Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM FANBF 86038

Facility

$75.00

Service Code	CPT 86038
Hospital Charge Code	900914925
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Cigna of CA HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM FANBF 86038

Facility

$75.00

Service Code	CPT 86038 90
Hospital Charge Code	900914925
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Cigna of CA HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM FAP KNOWN MUT EXTRACT

Facility

$318.21

Service Code	CPT 81202
Hospital Charge Code	900914620
Hospital Revenue Code	309
Min. Negotiated Rate	$175.02
Max. Negotiated Rate	$238.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$190.93
Rate for Payer: Aetna of CA Government/Medicare	$190.93
Rate for Payer: Cash Price	$143.19
Rate for Payer: Health Smart Auto/Commercial	$190.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$190.93
Rate for Payer: LLUH Dept of Risk Management WC	$175.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$238.66

HC SOM FAP KNOWN MUT EXTRACT

Facility

$318.21

Service Code	CPT 81202 90
Hospital Charge Code	900914620
Hospital Revenue Code	301
Min. Negotiated Rate	$175.02
Max. Negotiated Rate	$238.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$190.93
Rate for Payer: Aetna of CA Government/Medicare	$190.93
Rate for Payer: Cash Price	$143.19
Rate for Payer: Health Smart Auto/Commercial	$190.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$190.93
Rate for Payer: LLUH Dept of Risk Management WC	$175.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$238.66

HC SOM FAP KNOWN MUT EXTRACT

Facility

$318.21

Service Code	CPT 81202
Hospital Charge Code	900914620
Hospital Revenue Code	309
Min. Negotiated Rate	$175.02
Max. Negotiated Rate	$254.57
Rate for Payer: Cash Price	$143.19
Rate for Payer: Cigna of CA HMO/PPO	$254.57
Rate for Payer: Health Smart Auto/Commercial	$190.93
Rate for Payer: LLUH Dept of Risk Management WC	$175.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$238.66

HC SOM FAP KNOWN MUT EXTRACT

Facility

$318.21

Service Code	CPT 81202 90
Hospital Charge Code	900914620
Hospital Revenue Code	301
Min. Negotiated Rate	$175.02
Max. Negotiated Rate	$254.57
Rate for Payer: Cash Price	$143.19
Rate for Payer: Cigna of CA HMO/PPO	$254.57
Rate for Payer: Health Smart Auto/Commercial	$190.93
Rate for Payer: LLUH Dept of Risk Management WC	$175.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$238.66

HC SOM FAT FECAL QUANT

Facility

$28.02

Service Code	CPT 82710 90
Hospital Charge Code	900911139
Hospital Revenue Code	301
Min. Negotiated Rate	$15.41
Max. Negotiated Rate	$21.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.81
Rate for Payer: Aetna of CA Government/Medicare	$16.81
Rate for Payer: Cash Price	$12.61
Rate for Payer: Health Smart Auto/Commercial	$16.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.81
Rate for Payer: LLUH Dept of Risk Management WC	$15.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.02

HC SOM FAT FECAL QUANT

Facility

$28.02

Service Code	CPT 82710 90
Hospital Charge Code	900911139
Hospital Revenue Code	301
Min. Negotiated Rate	$15.41
Max. Negotiated Rate	$22.42
Rate for Payer: Cash Price	$12.61
Rate for Payer: Cigna of CA HMO/PPO	$22.42
Rate for Payer: Health Smart Auto/Commercial	$16.81
Rate for Payer: LLUH Dept of Risk Management WC	$15.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.02

HC SOM FAT FECAL QUANT

Facility

$28.02

Service Code	CPT 82710
Hospital Charge Code	900911139
Hospital Revenue Code	301
Min. Negotiated Rate	$15.41
Max. Negotiated Rate	$21.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.81
Rate for Payer: Aetna of CA Government/Medicare	$16.81
Rate for Payer: Cash Price	$12.61
Rate for Payer: Health Smart Auto/Commercial	$16.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.81
Rate for Payer: LLUH Dept of Risk Management WC	$15.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.02

HC SOM FAT FECAL QUANT

Facility

$28.02

Service Code	CPT 82710
Hospital Charge Code	900911139
Hospital Revenue Code	301
Min. Negotiated Rate	$15.41
Max. Negotiated Rate	$22.42
Rate for Payer: Cash Price	$12.61
Rate for Payer: Cigna of CA HMO/PPO	$22.42
Rate for Payer: Health Smart Auto/Commercial	$16.81
Rate for Payer: LLUH Dept of Risk Management WC	$15.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.02

HC SOM FATTY ACIDS FREE

Facility

$200.00

Service Code	CPT 82725
Hospital Charge Code	900910286
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 FATTY ACIDS FREE

Facility

$200.00

Service Code	CPT 82725 90
Hospital Charge Code	900910286
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 FATTY ACIDS FREE

Facility

$200.00

Service Code	CPT 82725 90
Hospital Charge Code	900910286
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 FATTY ACIDS FREE

Facility

$200.00

Service Code	CPT 82725
Hospital Charge Code	900910286
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 FATTY ACIDS PEROXISOMAL

Facility

$150.00

Service Code	CPT 82726
Hospital Charge Code	900911471
Hospital Revenue Code	301
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$120.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna of CA HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.50

HC SOM FATTY ACIDS PEROXISOMAL

Facility

$150.00

Service Code	CPT 82726 90
Hospital Charge Code	900911471
Hospital Revenue Code	301
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.00
Rate for Payer: Aetna of CA Government/Medicare	$90.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.50

HC SOM FATTY ACIDS PEROXISOMAL

Facility

$150.00

Service Code	CPT 82726 90
Hospital Charge Code	900911471
Hospital Revenue Code	301
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$120.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna of CA HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.50

HC SOM FATTY ACIDS PEROXISOMAL

Facility

$150.00

Service Code	CPT 82726
Hospital Charge Code	900911471
Hospital Revenue Code	301
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.00
Rate for Payer: Aetna of CA Government/Medicare	$90.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.50

HC SOM FBP1 88273

Facility

$84.86

Service Code	CPT 88273
Hospital Charge Code	900914874
Hospital Revenue Code	309
Min. Negotiated Rate	$46.67
Max. Negotiated Rate	$67.89
Rate for Payer: Cash Price	$38.19
Rate for Payer: Cigna of CA HMO/PPO	$67.89
Rate for Payer: Health Smart Auto/Commercial	$50.92
Rate for Payer: LLUH Dept of Risk Management WC	$46.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.64

HC SOM FBP1 88273

Facility

$84.86

Service Code	CPT 88273
Hospital Charge Code	900914874
Hospital Revenue Code	309
Min. Negotiated Rate	$46.67
Max. Negotiated Rate	$63.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.92
Rate for Payer: Aetna of CA Government/Medicare	$50.92
Rate for Payer: Cash Price	$38.19
Rate for Payer: Health Smart Auto/Commercial	$50.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.92
Rate for Payer: LLUH Dept of Risk Management WC	$46.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.64

HC SOM FBP1 88273

Facility

$84.86

Service Code	CPT 88273 90
Hospital Charge Code	900914874
Hospital Revenue Code	310
Min. Negotiated Rate	$46.67
Max. Negotiated Rate	$67.89
Rate for Payer: Cash Price	$38.19
Rate for Payer: Cigna of CA HMO/PPO	$67.89
Rate for Payer: Health Smart Auto/Commercial	$50.92
Rate for Payer: LLUH Dept of Risk Management WC	$46.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.64

HC SOM FBP1 88273

Facility

$84.86

Service Code	CPT 88273 90
Hospital Charge Code	900914874
Hospital Revenue Code	310
Min. Negotiated Rate	$46.67
Max. Negotiated Rate	$63.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.92
Rate for Payer: Aetna of CA Government/Medicare	$50.92
Rate for Payer: Cash Price	$38.19
Rate for Payer: Health Smart Auto/Commercial	$50.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.92
Rate for Payer: LLUH Dept of Risk Management WC	$46.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.64

HC SOM FBP1 88291

Facility

$71.15

Service Code	CPT 88291
Hospital Charge Code	900914873
Hospital Revenue Code	309
Min. Negotiated Rate	$39.13
Max. Negotiated Rate	$56.92
Rate for Payer: Cash Price	$32.02
Rate for Payer: Cigna of CA HMO/PPO	$56.92
Rate for Payer: Health Smart Auto/Commercial	$42.69
Rate for Payer: LLUH Dept of Risk Management WC	$39.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.36

HC SOM FBP1 88291

Facility

$71.15

Service Code	CPT 88291
Hospital Charge Code	900914873
Hospital Revenue Code	309
Min. Negotiated Rate	$39.13
Max. Negotiated Rate	$53.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.69
Rate for Payer: Aetna of CA Government/Medicare	$42.69
Rate for Payer: Cash Price	$32.02
Rate for Payer: Health Smart Auto/Commercial	$42.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.69
Rate for Payer: LLUH Dept of Risk Management WC	$39.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.36

HC SOM FBP1 88291

Facility

$71.15

Service Code	CPT 88291 90
Hospital Charge Code	900914873
Hospital Revenue Code	310
Min. Negotiated Rate	$39.13
Max. Negotiated Rate	$53.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.69
Rate for Payer: Aetna of CA Government/Medicare	$42.69
Rate for Payer: Cash Price	$32.02
Rate for Payer: Health Smart Auto/Commercial	$42.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.69
Rate for Payer: LLUH Dept of Risk Management WC	$39.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.36

Know your out-of-pocket cost for care.

All Charges