Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC LAB REF ENTEROVIRUS AB COXSACKIE B3

Facility

$18.00

Service Code	CPT 86658
Hospital Charge Code	900912733
Hospital Revenue Code	302
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$14.40
Rate for Payer: Cash Price	$8.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$13.50

HC LAB REF ENTEROVIRUS AB COXSACKIE B4

Facility

$20.00

Service Code	CPT 86658
Hospital Charge Code	900912734
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC LAB REF ENTEROVIRUS AB COXSACKIE B4

Facility

$20.00

Service Code	CPT 86658
Hospital Charge Code	900912734
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Intervalley Health Plan Commercial	$13.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC LAB REF ENTEROVIRUS AB COXSACKIE B5

Facility

$20.00

Service Code	CPT 86658
Hospital Charge Code	900912735
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Intervalley Health Plan Commercial	$13.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC LAB REF ENTEROVIRUS AB COXSACKIE B5

Facility

$20.00

Service Code	CPT 86658
Hospital Charge Code	900912735
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC LAB REF ENTEROVIRUS AB COXSACKIE B6

Facility

$20.00

Service Code	CPT 86658
Hospital Charge Code	900912736
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Intervalley Health Plan Commercial	$13.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC LAB REF ENTEROVIRUS AB COXSACKIE B6

Facility

$20.00

Service Code	CPT 86658
Hospital Charge Code	900912736
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC LAB REF ENTEROVIRUS AB ECHOVIRUS 11

Facility

$22.00

Service Code	CPT 86658
Hospital Charge Code	900911760
Hospital Revenue Code	302
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$16.50

HC LAB REF ENTEROVIRUS AB ECHOVIRUS 11

Facility

$22.00

Service Code	CPT 86658
Hospital Charge Code	900911760
Hospital Revenue Code	302
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
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: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Intervalley Health Plan Commercial	$13.03
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 Commercial	$16.50

HC LAB REF ENTEROVIRUS AB ECHOVIRUS 30

Facility

$22.00

Service Code	CPT 86658
Hospital Charge Code	900912740
Hospital Revenue Code	302
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$16.50

HC LAB REF ENTEROVIRUS AB ECHOVIRUS 30

Facility

$22.00

Service Code	CPT 86658
Hospital Charge Code	900912740
Hospital Revenue Code	302
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
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: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Intervalley Health Plan Commercial	$13.03
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 Commercial	$16.50

HC LAB REF ENTEROVIRUS AB ECHOVIRUS 4

Facility

$22.00

Service Code	CPT 86658
Hospital Charge Code	900912737
Hospital Revenue Code	302
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$16.50

HC LAB REF ENTEROVIRUS AB ECHOVIRUS 4

Facility

$22.00

Service Code	CPT 86658
Hospital Charge Code	900912737
Hospital Revenue Code	302
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
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: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Intervalley Health Plan Commercial	$13.03
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 Commercial	$16.50

HC LAB REF ENTEROVIRUS AB ECHOVIRUS 7

Facility

$22.00

Service Code	CPT 86658
Hospital Charge Code	900912738
Hospital Revenue Code	302
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$16.50

HC LAB REF ENTEROVIRUS AB ECHOVIRUS 7

Facility

$22.00

Service Code	CPT 86658
Hospital Charge Code	900912738
Hospital Revenue Code	302
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
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: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Intervalley Health Plan Commercial	$13.03
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 Commercial	$16.50

HC LAB REF ENTEROVIRUS AB ECHOVIRUS 9

Facility

$22.00

Service Code	CPT 86658
Hospital Charge Code	900912739
Hospital Revenue Code	302
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
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: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Intervalley Health Plan Commercial	$13.03
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 Commercial	$16.50

HC LAB REF ENTEROVIRUS AB ECHOVIRUS 9

Facility

$22.00

Service Code	CPT 86658
Hospital Charge Code	900912739
Hospital Revenue Code	302
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$16.50

HC LAB REF ENTEROVIRUS AB POLIO 1

Facility

$28.00

Service Code	CPT 86658
Hospital Charge Code	900911777
Hospital Revenue Code	302
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.40
Rate for Payer: Cash Price	$12.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.40
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Commercial	$21.00

HC LAB REF ENTEROVIRUS AB POLIO 1

Facility

$28.00

Service Code	CPT 86658
Hospital Charge Code	900911777
Hospital Revenue Code	302
Min. Negotiated Rate	$13.03
Max. Negotiated Rate	$22.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.80
Rate for Payer: Aetna of CA Government/Medicare	$16.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.40
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: Intervalley Health Plan Commercial	$13.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Commercial	$21.00

HC LAB REF ENTEROVIRUS AB POLIO 2

Facility

$28.00

Service Code	CPT 86658
Hospital Charge Code	900912741
Hospital Revenue Code	302
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.40
Rate for Payer: Cash Price	$12.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.40
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Commercial	$21.00

HC LAB REF ENTEROVIRUS AB POLIO 2

Facility

$28.00

Service Code	CPT 86658
Hospital Charge Code	900912741
Hospital Revenue Code	302
Min. Negotiated Rate	$13.03
Max. Negotiated Rate	$22.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.80
Rate for Payer: Aetna of CA Government/Medicare	$16.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.40
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: Intervalley Health Plan Commercial	$13.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Commercial	$21.00

HC LAB REF ENTEROVIRUS AB POLIO 3

Facility

$28.00

Service Code	CPT 86658
Hospital Charge Code	900912726
Hospital Revenue Code	302
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.40
Rate for Payer: Cash Price	$12.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.40
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Commercial	$21.00

HC LAB REF ENTEROVIRUS AB POLIO 3

Facility

$28.00

Service Code	CPT 86658
Hospital Charge Code	900912726
Hospital Revenue Code	302
Min. Negotiated Rate	$13.03
Max. Negotiated Rate	$22.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.80
Rate for Payer: Aetna of CA Government/Medicare	$16.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.40
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: Intervalley Health Plan Commercial	$13.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Commercial	$21.00

HC LAB REF EPI CELL AB BMZ

Facility

$19.00

Service Code	CPT 86255
Hospital Charge Code	900912804
Hospital Revenue Code	302
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$15.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.40
Rate for Payer: Aetna of CA Government/Medicare	$11.40
Rate for Payer: Cash Price	$8.55
Rate for Payer: Cash Price	$8.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.20
Rate for Payer: Health Smart Auto/Commercial	$11.40
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.40
Rate for Payer: LLUH Dept of Risk Management WC	$10.45
Rate for Payer: Multiplan Commercial	$14.25

HC LAB REF EPI CELL AB BMZ

Facility

$19.00

Service Code	CPT 86255
Hospital Charge Code	900912804
Hospital Revenue Code	302
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$15.20
Rate for Payer: Cash Price	$8.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.20
Rate for Payer: Health Smart Auto/Commercial	$11.40
Rate for Payer: LLUH Dept of Risk Management WC	$10.45
Rate for Payer: Multiplan Commercial	$14.25

Know your out-of-pocket cost for care.

All Charges