Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM ACID PHOSPHATASE TOTAL

Facility

$174.77

Service Code	CPT 84066
Hospital Charge Code	900910217
Hospital Revenue Code	301
Min. Negotiated Rate	$96.12
Max. Negotiated Rate	$139.82
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cigna of CA HMO/PPO	$139.82
Rate for Payer: Health Smart Auto/Commercial	$104.86
Rate for Payer: LLUH Dept of Risk Management WC	$96.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.08

HC SOM ACID PHOSPHATASE TOTAL

Facility

$174.77

Service Code	CPT 84066 90
Hospital Charge Code	900910217
Hospital Revenue Code	301
Min. Negotiated Rate	$96.12
Max. Negotiated Rate	$139.82
Rate for Payer: Cash Price	$78.65
Rate for Payer: Cigna of CA HMO/PPO	$139.82
Rate for Payer: Health Smart Auto/Commercial	$104.86
Rate for Payer: LLUH Dept of Risk Management WC	$96.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.08

HC SOM ACTIVATED PROTEIN C RESISTANCE

Facility

$35.00

Service Code	CPT 85307 90
Hospital Charge Code	900912508
Hospital Revenue Code	305
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$26.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.00
Rate for Payer: Aetna of CA Government/Medicare	$21.00
Rate for Payer: Cash Price	$15.75
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.25

HC SOM ACTIVATED PROTEIN C RESISTANCE

Facility

$35.00

Service Code	CPT 85307
Hospital Charge Code	900912508
Hospital Revenue Code	305
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$26.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.00
Rate for Payer: Aetna of CA Government/Medicare	$21.00
Rate for Payer: Cash Price	$15.75
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.25

HC SOM ACTIVATED PROTEIN C RESISTANCE

Facility

$35.00

Service Code	CPT 85307 90
Hospital Charge Code	900912508
Hospital Revenue Code	305
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$28.00
Rate for Payer: Cash Price	$15.75
Rate for Payer: Cigna of CA HMO/PPO	$28.00
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.25

HC SOM ACTIVATED PROTEIN C RESISTANCE

Facility

$35.00

Service Code	CPT 85307
Hospital Charge Code	900912508
Hospital Revenue Code	305
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$28.00
Rate for Payer: Cash Price	$15.75
Rate for Payer: Cigna of CA HMO/PPO	$28.00
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$26.25

HC SOM ACYCLOVIR

Facility

$164.00

Service Code	CPT 80299 90
Hospital Charge Code	900910711
Hospital Revenue Code	301
Min. Negotiated Rate	$90.20
Max. Negotiated Rate	$131.20
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna of CA HMO/PPO	$131.20
Rate for Payer: Health Smart Auto/Commercial	$98.40
Rate for Payer: LLUH Dept of Risk Management WC	$90.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$123.00

HC SOM ACYCLOVIR

Facility

$164.00

Service Code	CPT 80299 90
Hospital Charge Code	900910711
Hospital Revenue Code	301
Min. Negotiated Rate	$90.20
Max. Negotiated Rate	$123.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$98.40
Rate for Payer: Aetna of CA Government/Medicare	$98.40
Rate for Payer: Cash Price	$73.80
Rate for Payer: Health Smart Auto/Commercial	$98.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$98.40
Rate for Payer: LLUH Dept of Risk Management WC	$90.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$123.00

HC SOM ACYCLOVIR

Facility

$164.00

Service Code	CPT 80299
Hospital Charge Code	900910711
Hospital Revenue Code	301
Min. Negotiated Rate	$90.20
Max. Negotiated Rate	$123.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$98.40
Rate for Payer: Aetna of CA Government/Medicare	$98.40
Rate for Payer: Cash Price	$73.80
Rate for Payer: Health Smart Auto/Commercial	$98.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$98.40
Rate for Payer: LLUH Dept of Risk Management WC	$90.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$123.00

HC SOM ACYCLOVIR

Facility

$164.00

Service Code	CPT 80299
Hospital Charge Code	900910711
Hospital Revenue Code	301
Min. Negotiated Rate	$90.20
Max. Negotiated Rate	$131.20
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna of CA HMO/PPO	$131.20
Rate for Payer: Health Smart Auto/Commercial	$98.40
Rate for Payer: LLUH Dept of Risk Management WC	$90.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$123.00

HC SOM ACYLCARNITINE PROFILE(PKU CARD

Facility

$41.20

Service Code	CPT 82017 90
Hospital Charge Code	900911486
Hospital Revenue Code	301
Min. Negotiated Rate	$22.66
Max. Negotiated Rate	$30.90
Rate for Payer: Health Smart Auto/Commercial	$24.72
Rate for Payer: Cash Price	$18.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.72
Rate for Payer: Aetna of CA Government/Medicare	$24.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.72
Rate for Payer: LLUH Dept of Risk Management WC	$22.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.90

HC SOM ACYLCARNITINE PROFILE(PKU CARD

Facility

$41.20

Service Code	CPT 82017
Hospital Charge Code	900911486
Hospital Revenue Code	301
Min. Negotiated Rate	$22.66
Max. Negotiated Rate	$32.96
Rate for Payer: Cash Price	$18.54
Rate for Payer: Cigna of CA HMO/PPO	$32.96
Rate for Payer: Health Smart Auto/Commercial	$24.72
Rate for Payer: LLUH Dept of Risk Management WC	$22.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.90

HC SOM ACYLCARNITINE PROFILE(PKU CARD

Facility

$41.20

Service Code	CPT 82017 90
Hospital Charge Code	900911486
Hospital Revenue Code	301
Min. Negotiated Rate	$22.66
Max. Negotiated Rate	$32.96
Rate for Payer: Cash Price	$18.54
Rate for Payer: Cigna of CA HMO/PPO	$32.96
Rate for Payer: Health Smart Auto/Commercial	$24.72
Rate for Payer: LLUH Dept of Risk Management WC	$22.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.90

HC SOM ACYLCARNITINE PROFILE(PKU CARD

Facility

$41.20

Service Code	CPT 82017
Hospital Charge Code	900911486
Hospital Revenue Code	301
Min. Negotiated Rate	$22.66
Max. Negotiated Rate	$30.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.72
Rate for Payer: Aetna of CA Government/Medicare	$24.72
Rate for Payer: Cash Price	$18.54
Rate for Payer: Health Smart Auto/Commercial	$24.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.72
Rate for Payer: LLUH Dept of Risk Management WC	$22.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.90

HC SOM ACYLGLYCINE

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900910712
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$131.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM ACYLGLYCINE

Facility

$175.00

Service Code	CPT 82542 90
Hospital Charge Code	900910712
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$131.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM ACYLGLYCINE

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900910712
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Cigna of CA HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM ACYLGLYCINE

Facility

$175.00

Service Code	CPT 82542 90
Hospital Charge Code	900910712
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Cigna of CA HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM ADENOSINE DEAMINASE

Facility

$145.00

Service Code	CPT 84311
Hospital Charge Code	900911409
Hospital Revenue Code	301
Min. Negotiated Rate	$79.75
Max. Negotiated Rate	$108.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$87.00
Rate for Payer: Aetna of CA Government/Medicare	$87.00
Rate for Payer: Cash Price	$65.25
Rate for Payer: Health Smart Auto/Commercial	$87.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$87.00
Rate for Payer: LLUH Dept of Risk Management WC	$79.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$108.75

HC SOM ADENOSINE DEAMINASE

Facility

$145.00

Service Code	CPT 84311 90
Hospital Charge Code	900911409
Hospital Revenue Code	301
Min. Negotiated Rate	$79.75
Max. Negotiated Rate	$116.00
Rate for Payer: Cash Price	$65.25
Rate for Payer: Cigna of CA HMO/PPO	$116.00
Rate for Payer: Health Smart Auto/Commercial	$87.00
Rate for Payer: LLUH Dept of Risk Management WC	$79.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$108.75

HC SOM ADENOSINE DEAMINASE

Facility

$145.00

Service Code	CPT 84311 90
Hospital Charge Code	900911409
Hospital Revenue Code	301
Min. Negotiated Rate	$79.75
Max. Negotiated Rate	$108.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$87.00
Rate for Payer: Aetna of CA Government/Medicare	$87.00
Rate for Payer: Cash Price	$65.25
Rate for Payer: Health Smart Auto/Commercial	$87.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$87.00
Rate for Payer: LLUH Dept of Risk Management WC	$79.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$108.75

HC SOM ADENOSINE DEAMINASE

Facility

$145.00

Service Code	CPT 84311
Hospital Charge Code	900911409
Hospital Revenue Code	301
Min. Negotiated Rate	$79.75
Max. Negotiated Rate	$116.00
Rate for Payer: Cash Price	$65.25
Rate for Payer: Cigna of CA HMO/PPO	$116.00
Rate for Payer: Health Smart Auto/Commercial	$87.00
Rate for Payer: LLUH Dept of Risk Management WC	$79.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$108.75

HC SOM ADENOVIRUS DNA PCR

Facility

$50.27

Service Code	CPT 87798 90
Hospital Charge Code	900912712
Hospital Revenue Code	300
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 ADENOVIRUS DNA PCR

Facility

$50.27

Service Code	CPT 87798
Hospital Charge Code	900912712
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 ADENOVIRUS DNA PCR

Facility

$50.27

Service Code	CPT 87798
Hospital Charge Code	900912712
Hospital Revenue Code	306
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$37.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.16
Rate for Payer: Aetna of CA Government/Medicare	$30.16
Rate for Payer: Cash Price	$22.62
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.70

Know your out-of-pocket cost for care.

All Charges