Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC LAB REF TISSUE INSITU INTERP & REPORT

Facility

$54.00

Service Code	CPT 88365
Hospital Charge Code	900910703
Hospital Revenue Code	310
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$43.20
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna of CA HMO/PPO	$43.20
Rate for Payer: Health Smart Auto/Commercial	$32.40
Rate for Payer: LLUH Dept of Risk Management WC	$29.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$40.50

HC LAB REF TRYPSINOGEN

Facility

$70.00

Service Code	CPT 83519 90
Hospital Charge Code	900910733
Hospital Revenue Code	301
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$56.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna of CA HMO/PPO	$56.00
Rate for Payer: Health Smart Auto/Commercial	$42.00
Rate for Payer: LLUH Dept of Risk Management WC	$38.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.50

HC LAB REF TRYPSINOGEN

Facility

$70.00

Service Code	CPT 83519 90
Hospital Charge Code	900910733
Hospital Revenue Code	301
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$52.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.00
Rate for Payer: Aetna of CA Government/Medicare	$42.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Health Smart Auto/Commercial	$42.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.00
Rate for Payer: LLUH Dept of Risk Management WC	$38.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.50

HC LAB REF TRYPSINOGEN

Facility

$70.00

Service Code	CPT 83519
Hospital Charge Code	900910733
Hospital Revenue Code	301
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$56.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna of CA HMO/PPO	$56.00
Rate for Payer: Health Smart Auto/Commercial	$42.00
Rate for Payer: LLUH Dept of Risk Management WC	$38.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.50

HC LAB REF TRYPSINOGEN

Facility

$70.00

Service Code	CPT 83519
Hospital Charge Code	900910733
Hospital Revenue Code	301
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$52.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.00
Rate for Payer: Aetna of CA Government/Medicare	$42.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Health Smart Auto/Commercial	$42.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.00
Rate for Payer: LLUH Dept of Risk Management WC	$38.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.50

HC LAB REF VARICELLA-ZOSTER AB ACIF CSF

Facility

$43.00

Service Code	CPT 87798
Hospital Charge Code	900911362
Hospital Revenue Code	302
Min. Negotiated Rate	$23.65
Max. Negotiated Rate	$32.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.80
Rate for Payer: Aetna of CA Government/Medicare	$25.80
Rate for Payer: Cash Price	$19.35
Rate for Payer: Health Smart Auto/Commercial	$25.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.80
Rate for Payer: LLUH Dept of Risk Management WC	$23.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$32.25

HC LAB REF VARICELLA-ZOSTER AB ACIF CSF

Facility

$43.00

Service Code	CPT 87798 90
Hospital Charge Code	900911362
Hospital Revenue Code	302
Min. Negotiated Rate	$23.65
Max. Negotiated Rate	$34.40
Rate for Payer: Cash Price	$19.35
Rate for Payer: Cigna of CA HMO/PPO	$34.40
Rate for Payer: Health Smart Auto/Commercial	$25.80
Rate for Payer: LLUH Dept of Risk Management WC	$23.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$32.25

HC LAB REF VARICELLA-ZOSTER AB ACIF CSF

Facility

$43.00

Service Code	CPT 87798
Hospital Charge Code	900911362
Hospital Revenue Code	302
Min. Negotiated Rate	$23.65
Max. Negotiated Rate	$34.40
Rate for Payer: Cash Price	$19.35
Rate for Payer: Cigna of CA HMO/PPO	$34.40
Rate for Payer: Health Smart Auto/Commercial	$25.80
Rate for Payer: LLUH Dept of Risk Management WC	$23.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$32.25

HC LAB REF VARICELLA-ZOSTER AB ACIF CSF

Facility

$43.00

Service Code	CPT 87798 90
Hospital Charge Code	900911362
Hospital Revenue Code	302
Min. Negotiated Rate	$23.65
Max. Negotiated Rate	$32.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.80
Rate for Payer: Aetna of CA Government/Medicare	$25.80
Rate for Payer: Cash Price	$19.35
Rate for Payer: Health Smart Auto/Commercial	$25.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.80
Rate for Payer: LLUH Dept of Risk Management WC	$23.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$32.25

HC LAB REF VITAMIN D 1 25-DIHYDROXY

Facility

$24.00

Service Code	CPT 82652 90
Hospital Charge Code	900911098
Hospital Revenue Code	301
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 VITAMIN D 1 25-DIHYDROXY

Facility

$24.00

Service Code	CPT 82652 90
Hospital Charge Code	900911098
Hospital Revenue Code	301
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 VITAMIN D 1 25-DIHYDROXY

Facility

$24.00

Service Code	CPT 82652
Hospital Charge Code	900911098
Hospital Revenue Code	301
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 VITAMIN D 1 25-DIHYDROXY

Facility

$24.00

Service Code	CPT 82652
Hospital Charge Code	900911098
Hospital Revenue Code	301
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 VITAMIN E

Facility

$22.00

Service Code	CPT 84446 90
Hospital Charge Code	900911174
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$16.50

HC LAB REF VITAMIN E

Facility

$22.00

Service Code	CPT 84446 90
Hospital Charge Code	900911174
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$16.50
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Cash Price	$9.90
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: 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 Beech St/Commercial/PHCS	$16.50

HC LAB REF VITAMIN E

Facility

$22.00

Service Code	CPT 84446
Hospital Charge Code	900911174
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$16.50
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: Health Smart Auto/Commercial	$13.20
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 Beech St/Commercial/PHCS	$16.50

HC LAB REF VITAMIN E

Facility

$22.00

Service Code	CPT 84446
Hospital Charge Code	900911174
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$16.50

HC LAB REF VITAMIN K

Facility

$51.00

Service Code	CPT 84597
Hospital Charge Code	900911429
Hospital Revenue Code	301
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$40.80
Rate for Payer: Cash Price	$22.95
Rate for Payer: Cigna of CA HMO/PPO	$40.80
Rate for Payer: Health Smart Auto/Commercial	$30.60
Rate for Payer: LLUH Dept of Risk Management WC	$28.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.25

HC LAB REF VITAMIN K

Facility

$51.00

Service Code	CPT 84597 90
Hospital Charge Code	900911429
Hospital Revenue Code	301
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$40.80
Rate for Payer: Cash Price	$22.95
Rate for Payer: Cigna of CA HMO/PPO	$40.80
Rate for Payer: Health Smart Auto/Commercial	$30.60
Rate for Payer: LLUH Dept of Risk Management WC	$28.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.25

HC LAB REF VITAMIN K

Facility

$51.00

Service Code	CPT 84597 90
Hospital Charge Code	900911429
Hospital Revenue Code	301
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$38.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.60
Rate for Payer: Aetna of CA Government/Medicare	$30.60
Rate for Payer: Cash Price	$22.95
Rate for Payer: Health Smart Auto/Commercial	$30.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.60
Rate for Payer: LLUH Dept of Risk Management WC	$28.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.25

HC LAB REF VITAMIN K

Facility

$51.00

Service Code	CPT 84597
Hospital Charge Code	900911429
Hospital Revenue Code	301
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$38.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.60
Rate for Payer: Aetna of CA Government/Medicare	$30.60
Rate for Payer: Cash Price	$22.95
Rate for Payer: Health Smart Auto/Commercial	$30.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.60
Rate for Payer: LLUH Dept of Risk Management WC	$28.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$38.25

HC LAB REF VZV AB IMMUNITY SCREEN

Facility

$87.00

Service Code	CPT 86787 90
Hospital Charge Code	900912872
Hospital Revenue Code	302
Min. Negotiated Rate	$47.85
Max. Negotiated Rate	$69.60
Rate for Payer: Cash Price	$39.15
Rate for Payer: Cigna of CA HMO/PPO	$69.60
Rate for Payer: Health Smart Auto/Commercial	$52.20
Rate for Payer: LLUH Dept of Risk Management WC	$47.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.25

HC LAB REF VZV AB IMMUNITY SCREEN

Facility

$87.00

Service Code	CPT 86787
Hospital Charge Code	900912872
Hospital Revenue Code	302
Min. Negotiated Rate	$47.85
Max. Negotiated Rate	$65.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.20
Rate for Payer: Aetna of CA Government/Medicare	$52.20
Rate for Payer: Cash Price	$39.15
Rate for Payer: Health Smart Auto/Commercial	$52.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.20
Rate for Payer: LLUH Dept of Risk Management WC	$47.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.25

HC LAB REF VZV AB IMMUNITY SCREEN

Facility

$87.00

Service Code	CPT 86787
Hospital Charge Code	900912872
Hospital Revenue Code	302
Min. Negotiated Rate	$47.85
Max. Negotiated Rate	$69.60
Rate for Payer: Cash Price	$39.15
Rate for Payer: Cigna of CA HMO/PPO	$69.60
Rate for Payer: Health Smart Auto/Commercial	$52.20
Rate for Payer: LLUH Dept of Risk Management WC	$47.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.25

HC LAB REF VZV AB IMMUNITY SCREEN

Facility

$87.00

Service Code	CPT 86787 90
Hospital Charge Code	900912872
Hospital Revenue Code	302
Min. Negotiated Rate	$47.85
Max. Negotiated Rate	$65.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.20
Rate for Payer: Aetna of CA Government/Medicare	$52.20
Rate for Payer: Cash Price	$39.15
Rate for Payer: Health Smart Auto/Commercial	$52.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.20
Rate for Payer: LLUH Dept of Risk Management WC	$47.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.25

Know your out-of-pocket cost for care.

All Charges