Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC URIC ACID URINE

Facility

$18.00

Service Code	CPT 84560
Hospital Charge Code	900910216
Hospital Revenue Code	301
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Cash Price	$8.10
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.50

HC URINE CHEMISTRY SCREEN

Facility

$12.00

Service Code	CPT 81003
Hospital Charge Code	900910180
Hospital Revenue Code	307
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.00

HC URINE CHEMISTRY SCREEN

Facility

$89.00

Service Code	CPT 81003
Hospital Charge Code	900910180
Hospital Revenue Code	307
Min. Negotiated Rate	$48.95
Max. Negotiated Rate	$71.20
Rate for Payer: Cash Price	$40.05
Rate for Payer: Cigna of CA HMO/PPO	$71.20
Rate for Payer: Health Smart Auto/Commercial	$53.40
Rate for Payer: LLUH Dept of Risk Management WC	$48.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.75

HC URINE CHEM SCREEN POC

Facility

$89.00

Service Code	CPT 81003
Hospital Charge Code	900912015
Hospital Revenue Code	306
Min. Negotiated Rate	$48.95
Max. Negotiated Rate	$71.20
Rate for Payer: Cash Price	$40.05
Rate for Payer: Cigna of CA HMO/PPO	$71.20
Rate for Payer: Health Smart Auto/Commercial	$53.40
Rate for Payer: LLUH Dept of Risk Management WC	$48.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.75

HC URINE CHEM SCREEN POC

Facility

$89.00

Service Code	CPT 81003
Hospital Charge Code	900912015
Hospital Revenue Code	306
Min. Negotiated Rate	$48.95
Max. Negotiated Rate	$66.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.40
Rate for Payer: Aetna of CA Government/Medicare	$53.40
Rate for Payer: Cash Price	$40.05
Rate for Payer: Health Smart Auto/Commercial	$53.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.40
Rate for Payer: LLUH Dept of Risk Management WC	$48.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.75

HC VALPROIC ACID (DEPAKENE)

Facility

$50.00

Service Code	CPT 80164
Hospital Charge Code	900910927
Hospital Revenue Code	301
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 VALPROIC ACID (DEPAKENE)

Facility

$223.00

Service Code	CPT 80164
Hospital Charge Code	900910927
Hospital Revenue Code	301
Min. Negotiated Rate	$122.65
Max. Negotiated Rate	$178.40
Rate for Payer: Cash Price	$100.35
Rate for Payer: Cigna of CA HMO/PPO	$178.40
Rate for Payer: Health Smart Auto/Commercial	$133.80
Rate for Payer: LLUH Dept of Risk Management WC	$122.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$167.25

HC VANCOMYCIN

Facility

$250.00

Service Code	CPT 80202
Hospital Charge Code	900910934
Hospital Revenue Code	301
Min. Negotiated Rate	$137.50
Max. Negotiated Rate	$200.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna of CA HMO/PPO	$200.00
Rate for Payer: Health Smart Auto/Commercial	$150.00
Rate for Payer: LLUH Dept of Risk Management WC	$137.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$187.50

HC VANCOMYCIN

Facility

$50.00

Service Code	CPT 80202
Hospital Charge Code	900910934
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Cash Price	$22.50
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: 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 VANILMANDELIC ACID

Facility

$204.00

Service Code	CPT 84585
Hospital Charge Code	900910531
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

HC VANILMANDELIC ACID

Facility

$59.00

Service Code	CPT 84585
Hospital Charge Code	900910531
Hospital Revenue Code	301
Min. Negotiated Rate	$32.45
Max. Negotiated Rate	$44.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.40
Rate for Payer: Aetna of CA Government/Medicare	$35.40
Rate for Payer: Cash Price	$26.55
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.40
Rate for Payer: LLUH Dept of Risk Management WC	$32.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.25

HC VARICELLA ZOSTER ANTIBODY

Facility

$58.00

Service Code	CPT 86787
Hospital Charge Code	900913671
Hospital Revenue Code	302
Min. Negotiated Rate	$31.90
Max. Negotiated Rate	$46.40
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna of CA HMO/PPO	$46.40
Rate for Payer: Health Smart Auto/Commercial	$34.80
Rate for Payer: LLUH Dept of Risk Management WC	$31.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$43.50

HC VARICELLA ZOSTER ANTIBODY

Facility

$39.00

Service Code	CPT 86787
Hospital Charge Code	900913671
Hospital Revenue Code	302
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$29.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.40
Rate for Payer: Aetna of CA Government/Medicare	$23.40
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.25

HC VITAMIN B12

Facility

$30.00

Service Code	CPT 82607
Hospital Charge Code	900910830
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC VITAMIN B12

Facility

$244.00

Service Code	CPT 82607
Hospital Charge Code	900910830
Hospital Revenue Code	301
Min. Negotiated Rate	$134.20
Max. Negotiated Rate	$195.20
Rate for Payer: Cash Price	$109.80
Rate for Payer: Cigna of CA HMO/PPO	$195.20
Rate for Payer: Health Smart Auto/Commercial	$146.40
Rate for Payer: LLUH Dept of Risk Management WC	$134.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$183.00

HC VITAMIN D TOTAL

Facility

$64.00

Service Code	CPT 82306
Hospital Charge Code	900912240
Hospital Revenue Code	302
Min. Negotiated Rate	$35.20
Max. Negotiated Rate	$51.20
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna of CA HMO/PPO	$51.20
Rate for Payer: Health Smart Auto/Commercial	$38.40
Rate for Payer: LLUH Dept of Risk Management WC	$35.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$48.00

HC VITAMIN D TOTAL

Facility

$45.00

Service Code	CPT 82306
Hospital Charge Code	900912240
Hospital Revenue Code	302
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 VOIDING CYSTO URETHROGRAM

Facility

$1,155.00

Service Code	CPT 74455 TC
Hospital Charge Code	909001902
Hospital Revenue Code	320
Min. Negotiated Rate	$635.25
Max. Negotiated Rate	$866.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$693.00
Rate for Payer: Aetna of CA Government/Medicare	$693.00
Rate for Payer: Cash Price	$519.75
Rate for Payer: Health Smart Auto/Commercial	$693.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$693.00
Rate for Payer: LLUH Dept of Risk Management WC	$635.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$866.25

HC VOIDING CYSTO URETHROGRAM

Facility

$1,155.00

Service Code	CPT 74455
Hospital Charge Code	909001902
Hospital Revenue Code	320
Min. Negotiated Rate	$635.25
Max. Negotiated Rate	$866.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$693.00
Rate for Payer: Aetna of CA Government/Medicare	$693.00
Rate for Payer: Cash Price	$519.75
Rate for Payer: Health Smart Auto/Commercial	$693.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$693.00
Rate for Payer: LLUH Dept of Risk Management WC	$635.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$866.25

HC VOIDING CYSTO URETHROGRAM

Facility

$1,155.00

Service Code	CPT 74455
Hospital Charge Code	909001902
Hospital Revenue Code	320
Min. Negotiated Rate	$635.25
Max. Negotiated Rate	$924.00
Rate for Payer: Cash Price	$519.75
Rate for Payer: Cigna of CA HMO/PPO	$924.00
Rate for Payer: Health Smart Auto/Commercial	$693.00
Rate for Payer: LLUH Dept of Risk Management WC	$635.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$866.25

HC VOIDING CYSTO URETHROGRAM

Facility

$1,155.00

Service Code	CPT 74455 TC
Hospital Charge Code	909001902
Hospital Revenue Code	320
Min. Negotiated Rate	$635.25
Max. Negotiated Rate	$924.00
Rate for Payer: Cash Price	$519.75
Rate for Payer: Cigna of CA HMO/PPO	$924.00
Rate for Payer: Health Smart Auto/Commercial	$693.00
Rate for Payer: LLUH Dept of Risk Management WC	$635.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$866.25

HC VZV AB

Facility

$204.00

Service Code	CPT 86787
Hospital Charge Code	900913532
Hospital Revenue Code	302
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

HC VZV AB

Facility

$27.00

Service Code	CPT 86787
Hospital Charge Code	900913532
Hospital Revenue Code	302
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$20.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.20
Rate for Payer: Aetna of CA Government/Medicare	$16.20
Rate for Payer: Cash Price	$12.15
Rate for Payer: Health Smart Auto/Commercial	$16.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.20
Rate for Payer: LLUH Dept of Risk Management WC	$14.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.25

HC WEAK ACIDIC DRUG CONF & ID

Facility

$271.00

Service Code	CPT G0480
Hospital Charge Code	900910512
Hospital Revenue Code	301
Min. Negotiated Rate	$149.05
Max. Negotiated Rate	$216.80
Rate for Payer: Cash Price	$121.95
Rate for Payer: Cigna of CA HMO/PPO	$216.80
Rate for Payer: Health Smart Auto/Commercial	$162.60
Rate for Payer: LLUH Dept of Risk Management WC	$149.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$203.25

HC WEAK ACIDIC DRUG CONF & ID

Facility

$225.00

Service Code	CPT G0480
Hospital Charge Code	900910512
Hospital Revenue Code	301
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$168.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$135.00
Rate for Payer: Aetna of CA Government/Medicare	$135.00
Rate for Payer: Cash Price	$101.25
Rate for Payer: Health Smart Auto/Commercial	$135.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$135.00
Rate for Payer: LLUH Dept of Risk Management WC	$123.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$168.75

Know your out-of-pocket cost for care.

All Charges