Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC LAB REF GREEN COFFEE BEAN IGE

Facility

$13.00

Service Code	CPT 86003 90
Hospital Charge Code	900912523
Hospital Revenue Code	302
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cigna of CA HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.75

HC LAB REF GREEN COFFEE BEAN IGE

Facility

$13.00

Service Code	CPT 86003
Hospital Charge Code	900912523
Hospital Revenue Code	302
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cigna of CA HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.75

HC LAB REF GREEN COFFEE BEAN IGE

Facility

$13.00

Service Code	CPT 86003
Hospital Charge Code	900912523
Hospital Revenue Code	302
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$9.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.80
Rate for Payer: Aetna of CA Government/Medicare	$7.80
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.75

HC LAB REF GREEN COFFEE BEAN IGE

Facility

$13.00

Service Code	CPT 86003 90
Hospital Charge Code	900912523
Hospital Revenue Code	302
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$9.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.80
Rate for Payer: Aetna of CA Government/Medicare	$7.80
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.75

HC LAB REF HEAVY METALS UR ARSENIC

Facility

$79.00

Service Code	CPT 82175
Hospital Charge Code	900912663
Hospital Revenue Code	301
Min. Negotiated Rate	$43.45
Max. Negotiated Rate	$63.20
Rate for Payer: Cash Price	$35.55
Rate for Payer: Cigna of CA HMO/PPO	$63.20
Rate for Payer: Health Smart Auto/Commercial	$47.40
Rate for Payer: LLUH Dept of Risk Management WC	$43.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$59.25

HC LAB REF HEAVY METALS UR ARSENIC

Facility

$79.00

Service Code	CPT 82175 90
Hospital Charge Code	900912663
Hospital Revenue Code	301
Min. Negotiated Rate	$43.45
Max. Negotiated Rate	$59.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$47.40
Rate for Payer: Aetna of CA Government/Medicare	$47.40
Rate for Payer: Cash Price	$35.55
Rate for Payer: Health Smart Auto/Commercial	$47.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$47.40
Rate for Payer: LLUH Dept of Risk Management WC	$43.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$59.25

HC LAB REF HEAVY METALS UR ARSENIC

Facility

$79.00

Service Code	CPT 82175 90
Hospital Charge Code	900912663
Hospital Revenue Code	301
Min. Negotiated Rate	$43.45
Max. Negotiated Rate	$63.20
Rate for Payer: Cash Price	$35.55
Rate for Payer: Cigna of CA HMO/PPO	$63.20
Rate for Payer: Health Smart Auto/Commercial	$47.40
Rate for Payer: LLUH Dept of Risk Management WC	$43.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$59.25

HC LAB REF HEAVY METALS UR ARSENIC

Facility

$79.00

Service Code	CPT 82175
Hospital Charge Code	900912663
Hospital Revenue Code	301
Min. Negotiated Rate	$43.45
Max. Negotiated Rate	$59.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$47.40
Rate for Payer: Aetna of CA Government/Medicare	$47.40
Rate for Payer: Cash Price	$35.55
Rate for Payer: Health Smart Auto/Commercial	$47.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$47.40
Rate for Payer: LLUH Dept of Risk Management WC	$43.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$59.25

HC LAB REF HEAVY METALS UR CADMIUM

Facility

$96.00

Service Code	CPT 82300
Hospital Charge Code	900912662
Hospital Revenue Code	301
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.60
Rate for Payer: Aetna of CA Government/Medicare	$57.60
Rate for Payer: Cash Price	$43.20
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$72.00

HC LAB REF HEAVY METALS UR CADMIUM

Facility

$96.00

Service Code	CPT 82300
Hospital Charge Code	900912662
Hospital Revenue Code	301
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$76.80
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna of CA HMO/PPO	$76.80
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$72.00

HC LAB REF HEAVY METALS UR CADMIUM

Facility

$96.00

Service Code	CPT 82300 90
Hospital Charge Code	900912662
Hospital Revenue Code	301
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$72.00
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: Cash Price	$43.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.60
Rate for Payer: Aetna of CA Government/Medicare	$57.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$72.00

HC LAB REF HEAVY METALS UR CADMIUM

Facility

$96.00

Service Code	CPT 82300 90
Hospital Charge Code	900912662
Hospital Revenue Code	301
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$76.80
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna of CA HMO/PPO	$76.80
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$72.00

HC LAB REF HEAVY METALS UR LEAD

Facility

$50.00

Service Code	CPT 83655
Hospital Charge Code	900912661
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC LAB REF HEAVY METALS UR LEAD

Facility

$50.00

Service Code	CPT 83655 90
Hospital Charge Code	900912661
Hospital Revenue Code	301
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 LAB REF HEAVY METALS UR LEAD

Facility

$50.00

Service Code	CPT 83655 90
Hospital Charge Code	900912661
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC LAB REF HEAVY METALS UR LEAD

Facility

$50.00

Service Code	CPT 83655
Hospital Charge Code	900912661
Hospital Revenue Code	301
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 LAB REF HEAVY METALS UR MERCURY

Facility

$68.00

Service Code	CPT 83825
Hospital Charge Code	900912664
Hospital Revenue Code	301
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC LAB REF HEAVY METALS UR MERCURY

Facility

$68.00

Service Code	CPT 83825
Hospital Charge Code	900912664
Hospital Revenue Code	301
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$54.40
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna of CA HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC LAB REF HEAVY METALS UR MERCURY

Facility

$68.00

Service Code	CPT 83825 90
Hospital Charge Code	900912664
Hospital Revenue Code	301
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC LAB REF HEAVY METALS UR MERCURY

Facility

$68.00

Service Code	CPT 83825 90
Hospital Charge Code	900912664
Hospital Revenue Code	301
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$54.40
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna of CA HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC LAB REF HERPESVIRUS 6 AB IGG

Facility

$56.00

Service Code	CPT 86790 90
Hospital Charge Code	900910749
Hospital Revenue Code	302
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.80
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna of CA HMO/PPO	$44.80
Rate for Payer: Health Smart Auto/Commercial	$33.60
Rate for Payer: LLUH Dept of Risk Management WC	$30.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.00

HC LAB REF HERPESVIRUS 6 AB IGG

Facility

$56.00

Service Code	CPT 86790
Hospital Charge Code	900910749
Hospital Revenue Code	302
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.60
Rate for Payer: Aetna of CA Government/Medicare	$33.60
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Smart Auto/Commercial	$33.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.60
Rate for Payer: LLUH Dept of Risk Management WC	$30.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.00

HC LAB REF HERPESVIRUS 6 AB IGG

Facility

$56.00

Service Code	CPT 86790 90
Hospital Charge Code	900910749
Hospital Revenue Code	302
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.60
Rate for Payer: Aetna of CA Government/Medicare	$33.60
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Smart Auto/Commercial	$33.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.60
Rate for Payer: LLUH Dept of Risk Management WC	$30.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.00

HC LAB REF HERPESVIRUS 6 AB IGG

Facility

$56.00

Service Code	CPT 86790
Hospital Charge Code	900910749
Hospital Revenue Code	302
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.80
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna of CA HMO/PPO	$44.80
Rate for Payer: Health Smart Auto/Commercial	$33.60
Rate for Payer: LLUH Dept of Risk Management WC	$30.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.00

HC LAB REF HERPESVIRUS 6 AB, IGM

Facility

$56.00

Service Code	CPT 86790
Hospital Charge Code	900911421
Hospital Revenue Code	302
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.60
Rate for Payer: Aetna of CA Government/Medicare	$33.60
Rate for Payer: Cash Price	$25.20
Rate for Payer: Health Smart Auto/Commercial	$33.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.60
Rate for Payer: LLUH Dept of Risk Management WC	$30.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.00

Know your out-of-pocket cost for care.

All Charges