Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC LAB REF STRIATIONAL ABS

Facility

$21.00

Service Code	CPT 83520
Hospital Charge Code	900912585
Hospital Revenue Code	301
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$15.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.60
Rate for Payer: Aetna of CA Government/Medicare	$12.60
Rate for Payer: Cash Price	$9.45
Rate for Payer: Health Smart Auto/Commercial	$12.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.60
Rate for Payer: LLUH Dept of Risk Management WC	$11.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.75

HC LAB REF STRYCHNINE

Facility

$143.00

Service Code	CPT 80323 90
Hospital Charge Code	900911075
Hospital Revenue Code	301
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$107.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$85.80
Rate for Payer: Aetna of CA Government/Medicare	$85.80
Rate for Payer: Cash Price	$64.35
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC LAB REF STRYCHNINE

Facility

$143.00

Service Code	CPT 80323 90
Hospital Charge Code	900911075
Hospital Revenue Code	301
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$114.40
Rate for Payer: Cash Price	$64.35
Rate for Payer: Cigna of CA HMO/PPO	$114.40
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC LAB REF STRYCHNINE

Facility

$143.00

Service Code	CPT 80323
Hospital Charge Code	900911075
Hospital Revenue Code	301
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$107.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$85.80
Rate for Payer: Aetna of CA Government/Medicare	$85.80
Rate for Payer: Cash Price	$64.35
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC LAB REF STRYCHNINE

Facility

$143.00

Service Code	CPT 80323
Hospital Charge Code	900911075
Hospital Revenue Code	301
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$114.40
Rate for Payer: Cash Price	$64.35
Rate for Payer: Cigna of CA HMO/PPO	$114.40
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC LAB REF SULFHEMOGLOBIN

Facility

$10.00

Service Code	CPT 83060
Hospital Charge Code	900910299
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 SULFHEMOGLOBIN

Facility

$10.00

Service Code	CPT 83060
Hospital Charge Code	900910299
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 SULFHEMOGLOBIN

Facility

$10.00

Service Code	CPT 83060 90
Hospital Charge Code	900910299
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 SULFHEMOGLOBIN

Facility

$10.00

Service Code	CPT 83060 90
Hospital Charge Code	900910299
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 T3 UPTAKE

Facility

$10.00

Service Code	CPT 84479 90
Hospital Charge Code	900910792
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 T3 UPTAKE

Facility

$10.00

Service Code	CPT 84479 90
Hospital Charge Code	900910792
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 T3 UPTAKE

Facility

$10.00

Service Code	CPT 84479
Hospital Charge Code	900910792
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 T3 UPTAKE

Facility

$10.00

Service Code	CPT 84479
Hospital Charge Code	900910792
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 TALWIN (PENTAZ)

Facility

$92.00

Service Code	CPT 82542
Hospital Charge Code	900911096
Hospital Revenue Code	301
Min. Negotiated Rate	$50.60
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.20
Rate for Payer: Aetna of CA Government/Medicare	$55.20
Rate for Payer: Cash Price	$41.40
Rate for Payer: Health Smart Auto/Commercial	$55.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$55.20
Rate for Payer: LLUH Dept of Risk Management WC	$50.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$69.00

HC LAB REF TALWIN (PENTAZ)

Facility

$92.00

Service Code	CPT 82542
Hospital Charge Code	900911096
Hospital Revenue Code	301
Min. Negotiated Rate	$50.60
Max. Negotiated Rate	$73.60
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna of CA HMO/PPO	$73.60
Rate for Payer: Health Smart Auto/Commercial	$55.20
Rate for Payer: LLUH Dept of Risk Management WC	$50.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$69.00

HC LAB REF TALWIN (PENTAZ)

Facility

$92.00

Service Code	CPT 82542 90
Hospital Charge Code	900911096
Hospital Revenue Code	301
Min. Negotiated Rate	$50.60
Max. Negotiated Rate	$73.60
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna of CA HMO/PPO	$73.60
Rate for Payer: Health Smart Auto/Commercial	$55.20
Rate for Payer: LLUH Dept of Risk Management WC	$50.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$69.00

HC LAB REF TALWIN (PENTAZ)

Facility

$92.00

Service Code	CPT 82542 90
Hospital Charge Code	900911096
Hospital Revenue Code	301
Min. Negotiated Rate	$50.60
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.20
Rate for Payer: Aetna of CA Government/Medicare	$55.20
Rate for Payer: Cash Price	$41.40
Rate for Payer: Health Smart Auto/Commercial	$55.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$55.20
Rate for Payer: LLUH Dept of Risk Management WC	$50.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$69.00

HC LAB REF THIOPENTAL (PENTOTHAL)

Facility

$143.00

Service Code	CPT G0480
Hospital Charge Code	900910555
Hospital Revenue Code	301
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$107.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$85.80
Rate for Payer: Aetna of CA Government/Medicare	$85.80
Rate for Payer: Cash Price	$64.35
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC LAB REF THIOPENTAL (PENTOTHAL)

Facility

$143.00

Service Code	CPT 80345
Hospital Charge Code	900910555
Hospital Revenue Code	301
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$114.40
Rate for Payer: Cash Price	$64.35
Rate for Payer: Cigna of CA HMO/PPO	$114.40
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC LAB REF THIOPENTAL (PENTOTHAL)

Facility

$143.00

Service Code	CPT 80345
Hospital Charge Code	900910555
Hospital Revenue Code	301
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$107.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$85.80
Rate for Payer: Aetna of CA Government/Medicare	$85.80
Rate for Payer: Cash Price	$64.35
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC LAB REF THIOPENTAL (PENTOTHAL)

Facility

$143.00

Service Code	CPT G0480 90
Hospital Charge Code	900910555
Hospital Revenue Code	301
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$114.40
Rate for Payer: Cash Price	$64.35
Rate for Payer: Cigna of CA HMO/PPO	$114.40
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC LAB REF THIOPENTAL (PENTOTHAL)

Facility

$143.00

Service Code	CPT G0480 90
Hospital Charge Code	900910555
Hospital Revenue Code	301
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$107.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$85.80
Rate for Payer: Aetna of CA Government/Medicare	$85.80
Rate for Payer: Cash Price	$64.35
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC LAB REF THIOPENTAL (PENTOTHAL)

Facility

$143.00

Service Code	CPT G0480
Hospital Charge Code	900910555
Hospital Revenue Code	301
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$114.40
Rate for Payer: Cash Price	$64.35
Rate for Payer: Cigna of CA HMO/PPO	$114.40
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC LAB REF TIAGABINE LEVEL

Facility

$99.00

Service Code	CPT 80199
Hospital Charge Code	900912716
Hospital Revenue Code	301
Min. Negotiated Rate	$54.45
Max. Negotiated Rate	$79.20
Rate for Payer: Cash Price	$44.55
Rate for Payer: Cigna of CA HMO/PPO	$79.20
Rate for Payer: Health Smart Auto/Commercial	$59.40
Rate for Payer: LLUH Dept of Risk Management WC	$54.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$74.25

HC LAB REF TIAGABINE LEVEL

Facility

$99.00

Service Code	CPT 80199 90
Hospital Charge Code	900912716
Hospital Revenue Code	301
Min. Negotiated Rate	$54.45
Max. Negotiated Rate	$74.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$59.40
Rate for Payer: Aetna of CA Government/Medicare	$59.40
Rate for Payer: Cash Price	$44.55
Rate for Payer: Health Smart Auto/Commercial	$59.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$59.40
Rate for Payer: LLUH Dept of Risk Management WC	$54.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$74.25

Know your out-of-pocket cost for care.

All Charges