Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM TOPIRAMATE

Facility

$17.50

Service Code	CPT 80201
Hospital Charge Code	900910764
Hospital Revenue Code	301
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$13.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.50
Rate for Payer: Aetna of CA Government/Medicare	$10.50
Rate for Payer: Cash Price	$7.88
Rate for Payer: Health Smart Auto/Commercial	$10.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.50
Rate for Payer: LLUH Dept of Risk Management WC	$9.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.12

HC SOM TOPIRAMATE

Facility

$17.50

Service Code	CPT 80201 90
Hospital Charge Code	900910764
Hospital Revenue Code	301
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$13.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.50
Rate for Payer: Aetna of CA Government/Medicare	$10.50
Rate for Payer: Cash Price	$7.88
Rate for Payer: Health Smart Auto/Commercial	$10.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.50
Rate for Payer: LLUH Dept of Risk Management WC	$9.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.12

HC SOM TOPIRAMATE

Facility

$17.50

Service Code	CPT 80201 90
Hospital Charge Code	900910764
Hospital Revenue Code	301
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$14.00
Rate for Payer: Cash Price	$7.88
Rate for Payer: Cigna of CA HMO/PPO	$14.00
Rate for Payer: Health Smart Auto/Commercial	$10.50
Rate for Payer: LLUH Dept of Risk Management WC	$9.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.12

HC SOM TOXOCARA AB

Facility

$40.00

Service Code	CPT 86682
Hospital Charge Code	900911594
Hospital Revenue Code	302
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$32.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna of CA HMO/PPO	$32.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.00

HC SOM TOXOCARA AB

Facility

$40.00

Service Code	CPT 86682 90
Hospital Charge Code	900911594
Hospital Revenue Code	302
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$32.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna of CA HMO/PPO	$32.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.00

HC SOM TOXOCARA AB

Facility

$40.00

Service Code	CPT 86682 90
Hospital Charge Code	900911594
Hospital Revenue Code	302
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.00
Rate for Payer: Aetna of CA Government/Medicare	$24.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.00

HC SOM TOXOCARA AB

Facility

$40.00

Service Code	CPT 86682
Hospital Charge Code	900911594
Hospital Revenue Code	302
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.00
Rate for Payer: Aetna of CA Government/Medicare	$24.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.00

HC SOM TOXOPLASMA AB CSF IGG

Facility

$87.36

Service Code	CPT 86777 90
Hospital Charge Code	900911346
Hospital Revenue Code	302
Min. Negotiated Rate	$48.05
Max. Negotiated Rate	$69.89
Rate for Payer: Cash Price	$39.31
Rate for Payer: Cigna of CA HMO/PPO	$69.89
Rate for Payer: Health Smart Auto/Commercial	$52.42
Rate for Payer: LLUH Dept of Risk Management WC	$48.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.52

HC SOM TOXOPLASMA AB CSF IGG

Facility

$87.36

Service Code	CPT 86777 90
Hospital Charge Code	900911346
Hospital Revenue Code	302
Min. Negotiated Rate	$48.05
Max. Negotiated Rate	$65.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.42
Rate for Payer: Aetna of CA Government/Medicare	$52.42
Rate for Payer: Cash Price	$39.31
Rate for Payer: Health Smart Auto/Commercial	$52.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.42
Rate for Payer: LLUH Dept of Risk Management WC	$48.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.52

HC SOM TOXOPLASMA AB CSF IGG

Facility

$87.36

Service Code	CPT 86777
Hospital Charge Code	900911346
Hospital Revenue Code	302
Min. Negotiated Rate	$48.05
Max. Negotiated Rate	$65.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.42
Rate for Payer: Aetna of CA Government/Medicare	$52.42
Rate for Payer: Cash Price	$39.31
Rate for Payer: Health Smart Auto/Commercial	$52.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.42
Rate for Payer: LLUH Dept of Risk Management WC	$48.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.52

HC SOM TOXOPLASMA AB CSF IGG

Facility

$87.36

Service Code	CPT 86777
Hospital Charge Code	900911346
Hospital Revenue Code	302
Min. Negotiated Rate	$48.05
Max. Negotiated Rate	$69.89
Rate for Payer: Cash Price	$39.31
Rate for Payer: Cigna of CA HMO/PPO	$69.89
Rate for Payer: Health Smart Auto/Commercial	$52.42
Rate for Payer: LLUH Dept of Risk Management WC	$48.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.52

HC SOM TOXOPLASMA AB CSF IGM

Facility

$87.49

Service Code	CPT 86778 90
Hospital Charge Code	900914413
Hospital Revenue Code	302
Min. Negotiated Rate	$48.12
Max. Negotiated Rate	$65.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.49
Rate for Payer: Aetna of CA Government/Medicare	$52.49
Rate for Payer: Cash Price	$39.37
Rate for Payer: Health Smart Auto/Commercial	$52.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.49
Rate for Payer: LLUH Dept of Risk Management WC	$48.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.62

HC SOM TOXOPLASMA AB CSF IGM

Facility

$87.49

Service Code	CPT 86778 90
Hospital Charge Code	900914413
Hospital Revenue Code	302
Min. Negotiated Rate	$48.12
Max. Negotiated Rate	$69.99
Rate for Payer: Cash Price	$39.37
Rate for Payer: Cigna of CA HMO/PPO	$69.99
Rate for Payer: Health Smart Auto/Commercial	$52.49
Rate for Payer: LLUH Dept of Risk Management WC	$48.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.62

HC SOM TOXOPLASMA AB CSF IGM

Facility

$87.49

Service Code	CPT 86778
Hospital Charge Code	900914413
Hospital Revenue Code	302
Min. Negotiated Rate	$48.12
Max. Negotiated Rate	$65.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.49
Rate for Payer: Aetna of CA Government/Medicare	$52.49
Rate for Payer: Cash Price	$39.37
Rate for Payer: Health Smart Auto/Commercial	$52.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.49
Rate for Payer: LLUH Dept of Risk Management WC	$48.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.62

HC SOM TOXOPLASMA AB CSF IGM

Facility

$87.49

Service Code	CPT 86778
Hospital Charge Code	900914413
Hospital Revenue Code	302
Min. Negotiated Rate	$48.12
Max. Negotiated Rate	$69.99
Rate for Payer: Cash Price	$39.37
Rate for Payer: Cigna of CA HMO/PPO	$69.99
Rate for Payer: Health Smart Auto/Commercial	$52.49
Rate for Payer: LLUH Dept of Risk Management WC	$48.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.62

HC SOM TPPA 86780

Facility

$37.51

Service Code	CPT 86780 90
Hospital Charge Code	900914807
Hospital Revenue Code	300
Min. Negotiated Rate	$20.63
Max. Negotiated Rate	$30.01
Rate for Payer: Cash Price	$16.88
Rate for Payer: Cigna of CA HMO/PPO	$30.01
Rate for Payer: Health Smart Auto/Commercial	$22.51
Rate for Payer: LLUH Dept of Risk Management WC	$20.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.13

HC SOM TPPA 86780

Facility

$37.51

Service Code	CPT 86780 90
Hospital Charge Code	900914807
Hospital Revenue Code	300
Min. Negotiated Rate	$20.63
Max. Negotiated Rate	$28.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.51
Rate for Payer: Aetna of CA Government/Medicare	$22.51
Rate for Payer: Cash Price	$16.88
Rate for Payer: Health Smart Auto/Commercial	$22.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.51
Rate for Payer: LLUH Dept of Risk Management WC	$20.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.13

HC SOM TPPA 86780

Facility

$37.51

Service Code	CPT 86780
Hospital Charge Code	900914807
Hospital Revenue Code	301
Min. Negotiated Rate	$20.63
Max. Negotiated Rate	$30.01
Rate for Payer: Cash Price	$16.88
Rate for Payer: Cigna of CA HMO/PPO	$30.01
Rate for Payer: Health Smart Auto/Commercial	$22.51
Rate for Payer: LLUH Dept of Risk Management WC	$20.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.13

HC SOM TPPA 86780

Facility

$37.51

Service Code	CPT 86780
Hospital Charge Code	900914807
Hospital Revenue Code	301
Min. Negotiated Rate	$20.63
Max. Negotiated Rate	$28.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.51
Rate for Payer: Aetna of CA Government/Medicare	$22.51
Rate for Payer: Cash Price	$16.88
Rate for Payer: Health Smart Auto/Commercial	$22.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.51
Rate for Payer: LLUH Dept of Risk Management WC	$20.63
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.13

HC SOM TPPTL 82657

Facility

$25.86

Service Code	CPT 82657
Hospital Charge Code	900914893
Hospital Revenue Code	301
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$19.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.52
Rate for Payer: Aetna of CA Government/Medicare	$15.52
Rate for Payer: Cash Price	$11.64
Rate for Payer: Health Smart Auto/Commercial	$15.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.52
Rate for Payer: LLUH Dept of Risk Management WC	$14.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.40

HC SOM TPPTL 82657

Facility

$25.86

Service Code	CPT 82657 90
Hospital Charge Code	900914893
Hospital Revenue Code	301
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$19.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.52
Rate for Payer: Aetna of CA Government/Medicare	$15.52
Rate for Payer: Cash Price	$11.64
Rate for Payer: Health Smart Auto/Commercial	$15.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.52
Rate for Payer: LLUH Dept of Risk Management WC	$14.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.40

HC SOM TPPTL 82657

Facility

$25.86

Service Code	CPT 82657 90
Hospital Charge Code	900914893
Hospital Revenue Code	301
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$20.69
Rate for Payer: Cash Price	$11.64
Rate for Payer: Cigna of CA HMO/PPO	$20.69
Rate for Payer: Health Smart Auto/Commercial	$15.52
Rate for Payer: LLUH Dept of Risk Management WC	$14.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.40

HC SOM TPPTL 82657

Facility

$25.86

Service Code	CPT 82657
Hospital Charge Code	900914893
Hospital Revenue Code	301
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$20.69
Rate for Payer: Cash Price	$11.64
Rate for Payer: Cigna of CA HMO/PPO	$20.69
Rate for Payer: Health Smart Auto/Commercial	$15.52
Rate for Payer: LLUH Dept of Risk Management WC	$14.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.40

HC SOM TRAM 83925

Facility

$45.00

Service Code	CPT G0480
Hospital Charge Code	900915271
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Cigna of CA HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

HC SOM TRAM 83925

Facility

$45.00

Service Code	CPT 80373
Hospital Charge Code	900915271
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Cigna of CA HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

Know your out-of-pocket cost for care.

All Charges