Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM PENICILLIN V IGE

Facility

$4.75

Service Code	CPT 86003 90
Hospital Charge Code	900912842
Hospital Revenue Code	302
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.80
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cigna of CA HMO/PPO	$3.80
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.56

HC SOM PENICILLIN V IGE

Facility

$4.75

Service Code	CPT 86003
Hospital Charge Code	900912842
Hospital Revenue Code	302
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.80
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cigna of CA HMO/PPO	$3.80
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.56

HC SOM PHENCYCLIDINE CONFIRM, U

Facility

$61.00

Service Code	CPT 83992
Hospital Charge Code	900912920
Hospital Revenue Code	301
Min. Negotiated Rate	$33.55
Max. Negotiated Rate	$48.80
Rate for Payer: Cash Price	$27.45
Rate for Payer: Cigna of CA HMO/PPO	$48.80
Rate for Payer: Health Smart Auto/Commercial	$36.60
Rate for Payer: LLUH Dept of Risk Management WC	$33.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.75

HC SOM PHENCYCLIDINE CONFIRM, U

Facility

$61.00

Service Code	CPT 83992 90
Hospital Charge Code	900912920
Hospital Revenue Code	301
Min. Negotiated Rate	$33.55
Max. Negotiated Rate	$45.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.60
Rate for Payer: Aetna of CA Government/Medicare	$36.60
Rate for Payer: Cash Price	$27.45
Rate for Payer: Health Smart Auto/Commercial	$36.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.60
Rate for Payer: LLUH Dept of Risk Management WC	$33.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.75

HC SOM PHENCYCLIDINE CONFIRM, U

Facility

$61.00

Service Code	CPT 83992 90
Hospital Charge Code	900912920
Hospital Revenue Code	301
Min. Negotiated Rate	$33.55
Max. Negotiated Rate	$48.80
Rate for Payer: Cash Price	$27.45
Rate for Payer: Cigna of CA HMO/PPO	$48.80
Rate for Payer: Health Smart Auto/Commercial	$36.60
Rate for Payer: LLUH Dept of Risk Management WC	$33.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.75

HC SOM PHENCYCLIDINE CONFIRM, U

Facility

$61.00

Service Code	CPT 83992
Hospital Charge Code	900912920
Hospital Revenue Code	301
Min. Negotiated Rate	$33.55
Max. Negotiated Rate	$45.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.60
Rate for Payer: Aetna of CA Government/Medicare	$36.60
Rate for Payer: Cash Price	$27.45
Rate for Payer: Health Smart Auto/Commercial	$36.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.60
Rate for Payer: LLUH Dept of Risk Management WC	$33.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.75

HC SOM PHENOBARBITAL LEVEL

Facility

$23.99

Service Code	CPT 80184 90
Hospital Charge Code	900912658
Hospital Revenue Code	301
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$17.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.39
Rate for Payer: Aetna of CA Government/Medicare	$14.39
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Smart Auto/Commercial	$14.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.39
Rate for Payer: LLUH Dept of Risk Management WC	$13.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.99

HC SOM PHENOBARBITAL LEVEL

Facility

$23.99

Service Code	CPT 80184
Hospital Charge Code	900912658
Hospital Revenue Code	301
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$19.19
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna of CA HMO/PPO	$19.19
Rate for Payer: Health Smart Auto/Commercial	$14.39
Rate for Payer: LLUH Dept of Risk Management WC	$13.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.99

HC SOM PHENOBARBITAL LEVEL

Facility

$23.99

Service Code	CPT 80184
Hospital Charge Code	900912658
Hospital Revenue Code	301
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$17.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.39
Rate for Payer: Aetna of CA Government/Medicare	$14.39
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Smart Auto/Commercial	$14.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.39
Rate for Payer: LLUH Dept of Risk Management WC	$13.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.99

HC SOM PHENOBARBITAL LEVEL

Facility

$23.99

Service Code	CPT 80184 90
Hospital Charge Code	900912658
Hospital Revenue Code	301
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$19.19
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna of CA HMO/PPO	$19.19
Rate for Payer: Health Smart Auto/Commercial	$14.39
Rate for Payer: LLUH Dept of Risk Management WC	$13.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.99

HC SOM PHOSPHOLIPID AB IGA

Facility

$24.10

Service Code	CPT 86147 90
Hospital Charge Code	900914172
Hospital Revenue Code	302
Min. Negotiated Rate	$13.26
Max. Negotiated Rate	$19.28
Rate for Payer: Cash Price	$10.85
Rate for Payer: Cigna of CA HMO/PPO	$19.28
Rate for Payer: Health Smart Auto/Commercial	$14.46
Rate for Payer: LLUH Dept of Risk Management WC	$13.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.08

HC SOM PHOSPHOLIPID AB IGA

Facility

$24.10

Service Code	CPT 86147
Hospital Charge Code	900914172
Hospital Revenue Code	302
Min. Negotiated Rate	$13.26
Max. Negotiated Rate	$18.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.46
Rate for Payer: Aetna of CA Government/Medicare	$14.46
Rate for Payer: Cash Price	$10.85
Rate for Payer: Health Smart Auto/Commercial	$14.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.46
Rate for Payer: LLUH Dept of Risk Management WC	$13.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.08

HC SOM PHOSPHOLIPID AB IGA

Facility

$24.10

Service Code	CPT 86147
Hospital Charge Code	900914172
Hospital Revenue Code	302
Min. Negotiated Rate	$13.26
Max. Negotiated Rate	$19.28
Rate for Payer: Cash Price	$10.85
Rate for Payer: Cigna of CA HMO/PPO	$19.28
Rate for Payer: Health Smart Auto/Commercial	$14.46
Rate for Payer: LLUH Dept of Risk Management WC	$13.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.08

HC SOM PHOSPHOLIPID AB IGA

Facility

$24.10

Service Code	CPT 86147 90
Hospital Charge Code	900914172
Hospital Revenue Code	302
Min. Negotiated Rate	$13.26
Max. Negotiated Rate	$18.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.46
Rate for Payer: Aetna of CA Government/Medicare	$14.46
Rate for Payer: Cash Price	$10.85
Rate for Payer: Health Smart Auto/Commercial	$14.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.46
Rate for Payer: LLUH Dept of Risk Management WC	$13.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.08

HC SOM PI-LINKD AG FLOW EA ADD'L

Facility

$79.46

Service Code	CPT 88185 90
Hospital Charge Code	900914176
Hospital Revenue Code	301
Min. Negotiated Rate	$43.70
Max. Negotiated Rate	$63.57
Rate for Payer: Cash Price	$35.76
Rate for Payer: Cigna of CA HMO/PPO	$63.57
Rate for Payer: Health Smart Auto/Commercial	$47.68
Rate for Payer: LLUH Dept of Risk Management WC	$43.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$59.60

HC SOM PI-LINKD AG FLOW EA ADD'L

Facility

$79.46

Service Code	CPT 88185
Hospital Charge Code	900914176
Hospital Revenue Code	309
Min. Negotiated Rate	$43.70
Max. Negotiated Rate	$59.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$47.68
Rate for Payer: Aetna of CA Government/Medicare	$47.68
Rate for Payer: Cash Price	$35.76
Rate for Payer: Health Smart Auto/Commercial	$47.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$47.68
Rate for Payer: LLUH Dept of Risk Management WC	$43.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$59.60

HC SOM PI-LINKD AG FLOW EA ADD'L

Facility

$79.46

Service Code	CPT 88185 90
Hospital Charge Code	900914176
Hospital Revenue Code	301
Min. Negotiated Rate	$43.70
Max. Negotiated Rate	$59.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$47.68
Rate for Payer: Aetna of CA Government/Medicare	$47.68
Rate for Payer: Cash Price	$35.76
Rate for Payer: Health Smart Auto/Commercial	$47.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$47.68
Rate for Payer: LLUH Dept of Risk Management WC	$43.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$59.60

HC SOM PI-LINKD AG FLOW EA ADD'L

Facility

$79.46

Service Code	CPT 88185
Hospital Charge Code	900914176
Hospital Revenue Code	309
Min. Negotiated Rate	$43.70
Max. Negotiated Rate	$63.57
Rate for Payer: Cash Price	$35.76
Rate for Payer: Cigna of CA HMO/PPO	$63.57
Rate for Payer: Health Smart Auto/Commercial	$47.68
Rate for Payer: LLUH Dept of Risk Management WC	$43.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$59.60

HC SOM PI-LINKD AG FLOW TC 1 MRKR

Facility

$70.54

Service Code	CPT 88184
Hospital Charge Code	900914173
Hospital Revenue Code	309
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$56.43
Rate for Payer: Cash Price	$31.74
Rate for Payer: Cigna of CA HMO/PPO	$56.43
Rate for Payer: Health Smart Auto/Commercial	$42.32
Rate for Payer: LLUH Dept of Risk Management WC	$38.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.90

HC SOM PI-LINKD AG FLOW TC 1 MRKR

Facility

$70.54

Service Code	CPT 88184
Hospital Charge Code	900914173
Hospital Revenue Code	309
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$52.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.32
Rate for Payer: Aetna of CA Government/Medicare	$42.32
Rate for Payer: Cash Price	$31.74
Rate for Payer: Health Smart Auto/Commercial	$42.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.32
Rate for Payer: LLUH Dept of Risk Management WC	$38.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.90

HC SOM PI-LINKD AG FLOW TC 1 MRKR

Facility

$70.54

Service Code	CPT 88184 90
Hospital Charge Code	900914173
Hospital Revenue Code	301
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$52.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.32
Rate for Payer: Aetna of CA Government/Medicare	$42.32
Rate for Payer: Cash Price	$31.74
Rate for Payer: Health Smart Auto/Commercial	$42.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.32
Rate for Payer: LLUH Dept of Risk Management WC	$38.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.90

HC SOM PI-LINKD AG FLOW TC 1 MRKR

Facility

$70.54

Service Code	CPT 88184 90
Hospital Charge Code	900914173
Hospital Revenue Code	301
Min. Negotiated Rate	$38.80
Max. Negotiated Rate	$56.43
Rate for Payer: Cash Price	$31.74
Rate for Payer: Cigna of CA HMO/PPO	$56.43
Rate for Payer: Health Smart Auto/Commercial	$42.32
Rate for Payer: LLUH Dept of Risk Management WC	$38.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.90

HC SOM PLASMINOGEN ACTIVITY

Facility

$50.00

Service Code	CPT 85420 90
Hospital Charge Code	900911325
Hospital Revenue Code	305
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM PLASMINOGEN ACTIVITY

Facility

$50.00

Service Code	CPT 85420
Hospital Charge Code	900911325
Hospital Revenue Code	305
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna of CA HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM PLASMINOGEN ACTIVITY

Facility

$50.00

Service Code	CPT 85420
Hospital Charge Code	900911325
Hospital Revenue Code	305
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

Know your out-of-pocket cost for care.

All Charges