Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC LAB REF HERPESVIRUS 6 AB, IGM

Facility

$56.00

Service Code	CPT 86790 90
Hospital Charge Code	900911421
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 HERPESVIRUS 6 AB, IGM

Facility

$56.00

Service Code	CPT 86790 90
Hospital Charge Code	900911421
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 HERPESVIRUS 6 AB, IGM

Facility

$56.00

Service Code	CPT 86790
Hospital Charge Code	900911421
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 HIV 1

Facility

$24.00

Service Code	CPT 86689 90
Hospital Charge Code	900910666
Hospital Revenue Code	302
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna of CA HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

HC LAB REF HIV 1

Facility

$24.00

Service Code	CPT 86689 90
Hospital Charge Code	900910666
Hospital Revenue Code	302
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.40
Rate for Payer: Aetna of CA Government/Medicare	$14.40
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

HC LAB REF HIV 1

Facility

$24.00

Service Code	CPT 86689
Hospital Charge Code	900910666
Hospital Revenue Code	302
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna of CA HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

HC LAB REF HIV 1

Facility

$24.00

Service Code	CPT 86689
Hospital Charge Code	900910666
Hospital Revenue Code	302
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.40
Rate for Payer: Aetna of CA Government/Medicare	$14.40
Rate for Payer: Cash Price	$10.80
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.00

HC LAB REF HIV 1/2 CONFIRM. EVAL

Facility

$31.00

Service Code	CPT 86689 90
Hospital Charge Code	900912813
Hospital Revenue Code	302
Min. Negotiated Rate	$17.05
Max. Negotiated Rate	$24.80
Rate for Payer: Cash Price	$13.95
Rate for Payer: Cigna of CA HMO/PPO	$24.80
Rate for Payer: Health Smart Auto/Commercial	$18.60
Rate for Payer: LLUH Dept of Risk Management WC	$17.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.25

HC LAB REF HIV 1/2 CONFIRM. EVAL

Facility

$31.00

Service Code	CPT 86689
Hospital Charge Code	900912813
Hospital Revenue Code	302
Min. Negotiated Rate	$17.05
Max. Negotiated Rate	$23.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.60
Rate for Payer: Aetna of CA Government/Medicare	$18.60
Rate for Payer: Cash Price	$13.95
Rate for Payer: Health Smart Auto/Commercial	$18.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.60
Rate for Payer: LLUH Dept of Risk Management WC	$17.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.25

HC LAB REF HIV 1/2 CONFIRM. EVAL

Facility

$31.00

Service Code	CPT 86689
Hospital Charge Code	900912813
Hospital Revenue Code	302
Min. Negotiated Rate	$17.05
Max. Negotiated Rate	$24.80
Rate for Payer: Cash Price	$13.95
Rate for Payer: Cigna of CA HMO/PPO	$24.80
Rate for Payer: Health Smart Auto/Commercial	$18.60
Rate for Payer: LLUH Dept of Risk Management WC	$17.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.25

HC LAB REF HIV 1/2 CONFIRM. EVAL

Facility

$31.00

Service Code	CPT 86689 90
Hospital Charge Code	900912813
Hospital Revenue Code	302
Min. Negotiated Rate	$17.05
Max. Negotiated Rate	$23.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.60
Rate for Payer: Aetna of CA Government/Medicare	$18.60
Rate for Payer: Cash Price	$13.95
Rate for Payer: Health Smart Auto/Commercial	$18.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.60
Rate for Payer: LLUH Dept of Risk Management WC	$17.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.25

HC LAB REF HPA ANTIBODIES

Facility

$29.00

Service Code	CPT 86022
Hospital Charge Code	900911214
Hospital Revenue Code	302
Min. Negotiated Rate	$15.95
Max. Negotiated Rate	$23.20
Rate for Payer: Cash Price	$13.05
Rate for Payer: Cigna of CA HMO/PPO	$23.20
Rate for Payer: Health Smart Auto/Commercial	$17.40
Rate for Payer: LLUH Dept of Risk Management WC	$15.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.75

HC LAB REF HPA ANTIBODIES

Facility

$29.00

Service Code	CPT 86022
Hospital Charge Code	900911214
Hospital Revenue Code	302
Min. Negotiated Rate	$15.95
Max. Negotiated Rate	$21.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.40
Rate for Payer: Aetna of CA Government/Medicare	$17.40
Rate for Payer: Cash Price	$13.05
Rate for Payer: Health Smart Auto/Commercial	$17.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.40
Rate for Payer: LLUH Dept of Risk Management WC	$15.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.75

HC LAB REF HPA ANTIBODIES

Facility

$29.00

Service Code	CPT 86022 90
Hospital Charge Code	900911214
Hospital Revenue Code	302
Min. Negotiated Rate	$15.95
Max. Negotiated Rate	$23.20
Rate for Payer: Cash Price	$13.05
Rate for Payer: Cigna of CA HMO/PPO	$23.20
Rate for Payer: Health Smart Auto/Commercial	$17.40
Rate for Payer: LLUH Dept of Risk Management WC	$15.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.75

HC LAB REF HPA ANTIBODIES

Facility

$29.00

Service Code	CPT 86022 90
Hospital Charge Code	900911214
Hospital Revenue Code	302
Min. Negotiated Rate	$15.95
Max. Negotiated Rate	$21.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.40
Rate for Payer: Aetna of CA Government/Medicare	$17.40
Rate for Payer: Cash Price	$13.05
Rate for Payer: Health Smart Auto/Commercial	$17.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.40
Rate for Payer: LLUH Dept of Risk Management WC	$15.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.75

HC LAB REF HSV 1/2 IGM CSF

Facility

$119.00

Hospital Charge Code	900911351
Hospital Revenue Code	302
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$89.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.40
Rate for Payer: Aetna of CA Government/Medicare	$71.40
Rate for Payer: Cash Price	$53.55
Rate for Payer: Health Smart Auto/Commercial	$71.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.40
Rate for Payer: LLUH Dept of Risk Management WC	$65.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.25

HC LAB REF HSV 1/2 IGM CSF

Facility

$119.00

Hospital Charge Code	900911351
Hospital Revenue Code	302
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$95.20
Rate for Payer: Cash Price	$53.55
Rate for Payer: Cigna of CA HMO/PPO	$95.20
Rate for Payer: Health Smart Auto/Commercial	$71.40
Rate for Payer: LLUH Dept of Risk Management WC	$65.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.25

HC LAB REF HSV 1/2 IGM CSF

Facility

$119.00

Hospital Charge Code	900911351
Hospital Revenue Code	302
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$89.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.40
Rate for Payer: Aetna of CA Government/Medicare	$71.40
Rate for Payer: Cash Price	$53.55
Rate for Payer: Health Smart Auto/Commercial	$71.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.40
Rate for Payer: LLUH Dept of Risk Management WC	$65.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.25

HC LAB REF HSV 1/2 IGM CSF

Facility

$119.00

Hospital Charge Code	900911351
Hospital Revenue Code	302
Min. Negotiated Rate	$65.45
Max. Negotiated Rate	$95.20
Rate for Payer: Cash Price	$53.55
Rate for Payer: Cigna of CA HMO/PPO	$95.20
Rate for Payer: Health Smart Auto/Commercial	$71.40
Rate for Payer: LLUH Dept of Risk Management WC	$65.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$89.25

HC LAB REF HSV 1 IGG

Facility

$16.00

Service Code	CPT 86695
Hospital Charge Code	900911468
Hospital Revenue Code	302
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 HSV 1 IGG

Facility

$16.00

Service Code	CPT 86695
Hospital Charge Code	900911468
Hospital Revenue Code	302
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 HSV 1 IGG

Facility

$16.00

Service Code	CPT 86695 90
Hospital Charge Code	900911468
Hospital Revenue Code	302
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 HSV 1 IGG

Facility

$16.00

Service Code	CPT 86695 90
Hospital Charge Code	900911468
Hospital Revenue Code	302
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 HSV 2 IGG

Facility

$16.00

Service Code	CPT 86696 90
Hospital Charge Code	900911469
Hospital Revenue Code	306
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 HSV 2 IGG

Facility

$16.00

Service Code	CPT 86696
Hospital Charge Code	900911469
Hospital Revenue Code	306
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

Know your out-of-pocket cost for care.

All Charges