Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM CARB DEF TRANS CONGENITAL

Facility

$200.00

Service Code	CPT 82373
Hospital Charge Code	900912514
Hospital Revenue Code	301
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$120.00
Rate for Payer: Aetna of CA Government/Medicare	$120.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$150.00

HC SOM CARB DEF TRANS CONGENITAL

Facility

$200.00

Service Code	CPT 82373 90
Hospital Charge Code	900912514
Hospital Revenue Code	301
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cigna of CA HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$150.00

HC SOM CARB DEF TRANSFERRIN ADULT

Facility

$342.30

Service Code	CPT 82373 90
Hospital Charge Code	900912717
Hospital Revenue Code	301
Min. Negotiated Rate	$188.26
Max. Negotiated Rate	$256.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$205.38
Rate for Payer: Aetna of CA Government/Medicare	$205.38
Rate for Payer: Cash Price	$154.04
Rate for Payer: Health Smart Auto/Commercial	$205.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$205.38
Rate for Payer: LLUH Dept of Risk Management WC	$188.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$256.72

HC SOM CARB DEF TRANSFERRIN ADULT

Facility

$342.30

Service Code	CPT 82373
Hospital Charge Code	900912717
Hospital Revenue Code	301
Min. Negotiated Rate	$188.26
Max. Negotiated Rate	$273.84
Rate for Payer: Cash Price	$154.04
Rate for Payer: Cigna of CA HMO/PPO	$273.84
Rate for Payer: Health Smart Auto/Commercial	$205.38
Rate for Payer: LLUH Dept of Risk Management WC	$188.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$256.72

HC SOM CARB DEF TRANSFERRIN ADULT

Facility

$342.30

Service Code	CPT 82373 90
Hospital Charge Code	900912717
Hospital Revenue Code	301
Min. Negotiated Rate	$188.26
Max. Negotiated Rate	$273.84
Rate for Payer: Cash Price	$154.04
Rate for Payer: Cigna of CA HMO/PPO	$273.84
Rate for Payer: Health Smart Auto/Commercial	$205.38
Rate for Payer: LLUH Dept of Risk Management WC	$188.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$256.72

HC SOM CARB DEF TRANSFERRIN ADULT

Facility

$342.30

Service Code	CPT 82373
Hospital Charge Code	900912717
Hospital Revenue Code	301
Min. Negotiated Rate	$188.26
Max. Negotiated Rate	$256.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$205.38
Rate for Payer: Aetna of CA Government/Medicare	$205.38
Rate for Payer: Cash Price	$154.04
Rate for Payer: Health Smart Auto/Commercial	$205.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$205.38
Rate for Payer: LLUH Dept of Risk Management WC	$188.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$256.72

HC SOM CARBOXYHEMOGLOBIN

Facility

$35.00

Service Code	CPT 82375
Hospital Charge Code	900911041
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 CARBOXYHEMOGLOBIN

Facility

$35.00

Service Code	CPT 82375
Hospital Charge Code	900911041
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 CARBOXYHEMOGLOBIN

Facility

$35.00

Service Code	CPT 82375 90
Hospital Charge Code	900911041
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 CARBOXYHEMOGLOBIN

Facility

$35.00

Service Code	CPT 82375 90
Hospital Charge Code	900911041
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 CARNITINE PLASMA

Facility

$25.00

Service Code	CPT 82379
Hospital Charge Code	900911103
Hospital Revenue Code	301
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 CARNITINE PLASMA

Facility

$25.00

Service Code	CPT 82379 90
Hospital Charge Code	900911103
Hospital Revenue Code	301
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 CARNITINE PLASMA

Facility

$25.00

Service Code	CPT 82379 90
Hospital Charge Code	900911103
Hospital Revenue Code	301
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 CARNITINE PLASMA

Facility

$25.00

Service Code	CPT 82379
Hospital Charge Code	900911103
Hospital Revenue Code	301
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 CARNITINE URINE

Facility

$60.00

Service Code	CPT 82379
Hospital Charge Code	900910730
Hospital Revenue Code	301
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$48.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna of CA HMO/PPO	$48.00
Rate for Payer: Health Smart Auto/Commercial	$36.00
Rate for Payer: LLUH Dept of Risk Management WC	$33.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.00

HC SOM CARNITINE URINE

Facility

$60.00

Service Code	CPT 82379 90
Hospital Charge Code	900910730
Hospital Revenue Code	301
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.00
Rate for Payer: Aetna of CA Government/Medicare	$36.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Smart Auto/Commercial	$36.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.00
Rate for Payer: LLUH Dept of Risk Management WC	$33.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.00

HC SOM CARNITINE URINE

Facility

$60.00

Service Code	CPT 82379 90
Hospital Charge Code	900910730
Hospital Revenue Code	301
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$48.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna of CA HMO/PPO	$48.00
Rate for Payer: Health Smart Auto/Commercial	$36.00
Rate for Payer: LLUH Dept of Risk Management WC	$33.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.00

HC SOM CARNITINE URINE

Facility

$60.00

Service Code	CPT 82379
Hospital Charge Code	900910730
Hospital Revenue Code	301
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.00
Rate for Payer: Aetna of CA Government/Medicare	$36.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Health Smart Auto/Commercial	$36.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.00
Rate for Payer: LLUH Dept of Risk Management WC	$33.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.00

HC SOM CAROTENE

Facility

$122.75

Service Code	CPT 82380
Hospital Charge Code	900911303
Hospital Revenue Code	301
Min. Negotiated Rate	$67.51
Max. Negotiated Rate	$98.20
Rate for Payer: Cash Price	$55.24
Rate for Payer: Cigna of CA HMO/PPO	$98.20
Rate for Payer: Health Smart Auto/Commercial	$73.65
Rate for Payer: LLUH Dept of Risk Management WC	$67.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$92.06

HC SOM CAROTENE

Facility

$122.75

Service Code	CPT 82380 90
Hospital Charge Code	900911303
Hospital Revenue Code	301
Min. Negotiated Rate	$67.51
Max. Negotiated Rate	$92.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$73.65
Rate for Payer: Aetna of CA Government/Medicare	$73.65
Rate for Payer: Cash Price	$55.24
Rate for Payer: Health Smart Auto/Commercial	$73.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$73.65
Rate for Payer: LLUH Dept of Risk Management WC	$67.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$92.06

HC SOM CAROTENE

Facility

$122.75

Service Code	CPT 82380 90
Hospital Charge Code	900911303
Hospital Revenue Code	301
Min. Negotiated Rate	$67.51
Max. Negotiated Rate	$98.20
Rate for Payer: Cash Price	$55.24
Rate for Payer: Cigna of CA HMO/PPO	$98.20
Rate for Payer: Health Smart Auto/Commercial	$73.65
Rate for Payer: LLUH Dept of Risk Management WC	$67.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$92.06

HC SOM CAROTENE

Facility

$122.75

Service Code	CPT 82380
Hospital Charge Code	900911303
Hospital Revenue Code	301
Min. Negotiated Rate	$67.51
Max. Negotiated Rate	$92.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$73.65
Rate for Payer: Aetna of CA Government/Medicare	$73.65
Rate for Payer: Cash Price	$55.24
Rate for Payer: Health Smart Auto/Commercial	$73.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$73.65
Rate for Payer: LLUH Dept of Risk Management WC	$67.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$92.06

HC SOM CATECHOLAMINE FRACT FREE UR

Facility

$30.00

Service Code	CPT 82384
Hospital Charge Code	900914081
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM CATECHOLAMINE FRACT FREE UR

Facility

$30.00

Service Code	CPT 82384
Hospital Charge Code	900914081
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 CATECHOLAMINE FRACT FREE UR

Facility

$30.00

Service Code	CPT 82384 90
Hospital Charge Code	900914081
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

Know your out-of-pocket cost for care.

All Charges