Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM IGG FRAC. TOTAL IGG

Facility

$6.00

Service Code	CPT 82784 90
Hospital Charge Code	900912808
Hospital Revenue Code	302
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

HC SOM IGG SYNTHESIS INDEX-CSF

Facility

$10.35

Service Code	CPT 82784
Hospital Charge Code	900911436
Hospital Revenue Code	301
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$8.28
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cigna of CA HMO/PPO	$8.28
Rate for Payer: Health Smart Auto/Commercial	$6.21
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.76

HC SOM IGG SYNTHESIS INDEX-CSF

Facility

$10.35

Service Code	CPT 82784 90
Hospital Charge Code	900911436
Hospital Revenue Code	301
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$8.28
Rate for Payer: Cash Price	$4.66
Rate for Payer: Cigna of CA HMO/PPO	$8.28
Rate for Payer: Health Smart Auto/Commercial	$6.21
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.76

HC SOM IGG SYNTHESIS INDEX-CSF

Facility

$10.35

Service Code	CPT 82784 90
Hospital Charge Code	900911436
Hospital Revenue Code	301
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$7.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.21
Rate for Payer: Aetna of CA Government/Medicare	$6.21
Rate for Payer: Cash Price	$4.66
Rate for Payer: Health Smart Auto/Commercial	$6.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.21
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.76

HC SOM IGG SYNTHESIS INDEX-CSF

Facility

$10.35

Service Code	CPT 82784
Hospital Charge Code	900911436
Hospital Revenue Code	301
Min. Negotiated Rate	$5.69
Max. Negotiated Rate	$7.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.21
Rate for Payer: Aetna of CA Government/Medicare	$6.21
Rate for Payer: Cash Price	$4.66
Rate for Payer: Health Smart Auto/Commercial	$6.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.21
Rate for Payer: LLUH Dept of Risk Management WC	$5.69
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.76

HC SOM IL 28 B POLYMORPHISM GENOT

Facility

$312.70

Service Code	CPT 81400 90
Hospital Charge Code	900912991
Hospital Revenue Code	300
Min. Negotiated Rate	$171.98
Max. Negotiated Rate	$234.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$187.62
Rate for Payer: Aetna of CA Government/Medicare	$187.62
Rate for Payer: Cash Price	$140.72
Rate for Payer: Health Smart Auto/Commercial	$187.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$187.62
Rate for Payer: LLUH Dept of Risk Management WC	$171.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$234.52

HC SOM IL 28 B POLYMORPHISM GENOT

Facility

$312.70

Service Code	CPT 81400
Hospital Charge Code	900912991
Hospital Revenue Code	309
Min. Negotiated Rate	$171.98
Max. Negotiated Rate	$234.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$187.62
Rate for Payer: Aetna of CA Government/Medicare	$187.62
Rate for Payer: Cash Price	$140.72
Rate for Payer: Health Smart Auto/Commercial	$187.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$187.62
Rate for Payer: LLUH Dept of Risk Management WC	$171.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$234.52

HC SOM IL 28 B POLYMORPHISM GENOT

Facility

$312.70

Service Code	CPT 81400 90
Hospital Charge Code	900912991
Hospital Revenue Code	300
Min. Negotiated Rate	$171.98
Max. Negotiated Rate	$250.16
Rate for Payer: Cash Price	$140.72
Rate for Payer: Cigna of CA HMO/PPO	$250.16
Rate for Payer: Health Smart Auto/Commercial	$187.62
Rate for Payer: LLUH Dept of Risk Management WC	$171.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$234.52

HC SOM IL 28 B POLYMORPHISM GENOT

Facility

$312.70

Service Code	CPT 81400
Hospital Charge Code	900912991
Hospital Revenue Code	309
Min. Negotiated Rate	$171.98
Max. Negotiated Rate	$250.16
Rate for Payer: Cash Price	$140.72
Rate for Payer: Cigna of CA HMO/PPO	$250.16
Rate for Payer: Health Smart Auto/Commercial	$187.62
Rate for Payer: LLUH Dept of Risk Management WC	$171.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$234.52

HC SOM IL-6

Facility

$75.00

Service Code	CPT 83520 90
Hospital Charge Code	900913874
Hospital Revenue Code	302
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 IL-6

Facility

$75.00

Service Code	CPT 83520 90
Hospital Charge Code	900913874
Hospital Revenue Code	302
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 IL-6

Facility

$75.00

Service Code	CPT 83520
Hospital Charge Code	900913874
Hospital Revenue Code	302
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 IL-6

Facility

$75.00

Service Code	CPT 83520
Hospital Charge Code	900913874
Hospital Revenue Code	302
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 IMMUNOFIXATION, RANDOM, U

Facility

$50.00

Service Code	CPT 86335 90
Hospital Charge Code	900912893
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM IMMUNOFIXATION, RANDOM, U

Facility

$50.00

Service Code	CPT 86335
Hospital Charge Code	900912893
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna of CA HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM IMMUNOFIXATION, RANDOM, U

Facility

$50.00

Service Code	CPT 86335
Hospital Charge Code	900912893
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM IMMUNOFIXATION, RANDOM, U

Facility

$50.00

Service Code	CPT 86335 90
Hospital Charge Code	900912893
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna of CA HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM IMMUNOGLOBULIN IGD

Facility

$26.40

Service Code	CPT 82784 90
Hospital Charge Code	900910574
Hospital Revenue Code	301
Min. Negotiated Rate	$14.52
Max. Negotiated Rate	$21.12
Rate for Payer: Cash Price	$11.88
Rate for Payer: Cigna of CA HMO/PPO	$21.12
Rate for Payer: Health Smart Auto/Commercial	$15.84
Rate for Payer: LLUH Dept of Risk Management WC	$14.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.80

HC SOM IMMUNOGLOBULIN IGD

Facility

$26.40

Service Code	CPT 82784 90
Hospital Charge Code	900910574
Hospital Revenue Code	301
Min. Negotiated Rate	$14.52
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.84
Rate for Payer: Aetna of CA Government/Medicare	$15.84
Rate for Payer: Cash Price	$11.88
Rate for Payer: Health Smart Auto/Commercial	$15.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.84
Rate for Payer: LLUH Dept of Risk Management WC	$14.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.80

HC SOM IMMUNOGLOBULIN IGD

Facility

$26.40

Service Code	CPT 82784
Hospital Charge Code	900910574
Hospital Revenue Code	301
Min. Negotiated Rate	$14.52
Max. Negotiated Rate	$21.12
Rate for Payer: Cash Price	$11.88
Rate for Payer: Cigna of CA HMO/PPO	$21.12
Rate for Payer: Health Smart Auto/Commercial	$15.84
Rate for Payer: LLUH Dept of Risk Management WC	$14.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.80

HC SOM IMMUNOGLOBULIN IGD

Facility

$26.40

Service Code	CPT 82784
Hospital Charge Code	900910574
Hospital Revenue Code	301
Min. Negotiated Rate	$14.52
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.84
Rate for Payer: Aetna of CA Government/Medicare	$15.84
Rate for Payer: Cash Price	$11.88
Rate for Payer: Health Smart Auto/Commercial	$15.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.84
Rate for Payer: LLUH Dept of Risk Management WC	$14.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.80

HC SOM IMMUNOGLOBULINS,IGC SUBCLASS 1

Facility

$6.00

Service Code	CPT 82787 90
Hospital Charge Code	900911271
Hospital Revenue Code	301
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

HC SOM IMMUNOGLOBULINS,IGC SUBCLASS 1

Facility

$6.00

Service Code	CPT 82787
Hospital Charge Code	900911271
Hospital Revenue Code	301
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

HC SOM IMMUNOGLOBULINS,IGC SUBCLASS 1

Facility

$6.00

Service Code	CPT 82787
Hospital Charge Code	900911271
Hospital Revenue Code	301
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

HC SOM IMMUNOGLOBULINS,IGC SUBCLASS 1

Facility

$6.00

Service Code	CPT 82787 90
Hospital Charge Code	900911271
Hospital Revenue Code	301
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna of CA HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.50

Know your out-of-pocket cost for care.

All Charges