Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC LAB REF LCM IGM

Facility

$44.00

Service Code	CPT 86727
Hospital Charge Code	900912723
Hospital Revenue Code	302
Min. Negotiated Rate	$24.20
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$26.40
Rate for Payer: Aetna of CA Government/Medicare	$26.40
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Smart Auto/Commercial	$26.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$26.40
Rate for Payer: LLUH Dept of Risk Management WC	$24.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.00

HC LAB REF LCM IGM

Facility

$44.00

Service Code	CPT 86727
Hospital Charge Code	900912723
Hospital Revenue Code	302
Min. Negotiated Rate	$24.20
Max. Negotiated Rate	$35.20
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna of CA HMO/PPO	$35.20
Rate for Payer: Health Smart Auto/Commercial	$26.40
Rate for Payer: LLUH Dept of Risk Management WC	$24.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.00

HC LAB REF LIDOCAINE

Facility

$18.00

Service Code	CPT 80176
Hospital Charge Code	900910404
Hospital Revenue Code	301
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$14.40
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna of CA HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.50

HC LAB REF LIDOCAINE

Facility

$18.00

Service Code	CPT 80176 90
Hospital Charge Code	900910404
Hospital Revenue Code	301
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Cash Price	$8.10
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.50

HC LAB REF LIDOCAINE

Facility

$18.00

Service Code	CPT 80176
Hospital Charge Code	900910404
Hospital Revenue Code	301
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Cash Price	$8.10
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.50

HC LAB REF LIDOCAINE

Facility

$18.00

Service Code	CPT 80176 90
Hospital Charge Code	900910404
Hospital Revenue Code	301
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$14.40
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna of CA HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.50

HC LAB REF LISTERIA AB

Facility

$110.00

Service Code	CPT 86609
Hospital Charge Code	900911391
Hospital Revenue Code	302
Min. Negotiated Rate	$60.50
Max. Negotiated Rate	$88.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna of CA HMO/PPO	$88.00
Rate for Payer: Health Smart Auto/Commercial	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$60.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$82.50

HC LAB REF LISTERIA AB

Facility

$110.00

Service Code	CPT 86609
Hospital Charge Code	900911391
Hospital Revenue Code	302
Min. Negotiated Rate	$60.50
Max. Negotiated Rate	$82.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$66.00
Rate for Payer: Aetna of CA Government/Medicare	$66.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Health Smart Auto/Commercial	$66.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$60.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$82.50

HC LAB REF LISTERIA AB

Facility

$110.00

Service Code	CPT 86609 90
Hospital Charge Code	900911391
Hospital Revenue Code	302
Min. Negotiated Rate	$60.50
Max. Negotiated Rate	$82.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$66.00
Rate for Payer: Aetna of CA Government/Medicare	$66.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Health Smart Auto/Commercial	$66.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$60.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$82.50

HC LAB REF LISTERIA AB

Facility

$110.00

Service Code	CPT 86609 90
Hospital Charge Code	900911391
Hospital Revenue Code	302
Min. Negotiated Rate	$60.50
Max. Negotiated Rate	$88.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna of CA HMO/PPO	$88.00
Rate for Payer: Health Smart Auto/Commercial	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$60.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$82.50

HC LAB REF MERCURY URINE

Facility

$23.00

Service Code	CPT 83830
Hospital Charge Code	900911144
Hospital Revenue Code	301
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$17.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.80
Rate for Payer: Aetna of CA Government/Medicare	$13.80
Rate for Payer: Cash Price	$10.35
Rate for Payer: Health Smart Auto/Commercial	$13.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.80
Rate for Payer: LLUH Dept of Risk Management WC	$12.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.25

HC LAB REF MERCURY URINE

Facility

$23.00

Service Code	CPT 83830 90
Hospital Charge Code	900911144
Hospital Revenue Code	301
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$17.25
Rate for Payer: Health Smart Auto/Commercial	$13.80
Rate for Payer: Cash Price	$10.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.80
Rate for Payer: Aetna of CA Government/Medicare	$13.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.80
Rate for Payer: LLUH Dept of Risk Management WC	$12.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.25

HC LAB REF MERCURY URINE

Facility

$23.00

Service Code	CPT 83830
Hospital Charge Code	900911144
Hospital Revenue Code	301
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$18.40
Rate for Payer: Cash Price	$10.35
Rate for Payer: Cigna of CA HMO/PPO	$18.40
Rate for Payer: Health Smart Auto/Commercial	$13.80
Rate for Payer: LLUH Dept of Risk Management WC	$12.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.25

HC LAB REF MERCURY URINE

Facility

$23.00

Service Code	CPT 83830 90
Hospital Charge Code	900911144
Hospital Revenue Code	301
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$18.40
Rate for Payer: Cash Price	$10.35
Rate for Payer: Cigna of CA HMO/PPO	$18.40
Rate for Payer: Health Smart Auto/Commercial	$13.80
Rate for Payer: LLUH Dept of Risk Management WC	$12.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.25

HC LAB REF METHEMALBUMIN

Facility

$115.00

Service Code	CPT 83857 90
Hospital Charge Code	900911067
Hospital Revenue Code	301
Min. Negotiated Rate	$63.25
Max. Negotiated Rate	$86.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$69.00
Rate for Payer: Aetna of CA Government/Medicare	$69.00
Rate for Payer: Cash Price	$51.75
Rate for Payer: Health Smart Auto/Commercial	$69.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$69.00
Rate for Payer: LLUH Dept of Risk Management WC	$63.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$86.25

HC LAB REF METHEMALBUMIN

Facility

$115.00

Service Code	CPT 83857 90
Hospital Charge Code	900911067
Hospital Revenue Code	301
Min. Negotiated Rate	$63.25
Max. Negotiated Rate	$92.00
Rate for Payer: Cash Price	$51.75
Rate for Payer: Cigna of CA HMO/PPO	$92.00
Rate for Payer: Health Smart Auto/Commercial	$69.00
Rate for Payer: LLUH Dept of Risk Management WC	$63.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$86.25

HC LAB REF METHEMALBUMIN

Facility

$115.00

Service Code	CPT 83857
Hospital Charge Code	900911067
Hospital Revenue Code	301
Min. Negotiated Rate	$63.25
Max. Negotiated Rate	$86.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$69.00
Rate for Payer: Aetna of CA Government/Medicare	$69.00
Rate for Payer: Cash Price	$51.75
Rate for Payer: Health Smart Auto/Commercial	$69.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$69.00
Rate for Payer: LLUH Dept of Risk Management WC	$63.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$86.25

HC LAB REF METHEMALBUMIN

Facility

$115.00

Service Code	CPT 83857
Hospital Charge Code	900911067
Hospital Revenue Code	301
Min. Negotiated Rate	$63.25
Max. Negotiated Rate	$92.00
Rate for Payer: Cash Price	$51.75
Rate for Payer: Cigna of CA HMO/PPO	$92.00
Rate for Payer: Health Smart Auto/Commercial	$69.00
Rate for Payer: LLUH Dept of Risk Management WC	$63.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$86.25

HC LAB REF METHEMOGLOBIN

Facility

$10.00

Service Code	CPT 83050
Hospital Charge Code	900910295
Hospital Revenue Code	301
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna of CA HMO/PPO	$8.00
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

HC LAB REF METHEMOGLOBIN

Facility

$10.00

Service Code	CPT 83050 90
Hospital Charge Code	900910295
Hospital Revenue Code	301
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna of CA HMO/PPO	$8.00
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

HC LAB REF METHEMOGLOBIN

Facility

$10.00

Service Code	CPT 83050 90
Hospital Charge Code	900910295
Hospital Revenue Code	301
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.00
Rate for Payer: Aetna of CA Government/Medicare	$6.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

HC LAB REF METHEMOGLOBIN

Facility

$10.00

Service Code	CPT 83050
Hospital Charge Code	900910295
Hospital Revenue Code	301
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.00
Rate for Payer: Aetna of CA Government/Medicare	$6.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

HC LAB REF MITOCHONDRIAL DNA

Facility

$1,316.00

Service Code	CPT 84999 90
Hospital Charge Code	900911407
Hospital Revenue Code	302
Min. Negotiated Rate	$723.80
Max. Negotiated Rate	$987.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$789.60
Rate for Payer: Aetna of CA Government/Medicare	$789.60
Rate for Payer: Cash Price	$592.20
Rate for Payer: Health Smart Auto/Commercial	$789.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$789.60
Rate for Payer: LLUH Dept of Risk Management WC	$723.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$987.00

HC LAB REF MITOCHONDRIAL DNA

Facility

$1,316.00

Service Code	CPT 84999
Hospital Charge Code	900911407
Hospital Revenue Code	302
Min. Negotiated Rate	$723.80
Max. Negotiated Rate	$1,052.80
Rate for Payer: Cash Price	$592.20
Rate for Payer: Cigna of CA HMO/PPO	$1,052.80
Rate for Payer: Health Smart Auto/Commercial	$789.60
Rate for Payer: LLUH Dept of Risk Management WC	$723.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$987.00

HC LAB REF MITOCHONDRIAL DNA

Facility

$1,316.00

Service Code	CPT 84999 90
Hospital Charge Code	900911407
Hospital Revenue Code	302
Min. Negotiated Rate	$723.80
Max. Negotiated Rate	$1,052.80
Rate for Payer: Cash Price	$592.20
Rate for Payer: Cigna of CA HMO/PPO	$1,052.80
Rate for Payer: Health Smart Auto/Commercial	$789.60
Rate for Payer: LLUH Dept of Risk Management WC	$723.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$987.00

Know your out-of-pocket cost for care.

All Charges