Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC HEPATITIS B SURFACE AG (CONF)

Facility

$248.00

Service Code	CPT 87341
Hospital Charge Code	900910812
Hospital Revenue Code	306
Min. Negotiated Rate	$136.40
Max. Negotiated Rate	$198.40
Rate for Payer: Cash Price	$111.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$198.40
Rate for Payer: Health Smart Auto/Commercial	$148.80
Rate for Payer: LLUH Dept of Risk Management WC	$136.40
Rate for Payer: Multiplan Commercial	$186.00

HC HEPATITIS B SURFACE AG (CONF)

Facility

$90.00

Service Code	CPT 87341
Hospital Charge Code	900910812
Hospital Revenue Code	306
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.00
Rate for Payer: Aetna of CA Government/Medicare	$54.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cash Price	$40.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: Intervalley Health Plan Commercial	$10.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Commercial	$67.50

HC HEPATITIS B SURFACE AG INDIVIDUAL

Facility

$82.00

Service Code	CPT 87340
Hospital Charge Code	900912333
Hospital Revenue Code	306
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$65.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.20
Rate for Payer: Aetna of CA Government/Medicare	$49.20
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cash Price	$36.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$65.60
Rate for Payer: Health Smart Auto/Commercial	$49.20
Rate for Payer: Intervalley Health Plan Commercial	$10.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.20
Rate for Payer: LLUH Dept of Risk Management WC	$45.10
Rate for Payer: Multiplan Commercial	$61.50

HC HEPATITIS B SURFACE AG INDIVIDUAL

Facility

$138.00

Service Code	CPT 87340
Hospital Charge Code	900912333
Hospital Revenue Code	306
Min. Negotiated Rate	$75.90
Max. Negotiated Rate	$110.40
Rate for Payer: Cash Price	$62.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$110.40
Rate for Payer: Health Smart Auto/Commercial	$82.80
Rate for Payer: LLUH Dept of Risk Management WC	$75.90
Rate for Payer: Multiplan Commercial	$103.50

HC HEPATITIS B SURFACE ANTIBODY

Facility

$97.44

Service Code	CPT 86706
Hospital Charge Code	900910860
Hospital Revenue Code	302
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$77.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$58.46
Rate for Payer: Aetna of CA Government/Medicare	$58.46
Rate for Payer: Cash Price	$43.85
Rate for Payer: Cash Price	$43.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$77.95
Rate for Payer: Health Smart Auto/Commercial	$58.46
Rate for Payer: Intervalley Health Plan Commercial	$10.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$58.46
Rate for Payer: LLUH Dept of Risk Management WC	$53.59
Rate for Payer: Multiplan Commercial	$73.08

HC HEPATITIS B SURFACE ANTIBODY

Facility

$223.00

Service Code	CPT 86706
Hospital Charge Code	900910860
Hospital Revenue Code	302
Min. Negotiated Rate	$122.65
Max. Negotiated Rate	$178.40
Rate for Payer: Cash Price	$100.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$178.40
Rate for Payer: Health Smart Auto/Commercial	$133.80
Rate for Payer: LLUH Dept of Risk Management WC	$122.65
Rate for Payer: Multiplan Commercial	$167.25

HC HEPATITIS C AB TOTAL

Facility

$141.07

Service Code	CPT 86803
Hospital Charge Code	900912155
Hospital Revenue Code	302
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$112.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$84.64
Rate for Payer: Aetna of CA Government/Medicare	$84.64
Rate for Payer: Cash Price	$63.48
Rate for Payer: Cash Price	$63.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$112.86
Rate for Payer: Health Smart Auto/Commercial	$84.64
Rate for Payer: Intervalley Health Plan Commercial	$14.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$84.64
Rate for Payer: LLUH Dept of Risk Management WC	$77.59
Rate for Payer: Multiplan Commercial	$105.80

HC HEPATITIS C AB TOTAL

Facility

$319.00

Service Code	CPT 86803
Hospital Charge Code	900912155
Hospital Revenue Code	302
Min. Negotiated Rate	$175.45
Max. Negotiated Rate	$255.20
Rate for Payer: Cash Price	$143.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$255.20
Rate for Payer: Health Smart Auto/Commercial	$191.40
Rate for Payer: LLUH Dept of Risk Management WC	$175.45
Rate for Payer: Multiplan Commercial	$239.25

HC HEPATITIS C AB TOTAL INDIVIDUAL

Facility

$126.00

Service Code	CPT 86803
Hospital Charge Code	900912156
Hospital Revenue Code	302
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.60
Rate for Payer: Aetna of CA Government/Medicare	$75.60
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cash Price	$56.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.80
Rate for Payer: Health Smart Auto/Commercial	$75.60
Rate for Payer: Intervalley Health Plan Commercial	$14.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.60
Rate for Payer: LLUH Dept of Risk Management WC	$69.30
Rate for Payer: Multiplan Commercial	$94.50

HC HEPATITIS C AB TOTAL INDIVIDUAL

Facility

$319.00

Service Code	CPT 86803
Hospital Charge Code	900912156
Hospital Revenue Code	302
Min. Negotiated Rate	$175.45
Max. Negotiated Rate	$255.20
Rate for Payer: Cash Price	$143.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$255.20
Rate for Payer: Health Smart Auto/Commercial	$191.40
Rate for Payer: LLUH Dept of Risk Management WC	$175.45
Rate for Payer: Multiplan Commercial	$239.25

HC HERPES SIMPLEX TYPE 1

Facility

$134.00

Service Code	CPT 86695
Hospital Charge Code	900913660
Hospital Revenue Code	302
Min. Negotiated Rate	$73.70
Max. Negotiated Rate	$107.20
Rate for Payer: Cash Price	$60.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$107.20
Rate for Payer: Health Smart Auto/Commercial	$80.40
Rate for Payer: LLUH Dept of Risk Management WC	$73.70
Rate for Payer: Multiplan Commercial	$100.50

HC HERPES SIMPLEX TYPE 1

Facility

$98.00

Service Code	CPT 86695
Hospital Charge Code	900913660
Hospital Revenue Code	302
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$78.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$58.80
Rate for Payer: Aetna of CA Government/Medicare	$58.80
Rate for Payer: Cash Price	$44.10
Rate for Payer: Cash Price	$44.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$78.40
Rate for Payer: Health Smart Auto/Commercial	$58.80
Rate for Payer: Intervalley Health Plan Commercial	$13.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$58.80
Rate for Payer: LLUH Dept of Risk Management WC	$53.90
Rate for Payer: Multiplan Commercial	$73.50

HC HERPES SIMPLEX TYPE 2

Facility

$98.00

Service Code	CPT 86696
Hospital Charge Code	900913661
Hospital Revenue Code	302
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$78.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$58.80
Rate for Payer: Aetna of CA Government/Medicare	$58.80
Rate for Payer: Cash Price	$44.10
Rate for Payer: Cash Price	$44.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$78.40
Rate for Payer: Health Smart Auto/Commercial	$58.80
Rate for Payer: Intervalley Health Plan Commercial	$19.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$58.80
Rate for Payer: LLUH Dept of Risk Management WC	$53.90
Rate for Payer: Multiplan Commercial	$73.50

HC HERPES SIMPLEX TYPE 2

Facility

$134.00

Service Code	CPT 86696
Hospital Charge Code	900913661
Hospital Revenue Code	302
Min. Negotiated Rate	$73.70
Max. Negotiated Rate	$107.20
Rate for Payer: Cash Price	$60.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$107.20
Rate for Payer: Health Smart Auto/Commercial	$80.40
Rate for Payer: LLUH Dept of Risk Management WC	$73.70
Rate for Payer: Multiplan Commercial	$100.50

HC HISTONE AUTO AB

Facility

$64.00

Service Code	CPT 86255
Hospital Charge Code	900913528
Hospital Revenue Code	302
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$51.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$38.40
Rate for Payer: Aetna of CA Government/Medicare	$38.40
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$51.20
Rate for Payer: Health Smart Auto/Commercial	$38.40
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$38.40
Rate for Payer: LLUH Dept of Risk Management WC	$35.20
Rate for Payer: Multiplan Commercial	$48.00

HC HISTONE AUTO AB

Facility

$186.00

Service Code	CPT 86255
Hospital Charge Code	900913528
Hospital Revenue Code	302
Min. Negotiated Rate	$102.30
Max. Negotiated Rate	$148.80
Rate for Payer: Cash Price	$83.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$148.80
Rate for Payer: Health Smart Auto/Commercial	$111.60
Rate for Payer: LLUH Dept of Risk Management WC	$102.30
Rate for Payer: Multiplan Commercial	$139.50

HC HIV ANTIGEN, ANTIBODY

Facility

$42.00

Service Code	CPT 87389
Hospital Charge Code	900913662
Hospital Revenue Code	302
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.20
Rate for Payer: Aetna of CA Government/Medicare	$25.20
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cash Price	$18.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.60
Rate for Payer: Health Smart Auto/Commercial	$25.20
Rate for Payer: Intervalley Health Plan Commercial	$24.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.20
Rate for Payer: LLUH Dept of Risk Management WC	$23.10
Rate for Payer: Multiplan Commercial	$31.50

HC HIV ANTIGEN, ANTIBODY

Facility

$57.00

Service Code	CPT 87389
Hospital Charge Code	900913662
Hospital Revenue Code	302
Min. Negotiated Rate	$31.35
Max. Negotiated Rate	$45.60
Rate for Payer: Cash Price	$25.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$45.60
Rate for Payer: Health Smart Auto/Commercial	$34.20
Rate for Payer: LLUH Dept of Risk Management WC	$31.35
Rate for Payer: Multiplan Commercial	$42.75

HC HIV RAPID TESTING

Facility

$126.00

Service Code	CPT 86703
Hospital Charge Code	900912325
Hospital Revenue Code	302
Min. Negotiated Rate	$13.71
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.60
Rate for Payer: Aetna of CA Government/Medicare	$75.60
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cash Price	$56.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.80
Rate for Payer: Health Smart Auto/Commercial	$75.60
Rate for Payer: Intervalley Health Plan Commercial	$13.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.60
Rate for Payer: LLUH Dept of Risk Management WC	$69.30
Rate for Payer: Multiplan Commercial	$94.50

HC HIV RAPID TESTING

Facility

$270.00

Service Code	CPT 86703
Hospital Charge Code	900912325
Hospital Revenue Code	302
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$216.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$202.50

HC HOMOVANILLIC ACID (HVA)

Facility

$226.00

Service Code	CPT 83150
Hospital Charge Code	900910532
Hospital Revenue Code	301
Min. Negotiated Rate	$124.30
Max. Negotiated Rate	$180.80
Rate for Payer: Cash Price	$101.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$180.80
Rate for Payer: Health Smart Auto/Commercial	$135.60
Rate for Payer: LLUH Dept of Risk Management WC	$124.30
Rate for Payer: Multiplan Commercial	$169.50

HC HOMOVANILLIC ACID (HVA)

Facility

$85.00

Service Code	CPT 83150
Hospital Charge Code	900910532
Hospital Revenue Code	301
Min. Negotiated Rate	$22.41
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.00
Rate for Payer: Aetna of CA Government/Medicare	$51.00
Rate for Payer: Cash Price	$38.25
Rate for Payer: Cash Price	$38.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.00
Rate for Payer: Health Smart Auto/Commercial	$51.00
Rate for Payer: Intervalley Health Plan Commercial	$22.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.00
Rate for Payer: LLUH Dept of Risk Management WC	$46.75
Rate for Payer: Multiplan Commercial	$63.75

HC H. PYLORI AB, IGG

Facility

$270.00

Service Code	CPT 86677
Hospital Charge Code	900913556
Hospital Revenue Code	302
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$216.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$202.50

HC H. PYLORI AB, IGG

Facility

$74.00

Service Code	CPT 86677
Hospital Charge Code	900913556
Hospital Revenue Code	302
Min. Negotiated Rate	$16.85
Max. Negotiated Rate	$59.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.40
Rate for Payer: Aetna of CA Government/Medicare	$44.40
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cash Price	$33.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$59.20
Rate for Payer: Health Smart Auto/Commercial	$44.40
Rate for Payer: Intervalley Health Plan Commercial	$16.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.40
Rate for Payer: LLUH Dept of Risk Management WC	$40.70
Rate for Payer: Multiplan Commercial	$55.50

HC HSV 1,2 IGM

Facility

$31.00

Service Code	CPT 86694
Hospital Charge Code	900913562
Hospital Revenue Code	302
Min. Negotiated Rate	$14.39
Max. Negotiated Rate	$24.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.60
Rate for Payer: Aetna of CA Government/Medicare	$18.60
Rate for Payer: Cash Price	$13.95
Rate for Payer: Cash Price	$13.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.80
Rate for Payer: Health Smart Auto/Commercial	$18.60
Rate for Payer: Intervalley Health Plan Commercial	$14.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.60
Rate for Payer: LLUH Dept of Risk Management WC	$17.05
Rate for Payer: Multiplan Commercial	$23.25

Know your out-of-pocket cost for care.

All Charges