Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM METHYLMALONIC ACID

Facility

$22.00

Service Code	CPT 83921
Hospital Charge Code	900911265
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$16.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.20
Rate for Payer: Aetna of CA Government/Medicare	$13.20
Rate for Payer: Cash Price	$9.90
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM METHYLMALONIC ACID

Facility

$22.00

Service Code	CPT 83921
Hospital Charge Code	900911265
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna of CA HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM METHYLMALONIC ACID URINE

Facility

$22.00

Service Code	CPT 83921 90
Hospital Charge Code	900910587
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$16.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.20
Rate for Payer: Aetna of CA Government/Medicare	$13.20
Rate for Payer: Cash Price	$9.90
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM METHYLMALONIC ACID URINE

Facility

$22.00

Service Code	CPT 83921 90
Hospital Charge Code	900910587
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna of CA HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM METHYLMALONIC ACID URINE

Facility

$22.00

Service Code	CPT 83921
Hospital Charge Code	900910587
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$16.50
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Cash Price	$9.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.20
Rate for Payer: Aetna of CA Government/Medicare	$13.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM METHYLMALONIC ACID URINE

Facility

$22.00

Service Code	CPT 83921
Hospital Charge Code	900910587
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna of CA HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM MEXILETINE PLASMA

Facility

$266.46

Service Code	CPT 80299
Hospital Charge Code	900911280
Hospital Revenue Code	301
Min. Negotiated Rate	$146.55
Max. Negotiated Rate	$213.17
Rate for Payer: Cash Price	$119.91
Rate for Payer: Cigna of CA HMO/PPO	$213.17
Rate for Payer: Health Smart Auto/Commercial	$159.88
Rate for Payer: LLUH Dept of Risk Management WC	$146.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$199.84

HC SOM MEXILETINE PLASMA

Facility

$266.46

Service Code	CPT 80299
Hospital Charge Code	900911280
Hospital Revenue Code	301
Min. Negotiated Rate	$146.55
Max. Negotiated Rate	$199.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$159.88
Rate for Payer: Aetna of CA Government/Medicare	$159.88
Rate for Payer: Cash Price	$119.91
Rate for Payer: Health Smart Auto/Commercial	$159.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$159.88
Rate for Payer: LLUH Dept of Risk Management WC	$146.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$199.84

HC SOM MEXILETINE PLASMA

Facility

$266.46

Service Code	CPT 80299 90
Hospital Charge Code	900911280
Hospital Revenue Code	301
Min. Negotiated Rate	$146.55
Max. Negotiated Rate	$199.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$159.88
Rate for Payer: Aetna of CA Government/Medicare	$159.88
Rate for Payer: Cash Price	$119.91
Rate for Payer: Health Smart Auto/Commercial	$159.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$159.88
Rate for Payer: LLUH Dept of Risk Management WC	$146.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$199.84

HC SOM MEXILETINE PLASMA

Facility

$266.46

Service Code	CPT 80299 90
Hospital Charge Code	900911280
Hospital Revenue Code	301
Min. Negotiated Rate	$146.55
Max. Negotiated Rate	$213.17
Rate for Payer: Cash Price	$119.91
Rate for Payer: Cigna of CA HMO/PPO	$213.17
Rate for Payer: Health Smart Auto/Commercial	$159.88
Rate for Payer: LLUH Dept of Risk Management WC	$146.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$199.84

HC SOM MGLE ACH RECEPTOR BINDING AB

Facility

$269.00

Service Code	CPT 83519
Hospital Charge Code	900911445
Hospital Revenue Code	300
Min. Negotiated Rate	$147.95
Max. Negotiated Rate	$201.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$161.40
Rate for Payer: Aetna of CA Government/Medicare	$161.40
Rate for Payer: Cash Price	$121.05
Rate for Payer: Health Smart Auto/Commercial	$161.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$161.40
Rate for Payer: LLUH Dept of Risk Management WC	$147.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$201.75

HC SOM MGLE ACH RECEPTOR BINDING AB

Facility

$269.00

Service Code	CPT 83519 90
Hospital Charge Code	900911445
Hospital Revenue Code	300
Min. Negotiated Rate	$147.95
Max. Negotiated Rate	$201.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$161.40
Rate for Payer: Aetna of CA Government/Medicare	$161.40
Rate for Payer: Cash Price	$121.05
Rate for Payer: Health Smart Auto/Commercial	$161.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$161.40
Rate for Payer: LLUH Dept of Risk Management WC	$147.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$201.75

HC SOM MGLE ACH RECEPTOR BINDING AB

Facility

$269.00

Service Code	CPT 83519
Hospital Charge Code	900911445
Hospital Revenue Code	300
Min. Negotiated Rate	$147.95
Max. Negotiated Rate	$215.20
Rate for Payer: Cash Price	$121.05
Rate for Payer: Cigna of CA HMO/PPO	$215.20
Rate for Payer: Health Smart Auto/Commercial	$161.40
Rate for Payer: LLUH Dept of Risk Management WC	$147.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$201.75

HC SOM MGLE ACH RECEPTOR BINDING AB

Facility

$269.00

Service Code	CPT 83519 90
Hospital Charge Code	900911445
Hospital Revenue Code	300
Min. Negotiated Rate	$147.95
Max. Negotiated Rate	$215.20
Rate for Payer: Cash Price	$121.05
Rate for Payer: Cigna of CA HMO/PPO	$215.20
Rate for Payer: Health Smart Auto/Commercial	$161.40
Rate for Payer: LLUH Dept of Risk Management WC	$147.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$201.75

HC SOM MICROSPORIDIA CULTURE

Facility

$100.06

Service Code	CPT 87015
Hospital Charge Code	900912827
Hospital Revenue Code	306
Min. Negotiated Rate	$55.03
Max. Negotiated Rate	$80.05
Rate for Payer: Cash Price	$45.03
Rate for Payer: Cigna of CA HMO/PPO	$80.05
Rate for Payer: Health Smart Auto/Commercial	$60.04
Rate for Payer: LLUH Dept of Risk Management WC	$55.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.04

HC SOM MICROSPORIDIA CULTURE

Facility

$100.06

Service Code	CPT 87015 90
Hospital Charge Code	900912827
Hospital Revenue Code	306
Min. Negotiated Rate	$55.03
Max. Negotiated Rate	$80.05
Rate for Payer: Cash Price	$45.03
Rate for Payer: Cigna of CA HMO/PPO	$80.05
Rate for Payer: Health Smart Auto/Commercial	$60.04
Rate for Payer: LLUH Dept of Risk Management WC	$55.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.04

HC SOM MICROSPORIDIA CULTURE

Facility

$100.06

Service Code	CPT 87015
Hospital Charge Code	900912827
Hospital Revenue Code	306
Min. Negotiated Rate	$55.03
Max. Negotiated Rate	$75.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.04
Rate for Payer: Aetna of CA Government/Medicare	$60.04
Rate for Payer: Cash Price	$45.03
Rate for Payer: Health Smart Auto/Commercial	$60.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.04
Rate for Payer: LLUH Dept of Risk Management WC	$55.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.04

HC SOM MICROSPORIDIA CULTURE

Facility

$100.06

Service Code	CPT 87015 90
Hospital Charge Code	900912827
Hospital Revenue Code	306
Min. Negotiated Rate	$55.03
Max. Negotiated Rate	$75.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.04
Rate for Payer: Aetna of CA Government/Medicare	$60.04
Rate for Payer: Cash Price	$45.03
Rate for Payer: Health Smart Auto/Commercial	$60.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.04
Rate for Payer: LLUH Dept of Risk Management WC	$55.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.04

HC SOM MICROSPORIDIA DETECTION

Facility

$89.72

Service Code	CPT 87207 90
Hospital Charge Code	900911588
Hospital Revenue Code	306
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$40.37
Rate for Payer: Cigna of CA HMO/PPO	$71.78
Rate for Payer: Health Smart Auto/Commercial	$53.83
Rate for Payer: LLUH Dept of Risk Management WC	$49.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.29

HC SOM MICROSPORIDIA DETECTION

Facility

$89.72

Service Code	CPT 87207
Hospital Charge Code	900911588
Hospital Revenue Code	306
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$40.37
Rate for Payer: Cigna of CA HMO/PPO	$71.78
Rate for Payer: Health Smart Auto/Commercial	$53.83
Rate for Payer: LLUH Dept of Risk Management WC	$49.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.29

HC SOM MICROSPORIDIA DETECTION

Facility

$89.72

Service Code	CPT 87207
Hospital Charge Code	900911588
Hospital Revenue Code	306
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$67.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.83
Rate for Payer: Aetna of CA Government/Medicare	$53.83
Rate for Payer: Cash Price	$40.37
Rate for Payer: Health Smart Auto/Commercial	$53.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.83
Rate for Payer: LLUH Dept of Risk Management WC	$49.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.29

HC SOM MICROSPORIDIA DETECTION

Facility

$89.72

Service Code	CPT 87207 90
Hospital Charge Code	900911588
Hospital Revenue Code	306
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$67.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.83
Rate for Payer: Aetna of CA Government/Medicare	$53.83
Rate for Payer: Cash Price	$40.37
Rate for Payer: Health Smart Auto/Commercial	$53.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.83
Rate for Payer: LLUH Dept of Risk Management WC	$49.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.29

HC SOM MILK PROCESSED IGE

Facility

$4.75

Service Code	CPT 86003 90
Hospital Charge Code	900914157
Hospital Revenue Code	302
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.80
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cigna of CA HMO/PPO	$3.80
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.56

HC SOM MILK PROCESSED IGE

Facility

$4.75

Service Code	CPT 86003 90
Hospital Charge Code	900914157
Hospital Revenue Code	302
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.85
Rate for Payer: Aetna of CA Government/Medicare	$2.85
Rate for Payer: Cash Price	$2.14
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.56

HC SOM MILK PROCESSED IGE

Facility

$4.75

Service Code	CPT 86003
Hospital Charge Code	900914157
Hospital Revenue Code	302
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.85
Rate for Payer: Aetna of CA Government/Medicare	$2.85
Rate for Payer: Cash Price	$2.14
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.56

Know your out-of-pocket cost for care.

All Charges