Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM VOLATILES URINE

Facility

$45.00

Service Code	CPT G0480
Hospital Charge Code	900910584
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 G0480
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

HC SOM VOLATILES URINE

Facility

$45.00

Service Code	CPT G0480 90
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

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	$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 G0480 90
Hospital Charge Code	900910584
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 VONWILLEBRAND AG

Facility

$25.34

Service Code	CPT 85246
Hospital Charge Code	900910112
Hospital Revenue Code	305
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.20
Rate for Payer: Aetna of CA Government/Medicare	$15.20
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Smart Auto/Commercial	$15.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.20
Rate for Payer: LLUH Dept of Risk Management WC	$13.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.00

HC SOM VONWILLEBRAND AG

Facility

$25.34

Service Code	CPT 85246 90
Hospital Charge Code	900910112
Hospital Revenue Code	305
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$20.27
Rate for Payer: Cash Price	$11.40
Rate for Payer: Cigna of CA HMO/PPO	$20.27
Rate for Payer: Health Smart Auto/Commercial	$15.20
Rate for Payer: LLUH Dept of Risk Management WC	$13.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.00

HC SOM VONWILLEBRAND AG

Facility

$25.34

Service Code	CPT 85246 90
Hospital Charge Code	900910112
Hospital Revenue Code	305
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.20
Rate for Payer: Aetna of CA Government/Medicare	$15.20
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Smart Auto/Commercial	$15.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.20
Rate for Payer: LLUH Dept of Risk Management WC	$13.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.00

HC SOM VONWILLEBRAND AG

Facility

$25.34

Service Code	CPT 85246
Hospital Charge Code	900910112
Hospital Revenue Code	305
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$20.27
Rate for Payer: Cash Price	$11.40
Rate for Payer: Cigna of CA HMO/PPO	$20.27
Rate for Payer: Health Smart Auto/Commercial	$15.20
Rate for Payer: LLUH Dept of Risk Management WC	$13.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.00

HC SOM VON WILLEBRAND FACTOR ACTIVITY

Facility

$74.20

Service Code	CPT 85397
Hospital Charge Code	900912874
Hospital Revenue Code	305
Min. Negotiated Rate	$40.81
Max. Negotiated Rate	$55.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.52
Rate for Payer: Aetna of CA Government/Medicare	$44.52
Rate for Payer: Cash Price	$33.39
Rate for Payer: Health Smart Auto/Commercial	$44.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.52
Rate for Payer: LLUH Dept of Risk Management WC	$40.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.65

HC SOM VON WILLEBRAND FACTOR ACTIVITY

Facility

$74.20

Service Code	CPT 85397
Hospital Charge Code	900912874
Hospital Revenue Code	305
Min. Negotiated Rate	$40.81
Max. Negotiated Rate	$59.36
Rate for Payer: Cash Price	$33.39
Rate for Payer: Cigna of CA HMO/PPO	$59.36
Rate for Payer: Health Smart Auto/Commercial	$44.52
Rate for Payer: LLUH Dept of Risk Management WC	$40.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.65

HC SOM VON WILLEBRAND FACTOR ACTIVITY

Facility

$74.20

Service Code	CPT 85397 90
Hospital Charge Code	900912874
Hospital Revenue Code	305
Min. Negotiated Rate	$40.81
Max. Negotiated Rate	$59.36
Rate for Payer: Cash Price	$33.39
Rate for Payer: Cigna of CA HMO/PPO	$59.36
Rate for Payer: Health Smart Auto/Commercial	$44.52
Rate for Payer: LLUH Dept of Risk Management WC	$40.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.65

HC SOM VON WILLEBRAND FACTOR ACTIVITY

Facility

$74.20

Service Code	CPT 85397 90
Hospital Charge Code	900912874
Hospital Revenue Code	305
Min. Negotiated Rate	$40.81
Max. Negotiated Rate	$55.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.52
Rate for Payer: Aetna of CA Government/Medicare	$44.52
Rate for Payer: Cash Price	$33.39
Rate for Payer: Health Smart Auto/Commercial	$44.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.52
Rate for Payer: LLUH Dept of Risk Management WC	$40.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.65

HC SOM VON WILLEBRAND FACTOR MULTIMER P

Facility

$51.10

Service Code	CPT 85247
Hospital Charge Code	900910113
Hospital Revenue Code	305
Min. Negotiated Rate	$28.10
Max. Negotiated Rate	$40.88
Rate for Payer: Cash Price	$23.00
Rate for Payer: Cigna of CA HMO/PPO	$40.88
Rate for Payer: Health Smart Auto/Commercial	$30.66
Rate for Payer: LLUH Dept of Risk Management WC	$28.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.32

HC SOM VON WILLEBRAND FACTOR MULTIMER P

Facility

$51.10

Service Code	CPT 85247
Hospital Charge Code	900910113
Hospital Revenue Code	305
Min. Negotiated Rate	$28.10
Max. Negotiated Rate	$38.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.66
Rate for Payer: Aetna of CA Government/Medicare	$30.66
Rate for Payer: Cash Price	$23.00
Rate for Payer: Health Smart Auto/Commercial	$30.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.66
Rate for Payer: LLUH Dept of Risk Management WC	$28.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.32

HC SOM VON WILLEBRAND FACTOR MULTIMER P

Facility

$51.10

Service Code	CPT 85247 90
Hospital Charge Code	900910113
Hospital Revenue Code	305
Min. Negotiated Rate	$28.10
Max. Negotiated Rate	$40.88
Rate for Payer: Cash Price	$23.00
Rate for Payer: Cigna of CA HMO/PPO	$40.88
Rate for Payer: Health Smart Auto/Commercial	$30.66
Rate for Payer: LLUH Dept of Risk Management WC	$28.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.32

HC SOM VON WILLEBRAND FACTOR MULTIMER P

Facility

$51.10

Service Code	CPT 85247 90
Hospital Charge Code	900910113
Hospital Revenue Code	305
Min. Negotiated Rate	$28.10
Max. Negotiated Rate	$38.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.66
Rate for Payer: Aetna of CA Government/Medicare	$30.66
Rate for Payer: Cash Price	$23.00
Rate for Payer: Health Smart Auto/Commercial	$30.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.66
Rate for Payer: LLUH Dept of Risk Management WC	$28.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.32

HC SOM VORICONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80285 90
Hospital Charge Code	900912707
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$20.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.27
Rate for Payer: Aetna of CA Government/Medicare	$16.27
Rate for Payer: Cash Price	$12.20
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.33

HC SOM VORICONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80285 90
Hospital Charge Code	900912707
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$21.69
Rate for Payer: Cash Price	$12.20
Rate for Payer: Cigna of CA HMO/PPO	$21.69
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.33

HC SOM VORICONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80285
Hospital Charge Code	900912707
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$21.69
Rate for Payer: Cash Price	$12.20
Rate for Payer: Cigna of CA HMO/PPO	$21.69
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.33

HC SOM VORICONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80285
Hospital Charge Code	900912707
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$20.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.27
Rate for Payer: Aetna of CA Government/Medicare	$16.27
Rate for Payer: Cash Price	$12.20
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.33

HC SOM WESTERN EQUINE ENCEPH AB IGG

Facility

$25.00

Service Code	CPT 86654
Hospital Charge Code	900911337
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM WESTERN EQUINE ENCEPH AB IGG

Facility

$25.00

Service Code	CPT 86654
Hospital Charge Code	900911337
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna of CA HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM WESTERN EQUINE ENCEPH AB IGG

Facility

$25.00

Service Code	CPT 86654 90
Hospital Charge Code	900911337
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna of CA HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM WESTERN EQUINE ENCEPH AB IGG

Facility

$25.00

Service Code	CPT 86654 90
Hospital Charge Code	900911337
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

Know your out-of-pocket cost for care.

All Charges