Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM VDER 87798

Facility

$50.27

Service Code	CPT 87798 90
Hospital Charge Code	900913966
Hospital Revenue Code	306
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$40.22
Rate for Payer: Cash Price	$22.62
Rate for Payer: Cigna of CA HMO/PPO	$40.22
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.70

HC SOM VDER 87798

Facility

$50.27

Service Code	CPT 87798
Hospital Charge Code	900913966
Hospital Revenue Code	306
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$40.22
Rate for Payer: Cash Price	$22.62
Rate for Payer: Cigna of CA HMO/PPO	$40.22
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.70

HC SOM VITAMIN A

Facility

$17.90

Service Code	CPT 84590
Hospital Charge Code	900911173
Hospital Revenue Code	301
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$13.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.74
Rate for Payer: Aetna of CA Government/Medicare	$10.74
Rate for Payer: Cash Price	$8.06
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.42

HC SOM VITAMIN A

Facility

$17.90

Service Code	CPT 84590
Hospital Charge Code	900911173
Hospital Revenue Code	301
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$14.32
Rate for Payer: Cash Price	$8.06
Rate for Payer: Cigna of CA HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.42

HC SOM VITAMIN A

Facility

$17.90

Service Code	CPT 84590 90
Hospital Charge Code	900911173
Hospital Revenue Code	301
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$13.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.74
Rate for Payer: Aetna of CA Government/Medicare	$10.74
Rate for Payer: Cash Price	$8.06
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.42

HC SOM VITAMIN A

Facility

$17.90

Service Code	CPT 84590 90
Hospital Charge Code	900911173
Hospital Revenue Code	301
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$14.32
Rate for Payer: Cash Price	$8.06
Rate for Payer: Cigna of CA HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.42

HC SOM VITAMIN B1 (THIAMINE)

Facility

$22.00

Service Code	CPT 84425
Hospital Charge Code	900911048
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna of CA HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM VITAMIN B1 (THIAMINE)

Facility

$22.00

Service Code	CPT 84425
Hospital Charge Code	900911048
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$16.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.20
Rate for Payer: Aetna of CA Government/Medicare	$13.20
Rate for Payer: Cash Price	$9.90
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM VITAMIN B1 (THIAMINE)

Facility

$22.00

Service Code	CPT 84425 90
Hospital Charge Code	900911048
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$16.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.20
Rate for Payer: Aetna of CA Government/Medicare	$13.20
Rate for Payer: Cash Price	$9.90
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM VITAMIN B1 (THIAMINE)

Facility

$22.00

Service Code	CPT 84425 90
Hospital Charge Code	900911048
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna of CA HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM VITAMIN B6

Facility

$28.25

Service Code	CPT 84207
Hospital Charge Code	900911400
Hospital Revenue Code	301
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$21.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.95
Rate for Payer: Aetna of CA Government/Medicare	$16.95
Rate for Payer: Cash Price	$12.71
Rate for Payer: Health Smart Auto/Commercial	$16.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.95
Rate for Payer: LLUH Dept of Risk Management WC	$15.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.19

HC SOM VITAMIN B6

Facility

$28.25

Service Code	CPT 84207 90
Hospital Charge Code	900911400
Hospital Revenue Code	301
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$21.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.95
Rate for Payer: Aetna of CA Government/Medicare	$16.95
Rate for Payer: Cash Price	$12.71
Rate for Payer: Health Smart Auto/Commercial	$16.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.95
Rate for Payer: LLUH Dept of Risk Management WC	$15.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.19

HC SOM VITAMIN B6

Facility

$28.25

Service Code	CPT 84207
Hospital Charge Code	900911400
Hospital Revenue Code	301
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$22.60
Rate for Payer: Cash Price	$12.71
Rate for Payer: Cigna of CA HMO/PPO	$22.60
Rate for Payer: Health Smart Auto/Commercial	$16.95
Rate for Payer: LLUH Dept of Risk Management WC	$15.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.19

HC SOM VITAMIN B6

Facility

$28.25

Service Code	CPT 84207 90
Hospital Charge Code	900911400
Hospital Revenue Code	301
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$22.60
Rate for Payer: Cash Price	$12.71
Rate for Payer: Cigna of CA HMO/PPO	$22.60
Rate for Payer: Health Smart Auto/Commercial	$16.95
Rate for Payer: LLUH Dept of Risk Management WC	$15.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.19

HC SOM VITAMIN D 25-HYDROXY

Facility

$8.00

Service Code	CPT 82306
Hospital Charge Code	900911032
Hospital Revenue Code	301
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.80
Rate for Payer: Aetna of CA Government/Medicare	$4.80
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.00

HC SOM VITAMIN D 25-HYDROXY

Facility

$8.00

Service Code	CPT 82306 90
Hospital Charge Code	900911032
Hospital Revenue Code	301
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.40
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna of CA HMO/PPO	$6.40
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.00

HC SOM VITAMIN D 25-HYDROXY

Facility

$8.00

Service Code	CPT 82306
Hospital Charge Code	900911032
Hospital Revenue Code	301
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.40
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna of CA HMO/PPO	$6.40
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.00

HC SOM VITAMIN D 25-HYDROXY

Facility

$8.00

Service Code	CPT 82306 90
Hospital Charge Code	900911032
Hospital Revenue Code	301
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.80
Rate for Payer: Aetna of CA Government/Medicare	$4.80
Rate for Payer: Cash Price	$3.60
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.00

HC SOM VOLATILES BLOOD

Facility

$45.00

Service Code	CPT G0480 90
Hospital Charge Code	900910583
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 VOLATILES BLOOD

Facility

$45.00

Service Code	CPT G0480 90
Hospital Charge Code	900910583
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 VOLATILES BLOOD

Facility

$45.00

Service Code	CPT G0480
Hospital Charge Code	900910583
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 VOLATILES BLOOD

Facility

$45.00

Service Code	CPT 80320
Hospital Charge Code	900910583
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 VOLATILES BLOOD

Facility

$45.00

Service Code	CPT 80320
Hospital Charge Code	900910583
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 VOLATILES BLOOD

Facility

$45.00

Service Code	CPT G0480
Hospital Charge Code	900910583
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 VOLATILES URINE

Facility

$45.00

Service Code	CPT 80320
Hospital Charge Code	900910584
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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