Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM FPSAP 84153

Facility

$89.50

Service Code	CPT 84153
Hospital Charge Code	900914765
Hospital Revenue Code	301
Min. Negotiated Rate	$49.22
Max. Negotiated Rate	$67.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.70
Rate for Payer: Aetna of CA Government/Medicare	$53.70
Rate for Payer: Cash Price	$40.28
Rate for Payer: Health Smart Auto/Commercial	$53.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.70
Rate for Payer: LLUH Dept of Risk Management WC	$49.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.12

HC SOM FPSAP 84153

Facility

$89.50

Service Code	CPT 84153 90
Hospital Charge Code	900914765
Hospital Revenue Code	301
Min. Negotiated Rate	$49.22
Max. Negotiated Rate	$71.60
Rate for Payer: Cash Price	$40.28
Rate for Payer: Cigna of CA HMO/PPO	$71.60
Rate for Payer: Health Smart Auto/Commercial	$53.70
Rate for Payer: LLUH Dept of Risk Management WC	$49.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.12

HC SOM FPSAP 84153

Facility

$89.50

Service Code	CPT 84153
Hospital Charge Code	900914765
Hospital Revenue Code	301
Min. Negotiated Rate	$49.22
Max. Negotiated Rate	$71.60
Rate for Payer: Cash Price	$40.28
Rate for Payer: Cigna of CA HMO/PPO	$71.60
Rate for Payer: Health Smart Auto/Commercial	$53.70
Rate for Payer: LLUH Dept of Risk Management WC	$49.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.12

HC SOM FPSAP 84153

Facility

$89.50

Service Code	CPT 84153 90
Hospital Charge Code	900914765
Hospital Revenue Code	301
Min. Negotiated Rate	$49.22
Max. Negotiated Rate	$67.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.70
Rate for Payer: Aetna of CA Government/Medicare	$53.70
Rate for Payer: Cash Price	$40.28
Rate for Payer: Health Smart Auto/Commercial	$53.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.70
Rate for Payer: LLUH Dept of Risk Management WC	$49.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.12

HC SOM FQUET 82491

Facility

$66.16

Service Code	CPT 82542
Hospital Charge Code	900914892
Hospital Revenue Code	301
Min. Negotiated Rate	$36.39
Max. Negotiated Rate	$49.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.70
Rate for Payer: Aetna of CA Government/Medicare	$39.70
Rate for Payer: Cash Price	$29.77
Rate for Payer: Health Smart Auto/Commercial	$39.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.70
Rate for Payer: LLUH Dept of Risk Management WC	$36.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.62

HC SOM FQUET 82491

Facility

$66.16

Service Code	CPT 82542 90
Hospital Charge Code	900914892
Hospital Revenue Code	301
Min. Negotiated Rate	$36.39
Max. Negotiated Rate	$52.93
Rate for Payer: Cash Price	$29.77
Rate for Payer: Cigna of CA HMO/PPO	$52.93
Rate for Payer: Health Smart Auto/Commercial	$39.70
Rate for Payer: LLUH Dept of Risk Management WC	$36.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.62

HC SOM FQUET 82491

Facility

$66.16

Service Code	CPT 82542 90
Hospital Charge Code	900914892
Hospital Revenue Code	301
Min. Negotiated Rate	$36.39
Max. Negotiated Rate	$49.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.70
Rate for Payer: Aetna of CA Government/Medicare	$39.70
Rate for Payer: Cash Price	$29.77
Rate for Payer: Health Smart Auto/Commercial	$39.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.70
Rate for Payer: LLUH Dept of Risk Management WC	$36.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.62

HC SOM FQUET 82491

Facility

$66.16

Service Code	CPT 82542
Hospital Charge Code	900914892
Hospital Revenue Code	301
Min. Negotiated Rate	$36.39
Max. Negotiated Rate	$52.93
Rate for Payer: Cash Price	$29.77
Rate for Payer: Cigna of CA HMO/PPO	$52.93
Rate for Payer: Health Smart Auto/Commercial	$39.70
Rate for Payer: LLUH Dept of Risk Management WC	$36.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$49.62

HC SOM FRAGILE X MOLECULAR ANALYSIS

Facility

$450.00

Service Code	CPT 81243
Hospital Charge Code	900912503
Hospital Revenue Code	301
Min. Negotiated Rate	$247.50
Max. Negotiated Rate	$360.00
Rate for Payer: Cash Price	$202.50
Rate for Payer: Cigna of CA HMO/PPO	$360.00
Rate for Payer: Health Smart Auto/Commercial	$270.00
Rate for Payer: LLUH Dept of Risk Management WC	$247.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.50

HC SOM FRAGILE X MOLECULAR ANALYSIS

Facility

$450.00

Service Code	CPT 81243 90
Hospital Charge Code	900912503
Hospital Revenue Code	301
Min. Negotiated Rate	$247.50
Max. Negotiated Rate	$360.00
Rate for Payer: Cash Price	$202.50
Rate for Payer: Cigna of CA HMO/PPO	$360.00
Rate for Payer: Health Smart Auto/Commercial	$270.00
Rate for Payer: LLUH Dept of Risk Management WC	$247.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.50

HC SOM FRAGILE X MOLECULAR ANALYSIS

Facility

$450.00

Service Code	CPT 81243 90
Hospital Charge Code	900912503
Hospital Revenue Code	301
Min. Negotiated Rate	$247.50
Max. Negotiated Rate	$337.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$270.00
Rate for Payer: Aetna of CA Government/Medicare	$270.00
Rate for Payer: Cash Price	$202.50
Rate for Payer: Health Smart Auto/Commercial	$270.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$270.00
Rate for Payer: LLUH Dept of Risk Management WC	$247.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.50

HC SOM FRAGILE X MOLECULAR ANALYSIS

Facility

$450.00

Service Code	CPT 81243
Hospital Charge Code	900912503
Hospital Revenue Code	301
Min. Negotiated Rate	$247.50
Max. Negotiated Rate	$337.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$270.00
Rate for Payer: Aetna of CA Government/Medicare	$270.00
Rate for Payer: Cash Price	$202.50
Rate for Payer: Health Smart Auto/Commercial	$270.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$270.00
Rate for Payer: LLUH Dept of Risk Management WC	$247.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$337.50

HC SOM FRANSICELLA AB

Facility

$47.50

Service Code	CPT 86000 90
Hospital Charge Code	900911647
Hospital Revenue Code	302
Min. Negotiated Rate	$26.12
Max. Negotiated Rate	$38.00
Rate for Payer: Cash Price	$21.38
Rate for Payer: Cigna of CA HMO/PPO	$38.00
Rate for Payer: Health Smart Auto/Commercial	$28.50
Rate for Payer: LLUH Dept of Risk Management WC	$26.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.62

HC SOM FRANSICELLA AB

Facility

$47.50

Service Code	CPT 86000
Hospital Charge Code	900911647
Hospital Revenue Code	302
Min. Negotiated Rate	$26.12
Max. Negotiated Rate	$38.00
Rate for Payer: Cash Price	$21.38
Rate for Payer: Cigna of CA HMO/PPO	$38.00
Rate for Payer: Health Smart Auto/Commercial	$28.50
Rate for Payer: LLUH Dept of Risk Management WC	$26.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.62

HC SOM FRANSICELLA AB

Facility

$47.50

Service Code	CPT 86000
Hospital Charge Code	900911647
Hospital Revenue Code	302
Min. Negotiated Rate	$26.12
Max. Negotiated Rate	$35.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.50
Rate for Payer: Aetna of CA Government/Medicare	$28.50
Rate for Payer: Cash Price	$21.38
Rate for Payer: Health Smart Auto/Commercial	$28.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.50
Rate for Payer: LLUH Dept of Risk Management WC	$26.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.62

HC SOM FRANSICELLA AB

Facility

$47.50

Service Code	CPT 86000 90
Hospital Charge Code	900911647
Hospital Revenue Code	302
Min. Negotiated Rate	$26.12
Max. Negotiated Rate	$35.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.50
Rate for Payer: Aetna of CA Government/Medicare	$28.50
Rate for Payer: Cash Price	$21.38
Rate for Payer: Health Smart Auto/Commercial	$28.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.50
Rate for Payer: LLUH Dept of Risk Management WC	$26.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.62

HC SOM FREE FATTY ACIDS

Facility

$32.00

Service Code	CPT 82725 90
Hospital Charge Code	900914522
Hospital Revenue Code	301
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$25.60
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna of CA HMO/PPO	$25.60
Rate for Payer: Health Smart Auto/Commercial	$19.20
Rate for Payer: LLUH Dept of Risk Management WC	$17.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.00

HC SOM FREE FATTY ACIDS

Facility

$32.00

Service Code	CPT 82725
Hospital Charge Code	900914522
Hospital Revenue Code	301
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$25.60
Rate for Payer: Health Smart Auto/Commercial	$19.20
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna of CA HMO/PPO	$25.60
Rate for Payer: LLUH Dept of Risk Management WC	$17.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.00

HC SOM FREE FATTY ACIDS

Facility

$32.00

Service Code	CPT 82725
Hospital Charge Code	900914522
Hospital Revenue Code	301
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.20
Rate for Payer: Aetna of CA Government/Medicare	$19.20
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Smart Auto/Commercial	$19.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.20
Rate for Payer: LLUH Dept of Risk Management WC	$17.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.00

HC SOM FREE FATTY ACIDS

Facility

$32.00

Service Code	CPT 82725 90
Hospital Charge Code	900914522
Hospital Revenue Code	301
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.20
Rate for Payer: Aetna of CA Government/Medicare	$19.20
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Smart Auto/Commercial	$19.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.20
Rate for Payer: LLUH Dept of Risk Management WC	$17.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.00

HC SOM FR TYR IDX BIND CAP

Facility

$9.27

Service Code	CPT 84479 90
Hospital Charge Code	900912805
Hospital Revenue Code	301
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$7.42
Rate for Payer: Cash Price	$4.17
Rate for Payer: Cigna of CA HMO/PPO	$7.42
Rate for Payer: Health Smart Auto/Commercial	$5.56
Rate for Payer: LLUH Dept of Risk Management WC	$5.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.95

HC SOM FR TYR IDX BIND CAP

Facility

$9.27

Service Code	CPT 84479 90
Hospital Charge Code	900912805
Hospital Revenue Code	301
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$6.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.56
Rate for Payer: Aetna of CA Government/Medicare	$5.56
Rate for Payer: Cash Price	$4.17
Rate for Payer: Health Smart Auto/Commercial	$5.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.56
Rate for Payer: LLUH Dept of Risk Management WC	$5.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.95

HC SOM FR TYR IDX BIND CAP

Facility

$9.27

Service Code	CPT 84479
Hospital Charge Code	900912805
Hospital Revenue Code	301
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$7.42
Rate for Payer: Cash Price	$4.17
Rate for Payer: Cigna of CA HMO/PPO	$7.42
Rate for Payer: Health Smart Auto/Commercial	$5.56
Rate for Payer: LLUH Dept of Risk Management WC	$5.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.95

HC SOM FR TYR IDX BIND CAP

Facility

$9.27

Service Code	CPT 84479
Hospital Charge Code	900912805
Hospital Revenue Code	301
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$6.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.56
Rate for Payer: Aetna of CA Government/Medicare	$5.56
Rate for Payer: Cash Price	$4.17
Rate for Payer: Health Smart Auto/Commercial	$5.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.56
Rate for Payer: LLUH Dept of Risk Management WC	$5.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.95

HC SOM FRUCTOSAMINE

Facility

$16.04

Service Code	CPT 82985 90
Hospital Charge Code	900913929
Hospital Revenue Code	301
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$12.83
Rate for Payer: Cash Price	$7.22
Rate for Payer: Cigna of CA HMO/PPO	$12.83
Rate for Payer: Health Smart Auto/Commercial	$9.62
Rate for Payer: LLUH Dept of Risk Management WC	$8.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.03

Know your out-of-pocket cost for care.

All Charges