Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM THYROPEROXIDASE AB

Facility

$11.90

Service Code	CPT 86376 90
Hospital Charge Code	900911315
Hospital Revenue Code	302
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$8.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.14
Rate for Payer: Aetna of CA Government/Medicare	$7.14
Rate for Payer: Cash Price	$5.36
Rate for Payer: Health Smart Auto/Commercial	$7.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.14
Rate for Payer: LLUH Dept of Risk Management WC	$6.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.92

HC SOM THYROPEROXIDASE AB

Facility

$11.90

Service Code	CPT 86376
Hospital Charge Code	900911315
Hospital Revenue Code	302
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$8.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.14
Rate for Payer: Aetna of CA Government/Medicare	$7.14
Rate for Payer: Cash Price	$5.36
Rate for Payer: Health Smart Auto/Commercial	$7.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.14
Rate for Payer: LLUH Dept of Risk Management WC	$6.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.92

HC SOM THYROPEROXIDASE AB

Facility

$11.90

Service Code	CPT 86376 90
Hospital Charge Code	900911315
Hospital Revenue Code	302
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$9.52
Rate for Payer: Cash Price	$5.36
Rate for Payer: Cigna of CA HMO/PPO	$9.52
Rate for Payer: Health Smart Auto/Commercial	$7.14
Rate for Payer: LLUH Dept of Risk Management WC	$6.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.92

HC SOM THYROPEROXIDASE AB

Facility

$11.90

Service Code	CPT 86376
Hospital Charge Code	900911315
Hospital Revenue Code	302
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$9.52
Rate for Payer: Cash Price	$5.36
Rate for Payer: Cigna of CA HMO/PPO	$9.52
Rate for Payer: Health Smart Auto/Commercial	$7.14
Rate for Payer: LLUH Dept of Risk Management WC	$6.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.92

HC SOM THYROTROPIN RECEPTOR

Facility

$17.27

Service Code	CPT 83520
Hospital Charge Code	900912541
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$13.82
Rate for Payer: Cash Price	$7.77
Rate for Payer: Cigna of CA HMO/PPO	$13.82
Rate for Payer: Health Smart Auto/Commercial	$10.36
Rate for Payer: LLUH Dept of Risk Management WC	$9.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.95

HC SOM THYROTROPIN RECEPTOR

Facility

$17.27

Service Code	CPT 83520
Hospital Charge Code	900912541
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$12.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.36
Rate for Payer: Aetna of CA Government/Medicare	$10.36
Rate for Payer: Cash Price	$7.77
Rate for Payer: Health Smart Auto/Commercial	$10.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.36
Rate for Payer: LLUH Dept of Risk Management WC	$9.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.95

HC SOM THYROTROPIN RECEPTOR

Facility

$17.27

Service Code	CPT 83520 90
Hospital Charge Code	900912541
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$12.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.36
Rate for Payer: Aetna of CA Government/Medicare	$10.36
Rate for Payer: Cash Price	$7.77
Rate for Payer: Health Smart Auto/Commercial	$10.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.36
Rate for Payer: LLUH Dept of Risk Management WC	$9.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.95

HC SOM THYROTROPIN RECEPTOR

Facility

$17.27

Service Code	CPT 83520 90
Hospital Charge Code	900912541
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$13.82
Rate for Payer: Cash Price	$7.77
Rate for Payer: Cigna of CA HMO/PPO	$13.82
Rate for Payer: Health Smart Auto/Commercial	$10.36
Rate for Payer: LLUH Dept of Risk Management WC	$9.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.95

HC SOM THYROXINE (T4), FREE

Facility

$121.28

Service Code	CPT 84439
Hospital Charge Code	900911005
Hospital Revenue Code	301
Min. Negotiated Rate	$66.70
Max. Negotiated Rate	$97.02
Rate for Payer: Cash Price	$54.58
Rate for Payer: Cigna of CA HMO/PPO	$97.02
Rate for Payer: Health Smart Auto/Commercial	$72.77
Rate for Payer: LLUH Dept of Risk Management WC	$66.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.96

HC SOM THYROXINE (T4), FREE

Facility

$121.28

Service Code	CPT 84439 90
Hospital Charge Code	900911005
Hospital Revenue Code	301
Min. Negotiated Rate	$66.70
Max. Negotiated Rate	$90.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.77
Rate for Payer: Aetna of CA Government/Medicare	$72.77
Rate for Payer: Cash Price	$54.58
Rate for Payer: Health Smart Auto/Commercial	$72.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.77
Rate for Payer: LLUH Dept of Risk Management WC	$66.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.96

HC SOM THYROXINE (T4), FREE

Facility

$121.28

Service Code	CPT 84439
Hospital Charge Code	900911005
Hospital Revenue Code	301
Min. Negotiated Rate	$66.70
Max. Negotiated Rate	$90.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.77
Rate for Payer: Aetna of CA Government/Medicare	$72.77
Rate for Payer: Cash Price	$54.58
Rate for Payer: Health Smart Auto/Commercial	$72.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.77
Rate for Payer: LLUH Dept of Risk Management WC	$66.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.96

HC SOM THYROXINE (T4), FREE

Facility

$121.28

Service Code	CPT 84439 90
Hospital Charge Code	900911005
Hospital Revenue Code	301
Min. Negotiated Rate	$66.70
Max. Negotiated Rate	$97.02
Rate for Payer: Cash Price	$54.58
Rate for Payer: Cigna of CA HMO/PPO	$97.02
Rate for Payer: Health Smart Auto/Commercial	$72.77
Rate for Payer: LLUH Dept of Risk Management WC	$66.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.96

HC SOM THYROXIN TOTAL

Facility

$9.84

Service Code	CPT 84436
Hospital Charge Code	900912522
Hospital Revenue Code	301
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$7.87
Rate for Payer: Cash Price	$4.43
Rate for Payer: Cigna of CA HMO/PPO	$7.87
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.38

HC SOM THYROXIN TOTAL

Facility

$9.84

Service Code	CPT 84436
Hospital Charge Code	900912522
Hospital Revenue Code	301
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$7.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.90
Rate for Payer: Aetna of CA Government/Medicare	$5.90
Rate for Payer: Cash Price	$4.43
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.38

HC SOM THYROXIN TOTAL

Facility

$9.84

Service Code	CPT 84436 90
Hospital Charge Code	900912522
Hospital Revenue Code	301
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$7.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.90
Rate for Payer: Aetna of CA Government/Medicare	$5.90
Rate for Payer: Cash Price	$4.43
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.38

HC SOM THYROXIN TOTAL

Facility

$9.84

Service Code	CPT 84436 90
Hospital Charge Code	900912522
Hospital Revenue Code	301
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$7.87
Rate for Payer: Cash Price	$4.43
Rate for Payer: Cigna of CA HMO/PPO	$7.87
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.38

HC SOM TISSUE CULTURE NEOPLASTIC

Facility

$325.00

Service Code	CPT 88291 90
Hospital Charge Code	900910765
Hospital Revenue Code	310
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$260.00
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cigna of CA HMO/PPO	$260.00
Rate for Payer: Health Smart Auto/Commercial	$195.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.75

HC SOM TISSUE CULTURE NEOPLASTIC

Facility

$325.00

Service Code	CPT 88291
Hospital Charge Code	900910765
Hospital Revenue Code	310
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$243.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$195.00
Rate for Payer: Aetna of CA Government/Medicare	$195.00
Rate for Payer: Cash Price	$146.25
Rate for Payer: Health Smart Auto/Commercial	$195.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$195.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.75

HC SOM TISSUE CULTURE NEOPLASTIC

Facility

$325.00

Service Code	CPT 88291 90
Hospital Charge Code	900910765
Hospital Revenue Code	310
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$243.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$195.00
Rate for Payer: Aetna of CA Government/Medicare	$195.00
Rate for Payer: Cash Price	$146.25
Rate for Payer: Health Smart Auto/Commercial	$195.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$195.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.75

HC SOM TISSUE CULTURE NEOPLASTIC

Facility

$325.00

Service Code	CPT 88291
Hospital Charge Code	900910765
Hospital Revenue Code	310
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$260.00
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cigna of CA HMO/PPO	$260.00
Rate for Payer: Health Smart Auto/Commercial	$195.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.75

HC SOM TISSUE TRANSGLT AB IGA

Facility

$14.75

Service Code	CPT 83516 90
Hospital Charge Code	900914110
Hospital Revenue Code	302
Min. Negotiated Rate	$8.11
Max. Negotiated Rate	$11.80
Rate for Payer: Cash Price	$6.64
Rate for Payer: Cigna of CA HMO/PPO	$11.80
Rate for Payer: Health Smart Auto/Commercial	$8.85
Rate for Payer: LLUH Dept of Risk Management WC	$8.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.06

HC SOM TISSUE TRANSGLT AB IGA

Facility

$14.75

Service Code	CPT 83516 90
Hospital Charge Code	900914110
Hospital Revenue Code	302
Min. Negotiated Rate	$8.11
Max. Negotiated Rate	$11.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.85
Rate for Payer: Aetna of CA Government/Medicare	$8.85
Rate for Payer: Cash Price	$6.64
Rate for Payer: Health Smart Auto/Commercial	$8.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.85
Rate for Payer: LLUH Dept of Risk Management WC	$8.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.06

HC SOM TISSUE TRANSGLT AB IGA

Facility

$14.75

Service Code	CPT 83516
Hospital Charge Code	900914110
Hospital Revenue Code	302
Min. Negotiated Rate	$8.11
Max. Negotiated Rate	$11.80
Rate for Payer: Cash Price	$6.64
Rate for Payer: Cigna of CA HMO/PPO	$11.80
Rate for Payer: Health Smart Auto/Commercial	$8.85
Rate for Payer: LLUH Dept of Risk Management WC	$8.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.06

HC SOM TISSUE TRANSGLT AB IGA

Facility

$14.75

Service Code	CPT 83516
Hospital Charge Code	900914110
Hospital Revenue Code	302
Min. Negotiated Rate	$8.11
Max. Negotiated Rate	$11.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.85
Rate for Payer: Aetna of CA Government/Medicare	$8.85
Rate for Payer: Cash Price	$6.64
Rate for Payer: Health Smart Auto/Commercial	$8.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.85
Rate for Payer: LLUH Dept of Risk Management WC	$8.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.06

HC SOM TOPIRAMATE

Facility

$17.50

Service Code	CPT 80201
Hospital Charge Code	900910764
Hospital Revenue Code	301
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$14.00
Rate for Payer: Cash Price	$7.88
Rate for Payer: Cigna of CA HMO/PPO	$14.00
Rate for Payer: Health Smart Auto/Commercial	$10.50
Rate for Payer: LLUH Dept of Risk Management WC	$9.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.12

Know your out-of-pocket cost for care.

All Charges