Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM PLASMINOGEN ACTIVITY

Facility

$50.00

Service Code	CPT 85420 90
Hospital Charge Code	900911325
Hospital Revenue Code	305
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 PML/RARA QUANT, PCR

Facility

$255.94

Service Code	CPT 81315 90
Hospital Charge Code	900913891
Hospital Revenue Code	300
Min. Negotiated Rate	$140.77
Max. Negotiated Rate	$191.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$153.56
Rate for Payer: Aetna of CA Government/Medicare	$153.56
Rate for Payer: Cash Price	$115.17
Rate for Payer: Health Smart Auto/Commercial	$153.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$153.56
Rate for Payer: LLUH Dept of Risk Management WC	$140.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$191.96

HC SOM PML/RARA QUANT, PCR

Facility

$255.94

Service Code	CPT 81315
Hospital Charge Code	900913891
Hospital Revenue Code	309
Min. Negotiated Rate	$140.77
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$115.17
Rate for Payer: Cigna of CA HMO/PPO	$204.75
Rate for Payer: Health Smart Auto/Commercial	$153.56
Rate for Payer: LLUH Dept of Risk Management WC	$140.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$191.96

HC SOM PML/RARA QUANT, PCR

Facility

$255.94

Service Code	CPT 81315
Hospital Charge Code	900913891
Hospital Revenue Code	309
Min. Negotiated Rate	$140.77
Max. Negotiated Rate	$191.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$153.56
Rate for Payer: Aetna of CA Government/Medicare	$153.56
Rate for Payer: Cash Price	$115.17
Rate for Payer: Health Smart Auto/Commercial	$153.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$153.56
Rate for Payer: LLUH Dept of Risk Management WC	$140.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$191.96

HC SOM PML/RARA QUANT, PCR

Facility

$255.94

Service Code	CPT 81315 90
Hospital Charge Code	900913891
Hospital Revenue Code	300
Min. Negotiated Rate	$140.77
Max. Negotiated Rate	$204.75
Rate for Payer: Cash Price	$115.17
Rate for Payer: Cigna of CA HMO/PPO	$204.75
Rate for Payer: Health Smart Auto/Commercial	$153.56
Rate for Payer: LLUH Dept of Risk Management WC	$140.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$191.96

HC SOM PORPHOBILINOGEN QUANT.

Facility

$30.00

Service Code	CPT 84110
Hospital Charge Code	900912570
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM PORPHOBILINOGEN QUANT.

Facility

$30.00

Service Code	CPT 84110 90
Hospital Charge Code	900912570
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM PORPHOBILINOGEN QUANT.

Facility

$30.00

Service Code	CPT 84110
Hospital Charge Code	900912570
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM PORPHOBILINOGEN QUANT.

Facility

$30.00

Service Code	CPT 84110 90
Hospital Charge Code	900912570
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM PORPHYRINS URINE FRACTIONATED

Facility

$28.59

Service Code	CPT 84120
Hospital Charge Code	900911511
Hospital Revenue Code	301
Min. Negotiated Rate	$15.72
Max. Negotiated Rate	$22.87
Rate for Payer: Cash Price	$12.87
Rate for Payer: Cigna of CA HMO/PPO	$22.87
Rate for Payer: Health Smart Auto/Commercial	$17.15
Rate for Payer: LLUH Dept of Risk Management WC	$15.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.44

HC SOM PORPHYRINS URINE FRACTIONATED

Facility

$28.59

Service Code	CPT 84120 90
Hospital Charge Code	900911511
Hospital Revenue Code	301
Min. Negotiated Rate	$15.72
Max. Negotiated Rate	$22.87
Rate for Payer: Cash Price	$12.87
Rate for Payer: Cigna of CA HMO/PPO	$22.87
Rate for Payer: Health Smart Auto/Commercial	$17.15
Rate for Payer: LLUH Dept of Risk Management WC	$15.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.44

HC SOM PORPHYRINS URINE FRACTIONATED

Facility

$28.59

Service Code	CPT 84120
Hospital Charge Code	900911511
Hospital Revenue Code	301
Min. Negotiated Rate	$15.72
Max. Negotiated Rate	$21.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.15
Rate for Payer: Aetna of CA Government/Medicare	$17.15
Rate for Payer: Cash Price	$12.87
Rate for Payer: Health Smart Auto/Commercial	$17.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.15
Rate for Payer: LLUH Dept of Risk Management WC	$15.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.44

HC SOM PORPHYRINS URINE FRACTIONATED

Facility

$28.59

Service Code	CPT 84120 90
Hospital Charge Code	900911511
Hospital Revenue Code	301
Min. Negotiated Rate	$15.72
Max. Negotiated Rate	$21.44
Rate for Payer: Health Smart Auto/Commercial	$17.15
Rate for Payer: Cash Price	$12.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.15
Rate for Payer: Aetna of CA Government/Medicare	$17.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.15
Rate for Payer: LLUH Dept of Risk Management WC	$15.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.44

HC SOM PORPHYR UR FRAC PORPHOBIL

Facility

$16.41

Service Code	CPT 84110
Hospital Charge Code	900912814
Hospital Revenue Code	301
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$13.13
Rate for Payer: Cash Price	$7.38
Rate for Payer: Cigna of CA HMO/PPO	$13.13
Rate for Payer: Health Smart Auto/Commercial	$9.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.31

HC SOM PORPHYR UR FRAC PORPHOBIL

Facility

$16.41

Service Code	CPT 84110 90
Hospital Charge Code	900912814
Hospital Revenue Code	301
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$12.31
Rate for Payer: Health Smart Auto/Commercial	$9.85
Rate for Payer: Cash Price	$7.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.85
Rate for Payer: Aetna of CA Government/Medicare	$9.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.31

HC SOM PORPHYR UR FRAC PORPHOBIL

Facility

$16.41

Service Code	CPT 84110 90
Hospital Charge Code	900912814
Hospital Revenue Code	301
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$13.13
Rate for Payer: Cash Price	$7.38
Rate for Payer: Cigna of CA HMO/PPO	$13.13
Rate for Payer: Health Smart Auto/Commercial	$9.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.31

HC SOM PORPHYR UR FRAC PORPHOBIL

Facility

$16.41

Service Code	CPT 84110
Hospital Charge Code	900912814
Hospital Revenue Code	301
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$12.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.85
Rate for Payer: Aetna of CA Government/Medicare	$9.85
Rate for Payer: Cash Price	$7.38
Rate for Payer: Health Smart Auto/Commercial	$9.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.31

HC SOM POSACONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80187
Hospital Charge Code	900912708
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$21.69
Rate for Payer: Cash Price	$12.20
Rate for Payer: Cigna of CA HMO/PPO	$21.69
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.33

HC SOM POSACONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80187 90
Hospital Charge Code	900912708
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$20.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.27
Rate for Payer: Aetna of CA Government/Medicare	$16.27
Rate for Payer: Cash Price	$12.20
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.33

HC SOM POSACONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80187 90
Hospital Charge Code	900912708
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$21.69
Rate for Payer: Cash Price	$12.20
Rate for Payer: Cigna of CA HMO/PPO	$21.69
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.33

HC SOM POSACONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80187
Hospital Charge Code	900912708
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$20.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.27
Rate for Payer: Aetna of CA Government/Medicare	$16.27
Rate for Payer: Cash Price	$12.20
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.33

HC SOM PRADER WILLI SYNDROME ANALYSIS

Facility

$350.00

Service Code	CPT 81331
Hospital Charge Code	900910668
Hospital Revenue Code	301
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$210.00
Rate for Payer: Aetna of CA Government/Medicare	$210.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$262.50

HC SOM PRADER WILLI SYNDROME ANALYSIS

Facility

$350.00

Service Code	CPT 81331
Hospital Charge Code	900910668
Hospital Revenue Code	301
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna of CA HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$262.50

HC SOM PRADER WILLI SYNDROME ANALYSIS

Facility

$350.00

Service Code	CPT 81331 90
Hospital Charge Code	900910668
Hospital Revenue Code	301
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna of CA HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$262.50

HC SOM PRADER WILLI SYNDROME ANALYSIS

Facility

$350.00

Service Code	CPT 81331 90
Hospital Charge Code	900910668
Hospital Revenue Code	301
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$262.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$210.00
Rate for Payer: Aetna of CA Government/Medicare	$210.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$262.50

Know your out-of-pocket cost for care.

All Charges