Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM OXALATE

Facility

$20.00

Service Code	CPT 83945 90
Hospital Charge Code	900911124
Hospital Revenue Code	301
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

HC SOM OXALATE

Facility

$20.00

Service Code	CPT 83945
Hospital Charge Code	900911124
Hospital Revenue Code	301
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

HC SOM OXALATE

Facility

$20.00

Service Code	CPT 83945
Hospital Charge Code	900911124
Hospital Revenue Code	301
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 OXALATE

Facility

$20.00

Service Code	CPT 83945 90
Hospital Charge Code	900911124
Hospital Revenue Code	301
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 OXALATE PLASMA

Facility

$68.00

Service Code	CPT 83945
Hospital Charge Code	900910579
Hospital Revenue Code	301
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC SOM OXALATE PLASMA

Facility

$68.00

Service Code	CPT 83945 90
Hospital Charge Code	900910579
Hospital Revenue Code	301
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC SOM OXALATE PLASMA

Facility

$68.00

Service Code	CPT 83945
Hospital Charge Code	900910579
Hospital Revenue Code	301
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$54.40
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna of CA HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC SOM OXALATE PLASMA

Facility

$68.00

Service Code	CPT 83945 90
Hospital Charge Code	900910579
Hospital Revenue Code	301
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$54.40
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna of CA HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC SOM OXCARBAZEPINE LEVEL

Facility

$20.00

Service Code	CPT 80183 90
Hospital Charge Code	900912537
Hospital Revenue Code	301
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 OXCARBAZEPINE LEVEL

Facility

$20.00

Service Code	CPT 80183 90
Hospital Charge Code	900912537
Hospital Revenue Code	301
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

HC SOM OXCARBAZEPINE LEVEL

Facility

$20.00

Service Code	CPT 80183
Hospital Charge Code	900912537
Hospital Revenue Code	301
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

HC SOM OXCARBAZEPINE LEVEL

Facility

$20.00

Service Code	CPT 80183
Hospital Charge Code	900912537
Hospital Revenue Code	301
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 PANCREATIC ELASTASE/STOOL

Facility

$80.00

Service Code	CPT 82653
Hospital Charge Code	900912993
Hospital Revenue Code	301
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.00
Rate for Payer: Aetna of CA Government/Medicare	$48.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Smart Auto/Commercial	$48.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.00

HC SOM PANCREATIC ELASTASE/STOOL

Facility

$80.00

Service Code	CPT 82653 90
Hospital Charge Code	900912993
Hospital Revenue Code	301
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna of CA HMO/PPO	$64.00
Rate for Payer: Health Smart Auto/Commercial	$48.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.00

HC SOM PANCREATIC ELASTASE/STOOL

Facility

$80.00

Service Code	CPT 82653
Hospital Charge Code	900912993
Hospital Revenue Code	301
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna of CA HMO/PPO	$64.00
Rate for Payer: Health Smart Auto/Commercial	$48.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.00

HC SOM PANCREATIC ELASTASE/STOOL

Facility

$80.00

Service Code	CPT 82653 90
Hospital Charge Code	900912993
Hospital Revenue Code	301
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.00
Rate for Payer: Aetna of CA Government/Medicare	$48.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Smart Auto/Commercial	$48.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.00

HC SOM PANCREATIC POLYPEPTIDE

Facility

$555.29

Service Code	CPT 83519 90
Hospital Charge Code	900911326
Hospital Revenue Code	301
Min. Negotiated Rate	$305.41
Max. Negotiated Rate	$416.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$333.17
Rate for Payer: Aetna of CA Government/Medicare	$333.17
Rate for Payer: Cash Price	$249.88
Rate for Payer: Health Smart Auto/Commercial	$333.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$333.17
Rate for Payer: LLUH Dept of Risk Management WC	$305.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$416.47

HC SOM PANCREATIC POLYPEPTIDE

Facility

$555.29

Service Code	CPT 83519
Hospital Charge Code	900911326
Hospital Revenue Code	301
Min. Negotiated Rate	$305.41
Max. Negotiated Rate	$444.23
Rate for Payer: Cash Price	$249.88
Rate for Payer: Cigna of CA HMO/PPO	$444.23
Rate for Payer: Health Smart Auto/Commercial	$333.17
Rate for Payer: LLUH Dept of Risk Management WC	$305.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$416.47

HC SOM PANCREATIC POLYPEPTIDE

Facility

$555.29

Service Code	CPT 83519 90
Hospital Charge Code	900911326
Hospital Revenue Code	301
Min. Negotiated Rate	$305.41
Max. Negotiated Rate	$444.23
Rate for Payer: Cash Price	$249.88
Rate for Payer: Cigna of CA HMO/PPO	$444.23
Rate for Payer: Health Smart Auto/Commercial	$333.17
Rate for Payer: LLUH Dept of Risk Management WC	$305.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$416.47

HC SOM PANCREATIC POLYPEPTIDE

Facility

$555.29

Service Code	CPT 83519
Hospital Charge Code	900911326
Hospital Revenue Code	301
Min. Negotiated Rate	$305.41
Max. Negotiated Rate	$416.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$333.17
Rate for Payer: Aetna of CA Government/Medicare	$333.17
Rate for Payer: Cash Price	$249.88
Rate for Payer: Health Smart Auto/Commercial	$333.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$333.17
Rate for Payer: LLUH Dept of Risk Management WC	$305.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$416.47

HC SOM PARIETAL CELL AB

Facility

$25.00

Service Code	CPT 83516
Hospital Charge Code	900911267
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 PARIETAL CELL AB

Facility

$25.00

Service Code	CPT 83516
Hospital Charge Code	900911267
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 PARIETAL CELL AB

Facility

$25.00

Service Code	CPT 83516 90
Hospital Charge Code	900911267
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 PARIETAL CELL AB

Facility

$25.00

Service Code	CPT 83516 90
Hospital Charge Code	900911267
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 PARVOVIRUS B19 AB IGG

Facility

$11.23

Service Code	CPT 86747 90
Hospital Charge Code	900912538
Hospital Revenue Code	302
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$5.05
Rate for Payer: Cigna of CA HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.42

Know your out-of-pocket cost for care.

All Charges