Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM LYME DISEASE AB IGM

Facility

$15.00

Service Code	CPT 86617
Hospital Charge Code	900912696
Hospital Revenue Code	302
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Cigna of CA HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC SOM LYME DISEASE AB IGM

Facility

$15.00

Service Code	CPT 86617
Hospital Charge Code	900912696
Hospital Revenue Code	302
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC SOM LYME DISEASE AB SERUM

Facility

$16.30

Service Code	CPT 86618 90
Hospital Charge Code	900912568
Hospital Revenue Code	302
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$12.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.78
Rate for Payer: Aetna of CA Government/Medicare	$9.78
Rate for Payer: Cash Price	$7.34
Rate for Payer: Health Smart Auto/Commercial	$9.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.78
Rate for Payer: LLUH Dept of Risk Management WC	$8.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.22

HC SOM LYME DISEASE AB SERUM

Facility

$16.30

Service Code	CPT 86618 90
Hospital Charge Code	900912568
Hospital Revenue Code	302
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$13.04
Rate for Payer: Cash Price	$7.34
Rate for Payer: Cigna of CA HMO/PPO	$13.04
Rate for Payer: Health Smart Auto/Commercial	$9.78
Rate for Payer: LLUH Dept of Risk Management WC	$8.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.22

HC SOM LYME DISEASE AB SERUM

Facility

$16.30

Service Code	CPT 86618
Hospital Charge Code	900912568
Hospital Revenue Code	302
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$12.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.78
Rate for Payer: Aetna of CA Government/Medicare	$9.78
Rate for Payer: Cash Price	$7.34
Rate for Payer: Health Smart Auto/Commercial	$9.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.78
Rate for Payer: LLUH Dept of Risk Management WC	$8.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.22

HC SOM LYME DISEASE AB SERUM

Facility

$16.30

Service Code	CPT 86618
Hospital Charge Code	900912568
Hospital Revenue Code	302
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$13.04
Rate for Payer: Cash Price	$7.34
Rate for Payer: Cigna of CA HMO/PPO	$13.04
Rate for Payer: Health Smart Auto/Commercial	$9.78
Rate for Payer: LLUH Dept of Risk Management WC	$8.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.22

HC SOM MAGNESIUM RANDOM UR

Facility

$7.41

Service Code	CPT 83735
Hospital Charge Code	900913941
Hospital Revenue Code	301
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$5.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.45
Rate for Payer: Aetna of CA Government/Medicare	$4.45
Rate for Payer: Cash Price	$3.33
Rate for Payer: Health Smart Auto/Commercial	$4.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.45
Rate for Payer: LLUH Dept of Risk Management WC	$4.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.56

HC SOM MAGNESIUM RANDOM UR

Facility

$7.41

Service Code	CPT 83735
Hospital Charge Code	900913941
Hospital Revenue Code	301
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$5.93
Rate for Payer: Cash Price	$3.33
Rate for Payer: Cigna of CA HMO/PPO	$5.93
Rate for Payer: Health Smart Auto/Commercial	$4.45
Rate for Payer: LLUH Dept of Risk Management WC	$4.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.56

HC SOM MAGNESIUM RANDOM UR

Facility

$7.41

Service Code	CPT 83735 90
Hospital Charge Code	900913941
Hospital Revenue Code	301
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$5.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.45
Rate for Payer: Aetna of CA Government/Medicare	$4.45
Rate for Payer: Cash Price	$3.33
Rate for Payer: Health Smart Auto/Commercial	$4.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.45
Rate for Payer: LLUH Dept of Risk Management WC	$4.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.56

HC SOM MAGNESIUM RANDOM UR

Facility

$7.41

Service Code	CPT 83735 90
Hospital Charge Code	900913941
Hospital Revenue Code	301
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$5.93
Rate for Payer: Cash Price	$3.33
Rate for Payer: Cigna of CA HMO/PPO	$5.93
Rate for Payer: Health Smart Auto/Commercial	$4.45
Rate for Payer: LLUH Dept of Risk Management WC	$4.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.56

HC SOM MAGNESIUM, URINE

Facility

$22.00

Service Code	CPT 83735
Hospital Charge Code	900910757
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$16.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.20
Rate for Payer: Aetna of CA Government/Medicare	$13.20
Rate for Payer: Cash Price	$9.90
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM MAGNESIUM, URINE

Facility

$22.00

Service Code	CPT 83735
Hospital Charge Code	900910757
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna of CA HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM MAGNESIUM, URINE

Facility

$22.00

Service Code	CPT 83735 90
Hospital Charge Code	900910757
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna of CA HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM MAGNESIUM, URINE

Facility

$22.00

Service Code	CPT 83735 90
Hospital Charge Code	900910757
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$16.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.20
Rate for Payer: Aetna of CA Government/Medicare	$13.20
Rate for Payer: Cash Price	$9.90
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.50

HC SOM MANGANESE

Facility

$26.65

Service Code	CPT 83785 90
Hospital Charge Code	900911066
Hospital Revenue Code	301
Min. Negotiated Rate	$14.66
Max. Negotiated Rate	$21.32
Rate for Payer: Cash Price	$11.99
Rate for Payer: Cigna of CA HMO/PPO	$21.32
Rate for Payer: Health Smart Auto/Commercial	$15.99
Rate for Payer: LLUH Dept of Risk Management WC	$14.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.99

HC SOM MANGANESE

Facility

$26.65

Service Code	CPT 83785 90
Hospital Charge Code	900911066
Hospital Revenue Code	301
Min. Negotiated Rate	$14.66
Max. Negotiated Rate	$19.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.99
Rate for Payer: Aetna of CA Government/Medicare	$15.99
Rate for Payer: Cash Price	$11.99
Rate for Payer: Health Smart Auto/Commercial	$15.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.99
Rate for Payer: LLUH Dept of Risk Management WC	$14.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.99

HC SOM MANGANESE

Facility

$26.65

Service Code	CPT 83785
Hospital Charge Code	900911066
Hospital Revenue Code	301
Min. Negotiated Rate	$14.66
Max. Negotiated Rate	$19.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.99
Rate for Payer: Aetna of CA Government/Medicare	$15.99
Rate for Payer: Cash Price	$11.99
Rate for Payer: Health Smart Auto/Commercial	$15.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.99
Rate for Payer: LLUH Dept of Risk Management WC	$14.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.99

HC SOM MANGANESE

Facility

$26.65

Service Code	CPT 83785
Hospital Charge Code	900911066
Hospital Revenue Code	301
Min. Negotiated Rate	$14.66
Max. Negotiated Rate	$21.32
Rate for Payer: Cash Price	$11.99
Rate for Payer: Cigna of CA HMO/PPO	$21.32
Rate for Payer: Health Smart Auto/Commercial	$15.99
Rate for Payer: LLUH Dept of Risk Management WC	$14.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.99

HC SOM MCLON IFE U

Facility

$28.86

Service Code	CPT 86335 90
Hospital Charge Code	900912768
Hospital Revenue Code	301
Min. Negotiated Rate	$15.87
Max. Negotiated Rate	$21.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.32
Rate for Payer: Aetna of CA Government/Medicare	$17.32
Rate for Payer: Cash Price	$12.99
Rate for Payer: Health Smart Auto/Commercial	$17.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.32
Rate for Payer: LLUH Dept of Risk Management WC	$15.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.64

HC SOM MCLON IFE U

Facility

$28.86

Service Code	CPT 86335
Hospital Charge Code	900912768
Hospital Revenue Code	301
Min. Negotiated Rate	$15.87
Max. Negotiated Rate	$23.09
Rate for Payer: Cash Price	$12.99
Rate for Payer: Cigna of CA HMO/PPO	$23.09
Rate for Payer: Health Smart Auto/Commercial	$17.32
Rate for Payer: LLUH Dept of Risk Management WC	$15.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.64

HC SOM MCLON IFE U

Facility

$28.86

Service Code	CPT 86335 90
Hospital Charge Code	900912768
Hospital Revenue Code	301
Min. Negotiated Rate	$15.87
Max. Negotiated Rate	$23.09
Rate for Payer: Cash Price	$12.99
Rate for Payer: Cigna of CA HMO/PPO	$23.09
Rate for Payer: Health Smart Auto/Commercial	$17.32
Rate for Payer: LLUH Dept of Risk Management WC	$15.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.64

HC SOM MCLON IFE U

Facility

$28.86

Service Code	CPT 86335
Hospital Charge Code	900912768
Hospital Revenue Code	301
Min. Negotiated Rate	$15.87
Max. Negotiated Rate	$21.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.32
Rate for Payer: Aetna of CA Government/Medicare	$17.32
Rate for Payer: Cash Price	$12.99
Rate for Payer: Health Smart Auto/Commercial	$17.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.32
Rate for Payer: LLUH Dept of Risk Management WC	$15.87
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.64

HC SOM MCLON PROT ELEC. U

Facility

$17.53

Service Code	CPT 84166
Hospital Charge Code	900912767
Hospital Revenue Code	301
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$14.02
Rate for Payer: Cash Price	$7.89
Rate for Payer: Cigna of CA HMO/PPO	$14.02
Rate for Payer: Health Smart Auto/Commercial	$10.52
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.15

HC SOM MCLON PROT ELEC. U

Facility

$17.53

Service Code	CPT 84166 90
Hospital Charge Code	900912767
Hospital Revenue Code	301
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$13.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.52
Rate for Payer: Aetna of CA Government/Medicare	$10.52
Rate for Payer: Cash Price	$7.89
Rate for Payer: Health Smart Auto/Commercial	$10.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.52
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.15

HC SOM MCLON PROT ELEC. U

Facility

$17.53

Service Code	CPT 84166
Hospital Charge Code	900912767
Hospital Revenue Code	301
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$13.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.52
Rate for Payer: Aetna of CA Government/Medicare	$10.52
Rate for Payer: Cash Price	$7.89
Rate for Payer: Health Smart Auto/Commercial	$10.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.52
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.15

Know your out-of-pocket cost for care.

All Charges