Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM PROTEIN S PLASMA

Facility

$28.63

Service Code	CPT 85306 90
Hospital Charge Code	900911277
Hospital Revenue Code	305
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$21.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.18
Rate for Payer: Aetna of CA Government/Medicare	$17.18
Rate for Payer: Cash Price	$12.88
Rate for Payer: Health Smart Auto/Commercial	$17.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.18
Rate for Payer: LLUH Dept of Risk Management WC	$15.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.47

HC SOM PROTEIN S PLASMA

Facility

$28.63

Service Code	CPT 85306 90
Hospital Charge Code	900911277
Hospital Revenue Code	305
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$22.90
Rate for Payer: Cash Price	$12.88
Rate for Payer: Cigna of CA HMO/PPO	$22.90
Rate for Payer: Health Smart Auto/Commercial	$17.18
Rate for Payer: LLUH Dept of Risk Management WC	$15.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.47

HC SOM PROTEIN S PLASMA

Facility

$28.63

Service Code	CPT 85306
Hospital Charge Code	900911277
Hospital Revenue Code	305
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$21.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.18
Rate for Payer: Aetna of CA Government/Medicare	$17.18
Rate for Payer: Cash Price	$12.88
Rate for Payer: Health Smart Auto/Commercial	$17.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.18
Rate for Payer: LLUH Dept of Risk Management WC	$15.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.47

HC SOM PROTEIN, TOTAL, RANDOM, U

Facility

$4.13

Service Code	CPT 84156 90
Hospital Charge Code	900912892
Hospital Revenue Code	301
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.48
Rate for Payer: Aetna of CA Government/Medicare	$2.48
Rate for Payer: Cash Price	$1.86
Rate for Payer: Health Smart Auto/Commercial	$2.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.10

HC SOM PROTEIN, TOTAL, RANDOM, U

Facility

$4.13

Service Code	CPT 84156
Hospital Charge Code	900912892
Hospital Revenue Code	301
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Cash Price	$1.86
Rate for Payer: Cigna of CA HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.10

HC SOM PROTEIN, TOTAL, RANDOM, U

Facility

$4.13

Service Code	CPT 84156 90
Hospital Charge Code	900912892
Hospital Revenue Code	301
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Cash Price	$1.86
Rate for Payer: Cigna of CA HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.10

HC SOM PROTEIN, TOTAL, RANDOM, U

Facility

$4.13

Service Code	CPT 84156
Hospital Charge Code	900912892
Hospital Revenue Code	301
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.48
Rate for Payer: Aetna of CA Government/Medicare	$2.48
Rate for Payer: Cash Price	$1.86
Rate for Payer: Health Smart Auto/Commercial	$2.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.10

HC SOM PROTEIN TOTAL URINE

Facility

$5.12

Service Code	CPT 84156
Hospital Charge Code	900912826
Hospital Revenue Code	301
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$3.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.07
Rate for Payer: Aetna of CA Government/Medicare	$3.07
Rate for Payer: Cash Price	$2.30
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.07
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.84

HC SOM PROTEIN TOTAL URINE

Facility

$5.12

Service Code	CPT 84156 90
Hospital Charge Code	900912826
Hospital Revenue Code	301
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$3.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.07
Rate for Payer: Aetna of CA Government/Medicare	$3.07
Rate for Payer: Cash Price	$2.30
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.07
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.84

HC SOM PROTEIN TOTAL URINE

Facility

$5.12

Service Code	CPT 84156
Hospital Charge Code	900912826
Hospital Revenue Code	301
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.10
Rate for Payer: Cash Price	$2.30
Rate for Payer: Cigna of CA HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.84

HC SOM PROTEIN TOTAL URINE

Facility

$5.12

Service Code	CPT 84156 90
Hospital Charge Code	900912826
Hospital Revenue Code	301
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.10
Rate for Payer: Cash Price	$2.30
Rate for Payer: Cigna of CA HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.84

HC SOM PROTOPORPH FR RBC

Facility

$334.00

Service Code	CPT 82542 90
Hospital Charge Code	900911168
Hospital Revenue Code	301
Min. Negotiated Rate	$183.70
Max. Negotiated Rate	$267.20
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna of CA HMO/PPO	$267.20
Rate for Payer: Health Smart Auto/Commercial	$200.40
Rate for Payer: LLUH Dept of Risk Management WC	$183.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.50

HC SOM PROTOPORPH FR RBC

Facility

$334.00

Service Code	CPT 82542 90
Hospital Charge Code	900911168
Hospital Revenue Code	301
Min. Negotiated Rate	$183.70
Max. Negotiated Rate	$250.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$200.40
Rate for Payer: Aetna of CA Government/Medicare	$200.40
Rate for Payer: Cash Price	$150.30
Rate for Payer: Health Smart Auto/Commercial	$200.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$200.40
Rate for Payer: LLUH Dept of Risk Management WC	$183.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.50

HC SOM PROTOPORPH FR RBC

Facility

$334.00

Service Code	CPT 82542
Hospital Charge Code	900911168
Hospital Revenue Code	301
Min. Negotiated Rate	$183.70
Max. Negotiated Rate	$250.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$200.40
Rate for Payer: Aetna of CA Government/Medicare	$200.40
Rate for Payer: Cash Price	$150.30
Rate for Payer: Health Smart Auto/Commercial	$200.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$200.40
Rate for Payer: LLUH Dept of Risk Management WC	$183.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.50

HC SOM PROTOPORPH FR RBC

Facility

$334.00

Service Code	CPT 82542
Hospital Charge Code	900911168
Hospital Revenue Code	301
Min. Negotiated Rate	$183.70
Max. Negotiated Rate	$267.20
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna of CA HMO/PPO	$267.20
Rate for Payer: Health Smart Auto/Commercial	$200.40
Rate for Payer: LLUH Dept of Risk Management WC	$183.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$250.50

HC SOM PSA ULTRASENSITIVE

Facility

$123.40

Service Code	CPT 84153
Hospital Charge Code	900913953
Hospital Revenue Code	301
Min. Negotiated Rate	$67.87
Max. Negotiated Rate	$98.72
Rate for Payer: Cash Price	$55.53
Rate for Payer: Cigna of CA HMO/PPO	$98.72
Rate for Payer: Health Smart Auto/Commercial	$74.04
Rate for Payer: LLUH Dept of Risk Management WC	$67.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$92.55

HC SOM PSA ULTRASENSITIVE

Facility

$123.40

Service Code	CPT 84153 90
Hospital Charge Code	900913953
Hospital Revenue Code	301
Min. Negotiated Rate	$67.87
Max. Negotiated Rate	$98.72
Rate for Payer: Cash Price	$55.53
Rate for Payer: Cigna of CA HMO/PPO	$98.72
Rate for Payer: Health Smart Auto/Commercial	$74.04
Rate for Payer: LLUH Dept of Risk Management WC	$67.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$92.55

HC SOM PSA ULTRASENSITIVE

Facility

$123.40

Service Code	CPT 84153 90
Hospital Charge Code	900913953
Hospital Revenue Code	301
Min. Negotiated Rate	$67.87
Max. Negotiated Rate	$92.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$74.04
Rate for Payer: Aetna of CA Government/Medicare	$74.04
Rate for Payer: Cash Price	$55.53
Rate for Payer: Health Smart Auto/Commercial	$74.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$74.04
Rate for Payer: LLUH Dept of Risk Management WC	$67.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$92.55

HC SOM PSA ULTRASENSITIVE

Facility

$123.40

Service Code	CPT 84153
Hospital Charge Code	900913953
Hospital Revenue Code	301
Min. Negotiated Rate	$67.87
Max. Negotiated Rate	$92.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$74.04
Rate for Payer: Aetna of CA Government/Medicare	$74.04
Rate for Payer: Cash Price	$55.53
Rate for Payer: Health Smart Auto/Commercial	$74.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$74.04
Rate for Payer: LLUH Dept of Risk Management WC	$67.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$92.55

HC SOM PTH RELATED PROTEIN

Facility

$15.62

Service Code	CPT 82397 90
Hospital Charge Code	900911417
Hospital Revenue Code	301
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$12.50
Rate for Payer: Cash Price	$7.03
Rate for Payer: Cigna of CA HMO/PPO	$12.50
Rate for Payer: Health Smart Auto/Commercial	$9.37
Rate for Payer: LLUH Dept of Risk Management WC	$8.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.72

HC SOM PTH RELATED PROTEIN

Facility

$15.62

Service Code	CPT 82397
Hospital Charge Code	900911417
Hospital Revenue Code	301
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$11.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.37
Rate for Payer: Aetna of CA Government/Medicare	$9.37
Rate for Payer: Cash Price	$7.03
Rate for Payer: Health Smart Auto/Commercial	$9.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.37
Rate for Payer: LLUH Dept of Risk Management WC	$8.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.72

HC SOM PTH RELATED PROTEIN

Facility

$15.62

Service Code	CPT 82397
Hospital Charge Code	900911417
Hospital Revenue Code	301
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$12.50
Rate for Payer: Cash Price	$7.03
Rate for Payer: Cigna of CA HMO/PPO	$12.50
Rate for Payer: Health Smart Auto/Commercial	$9.37
Rate for Payer: LLUH Dept of Risk Management WC	$8.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.72

HC SOM PTH RELATED PROTEIN

Facility

$15.62

Service Code	CPT 82397 90
Hospital Charge Code	900911417
Hospital Revenue Code	301
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$11.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.37
Rate for Payer: Aetna of CA Government/Medicare	$9.37
Rate for Payer: Cash Price	$7.03
Rate for Payer: Health Smart Auto/Commercial	$9.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.37
Rate for Payer: LLUH Dept of Risk Management WC	$8.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.72

HC SOM PWDNA 81331

Facility

$561.17

Service Code	CPT 81331 90
Hospital Charge Code	900914888
Hospital Revenue Code	300
Min. Negotiated Rate	$308.64
Max. Negotiated Rate	$420.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$336.70
Rate for Payer: Aetna of CA Government/Medicare	$336.70
Rate for Payer: Cash Price	$252.53
Rate for Payer: Health Smart Auto/Commercial	$336.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$336.70
Rate for Payer: LLUH Dept of Risk Management WC	$308.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$420.88

HC SOM PWDNA 81331

Facility

$561.17

Service Code	CPT 81331
Hospital Charge Code	900914888
Hospital Revenue Code	309
Min. Negotiated Rate	$308.64
Max. Negotiated Rate	$448.94
Rate for Payer: Cash Price	$252.53
Rate for Payer: Cigna of CA HMO/PPO	$448.94
Rate for Payer: Health Smart Auto/Commercial	$336.70
Rate for Payer: LLUH Dept of Risk Management WC	$308.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$420.88

Know your out-of-pocket cost for care.

All Charges