Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM TRAM 83925

Facility

$45.00

Service Code	CPT G0480 90
Hospital Charge Code	900915271
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Cigna of CA HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

HC SOM TRAM 83925

Facility

$45.00

Service Code	CPT G0480
Hospital Charge Code	900915271
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

HC SOM TRAM 83925

Facility

$45.00

Service Code	CPT G0480 90
Hospital Charge Code	900915271
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

HC SOM TRAM 83925

Facility

$45.00

Service Code	CPT 80373
Hospital Charge Code	900915271
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

HC SOM TRANSGLUTAMINASE AB IGG

Facility

$14.75

Service Code	CPT 83516 90
Hospital Charge Code	900912640
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 TRANSGLUTAMINASE AB IGG

Facility

$14.75

Service Code	CPT 83516
Hospital Charge Code	900912640
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 TRANSGLUTAMINASE AB IGG

Facility

$14.75

Service Code	CPT 83516
Hospital Charge Code	900912640
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 TRANSGLUTAMINASE AB IGG

Facility

$14.75

Service Code	CPT 83516 90
Hospital Charge Code	900912640
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 TREE4 86003

Facility

$61.13

Service Code	CPT 86003
Hospital Charge Code	900914815
Hospital Revenue Code	302
Min. Negotiated Rate	$33.62
Max. Negotiated Rate	$45.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.68
Rate for Payer: Aetna of CA Government/Medicare	$36.68
Rate for Payer: Cash Price	$27.51
Rate for Payer: Health Smart Auto/Commercial	$36.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.68
Rate for Payer: LLUH Dept of Risk Management WC	$33.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.85

HC SOM TREE4 86003

Facility

$61.13

Service Code	CPT 86003 90
Hospital Charge Code	900914815
Hospital Revenue Code	300
Min. Negotiated Rate	$33.62
Max. Negotiated Rate	$45.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.68
Rate for Payer: Aetna of CA Government/Medicare	$36.68
Rate for Payer: Cash Price	$27.51
Rate for Payer: Health Smart Auto/Commercial	$36.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.68
Rate for Payer: LLUH Dept of Risk Management WC	$33.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.85

HC SOM TREE4 86003

Facility

$61.13

Service Code	CPT 86003 90
Hospital Charge Code	900914815
Hospital Revenue Code	300
Min. Negotiated Rate	$33.62
Max. Negotiated Rate	$48.90
Rate for Payer: Cash Price	$27.51
Rate for Payer: Cigna of CA HMO/PPO	$48.90
Rate for Payer: Health Smart Auto/Commercial	$36.68
Rate for Payer: LLUH Dept of Risk Management WC	$33.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.85

HC SOM TREE4 86003

Facility

$61.13

Service Code	CPT 86003
Hospital Charge Code	900914815
Hospital Revenue Code	302
Min. Negotiated Rate	$33.62
Max. Negotiated Rate	$48.90
Rate for Payer: Cash Price	$27.51
Rate for Payer: Cigna of CA HMO/PPO	$48.90
Rate for Payer: Health Smart Auto/Commercial	$36.68
Rate for Payer: LLUH Dept of Risk Management WC	$33.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$45.85

HC SOM TRYPTASE

Facility

$37.70

Service Code	CPT 83520
Hospital Charge Code	900910734
Hospital Revenue Code	302
Min. Negotiated Rate	$20.74
Max. Negotiated Rate	$28.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.62
Rate for Payer: Aetna of CA Government/Medicare	$22.62
Rate for Payer: Cash Price	$16.97
Rate for Payer: Health Smart Auto/Commercial	$22.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.62
Rate for Payer: LLUH Dept of Risk Management WC	$20.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.28

HC SOM TRYPTASE

Facility

$37.70

Service Code	CPT 83520 90
Hospital Charge Code	900910734
Hospital Revenue Code	302
Min. Negotiated Rate	$20.74
Max. Negotiated Rate	$30.16
Rate for Payer: Cash Price	$16.97
Rate for Payer: Cigna of CA HMO/PPO	$30.16
Rate for Payer: Health Smart Auto/Commercial	$22.62
Rate for Payer: LLUH Dept of Risk Management WC	$20.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.28

HC SOM TRYPTASE

Facility

$37.70

Service Code	CPT 83520
Hospital Charge Code	900910734
Hospital Revenue Code	302
Min. Negotiated Rate	$20.74
Max. Negotiated Rate	$30.16
Rate for Payer: Cash Price	$16.97
Rate for Payer: Cigna of CA HMO/PPO	$30.16
Rate for Payer: Health Smart Auto/Commercial	$22.62
Rate for Payer: LLUH Dept of Risk Management WC	$20.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.28

HC SOM TRYPTASE

Facility

$37.70

Service Code	CPT 83520 90
Hospital Charge Code	900910734
Hospital Revenue Code	302
Min. Negotiated Rate	$20.74
Max. Negotiated Rate	$28.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.62
Rate for Payer: Aetna of CA Government/Medicare	$22.62
Rate for Payer: Cash Price	$16.97
Rate for Payer: Health Smart Auto/Commercial	$22.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.62
Rate for Payer: LLUH Dept of Risk Management WC	$20.74
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$28.28

HC SOM TSH SENSITIVE, SERUM

Facility

$24.06

Service Code	CPT 84443 90
Hospital Charge Code	900913813
Hospital Revenue Code	301
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$18.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.44
Rate for Payer: Aetna of CA Government/Medicare	$14.44
Rate for Payer: Cash Price	$10.83
Rate for Payer: Health Smart Auto/Commercial	$14.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.44
Rate for Payer: LLUH Dept of Risk Management WC	$13.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.04

HC SOM TSH SENSITIVE, SERUM

Facility

$24.06

Service Code	CPT 84443 90
Hospital Charge Code	900913813
Hospital Revenue Code	301
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$19.25
Rate for Payer: Cash Price	$10.83
Rate for Payer: Cigna of CA HMO/PPO	$19.25
Rate for Payer: Health Smart Auto/Commercial	$14.44
Rate for Payer: LLUH Dept of Risk Management WC	$13.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.04

HC SOM TSH SENSITIVE, SERUM

Facility

$24.06

Service Code	CPT 84443
Hospital Charge Code	900913813
Hospital Revenue Code	301
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$19.25
Rate for Payer: Cash Price	$10.83
Rate for Payer: Cigna of CA HMO/PPO	$19.25
Rate for Payer: Health Smart Auto/Commercial	$14.44
Rate for Payer: LLUH Dept of Risk Management WC	$13.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.04

HC SOM TSH SENSITIVE, SERUM

Facility

$24.06

Service Code	CPT 84443
Hospital Charge Code	900913813
Hospital Revenue Code	301
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$18.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.44
Rate for Payer: Aetna of CA Government/Medicare	$14.44
Rate for Payer: Cash Price	$10.83
Rate for Payer: Health Smart Auto/Commercial	$14.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.44
Rate for Payer: LLUH Dept of Risk Management WC	$13.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.04

HC SOM UBEMS 81406

Facility

$967.50

Service Code	CPT 81406
Hospital Charge Code	900914886
Hospital Revenue Code	309
Min. Negotiated Rate	$532.12
Max. Negotiated Rate	$725.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$580.50
Rate for Payer: Aetna of CA Government/Medicare	$580.50
Rate for Payer: Cash Price	$435.38
Rate for Payer: Health Smart Auto/Commercial	$580.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$580.50
Rate for Payer: LLUH Dept of Risk Management WC	$532.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$725.62

HC SOM UBEMS 81406

Facility

$967.50

Service Code	CPT 81406 90
Hospital Charge Code	900914886
Hospital Revenue Code	300
Min. Negotiated Rate	$532.12
Max. Negotiated Rate	$774.00
Rate for Payer: Cash Price	$435.38
Rate for Payer: Cigna of CA HMO/PPO	$774.00
Rate for Payer: Health Smart Auto/Commercial	$580.50
Rate for Payer: LLUH Dept of Risk Management WC	$532.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$725.62

HC SOM UBEMS 81406

Facility

$967.50

Service Code	CPT 81406 90
Hospital Charge Code	900914886
Hospital Revenue Code	300
Min. Negotiated Rate	$532.12
Max. Negotiated Rate	$725.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$580.50
Rate for Payer: Aetna of CA Government/Medicare	$580.50
Rate for Payer: Cash Price	$435.38
Rate for Payer: Health Smart Auto/Commercial	$580.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$580.50
Rate for Payer: LLUH Dept of Risk Management WC	$532.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$725.62

HC SOM UBEMS 81406

Facility

$967.50

Service Code	CPT 81406
Hospital Charge Code	900914886
Hospital Revenue Code	309
Min. Negotiated Rate	$532.12
Max. Negotiated Rate	$774.00
Rate for Payer: Cash Price	$435.38
Rate for Payer: Cigna of CA HMO/PPO	$774.00
Rate for Payer: Health Smart Auto/Commercial	$580.50
Rate for Payer: LLUH Dept of Risk Management WC	$532.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$725.62

HC SOM UNIPARENTAL DISOMY AMP

Facility

$275.48

Service Code	CPT 81402 90
Hospital Charge Code	900914445
Hospital Revenue Code	301
Min. Negotiated Rate	$151.51
Max. Negotiated Rate	$220.38
Rate for Payer: Cash Price	$123.97
Rate for Payer: Cigna of CA HMO/PPO	$220.38
Rate for Payer: Health Smart Auto/Commercial	$165.29
Rate for Payer: LLUH Dept of Risk Management WC	$151.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$206.61

Know your out-of-pocket cost for care.

All Charges