Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC LAB REF CLOMIPRAMINE

Facility

$113.00

Service Code	CPT 82542
Hospital Charge Code	900910740
Hospital Revenue Code	301
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$90.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$67.80
Rate for Payer: Aetna of CA Government/Medicare	$67.80
Rate for Payer: Cash Price	$50.85
Rate for Payer: Cash Price	$50.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$90.40
Rate for Payer: Health Smart Auto/Commercial	$67.80
Rate for Payer: Intervalley Health Plan Commercial	$24.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$67.80
Rate for Payer: LLUH Dept of Risk Management WC	$62.15
Rate for Payer: Multiplan Commercial	$84.75

HC LAB REF COUNT 15-20 COLONIES 2 KARYOT

Facility

$200.00

Service Code	CPT 88262
Hospital Charge Code	900910763
Hospital Revenue Code	310
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Commercial	$150.00

HC LAB REF COUNT 15-20 COLONIES 2 KARYOT

Facility

$200.00

Service Code	CPT 88262
Hospital Charge Code	900910763
Hospital Revenue Code	310
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$120.00
Rate for Payer: Aetna of CA Government/Medicare	$120.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: Intervalley Health Plan Commercial	$125.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Commercial	$150.00

HC LAB REF COUNT 6-12 COLONIES, 1 KARYOTY

Facility

$267.00

Service Code	CPT 88269
Hospital Charge Code	900910738
Hospital Revenue Code	310
Min. Negotiated Rate	$146.85
Max. Negotiated Rate	$213.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$160.20
Rate for Payer: Aetna of CA Government/Medicare	$160.20
Rate for Payer: Cash Price	$120.15
Rate for Payer: Cash Price	$120.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$213.60
Rate for Payer: Health Smart Auto/Commercial	$160.20
Rate for Payer: Intervalley Health Plan Commercial	$173.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$160.20
Rate for Payer: LLUH Dept of Risk Management WC	$146.85
Rate for Payer: Multiplan Commercial	$200.25

HC LAB REF COUNT 6-12 COLONIES, 1 KARYOTY

Facility

$267.00

Service Code	CPT 88269
Hospital Charge Code	900910738
Hospital Revenue Code	310
Min. Negotiated Rate	$146.85
Max. Negotiated Rate	$213.60
Rate for Payer: Cash Price	$120.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$213.60
Rate for Payer: Health Smart Auto/Commercial	$160.20
Rate for Payer: LLUH Dept of Risk Management WC	$146.85
Rate for Payer: Multiplan Commercial	$200.25

HC LAB REF CRYOPRESERVATION CELL LINE EA

Facility

$16.00

Service Code	CPT 88240
Hospital Charge Code	900912793
Hospital Revenue Code	310
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$13.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.60
Rate for Payer: Aetna of CA Government/Medicare	$9.60
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.80
Rate for Payer: Health Smart Auto/Commercial	$9.60
Rate for Payer: Intervalley Health Plan Commercial	$13.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.60
Rate for Payer: LLUH Dept of Risk Management WC	$8.80
Rate for Payer: Multiplan Commercial	$12.00

HC LAB REF CRYOPRESERVATION CELL LINE EA

Facility

$16.00

Service Code	CPT 88240
Hospital Charge Code	900912793
Hospital Revenue Code	310
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$12.80
Rate for Payer: Cash Price	$7.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.80
Rate for Payer: Health Smart Auto/Commercial	$9.60
Rate for Payer: LLUH Dept of Risk Management WC	$8.80
Rate for Payer: Multiplan Commercial	$12.00

HC LAB REF CRYPTOCOCCUS AB

Facility

$98.00

Service Code	CPT 86641
Hospital Charge Code	900911339
Hospital Revenue Code	302
Min. Negotiated Rate	$14.41
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	$14.41
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 LAB REF CRYPTOCOCCUS AB

Facility

$98.00

Service Code	CPT 86641
Hospital Charge Code	900911339
Hospital Revenue Code	302
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$78.40
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: LLUH Dept of Risk Management WC	$53.90
Rate for Payer: Multiplan Commercial	$73.50

HC LAB REF CRYPTOCOCCUS AB CSF

Facility

$56.00

Service Code	CPT 86641
Hospital Charge Code	900912518
Hospital Revenue Code	302
Min. Negotiated Rate	$14.41
Max. Negotiated Rate	$44.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.60
Rate for Payer: Aetna of CA Government/Medicare	$33.60
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cash Price	$25.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.80
Rate for Payer: Health Smart Auto/Commercial	$33.60
Rate for Payer: Intervalley Health Plan Commercial	$14.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.60
Rate for Payer: LLUH Dept of Risk Management WC	$30.80
Rate for Payer: Multiplan Commercial	$42.00

HC LAB REF CRYPTOCOCCUS AB CSF

Facility

$56.00

Service Code	CPT 86641
Hospital Charge Code	900912518
Hospital Revenue Code	302
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.80
Rate for Payer: Cash Price	$25.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.80
Rate for Payer: Health Smart Auto/Commercial	$33.60
Rate for Payer: LLUH Dept of Risk Management WC	$30.80
Rate for Payer: Multiplan Commercial	$42.00

HC LAB REF CULTURE FOR MYCOPLASMA

Facility

$157.00

Service Code	CPT 87109
Hospital Charge Code	900911525
Hospital Revenue Code	306
Min. Negotiated Rate	$86.35
Max. Negotiated Rate	$125.60
Rate for Payer: Cash Price	$70.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.60
Rate for Payer: Health Smart Auto/Commercial	$94.20
Rate for Payer: LLUH Dept of Risk Management WC	$86.35
Rate for Payer: Multiplan Commercial	$117.75

HC LAB REF CULTURE FOR MYCOPLASMA

Facility

$157.00

Service Code	CPT 87109
Hospital Charge Code	900911525
Hospital Revenue Code	306
Min. Negotiated Rate	$15.39
Max. Negotiated Rate	$125.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$94.20
Rate for Payer: Aetna of CA Government/Medicare	$94.20
Rate for Payer: Cash Price	$70.65
Rate for Payer: Cash Price	$70.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.60
Rate for Payer: Health Smart Auto/Commercial	$94.20
Rate for Payer: Intervalley Health Plan Commercial	$15.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$94.20
Rate for Payer: LLUH Dept of Risk Management WC	$86.35
Rate for Payer: Multiplan Commercial	$117.75

HC LAB REF CULTURE MYCOPLASMA PNEUMONIAE

Facility

$105.00

Service Code	CPT 87109
Hospital Charge Code	900912762
Hospital Revenue Code	306
Min. Negotiated Rate	$57.75
Max. Negotiated Rate	$84.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$84.00
Rate for Payer: Health Smart Auto/Commercial	$63.00
Rate for Payer: LLUH Dept of Risk Management WC	$57.75
Rate for Payer: Multiplan Commercial	$78.75

HC LAB REF CULTURE MYCOPLASMA PNEUMONIAE

Facility

$105.00

Service Code	CPT 87109
Hospital Charge Code	900912762
Hospital Revenue Code	306
Min. Negotiated Rate	$15.39
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$63.00
Rate for Payer: Aetna of CA Government/Medicare	$63.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$84.00
Rate for Payer: Health Smart Auto/Commercial	$63.00
Rate for Payer: Intervalley Health Plan Commercial	$15.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$63.00
Rate for Payer: LLUH Dept of Risk Management WC	$57.75
Rate for Payer: Multiplan Commercial	$78.75

HC LAB REF CULTURE UREAPLASMA UREALYTICUM

Facility

$25.00

Service Code	CPT 87109
Hospital Charge Code	900912763
Hospital Revenue Code	306
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
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: Cash Price	$11.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Intervalley Health Plan Commercial	$15.39
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 Commercial	$18.75

HC LAB REF CULTURE UREAPLASMA UREALYTICUM

Facility

$25.00

Service Code	CPT 87109
Hospital Charge Code	900912763
Hospital Revenue Code	306
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$18.75

HC LAB REF DESIPRAMINE P

Facility

$141.00

Service Code	CPT 80335
Hospital Charge Code	900912506
Hospital Revenue Code	301
Min. Negotiated Rate	$77.55
Max. Negotiated Rate	$112.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$84.60
Rate for Payer: Aetna of CA Government/Medicare	$84.60
Rate for Payer: Cash Price	$63.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$112.80
Rate for Payer: Health Smart Auto/Commercial	$84.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$84.60
Rate for Payer: LLUH Dept of Risk Management WC	$77.55
Rate for Payer: Multiplan Commercial	$105.75

HC LAB REF DESIPRAMINE P

Facility

$141.00

Service Code	CPT 80335
Hospital Charge Code	900912506
Hospital Revenue Code	301
Min. Negotiated Rate	$77.55
Max. Negotiated Rate	$112.80
Rate for Payer: Cash Price	$63.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$112.80
Rate for Payer: Health Smart Auto/Commercial	$84.60
Rate for Payer: LLUH Dept of Risk Management WC	$77.55
Rate for Payer: Multiplan Commercial	$105.75

HC LAB REF DISOPYRAMIDE

Facility

$62.00

Service Code	CPT 80299
Hospital Charge Code	900911165
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$49.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.20
Rate for Payer: Aetna of CA Government/Medicare	$37.20
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cash Price	$27.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$49.60
Rate for Payer: Health Smart Auto/Commercial	$37.20
Rate for Payer: Intervalley Health Plan Commercial	$18.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.20
Rate for Payer: LLUH Dept of Risk Management WC	$34.10
Rate for Payer: Multiplan Commercial	$46.50

HC LAB REF DISOPYRAMIDE

Facility

$62.00

Service Code	CPT 80299
Hospital Charge Code	900911165
Hospital Revenue Code	301
Min. Negotiated Rate	$34.10
Max. Negotiated Rate	$49.60
Rate for Payer: Cash Price	$27.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$49.60
Rate for Payer: Health Smart Auto/Commercial	$37.20
Rate for Payer: LLUH Dept of Risk Management WC	$34.10
Rate for Payer: Multiplan Commercial	$46.50

HC LAB REF DNA PROBE

Facility

$34.00

Service Code	CPT 82271
Hospital Charge Code	900912580
Hospital Revenue Code	310
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$27.20
Rate for Payer: Cash Price	$15.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.20
Rate for Payer: Health Smart Auto/Commercial	$20.40
Rate for Payer: LLUH Dept of Risk Management WC	$18.70
Rate for Payer: Multiplan Commercial	$25.50

HC LAB REF DNA PROBE

Facility

$34.00

Service Code	CPT 82271
Hospital Charge Code	900912580
Hospital Revenue Code	310
Min. Negotiated Rate	$5.32
Max. Negotiated Rate	$27.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.40
Rate for Payer: Aetna of CA Government/Medicare	$20.40
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cash Price	$15.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$27.20
Rate for Payer: Health Smart Auto/Commercial	$20.40
Rate for Payer: Intervalley Health Plan Commercial	$5.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.40
Rate for Payer: LLUH Dept of Risk Management WC	$18.70
Rate for Payer: Multiplan Commercial	$25.50

HC LAB REF DOT/SLOT BLOT NA EA

Facility

$6.00

Service Code	CPT 83893
Hospital Charge Code	900912785
Hospital Revenue Code	310
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$2.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

HC LAB REF DOT/SLOT BLOT NA EA

Facility

$6.00

Service Code	CPT 83893
Hospital Charge Code	900912785
Hospital Revenue Code	310
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$2.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

Know your out-of-pocket cost for care.

All Charges