Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC LAB REF PHOSPHOTIDYLSERINE IGG

Facility

$49.00

Service Code	CPT 86148 90
Hospital Charge Code	900911382
Hospital Revenue Code	301
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$36.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.40
Rate for Payer: Aetna of CA Government/Medicare	$29.40
Rate for Payer: Cash Price	$22.05
Rate for Payer: Health Smart Auto/Commercial	$29.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.75

HC LAB REF PHOSPHOTIDYLSERINE IGG

Facility

$49.00

Service Code	CPT 86148 90
Hospital Charge Code	900911382
Hospital Revenue Code	301
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$39.20
Rate for Payer: Cash Price	$22.05
Rate for Payer: Cigna of CA HMO/PPO	$39.20
Rate for Payer: Health Smart Auto/Commercial	$29.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.75

HC LAB REF PHOSPHOTIDYLSERINE IGG

Facility

$49.00

Service Code	CPT 86148
Hospital Charge Code	900911382
Hospital Revenue Code	301
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$36.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.40
Rate for Payer: Aetna of CA Government/Medicare	$29.40
Rate for Payer: Cash Price	$22.05
Rate for Payer: Health Smart Auto/Commercial	$29.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.75

HC LAB REF PHOSPHOTIDYLSERINE IGG

Facility

$49.00

Service Code	CPT 86148
Hospital Charge Code	900911382
Hospital Revenue Code	301
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$39.20
Rate for Payer: Cash Price	$22.05
Rate for Payer: Cigna of CA HMO/PPO	$39.20
Rate for Payer: Health Smart Auto/Commercial	$29.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.75

HC LAB REF PHOSPHOTIDYLSERINE IGM

Facility

$49.00

Service Code	CPT 86148
Hospital Charge Code	900911383
Hospital Revenue Code	301
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$39.20
Rate for Payer: Cash Price	$22.05
Rate for Payer: Cigna of CA HMO/PPO	$39.20
Rate for Payer: Health Smart Auto/Commercial	$29.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.75

HC LAB REF PHOSPHOTIDYLSERINE IGM

Facility

$49.00

Service Code	CPT 86148 90
Hospital Charge Code	900911383
Hospital Revenue Code	301
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$39.20
Rate for Payer: Cash Price	$22.05
Rate for Payer: Cigna of CA HMO/PPO	$39.20
Rate for Payer: Health Smart Auto/Commercial	$29.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.75

HC LAB REF PHOSPHOTIDYLSERINE IGM

Facility

$49.00

Service Code	CPT 86148
Hospital Charge Code	900911383
Hospital Revenue Code	301
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$36.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.40
Rate for Payer: Aetna of CA Government/Medicare	$29.40
Rate for Payer: Cash Price	$22.05
Rate for Payer: Health Smart Auto/Commercial	$29.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.75

HC LAB REF PHOSPHOTIDYLSERINE IGM

Facility

$49.00

Service Code	CPT 86148 90
Hospital Charge Code	900911383
Hospital Revenue Code	301
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$36.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.40
Rate for Payer: Aetna of CA Government/Medicare	$29.40
Rate for Payer: Cash Price	$22.05
Rate for Payer: Health Smart Auto/Commercial	$29.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.75

HC LAB REF PROSTAGLANINS PGE2

Facility

$403.00

Service Code	CPT 84150
Hospital Charge Code	900910778
Hospital Revenue Code	301
Min. Negotiated Rate	$221.65
Max. Negotiated Rate	$322.40
Rate for Payer: Cash Price	$181.35
Rate for Payer: Cigna of CA HMO/PPO	$322.40
Rate for Payer: Health Smart Auto/Commercial	$241.80
Rate for Payer: LLUH Dept of Risk Management WC	$221.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$302.25

HC LAB REF PROSTAGLANINS PGE2

Facility

$403.00

Service Code	CPT 84150 90
Hospital Charge Code	900910778
Hospital Revenue Code	301
Min. Negotiated Rate	$221.65
Max. Negotiated Rate	$322.40
Rate for Payer: Cash Price	$181.35
Rate for Payer: Cigna of CA HMO/PPO	$322.40
Rate for Payer: Health Smart Auto/Commercial	$241.80
Rate for Payer: LLUH Dept of Risk Management WC	$221.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$302.25

HC LAB REF PROSTAGLANINS PGE2

Facility

$403.00

Service Code	CPT 84150
Hospital Charge Code	900910778
Hospital Revenue Code	301
Min. Negotiated Rate	$221.65
Max. Negotiated Rate	$302.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$241.80
Rate for Payer: Aetna of CA Government/Medicare	$241.80
Rate for Payer: Cash Price	$181.35
Rate for Payer: Health Smart Auto/Commercial	$241.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$241.80
Rate for Payer: LLUH Dept of Risk Management WC	$221.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$302.25

HC LAB REF PROSTAGLANINS PGE2

Facility

$403.00

Service Code	CPT 84150 90
Hospital Charge Code	900910778
Hospital Revenue Code	301
Min. Negotiated Rate	$221.65
Max. Negotiated Rate	$302.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$241.80
Rate for Payer: Aetna of CA Government/Medicare	$241.80
Rate for Payer: Cash Price	$181.35
Rate for Payer: Health Smart Auto/Commercial	$241.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$241.80
Rate for Payer: LLUH Dept of Risk Management WC	$221.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$302.25

HC LAB REF PROTEIN ELECT BODY FLUID

Facility

$28.00

Service Code	CPT 84166
Hospital Charge Code	900912678
Hospital Revenue Code	301
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.40
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna of CA HMO/PPO	$22.40
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.00

HC LAB REF PROTEIN ELECT BODY FLUID

Facility

$28.00

Service Code	CPT 84166 90
Hospital Charge Code	900912678
Hospital Revenue Code	301
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.40
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna of CA HMO/PPO	$22.40
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.00

HC LAB REF PROTEIN ELECT BODY FLUID

Facility

$28.00

Service Code	CPT 84166 90
Hospital Charge Code	900912678
Hospital Revenue Code	301
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.80
Rate for Payer: Aetna of CA Government/Medicare	$16.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.00

HC LAB REF PROTEIN ELECT BODY FLUID

Facility

$28.00

Service Code	CPT 84166
Hospital Charge Code	900912678
Hospital Revenue Code	301
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.80
Rate for Payer: Aetna of CA Government/Medicare	$16.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.00

HC LAB REF PROTEIN TOTAL (SO)

Facility

$36.00

Service Code	CPT 84155
Hospital Charge Code	900912825
Hospital Revenue Code	301
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna of CA HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.00

HC LAB REF PROTEIN TOTAL (SO)

Facility

$36.00

Service Code	CPT 84155 90
Hospital Charge Code	900912825
Hospital Revenue Code	301
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.60
Rate for Payer: Aetna of CA Government/Medicare	$21.60
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.00

HC LAB REF PROTEIN TOTAL (SO)

Facility

$36.00

Service Code	CPT 84155 90
Hospital Charge Code	900912825
Hospital Revenue Code	301
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna of CA HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.00

HC LAB REF PROTEIN TOTAL (SO)

Facility

$36.00

Service Code	CPT 84155
Hospital Charge Code	900912825
Hospital Revenue Code	301
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.60
Rate for Payer: Aetna of CA Government/Medicare	$21.60
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.00

HC LAB REF PROTRIPTYLINE (VIVACTYL)

Facility

$71.00

Service Code	CPT 80335 90
Hospital Charge Code	900911246
Hospital Revenue Code	301
Min. Negotiated Rate	$39.05
Max. Negotiated Rate	$53.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.60
Rate for Payer: Aetna of CA Government/Medicare	$42.60
Rate for Payer: Cash Price	$31.95
Rate for Payer: Health Smart Auto/Commercial	$42.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.60
Rate for Payer: LLUH Dept of Risk Management WC	$39.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.25

HC LAB REF PROTRIPTYLINE (VIVACTYL)

Facility

$71.00

Service Code	CPT 80335 90
Hospital Charge Code	900911246
Hospital Revenue Code	301
Min. Negotiated Rate	$39.05
Max. Negotiated Rate	$56.80
Rate for Payer: Cash Price	$31.95
Rate for Payer: Cigna of CA HMO/PPO	$56.80
Rate for Payer: Health Smart Auto/Commercial	$42.60
Rate for Payer: LLUH Dept of Risk Management WC	$39.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.25

HC LAB REF PROTRIPTYLINE (VIVACTYL)

Facility

$71.00

Service Code	CPT 80335
Hospital Charge Code	900911246
Hospital Revenue Code	301
Min. Negotiated Rate	$39.05
Max. Negotiated Rate	$56.80
Rate for Payer: Cash Price	$31.95
Rate for Payer: Cigna of CA HMO/PPO	$56.80
Rate for Payer: Health Smart Auto/Commercial	$42.60
Rate for Payer: LLUH Dept of Risk Management WC	$39.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.25

HC LAB REF PROTRIPTYLINE (VIVACTYL)

Facility

$71.00

Service Code	CPT 80335
Hospital Charge Code	900911246
Hospital Revenue Code	301
Min. Negotiated Rate	$39.05
Max. Negotiated Rate	$53.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.60
Rate for Payer: Aetna of CA Government/Medicare	$42.60
Rate for Payer: Cash Price	$31.95
Rate for Payer: Health Smart Auto/Commercial	$42.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.60
Rate for Payer: LLUH Dept of Risk Management WC	$39.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$53.25

HC LAB REF QUINIDINE

Facility

$67.00

Service Code	CPT 80194
Hospital Charge Code	900910456
Hospital Revenue Code	301
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$50.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.20
Rate for Payer: Aetna of CA Government/Medicare	$40.20
Rate for Payer: Cash Price	$30.15
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.25

Know your out-of-pocket cost for care.

All Charges