN NC05 CSF P-5-P 82491

Facility

$185.00

Service Code	CPT 82542
Hospital Charge Code	900914867
Hospital Revenue Code	301
Min. Negotiated Rate	$101.75
Max. Negotiated Rate	$148.00
Rate for Payer: Cash Price	$83.25
Rate for Payer: Cigna of CA HMO/PPO	$148.00
Rate for Payer: Health Smart Auto/Commercial	$111.00
Rate for Payer: LLUH Dept of Risk Management WC	$101.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$138.75

HC SOMN NC05 CSF P-5-P 82491

Facility

$185.00

Service Code	CPT 82542 90
Hospital Charge Code	900914867
Hospital Revenue Code	301
Min. Negotiated Rate	$101.75
Max. Negotiated Rate	$138.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$111.00
Rate for Payer: Aetna of CA Government/Medicare	$111.00
Rate for Payer: Cash Price	$83.25
Rate for Payer: Health Smart Auto/Commercial	$111.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$111.00
Rate for Payer: LLUH Dept of Risk Management WC	$101.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$138.75

HC SOMN NC05 CSF P-5-P 82491

Facility

$185.00

Service Code	CPT 82542 90
Hospital Charge Code	900914867
Hospital Revenue Code	301
Min. Negotiated Rate	$101.75
Max. Negotiated Rate	$148.00
Rate for Payer: Cash Price	$83.25
Rate for Payer: Cigna of CA HMO/PPO	$148.00
Rate for Payer: Health Smart Auto/Commercial	$111.00
Rate for Payer: LLUH Dept of Risk Management WC	$101.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$138.75

HC SOM NORCLOZAPINE LEVEL

Facility

$15.80

Service Code	CPT 80159 90
Hospital Charge Code	900912685
Hospital Revenue Code	301
Min. Negotiated Rate	$8.69
Max. Negotiated Rate	$12.64
Rate for Payer: Cash Price	$7.11
Rate for Payer: Cigna of CA HMO/PPO	$12.64
Rate for Payer: Health Smart Auto/Commercial	$9.48
Rate for Payer: LLUH Dept of Risk Management WC	$8.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.85

HC SOM NORCLOZAPINE LEVEL

Facility

$15.80

Service Code	CPT 80159 90
Hospital Charge Code	900912685
Hospital Revenue Code	301
Min. Negotiated Rate	$8.69
Max. Negotiated Rate	$11.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.48
Rate for Payer: Aetna of CA Government/Medicare	$9.48
Rate for Payer: Cash Price	$7.11
Rate for Payer: Health Smart Auto/Commercial	$9.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.48
Rate for Payer: LLUH Dept of Risk Management WC	$8.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.85

HC SOM NORCLOZAPINE LEVEL

Facility

$15.80

Service Code	CPT 80159
Hospital Charge Code	900912685
Hospital Revenue Code	301
Min. Negotiated Rate	$8.69
Max. Negotiated Rate	$12.64
Rate for Payer: Cash Price	$7.11
Rate for Payer: Cigna of CA HMO/PPO	$12.64
Rate for Payer: Health Smart Auto/Commercial	$9.48
Rate for Payer: LLUH Dept of Risk Management WC	$8.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.85

HC SOM NORCLOZAPINE LEVEL

Facility

$15.80

Service Code	CPT 80159
Hospital Charge Code	900912685
Hospital Revenue Code	301
Min. Negotiated Rate	$8.69
Max. Negotiated Rate	$11.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.48
Rate for Payer: Aetna of CA Government/Medicare	$9.48
Rate for Payer: Cash Price	$7.11
Rate for Payer: Health Smart Auto/Commercial	$9.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.48
Rate for Payer: LLUH Dept of Risk Management WC	$8.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.85

HC SOM NORDOXEPIN LEVEL

Facility

$35.00

Service Code	CPT 80335 90
Hospital Charge Code	900912562
Hospital Revenue Code	301
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$26.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.00
Rate for Payer: Aetna of CA Government/Medicare	$21.00
Rate for Payer: Cash Price	$15.75
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.25

HC SOM NORDOXEPIN LEVEL

Facility

$35.00

Service Code	CPT 80335
Hospital Charge Code	900912562
Hospital Revenue Code	301
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$26.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.00
Rate for Payer: Aetna of CA Government/Medicare	$21.00
Rate for Payer: Cash Price	$15.75
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.25

Know your out-of-pocket cost for care.

All Charges