Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: Cigna of CA 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 Beech St/Commercial/PHCS	$117.75

HC LAB REF CULTURE FOR MYCOPLASMA

Facility

$157.00

Service Code	CPT 87109 90
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

HC LAB REF CULTURE FOR MYCOPLASMA

Facility

$157.00

Service Code	CPT 87109 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$117.75

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: 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 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	$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 LAB REF CULTURE UREAPLASMA UREALYTICUM

Facility

$25.00

Service Code	CPT 87109 90
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: 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 LAB REF CULTURE UREAPLASMA UREALYTICUM

Facility

$25.00

Service Code	CPT 87109 90
Hospital Charge Code	900912763
Hospital Revenue Code	306
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Cash Price	$11.25
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: 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 LAB REF CYCLIC AMP URINE

Facility

$41.00

Service Code	CPT 82030 90
Hospital Charge Code	900911047
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$32.80
Rate for Payer: Cash Price	$18.45
Rate for Payer: Cigna of CA HMO/PPO	$32.80
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.75

HC LAB REF CYCLIC AMP URINE

Facility

$41.00

Service Code	CPT 82030
Hospital Charge Code	900911047
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$30.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.60
Rate for Payer: Aetna of CA Government/Medicare	$24.60
Rate for Payer: Cash Price	$18.45
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.75

HC LAB REF CYCLIC AMP URINE

Facility

$41.00

Service Code	CPT 82030
Hospital Charge Code	900911047
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$32.80
Rate for Payer: Cash Price	$18.45
Rate for Payer: Cigna of CA HMO/PPO	$32.80
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.75

HC LAB REF CYCLIC AMP URINE

Facility

$41.00

Service Code	CPT 82030 90
Hospital Charge Code	900911047
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$30.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.60
Rate for Payer: Aetna of CA Government/Medicare	$24.60
Rate for Payer: Cash Price	$18.45
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.75

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	$105.75
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: 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 Beech St/Commercial/PHCS	$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: Cigna of CA 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 Beech St/Commercial/PHCS	$105.75

HC LAB REF DESIPRAMINE P

Facility

$141.00

Service Code	CPT G6032
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: Cigna of CA 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 Beech St/Commercial/PHCS	$105.75

HC LAB REF DESIPRAMINE P

Facility

$141.00

Service Code	CPT 80335 90
Hospital Charge Code	900912506
Hospital Revenue Code	301
Min. Negotiated Rate	$77.55
Max. Negotiated Rate	$105.75
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: 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 Beech St/Commercial/PHCS	$105.75

HC LAB REF DESIPRAMINE P

Facility

$141.00

Service Code	CPT 80335 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$105.75

HC LAB REF DESIPRAMINE P

Facility

$141.00

Service Code	CPT G6032
Hospital Charge Code	900912506
Hospital Revenue Code	301
Min. Negotiated Rate	$77.55
Max. Negotiated Rate	$105.75
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: 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 Beech St/Commercial/PHCS	$105.75

HC LAB REF DNA PROBE

Facility

$34.00

Service Code	CPT 82271 TC
Hospital Charge Code	900912580
Hospital Revenue Code	310
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$25.50
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: Health Smart Auto/Commercial	$20.40
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 Beech St/Commercial/PHCS	$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	$18.70
Max. Negotiated Rate	$25.50
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: Health Smart Auto/Commercial	$20.40
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 Beech St/Commercial/PHCS	$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	$18.70
Max. Negotiated Rate	$27.20
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$25.50

HC LAB REF DNA PROBE

Facility

$34.00

Service Code	CPT 82271 TC
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: Cigna of CA 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 Beech St/Commercial/PHCS	$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	$4.50
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: 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 Beech St/Commercial/PHCS	$4.50

HC LAB REF DOT/SLOT BLOT NA EA

Facility

$6.00

Service Code	CPT 83893 90
Hospital Charge Code	900912785
Hospital Revenue Code	310
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.50
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: 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 Beech St/Commercial/PHCS	$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: Cash Price	$2.70
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$4.50

HC LAB REF DOT/SLOT BLOT NA EA

Facility

$6.00

Service Code	CPT 83893 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$4.50

Know your out-of-pocket cost for care.

All Charges