Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM FRUCTOSAMINE

Facility

$16.04

Service Code	CPT 82985
Hospital Charge Code	900913929
Hospital Revenue Code	301
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$12.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.62
Rate for Payer: Aetna of CA Government/Medicare	$9.62
Rate for Payer: Cash Price	$7.22
Rate for Payer: Health Smart Auto/Commercial	$9.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.62
Rate for Payer: LLUH Dept of Risk Management WC	$8.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.03

HC SOM FRUCTOSAMINE

Facility

$16.04

Service Code	CPT 82985
Hospital Charge Code	900913929
Hospital Revenue Code	301
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$12.83
Rate for Payer: Cash Price	$7.22
Rate for Payer: Cigna of CA HMO/PPO	$12.83
Rate for Payer: Health Smart Auto/Commercial	$9.62
Rate for Payer: LLUH Dept of Risk Management WC	$8.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.03

HC SOM FRUCTOSAMINE

Facility

$16.04

Service Code	CPT 82985 90
Hospital Charge Code	900913929
Hospital Revenue Code	301
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$12.03
Rate for Payer: Health Smart Auto/Commercial	$9.62
Rate for Payer: Cash Price	$7.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.62
Rate for Payer: Aetna of CA Government/Medicare	$9.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.62
Rate for Payer: LLUH Dept of Risk Management WC	$8.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.03

HC SOM FUNGITELL ASSAY

Facility

$130.00

Service Code	CPT 87449 90
Hospital Charge Code	900912985
Hospital Revenue Code	306
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$97.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$78.00
Rate for Payer: Aetna of CA Government/Medicare	$78.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$97.50

HC SOM FUNGITELL ASSAY

Facility

$130.00

Service Code	CPT 87449
Hospital Charge Code	900912985
Hospital Revenue Code	306
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$97.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$78.00
Rate for Payer: Aetna of CA Government/Medicare	$78.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$97.50

HC SOM FUNGITELL ASSAY

Facility

$130.00

Service Code	CPT 87449 90
Hospital Charge Code	900912985
Hospital Revenue Code	306
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$104.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna of CA HMO/PPO	$104.00
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$97.50

HC SOM FUNGITELL ASSAY

Facility

$130.00

Service Code	CPT 87449
Hospital Charge Code	900912985
Hospital Revenue Code	306
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$104.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna of CA HMO/PPO	$104.00
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$97.50

HC SOM GABAPENTIN (NEURONTIN)

Facility

$19.00

Service Code	CPT 80171
Hospital Charge Code	900910415
Hospital Revenue Code	301
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$14.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.40
Rate for Payer: Aetna of CA Government/Medicare	$11.40
Rate for Payer: Cash Price	$8.55
Rate for Payer: Health Smart Auto/Commercial	$11.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.40
Rate for Payer: LLUH Dept of Risk Management WC	$10.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.25

HC SOM GABAPENTIN (NEURONTIN)

Facility

$19.00

Service Code	CPT 80171 90
Hospital Charge Code	900910415
Hospital Revenue Code	301
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$15.20
Rate for Payer: Cash Price	$8.55
Rate for Payer: Cigna of CA HMO/PPO	$15.20
Rate for Payer: Health Smart Auto/Commercial	$11.40
Rate for Payer: LLUH Dept of Risk Management WC	$10.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.25

HC SOM GABAPENTIN (NEURONTIN)

Facility

$19.00

Service Code	CPT 80171
Hospital Charge Code	900910415
Hospital Revenue Code	301
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$15.20
Rate for Payer: Cash Price	$8.55
Rate for Payer: Cigna of CA HMO/PPO	$15.20
Rate for Payer: Health Smart Auto/Commercial	$11.40
Rate for Payer: LLUH Dept of Risk Management WC	$10.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.25

HC SOM GABAPENTIN (NEURONTIN)

Facility

$19.00

Service Code	CPT 80171 90
Hospital Charge Code	900910415
Hospital Revenue Code	301
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$14.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.40
Rate for Payer: Aetna of CA Government/Medicare	$11.40
Rate for Payer: Cash Price	$8.55
Rate for Payer: Health Smart Auto/Commercial	$11.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.40
Rate for Payer: LLUH Dept of Risk Management WC	$10.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.25

HC SOM GAD 65 ANTIBODIES

Facility

$18.08

Service Code	CPT 86341
Hospital Charge Code	900912683
Hospital Revenue Code	302
Min. Negotiated Rate	$9.94
Max. Negotiated Rate	$14.46
Rate for Payer: Cash Price	$8.14
Rate for Payer: Cigna of CA HMO/PPO	$14.46
Rate for Payer: Health Smart Auto/Commercial	$10.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.56

HC SOM GAD 65 ANTIBODIES

Facility

$18.08

Service Code	CPT 86341 90
Hospital Charge Code	900912683
Hospital Revenue Code	302
Min. Negotiated Rate	$9.94
Max. Negotiated Rate	$14.46
Rate for Payer: Cash Price	$8.14
Rate for Payer: Cigna of CA HMO/PPO	$14.46
Rate for Payer: Health Smart Auto/Commercial	$10.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.56

HC SOM GAD 65 ANTIBODIES

Facility

$18.08

Service Code	CPT 86341
Hospital Charge Code	900912683
Hospital Revenue Code	302
Min. Negotiated Rate	$9.94
Max. Negotiated Rate	$13.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.85
Rate for Payer: Aetna of CA Government/Medicare	$10.85
Rate for Payer: Cash Price	$8.14
Rate for Payer: Health Smart Auto/Commercial	$10.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.56

HC SOM GAD 65 ANTIBODIES

Facility

$18.08

Service Code	CPT 86341 90
Hospital Charge Code	900912683
Hospital Revenue Code	302
Min. Negotiated Rate	$9.94
Max. Negotiated Rate	$13.56
Rate for Payer: Health Smart Auto/Commercial	$10.85
Rate for Payer: Cash Price	$8.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.85
Rate for Payer: Aetna of CA Government/Medicare	$10.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.94
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.56

HC SOM GAL-1-PO4 URIDYL TR

Facility

$75.00

Service Code	CPT 82775 90
Hospital Charge Code	900911057
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 GAL-1-PO4 URIDYL TR

Facility

$75.00

Service Code	CPT 82775 90
Hospital Charge Code	900911057
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$56.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 GAL-1-PO4 URIDYL TR

Facility

$75.00

Service Code	CPT 82775
Hospital Charge Code	900911057
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$56.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 GAL-1-PO4 URIDYL TR

Facility

$75.00

Service Code	CPT 82775
Hospital Charge Code	900911057
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 GALACTOSE 1 PHOSPHATE ERYTHRO

Facility

$175.00

Service Code	CPT 84378 90
Hospital Charge Code	900910746
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 GALACTOSE 1 PHOSPHATE ERYTHRO

Facility

$175.00

Service Code	CPT 84378
Hospital Charge Code	900910746
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 GALACTOSE 1 PHOSPHATE ERYTHRO

Facility

$175.00

Service Code	CPT 84378 90
Hospital Charge Code	900910746
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 GALACTOSE 1 PHOSPHATE ERYTHRO

Facility

$175.00

Service Code	CPT 84378
Hospital Charge Code	900910746
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 GANGLIOSIDE AB IGG ASIALO

Facility

$20.00

Service Code	CPT 83516 90
Hospital Charge Code	900911440
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna of CA HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC SOM GANGLIOSIDE AB IGG ASIALO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900911440
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

Know your out-of-pocket cost for care.

All Charges