Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC PIN WORM PREP

Facility

$20.00

Service Code	CPT 87172
Hospital Charge Code	900911636
Hospital Revenue Code	306
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 PIN WORM PREP

Facility

$115.00

Service Code	CPT 87172
Hospital Charge Code	900911636
Hospital Revenue Code	306
Min. Negotiated Rate	$63.25
Max. Negotiated Rate	$92.00
Rate for Payer: Cash Price	$51.75
Rate for Payer: Cigna of CA HMO/PPO	$92.00
Rate for Payer: Health Smart Auto/Commercial	$69.00
Rate for Payer: LLUH Dept of Risk Management WC	$63.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$86.25

HC PIPERACILLIN/TAZOBACTAM E TEST

Facility

$105.00

Service Code	CPT 87181
Hospital Charge Code	900912422
Hospital Revenue Code	306
Min. Negotiated Rate	$57.75
Max. Negotiated Rate	$84.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cigna of CA HMO/PPO	$84.00
Rate for Payer: Health Smart Auto/Commercial	$63.00
Rate for Payer: LLUH Dept of Risk Management WC	$57.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$78.75

HC PIPERACILLIN/TAZOBACTAM E TEST

Facility

$18.00

Service Code	CPT 87181
Hospital Charge Code	900912422
Hospital Revenue Code	306
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Cash Price	$8.10
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.50

HC PLACENTAL ALPHA MICROGLOB-1POC

Facility

$246.00

Service Code	CPT 84112
Hospital Charge Code	900912139
Hospital Revenue Code	301
Min. Negotiated Rate	$135.30
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$147.60
Rate for Payer: Aetna of CA Government/Medicare	$147.60
Rate for Payer: Cash Price	$110.70
Rate for Payer: Health Smart Auto/Commercial	$147.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$147.60
Rate for Payer: LLUH Dept of Risk Management WC	$135.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$184.50

HC PLACENTAL ALPHA MICROGLOB-1POC

Facility

$868.00

Service Code	CPT 84112
Hospital Charge Code	900912139
Hospital Revenue Code	301
Min. Negotiated Rate	$477.40
Max. Negotiated Rate	$694.40
Rate for Payer: Cash Price	$390.60
Rate for Payer: Cigna of CA HMO/PPO	$694.40
Rate for Payer: Health Smart Auto/Commercial	$520.80
Rate for Payer: LLUH Dept of Risk Management WC	$477.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$651.00

HC PLATELET COUNT

Facility

$17.00

Service Code	CPT 85049
Hospital Charge Code	900910101
Hospital Revenue Code	305
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$12.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.20
Rate for Payer: Aetna of CA Government/Medicare	$10.20
Rate for Payer: Cash Price	$7.65
Rate for Payer: Health Smart Auto/Commercial	$10.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.20
Rate for Payer: LLUH Dept of Risk Management WC	$9.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.75

HC PLATELET COUNT

Facility

$125.00

Service Code	CPT 85049
Hospital Charge Code	900910101
Hospital Revenue Code	305
Min. Negotiated Rate	$68.75
Max. Negotiated Rate	$100.00
Rate for Payer: Cash Price	$56.25
Rate for Payer: Cigna of CA HMO/PPO	$100.00
Rate for Payer: Health Smart Auto/Commercial	$75.00
Rate for Payer: LLUH Dept of Risk Management WC	$68.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$93.75

HC PLATELET COUNT CITRATED

Facility

$17.00

Service Code	CPT 85049
Hospital Charge Code	900912026
Hospital Revenue Code	305
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$12.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.20
Rate for Payer: Aetna of CA Government/Medicare	$10.20
Rate for Payer: Cash Price	$7.65
Rate for Payer: Health Smart Auto/Commercial	$10.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.20
Rate for Payer: LLUH Dept of Risk Management WC	$9.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.75

HC PLATELET COUNT CITRATED

Facility

$125.00

Service Code	CPT 85049
Hospital Charge Code	900912026
Hospital Revenue Code	305
Min. Negotiated Rate	$68.75
Max. Negotiated Rate	$100.00
Rate for Payer: Cash Price	$56.25
Rate for Payer: Cigna of CA HMO/PPO	$100.00
Rate for Payer: Health Smart Auto/Commercial	$75.00
Rate for Payer: LLUH Dept of Risk Management WC	$68.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$93.75

HC PLATELET NEUTRALIZATION

Facility

$382.00

Service Code	CPT 85597
Hospital Charge Code	900912007
Hospital Revenue Code	305
Min. Negotiated Rate	$210.10
Max. Negotiated Rate	$305.60
Rate for Payer: Cash Price	$171.90
Rate for Payer: Cigna of CA HMO/PPO	$305.60
Rate for Payer: Health Smart Auto/Commercial	$229.20
Rate for Payer: LLUH Dept of Risk Management WC	$210.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$286.50

HC PLATELET NEUTRALIZATION

Facility

$55.00

Service Code	CPT 85597
Hospital Charge Code	900912007
Hospital Revenue Code	305
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$41.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.00
Rate for Payer: Aetna of CA Government/Medicare	$33.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.25

HC PNEUMOCYSTIS STAIN

Facility

$17.00

Service Code	CPT 87205
Hospital Charge Code	900911625
Hospital Revenue Code	306
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$12.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.20
Rate for Payer: Aetna of CA Government/Medicare	$10.20
Rate for Payer: Cash Price	$7.65
Rate for Payer: Health Smart Auto/Commercial	$10.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.20
Rate for Payer: LLUH Dept of Risk Management WC	$9.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.75

HC PNEUMOCYSTIS STAIN

Facility

$189.00

Service Code	CPT 87205
Hospital Charge Code	900911625
Hospital Revenue Code	306
Min. Negotiated Rate	$103.95
Max. Negotiated Rate	$151.20
Rate for Payer: Cash Price	$85.05
Rate for Payer: Cigna of CA HMO/PPO	$151.20
Rate for Payer: Health Smart Auto/Commercial	$113.40
Rate for Payer: LLUH Dept of Risk Management WC	$103.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$141.75

HC POLYS MICRO EXAM

Facility

$17.00

Service Code	CPT 89055
Hospital Charge Code	900910045
Hospital Revenue Code	300
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$12.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.20
Rate for Payer: Aetna of CA Government/Medicare	$10.20
Rate for Payer: Cash Price	$7.65
Rate for Payer: Health Smart Auto/Commercial	$10.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.20
Rate for Payer: LLUH Dept of Risk Management WC	$9.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.75

HC POLYS MICRO EXAM

Facility

$179.00

Service Code	CPT 89055
Hospital Charge Code	900910045
Hospital Revenue Code	300
Min. Negotiated Rate	$98.45
Max. Negotiated Rate	$143.20
Rate for Payer: Cash Price	$80.55
Rate for Payer: Cigna of CA HMO/PPO	$143.20
Rate for Payer: Health Smart Auto/Commercial	$107.40
Rate for Payer: LLUH Dept of Risk Management WC	$98.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$134.25

HC PORPHOBILINOGEN QUAL

Facility

$15.00

Service Code	CPT 84106
Hospital Charge Code	900910297
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC PORPHOBILINOGEN QUAL

Facility

$122.00

Service Code	CPT 84106
Hospital Charge Code	900910297
Hospital Revenue Code	301
Min. Negotiated Rate	$67.10
Max. Negotiated Rate	$97.60
Rate for Payer: Cash Price	$54.90
Rate for Payer: Cigna of CA HMO/PPO	$97.60
Rate for Payer: Health Smart Auto/Commercial	$73.20
Rate for Payer: LLUH Dept of Risk Management WC	$67.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$91.50

HC POS COMBO 43 PANEL ID

Facility

$22.00

Service Code	CPT 87077
Hospital Charge Code	900912490
Hospital Revenue Code	300
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 POS COMBO 43 PANEL ID

Facility

$32.00

Service Code	CPT 87077
Hospital Charge Code	900912490
Hospital Revenue Code	300
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$25.60
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna of CA HMO/PPO	$25.60
Rate for Payer: Health Smart Auto/Commercial	$19.20
Rate for Payer: LLUH Dept of Risk Management WC	$17.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$24.00

HC POTASSIUM

Facility

$89.00

Service Code	CPT 84132
Hospital Charge Code	900910266
Hospital Revenue Code	301
Min. Negotiated Rate	$48.95
Max. Negotiated Rate	$71.20
Rate for Payer: Cash Price	$40.05
Rate for Payer: Cigna of CA HMO/PPO	$71.20
Rate for Payer: Health Smart Auto/Commercial	$53.40
Rate for Payer: LLUH Dept of Risk Management WC	$48.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.75

HC POTASSIUM

Facility

$89.00

Service Code	CPT 84132
Hospital Charge Code	900910488
Hospital Revenue Code	301
Min. Negotiated Rate	$48.95
Max. Negotiated Rate	$71.20
Rate for Payer: Health Smart Auto/Commercial	$53.40
Rate for Payer: Cash Price	$40.05
Rate for Payer: Cigna of CA HMO/PPO	$71.20
Rate for Payer: LLUH Dept of Risk Management WC	$48.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.75

HC POTASSIUM

Facility

$15.00

Service Code	CPT 84132
Hospital Charge Code	900910488
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC POTASSIUM

Facility

$15.00

Service Code	CPT 84132
Hospital Charge Code	900910266
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$11.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC POTASSIUM BODY FLUID

Facility

$17.00

Service Code	CPT 84999
Hospital Charge Code	900912245
Hospital Revenue Code	301
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$12.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.20
Rate for Payer: Aetna of CA Government/Medicare	$10.20
Rate for Payer: Cash Price	$7.65
Rate for Payer: Health Smart Auto/Commercial	$10.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.20
Rate for Payer: LLUH Dept of Risk Management WC	$9.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.75

Know your out-of-pocket cost for care.

All Charges