Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM ALPHA-2-MACROGLOBULIN

Facility

$30.00

Service Code	CPT 83883 90
Hospital Charge Code	900911487
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 SOM ALPHA-2-MACROGLOBULIN

Facility

$30.00

Service Code	CPT 83883 90
Hospital Charge Code	900911487
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM ALPHA-2-MACROGLOBULIN

Facility

$30.00

Service Code	CPT 83883
Hospital Charge Code	900911487
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM ALPHA-FETOPROTEIN, AMNIOTIC FL

Facility

$35.00

Service Code	CPT 82106 90
Hospital Charge Code	900910946
Hospital Revenue Code	301
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 ALPHA-FETOPROTEIN, AMNIOTIC FL

Facility

$35.00

Service Code	CPT 82106
Hospital Charge Code	900910946
Hospital Revenue Code	301
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 ALPHA-FETOPROTEIN, AMNIOTIC FL

Facility

$35.00

Service Code	CPT 82106
Hospital Charge Code	900910946
Hospital Revenue Code	301
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 ALPHA-FETOPROTEIN, AMNIOTIC FL

Facility

$35.00

Service Code	CPT 82106 90
Hospital Charge Code	900910946
Hospital Revenue Code	301
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 ALPHA FETOPROTEIN CSF

Facility

$15.00

Service Code	CPT 86316
Hospital Charge Code	900910585
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC SOM ALPHA FETOPROTEIN CSF

Facility

$15.00

Service Code	CPT 86316 90
Hospital Charge Code	900910585
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Cigna of CA HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC SOM ALPHA FETOPROTEIN CSF

Facility

$15.00

Service Code	CPT 86316 90
Hospital Charge Code	900910585
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC SOM ALPHA FETOPROTEIN CSF

Facility

$15.00

Service Code	CPT 86316
Hospital Charge Code	900910585
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Cigna of CA HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC SOM ALPHA GALACTOSIDASE

Facility

$250.00

Service Code	CPT 82657
Hospital Charge Code	900910718
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 SOM ALPHA GALACTOSIDASE

Facility

$250.00

Service Code	CPT 82657 90
Hospital Charge Code	900910718
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 SOM ALPHA GALACTOSIDASE

Facility

$250.00

Service Code	CPT 82657
Hospital Charge Code	900910718
Hospital Revenue Code	301
Min. Negotiated Rate	$137.50
Max. Negotiated Rate	$187.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$150.00
Rate for Payer: Aetna of CA Government/Medicare	$150.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Health Smart Auto/Commercial	$150.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$150.00
Rate for Payer: LLUH Dept of Risk Management WC	$137.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$187.50

HC SOM ALPHA GALACTOSIDASE

Facility

$250.00

Service Code	CPT 82657 90
Hospital Charge Code	900910718
Hospital Revenue Code	301
Min. Negotiated Rate	$137.50
Max. Negotiated Rate	$187.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$150.00
Rate for Payer: Aetna of CA Government/Medicare	$150.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Health Smart Auto/Commercial	$150.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$150.00
Rate for Payer: LLUH Dept of Risk Management WC	$137.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$187.50

HC SOM ALUMINUM

Facility

$19.99

Service Code	CPT 82108
Hospital Charge Code	900911262
Hospital Revenue Code	301
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$14.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.99
Rate for Payer: Aetna of CA Government/Medicare	$11.99
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Smart Auto/Commercial	$11.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.99
Rate for Payer: LLUH Dept of Risk Management WC	$10.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.99

HC SOM ALUMINUM

Facility

$19.99

Service Code	CPT 82108 90
Hospital Charge Code	900911262
Hospital Revenue Code	301
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$14.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.99
Rate for Payer: Aetna of CA Government/Medicare	$11.99
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Smart Auto/Commercial	$11.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.99
Rate for Payer: LLUH Dept of Risk Management WC	$10.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.99

HC SOM ALUMINUM

Facility

$19.99

Service Code	CPT 82108
Hospital Charge Code	900911262
Hospital Revenue Code	301
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$15.99
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna of CA HMO/PPO	$15.99
Rate for Payer: Health Smart Auto/Commercial	$11.99
Rate for Payer: LLUH Dept of Risk Management WC	$10.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.99

HC SOM ALUMINUM

Facility

$19.99

Service Code	CPT 82108 90
Hospital Charge Code	900911262
Hospital Revenue Code	301
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$15.99
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna of CA HMO/PPO	$15.99
Rate for Payer: Health Smart Auto/Commercial	$11.99
Rate for Payer: LLUH Dept of Risk Management WC	$10.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.99

HC SOM AMEBIASIS AB TITER

Facility

$30.00

Service Code	CPT 86753 90
Hospital Charge Code	900911754
Hospital Revenue Code	302
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM AMEBIASIS AB TITER

Facility

$30.00

Service Code	CPT 86753
Hospital Charge Code	900911754
Hospital Revenue Code	302
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM AMEBIASIS AB TITER

Facility

$30.00

Service Code	CPT 86753
Hospital Charge Code	900911754
Hospital Revenue Code	302
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 SOM AMEBIASIS AB TITER

Facility

$30.00

Service Code	CPT 86753 90
Hospital Charge Code	900911754
Hospital Revenue Code	302
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 SOM AMINO ACID QUANT UR RANDOM

Facility

$100.00

Service Code	CPT 82139
Hospital Charge Code	900911210
Hospital Revenue Code	301
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.00
Rate for Payer: Aetna of CA Government/Medicare	$60.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Smart Auto/Commercial	$60.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.00

HC SOM AMINO ACID QUANT UR RANDOM

Facility

$100.00

Service Code	CPT 82139 90
Hospital Charge Code	900911210
Hospital Revenue Code	301
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.00
Rate for Payer: Aetna of CA Government/Medicare	$60.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Health Smart Auto/Commercial	$60.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.00

Know your out-of-pocket cost for care.

All Charges