Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$15.00
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: Health Smart Auto/Commercial	$12.00
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 Beech St/Commercial/PHCS	$15.00

HC LAB REF ENTEROVIRUS AB COXSACKIE B5

Facility

$20.00

Service Code	CPT 86658 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$15.00

HC LAB REF ENTEROVIRUS AB COXSACKIE B6

Facility

$20.00

Service Code	CPT 86658 90
Hospital Charge Code	900912736
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.00
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: Health Smart Auto/Commercial	$12.00
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 Beech St/Commercial/PHCS	$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: Cigna of CA 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 Beech St/Commercial/PHCS	$15.00

HC LAB REF ENTEROVIRUS AB COXSACKIE B6

Facility

$20.00

Service Code	CPT 86658 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$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	$15.00
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: Health Smart Auto/Commercial	$12.00
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 Beech St/Commercial/PHCS	$15.00

HC LAB REF ENTEROVIRUS AB POLIO 1

Facility

$28.00

Service Code	CPT 86658 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$21.00

HC LAB REF ENTEROVIRUS AB POLIO 1

Facility

$28.00

Service Code	CPT 86658 90
Hospital Charge Code	900911777
Hospital Revenue Code	302
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$21.00
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: Health Smart Auto/Commercial	$16.80
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 Beech St/Commercial/PHCS	$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	$15.40
Max. Negotiated Rate	$22.40
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	$15.40
Max. Negotiated Rate	$21.00
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: Health Smart Auto/Commercial	$16.80
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 Beech St/Commercial/PHCS	$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: Cigna of CA 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 Beech St/Commercial/PHCS	$21.00

HC LAB REF ENTEROVIRUS AB POLIO 2

Facility

$28.00

Service Code	CPT 86658 90
Hospital Charge Code	900912741
Hospital Revenue Code	302
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$21.00
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: Health Smart Auto/Commercial	$16.80
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 Beech St/Commercial/PHCS	$21.00

HC LAB REF ENTEROVIRUS AB POLIO 2

Facility

$28.00

Service Code	CPT 86658 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$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	$21.00
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: Health Smart Auto/Commercial	$16.80
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 Beech St/Commercial/PHCS	$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	$21.00
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: Health Smart Auto/Commercial	$16.80
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 Beech St/Commercial/PHCS	$21.00

HC LAB REF ENTEROVIRUS AB POLIO 3

Facility

$28.00

Service Code	CPT 86658 90
Hospital Charge Code	900912726
Hospital Revenue Code	302
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$21.00
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: Health Smart Auto/Commercial	$16.80
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 Beech St/Commercial/PHCS	$21.00

HC LAB REF ENTEROVIRUS AB POLIO 3

Facility

$28.00

Service Code	CPT 86658 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$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: Cigna of CA 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 Beech St/Commercial/PHCS	$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: Cash Price	$8.55
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$14.25

HC LAB REF EPI CELL AB BMZ

Facility

$19.00

Service Code	CPT 86255 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$14.25

HC LAB REF EPI CELL AB BMZ

Facility

$19.00

Service Code	CPT 86255 90
Hospital Charge Code	900912804
Hospital Revenue Code	302
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$14.25
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: Health Smart Auto/Commercial	$11.40
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 Beech St/Commercial/PHCS	$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	$14.25
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: Health Smart Auto/Commercial	$11.40
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 Beech St/Commercial/PHCS	$14.25

HC LAB REF FISH ANEUPLOIDY REFLEX, POC

Facility

$39.00

Service Code	CPT 88291 90
Hospital Charge Code	900912706
Hospital Revenue Code	310
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$31.20
Rate for Payer: Cash Price	$17.55
Rate for Payer: Cigna of CA HMO/PPO	$31.20
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.25

HC LAB REF FISH ANEUPLOIDY REFLEX, POC

Facility

$39.00

Service Code	CPT 88291 90
Hospital Charge Code	900912706
Hospital Revenue Code	310
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$29.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.40
Rate for Payer: Aetna of CA Government/Medicare	$23.40
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.25

HC LAB REF FISH ANEUPLOIDY REFLEX, POC

Facility

$39.00

Service Code	CPT 88291
Hospital Charge Code	900912706
Hospital Revenue Code	310
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$31.20
Rate for Payer: Cash Price	$17.55
Rate for Payer: Cigna of CA HMO/PPO	$31.20
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.25

Know your out-of-pocket cost for care.

All Charges