Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM MYOGLOBIN URINE

Facility

$18.00

Service Code	CPT 83874
Hospital Charge Code	900910762
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 SOM MYOGLOBIN URINE

Facility

$18.00

Service Code	CPT 83874
Hospital Charge Code	900910762
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 SOM NEOPTERIN

Facility

$179.25

Service Code	CPT 83520 90
Hospital Charge Code	900913946
Hospital Revenue Code	301
Min. Negotiated Rate	$98.59
Max. Negotiated Rate	$134.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$107.55
Rate for Payer: Aetna of CA Government/Medicare	$107.55
Rate for Payer: Cash Price	$80.66
Rate for Payer: Health Smart Auto/Commercial	$107.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$107.55
Rate for Payer: LLUH Dept of Risk Management WC	$98.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$134.44

HC SOM NEOPTERIN

Facility

$179.25

Service Code	CPT 83520
Hospital Charge Code	900913946
Hospital Revenue Code	301
Min. Negotiated Rate	$98.59
Max. Negotiated Rate	$143.40
Rate for Payer: Health Smart Auto/Commercial	$107.55
Rate for Payer: Cash Price	$80.66
Rate for Payer: Cigna of CA HMO/PPO	$143.40
Rate for Payer: LLUH Dept of Risk Management WC	$98.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$134.44

HC SOM NEOPTERIN

Facility

$179.25

Service Code	CPT 83520 90
Hospital Charge Code	900913946
Hospital Revenue Code	301
Min. Negotiated Rate	$98.59
Max. Negotiated Rate	$143.40
Rate for Payer: Cash Price	$80.66
Rate for Payer: Cigna of CA HMO/PPO	$143.40
Rate for Payer: Health Smart Auto/Commercial	$107.55
Rate for Payer: LLUH Dept of Risk Management WC	$98.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$134.44

HC SOM NEOPTERIN

Facility

$179.25

Service Code	CPT 83520
Hospital Charge Code	900913946
Hospital Revenue Code	301
Min. Negotiated Rate	$98.59
Max. Negotiated Rate	$134.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$107.55
Rate for Payer: Aetna of CA Government/Medicare	$107.55
Rate for Payer: Cash Price	$80.66
Rate for Payer: Health Smart Auto/Commercial	$107.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$107.55
Rate for Payer: LLUH Dept of Risk Management WC	$98.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$134.44

HC SOM NEURON SPECIFIC ENOLASE CSF

Facility

$30.00

Service Code	CPT 83520
Hospital Charge Code	900910766
Hospital Revenue Code	302
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM NEURON SPECIFIC ENOLASE CSF

Facility

$30.00

Service Code	CPT 83520
Hospital Charge Code	900910766
Hospital Revenue Code	302
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM NEURON SPECIFIC ENOLASE CSF

Facility

$30.00

Service Code	CPT 83520 90
Hospital Charge Code	900910766
Hospital Revenue Code	302
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna of CA HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM NEURON SPECIFIC ENOLASE CSF

Facility

$30.00

Service Code	CPT 83520 90
Hospital Charge Code	900910766
Hospital Revenue Code	302
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.50

HC SOM NEURON SPECIFIC ENOLASE SERUM

Facility

$25.00

Service Code	CPT 83520 90
Hospital Charge Code	900910767
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna of CA HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM NEURON SPECIFIC ENOLASE SERUM

Facility

$25.00

Service Code	CPT 83520 90
Hospital Charge Code	900910767
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM NEURON SPECIFIC ENOLASE SERUM

Facility

$25.00

Service Code	CPT 83520
Hospital Charge Code	900910767
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM NEURON SPECIFIC ENOLASE SERUM

Facility

$25.00

Service Code	CPT 83520
Hospital Charge Code	900910767
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna of CA HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM NEUROTENSIN

Facility

$270.00

Service Code	CPT 83519 90
Hospital Charge Code	900910768
Hospital Revenue Code	301
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$162.00
Rate for Payer: Aetna of CA Government/Medicare	$162.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Health Smart Auto/Commercial	$162.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$162.00
Rate for Payer: LLUH Dept of Risk Management WC	$148.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$202.50

HC SOM NEUROTENSIN

Facility

$270.00

Service Code	CPT 83519 90
Hospital Charge Code	900910768
Hospital Revenue Code	301
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$216.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna of CA HMO/PPO	$216.00
Rate for Payer: Health Smart Auto/Commercial	$162.00
Rate for Payer: LLUH Dept of Risk Management WC	$148.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$202.50

HC SOM NEUROTENSIN

Facility

$270.00

Service Code	CPT 83519
Hospital Charge Code	900910768
Hospital Revenue Code	301
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$216.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna of CA HMO/PPO	$216.00
Rate for Payer: Health Smart Auto/Commercial	$162.00
Rate for Payer: LLUH Dept of Risk Management WC	$148.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$202.50

HC SOM NEUROTENSIN

Facility

$270.00

Service Code	CPT 83519
Hospital Charge Code	900910768
Hospital Revenue Code	301
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$162.00
Rate for Payer: Aetna of CA Government/Medicare	$162.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Health Smart Auto/Commercial	$162.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$162.00
Rate for Payer: LLUH Dept of Risk Management WC	$148.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$202.50

HC SOM N.GONORRHOEAE AMP DNA FEMALE U

Facility

$194.68

Service Code	CPT 87591 90
Hospital Charge Code	900912876
Hospital Revenue Code	306
Min. Negotiated Rate	$107.07
Max. Negotiated Rate	$146.01
Rate for Payer: Health Smart Auto/Commercial	$116.81
Rate for Payer: Cash Price	$87.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$116.81
Rate for Payer: Aetna of CA Government/Medicare	$116.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$116.81
Rate for Payer: LLUH Dept of Risk Management WC	$107.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$146.01

HC SOM N.GONORRHOEAE AMP DNA FEMALE U

Facility

$194.68

Service Code	CPT 87591
Hospital Charge Code	900912876
Hospital Revenue Code	306
Min. Negotiated Rate	$107.07
Max. Negotiated Rate	$146.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$116.81
Rate for Payer: Aetna of CA Government/Medicare	$116.81
Rate for Payer: Cash Price	$87.61
Rate for Payer: Health Smart Auto/Commercial	$116.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$116.81
Rate for Payer: LLUH Dept of Risk Management WC	$107.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$146.01

HC SOM N.GONORRHOEAE AMP DNA FEMALE U

Facility

$194.68

Service Code	CPT 87591 90
Hospital Charge Code	900912876
Hospital Revenue Code	306
Min. Negotiated Rate	$107.07
Max. Negotiated Rate	$155.74
Rate for Payer: Cash Price	$87.61
Rate for Payer: Cigna of CA HMO/PPO	$155.74
Rate for Payer: Health Smart Auto/Commercial	$116.81
Rate for Payer: LLUH Dept of Risk Management WC	$107.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$146.01

HC SOM N.GONORRHOEAE AMP DNA FEMALE U

Facility

$194.68

Service Code	CPT 87591
Hospital Charge Code	900912876
Hospital Revenue Code	306
Min. Negotiated Rate	$107.07
Max. Negotiated Rate	$155.74
Rate for Payer: Cash Price	$87.61
Rate for Payer: Cigna of CA HMO/PPO	$155.74
Rate for Payer: Health Smart Auto/Commercial	$116.81
Rate for Payer: LLUH Dept of Risk Management WC	$107.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$146.01

HC SOM NICOTINE

Facility

$20.35

Service Code	CPT G0480
Hospital Charge Code	900910769
Hospital Revenue Code	301
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$16.28
Rate for Payer: Cash Price	$9.16
Rate for Payer: Cigna of CA HMO/PPO	$16.28
Rate for Payer: Health Smart Auto/Commercial	$12.21
Rate for Payer: LLUH Dept of Risk Management WC	$11.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.26

HC SOM NICOTINE

Facility

$20.35

Service Code	CPT G0480 90
Hospital Charge Code	900910769
Hospital Revenue Code	301
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$16.28
Rate for Payer: Cash Price	$9.16
Rate for Payer: Cigna of CA HMO/PPO	$16.28
Rate for Payer: Health Smart Auto/Commercial	$12.21
Rate for Payer: LLUH Dept of Risk Management WC	$11.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.26

HC SOM NICOTINE

Facility

$20.35

Service Code	CPT G0480
Hospital Charge Code	900910769
Hospital Revenue Code	301
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$15.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.21
Rate for Payer: Aetna of CA Government/Medicare	$12.21
Rate for Payer: Cash Price	$9.16
Rate for Payer: Health Smart Auto/Commercial	$12.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.21
Rate for Payer: LLUH Dept of Risk Management WC	$11.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.26

Know your out-of-pocket cost for care.

All Charges