Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM SULFA DRUGS

Facility

$55.00

Service Code	CPT 80299 90
Hospital Charge Code	900911100
Hospital Revenue Code	301
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 SULFA DRUGS

Facility

$55.00

Service Code	CPT 80299
Hospital Charge Code	900911100
Hospital Revenue Code	301
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 SULFA DRUGS

Facility

$55.00

Service Code	CPT 80299 90
Hospital Charge Code	900911100
Hospital Revenue Code	301
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 SULFA DRUGS

Facility

$55.00

Service Code	CPT 80299
Hospital Charge Code	900911100
Hospital Revenue Code	301
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$41.25
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Cash Price	$24.75
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: 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 TCP 86359

Facility

$115.35

Service Code	CPT 86359 90
Hospital Charge Code	900914880
Hospital Revenue Code	302
Min. Negotiated Rate	$63.44
Max. Negotiated Rate	$86.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$69.21
Rate for Payer: Aetna of CA Government/Medicare	$69.21
Rate for Payer: Cash Price	$51.91
Rate for Payer: Health Smart Auto/Commercial	$69.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$69.21
Rate for Payer: LLUH Dept of Risk Management WC	$63.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$86.51

HC SOM TCP 86359

Facility

$115.35

Service Code	CPT 86359
Hospital Charge Code	900914880
Hospital Revenue Code	309
Min. Negotiated Rate	$63.44
Max. Negotiated Rate	$86.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$69.21
Rate for Payer: Aetna of CA Government/Medicare	$69.21
Rate for Payer: Cash Price	$51.91
Rate for Payer: Health Smart Auto/Commercial	$69.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$69.21
Rate for Payer: LLUH Dept of Risk Management WC	$63.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$86.51

HC SOM TCP 86359

Facility

$115.35

Service Code	CPT 86359 90
Hospital Charge Code	900914880
Hospital Revenue Code	302
Min. Negotiated Rate	$63.44
Max. Negotiated Rate	$92.28
Rate for Payer: Cash Price	$51.91
Rate for Payer: Cigna of CA HMO/PPO	$92.28
Rate for Payer: Health Smart Auto/Commercial	$69.21
Rate for Payer: LLUH Dept of Risk Management WC	$63.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$86.51

HC SOM TCP 86359

Facility

$115.35

Service Code	CPT 86359
Hospital Charge Code	900914880
Hospital Revenue Code	309
Min. Negotiated Rate	$63.44
Max. Negotiated Rate	$92.28
Rate for Payer: Cash Price	$51.91
Rate for Payer: Cigna of CA HMO/PPO	$92.28
Rate for Payer: Health Smart Auto/Commercial	$69.21
Rate for Payer: LLUH Dept of Risk Management WC	$63.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$86.51

HC SOM TCP 86361

Facility

$81.87

Service Code	CPT 86361
Hospital Charge Code	900914881
Hospital Revenue Code	309
Min. Negotiated Rate	$45.03
Max. Negotiated Rate	$61.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.12
Rate for Payer: Aetna of CA Government/Medicare	$49.12
Rate for Payer: Cash Price	$36.84
Rate for Payer: Health Smart Auto/Commercial	$49.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.12
Rate for Payer: LLUH Dept of Risk Management WC	$45.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.40

HC SOM TCP 86361

Facility

$81.87

Service Code	CPT 86361
Hospital Charge Code	900914881
Hospital Revenue Code	309
Min. Negotiated Rate	$45.03
Max. Negotiated Rate	$65.50
Rate for Payer: Cash Price	$36.84
Rate for Payer: Cigna of CA HMO/PPO	$65.50
Rate for Payer: Health Smart Auto/Commercial	$49.12
Rate for Payer: LLUH Dept of Risk Management WC	$45.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.40

HC SOM TCP 86361

Facility

$81.87

Service Code	CPT 86361 90
Hospital Charge Code	900914881
Hospital Revenue Code	302
Min. Negotiated Rate	$45.03
Max. Negotiated Rate	$61.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.12
Rate for Payer: Aetna of CA Government/Medicare	$49.12
Rate for Payer: Cash Price	$36.84
Rate for Payer: Health Smart Auto/Commercial	$49.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.12
Rate for Payer: LLUH Dept of Risk Management WC	$45.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.40

HC SOM TCP 86361

Facility

$81.87

Service Code	CPT 86361 90
Hospital Charge Code	900914881
Hospital Revenue Code	302
Min. Negotiated Rate	$45.03
Max. Negotiated Rate	$65.50
Rate for Payer: Cash Price	$36.84
Rate for Payer: Cigna of CA HMO/PPO	$65.50
Rate for Payer: Health Smart Auto/Commercial	$49.12
Rate for Payer: LLUH Dept of Risk Management WC	$45.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.40

HC SOM TCP 88184

Facility

$199.38

Service Code	CPT 88184
Hospital Charge Code	900914882
Hospital Revenue Code	309
Min. Negotiated Rate	$109.66
Max. Negotiated Rate	$149.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$119.63
Rate for Payer: Aetna of CA Government/Medicare	$119.63
Rate for Payer: Cash Price	$89.72
Rate for Payer: Health Smart Auto/Commercial	$119.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$119.63
Rate for Payer: LLUH Dept of Risk Management WC	$109.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$149.54

HC SOM TCP 88184

Facility

$199.38

Service Code	CPT 88184
Hospital Charge Code	900914882
Hospital Revenue Code	309
Min. Negotiated Rate	$109.66
Max. Negotiated Rate	$159.50
Rate for Payer: Cash Price	$89.72
Rate for Payer: Cigna of CA HMO/PPO	$159.50
Rate for Payer: Health Smart Auto/Commercial	$119.63
Rate for Payer: LLUH Dept of Risk Management WC	$109.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$149.54

HC SOM TCP 88184

Facility

$199.38

Service Code	CPT 88184 90
Hospital Charge Code	900914882
Hospital Revenue Code	311
Min. Negotiated Rate	$109.66
Max. Negotiated Rate	$149.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$119.63
Rate for Payer: Aetna of CA Government/Medicare	$119.63
Rate for Payer: Cash Price	$89.72
Rate for Payer: Health Smart Auto/Commercial	$119.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$119.63
Rate for Payer: LLUH Dept of Risk Management WC	$109.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$149.54

HC SOM TCP 88184

Facility

$199.38

Service Code	CPT 88184 90
Hospital Charge Code	900914882
Hospital Revenue Code	311
Min. Negotiated Rate	$109.66
Max. Negotiated Rate	$159.50
Rate for Payer: Cash Price	$89.72
Rate for Payer: Cigna of CA HMO/PPO	$159.50
Rate for Payer: Health Smart Auto/Commercial	$119.63
Rate for Payer: LLUH Dept of Risk Management WC	$109.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$149.54

HC SOM TESTOSTERONE FREE

Facility

$8.94

Service Code	CPT 84402
Hospital Charge Code	900911131
Hospital Revenue Code	300
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$7.15
Rate for Payer: Cash Price	$4.02
Rate for Payer: Cigna of CA HMO/PPO	$7.15
Rate for Payer: Health Smart Auto/Commercial	$5.36
Rate for Payer: LLUH Dept of Risk Management WC	$4.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.70

HC SOM TESTOSTERONE FREE

Facility

$8.94

Service Code	CPT 84402
Hospital Charge Code	900911131
Hospital Revenue Code	300
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$6.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.36
Rate for Payer: Aetna of CA Government/Medicare	$5.36
Rate for Payer: Cash Price	$4.02
Rate for Payer: Health Smart Auto/Commercial	$5.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.36
Rate for Payer: LLUH Dept of Risk Management WC	$4.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.70

HC SOM TESTOSTERONE FREE

Facility

$8.94

Service Code	CPT 84402 90
Hospital Charge Code	900911131
Hospital Revenue Code	300
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$7.15
Rate for Payer: Cash Price	$4.02
Rate for Payer: Cigna of CA HMO/PPO	$7.15
Rate for Payer: Health Smart Auto/Commercial	$5.36
Rate for Payer: LLUH Dept of Risk Management WC	$4.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.70

HC SOM TESTOSTERONE FREE

Facility

$8.94

Service Code	CPT 84402 90
Hospital Charge Code	900911131
Hospital Revenue Code	300
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$6.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.36
Rate for Payer: Aetna of CA Government/Medicare	$5.36
Rate for Payer: Cash Price	$4.02
Rate for Payer: Health Smart Auto/Commercial	$5.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.36
Rate for Payer: LLUH Dept of Risk Management WC	$4.92
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.70

HC SOM TETANUS ANTITOXOID (ELISA)

Facility

$20.42

Service Code	CPT 86317 90
Hospital Charge Code	900911757
Hospital Revenue Code	302
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$15.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.25
Rate for Payer: Aetna of CA Government/Medicare	$12.25
Rate for Payer: Cash Price	$9.19
Rate for Payer: Health Smart Auto/Commercial	$12.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.25
Rate for Payer: LLUH Dept of Risk Management WC	$11.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.32

HC SOM TETANUS ANTITOXOID (ELISA)

Facility

$20.42

Service Code	CPT 86317
Hospital Charge Code	900911757
Hospital Revenue Code	302
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$15.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.25
Rate for Payer: Aetna of CA Government/Medicare	$12.25
Rate for Payer: Cash Price	$9.19
Rate for Payer: Health Smart Auto/Commercial	$12.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.25
Rate for Payer: LLUH Dept of Risk Management WC	$11.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.32

HC SOM TETANUS ANTITOXOID (ELISA)

Facility

$20.42

Service Code	CPT 86317 90
Hospital Charge Code	900911757
Hospital Revenue Code	302
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$16.34
Rate for Payer: Cash Price	$9.19
Rate for Payer: Cigna of CA HMO/PPO	$16.34
Rate for Payer: Health Smart Auto/Commercial	$12.25
Rate for Payer: LLUH Dept of Risk Management WC	$11.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.32

HC SOM TETANUS ANTITOXOID (ELISA)

Facility

$20.42

Service Code	CPT 86317
Hospital Charge Code	900911757
Hospital Revenue Code	302
Min. Negotiated Rate	$11.23
Max. Negotiated Rate	$16.34
Rate for Payer: Cash Price	$9.19
Rate for Payer: Cigna of CA HMO/PPO	$16.34
Rate for Payer: Health Smart Auto/Commercial	$12.25
Rate for Payer: LLUH Dept of Risk Management WC	$11.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.32

HC SOM THALLIUM URINE

Facility

$204.00

Service Code	CPT 83018
Hospital Charge Code	900911102
Hospital Revenue Code	301
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$163.20
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna of CA HMO/PPO	$163.20
Rate for Payer: Health Smart Auto/Commercial	$122.40
Rate for Payer: LLUH Dept of Risk Management WC	$112.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$153.00

Know your out-of-pocket cost for care.

All Charges