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	$62.15
Max. Negotiated Rate	$90.40
Rate for Payer: Cash Price	$50.85
Rate for Payer: Cigna of CA HMO/PPO	$90.40
Rate for Payer: Health Smart Auto/Commercial	$67.80
Rate for Payer: LLUH Dept of Risk Management WC	$62.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$84.75

HC LAB REF CLOMIPRAMINE

Facility

$113.00

Service Code	CPT 82542 90
Hospital Charge Code	900910740
Hospital Revenue Code	301
Min. Negotiated Rate	$62.15
Max. Negotiated Rate	$90.40
Rate for Payer: Cash Price	$50.85
Rate for Payer: Cigna of CA HMO/PPO	$90.40
Rate for Payer: Health Smart Auto/Commercial	$67.80
Rate for Payer: LLUH Dept of Risk Management WC	$62.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$84.75

HC LAB REF CLOMIPRAMINE

Facility

$113.00

Service Code	CPT 82542 90
Hospital Charge Code	900910740
Hospital Revenue Code	301
Min. Negotiated Rate	$62.15
Max. Negotiated Rate	$84.75
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: Health Smart Auto/Commercial	$67.80
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 Beech St/Commercial/PHCS	$84.75

HC LAB REF CLOMIPRAMINE

Facility

$113.00

Service Code	CPT 82542
Hospital Charge Code	900910740
Hospital Revenue Code	301
Min. Negotiated Rate	$62.15
Max. Negotiated Rate	$84.75
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: Health Smart Auto/Commercial	$67.80
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 Beech St/Commercial/PHCS	$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: Cigna of CA 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 Beech St/Commercial/PHCS	$150.00

HC LAB REF COUNT 15-20 COLONIES 2 KARYOT

Facility

$200.00

Service Code	CPT 88262 90,TC
Hospital Charge Code	900910763
Hospital Revenue Code	310
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$150.00
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: Health Smart Auto/Commercial	$120.00
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 Beech St/Commercial/PHCS	$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	$150.00
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: Health Smart Auto/Commercial	$120.00
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 Beech St/Commercial/PHCS	$150.00

HC LAB REF COUNT 15-20 COLONIES 2 KARYOT

Facility

$200.00

Service Code	CPT 88262 90,TC
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: Cigna of CA 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 Beech St/Commercial/PHCS	$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	$200.25
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: Health Smart Auto/Commercial	$160.20
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 Beech St/Commercial/PHCS	$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: Health Smart Auto/Commercial	$160.20
Rate for Payer: Cash Price	$120.15
Rate for Payer: Cigna of CA HMO/PPO	$213.60
Rate for Payer: LLUH Dept of Risk Management WC	$146.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$200.25

HC LAB REF COUNT 6-12 COLONIES, 1 KARYOTY

Facility

$267.00

Service Code	CPT 88269 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$200.25

HC LAB REF COUNT 6-12 COLONIES, 1 KARYOTY

Facility

$267.00

Service Code	CPT 88269 90
Hospital Charge Code	900910738
Hospital Revenue Code	310
Min. Negotiated Rate	$146.85
Max. Negotiated Rate	$200.25
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: Health Smart Auto/Commercial	$160.20
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 Beech St/Commercial/PHCS	$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	$12.80
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$12.00

HC LAB REF CRYOPRESERVATION CELL LINE EA

Facility

$16.00

Service Code	CPT 88240 90
Hospital Charge Code	900912793
Hospital Revenue Code	310
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$12.00
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: Health Smart Auto/Commercial	$9.60
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 Beech St/Commercial/PHCS	$12.00

HC LAB REF CRYOPRESERVATION CELL LINE EA

Facility

$16.00

Service Code	CPT 88240 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$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	$12.00
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: Health Smart Auto/Commercial	$9.60
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 Beech St/Commercial/PHCS	$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	$53.90
Max. Negotiated Rate	$73.50
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: Health Smart Auto/Commercial	$58.80
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 Beech St/Commercial/PHCS	$73.50

HC LAB REF CRYPTOCOCCUS AB

Facility

$98.00

Service Code	CPT 86641 90
Hospital Charge Code	900911339
Hospital Revenue Code	302
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$73.50
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: Health Smart Auto/Commercial	$58.80
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 Beech St/Commercial/PHCS	$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: Cigna of CA 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 Beech St/Commercial/PHCS	$73.50

HC LAB REF CRYPTOCOCCUS AB

Facility

$98.00

Service Code	CPT 86641 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$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	$30.80
Max. Negotiated Rate	$42.00
Rate for Payer: Health Smart Auto/Commercial	$33.60
Rate for Payer: Cash Price	$25.20
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: 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 Beech St/Commercial/PHCS	$42.00

HC LAB REF CRYPTOCOCCUS AB CSF

Facility

$56.00

Service Code	CPT 86641 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$42.00

HC LAB REF CRYPTOCOCCUS AB CSF

Facility

$56.00

Service Code	CPT 86641 90
Hospital Charge Code	900912518
Hospital Revenue Code	302
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$42.00
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: Health Smart Auto/Commercial	$33.60
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 Beech St/Commercial/PHCS	$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: Cigna of CA 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 Beech St/Commercial/PHCS	$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	$117.75
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: Health Smart Auto/Commercial	$94.20
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 Beech St/Commercial/PHCS	$117.75

Know your out-of-pocket cost for care.

All Charges