Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM HSV TYPE 1 AB, IGG, S

Facility

$11.75

Service Code	CPT 86695 90
Hospital Charge Code	900914085
Hospital Revenue Code	302
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$8.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.05
Rate for Payer: Aetna of CA Government/Medicare	$7.05
Rate for Payer: Cash Price	$5.29
Rate for Payer: Health Smart Auto/Commercial	$7.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.05
Rate for Payer: LLUH Dept of Risk Management WC	$6.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.81

HC SOM HSV TYPE 1 AB, IGG, S

Facility

$11.75

Service Code	CPT 86695
Hospital Charge Code	900914085
Hospital Revenue Code	302
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$9.40
Rate for Payer: Cash Price	$5.29
Rate for Payer: Cigna of CA HMO/PPO	$9.40
Rate for Payer: Health Smart Auto/Commercial	$7.05
Rate for Payer: LLUH Dept of Risk Management WC	$6.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.81

HC SOM HSV TYPE 1 AB, IGG, S

Facility

$11.75

Service Code	CPT 86695 90
Hospital Charge Code	900914085
Hospital Revenue Code	302
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$9.40
Rate for Payer: Cash Price	$5.29
Rate for Payer: Cigna of CA HMO/PPO	$9.40
Rate for Payer: Health Smart Auto/Commercial	$7.05
Rate for Payer: LLUH Dept of Risk Management WC	$6.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.81

HC SOM HSV TYPE 2 AB, IGG, S

Facility

$17.25

Service Code	CPT 86696 90
Hospital Charge Code	900914086
Hospital Revenue Code	302
Min. Negotiated Rate	$9.49
Max. Negotiated Rate	$13.80
Rate for Payer: Cash Price	$7.76
Rate for Payer: Cigna of CA HMO/PPO	$13.80
Rate for Payer: Health Smart Auto/Commercial	$10.35
Rate for Payer: LLUH Dept of Risk Management WC	$9.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.94

HC SOM HSV TYPE 2 AB, IGG, S

Facility

$17.25

Service Code	CPT 86696
Hospital Charge Code	900914086
Hospital Revenue Code	302
Min. Negotiated Rate	$9.49
Max. Negotiated Rate	$13.80
Rate for Payer: Cash Price	$7.76
Rate for Payer: Cigna of CA HMO/PPO	$13.80
Rate for Payer: Health Smart Auto/Commercial	$10.35
Rate for Payer: LLUH Dept of Risk Management WC	$9.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.94

HC SOM HSV TYPE 2 AB, IGG, S

Facility

$17.25

Service Code	CPT 86696 90
Hospital Charge Code	900914086
Hospital Revenue Code	302
Min. Negotiated Rate	$9.49
Max. Negotiated Rate	$12.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.35
Rate for Payer: Aetna of CA Government/Medicare	$10.35
Rate for Payer: Cash Price	$7.76
Rate for Payer: Health Smart Auto/Commercial	$10.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.35
Rate for Payer: LLUH Dept of Risk Management WC	$9.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.94

HC SOM HSV TYPE 2 AB, IGG, S

Facility

$17.25

Service Code	CPT 86696
Hospital Charge Code	900914086
Hospital Revenue Code	302
Min. Negotiated Rate	$9.49
Max. Negotiated Rate	$12.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.35
Rate for Payer: Aetna of CA Government/Medicare	$10.35
Rate for Payer: Cash Price	$7.76
Rate for Payer: Health Smart Auto/Commercial	$10.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.35
Rate for Payer: LLUH Dept of Risk Management WC	$9.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.94

HC SOM HTGFN 84432

Facility

$163.88

Service Code	CPT 84432 90
Hospital Charge Code	900914871
Hospital Revenue Code	302
Min. Negotiated Rate	$90.13
Max. Negotiated Rate	$122.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$98.33
Rate for Payer: Aetna of CA Government/Medicare	$98.33
Rate for Payer: Cash Price	$73.75
Rate for Payer: Health Smart Auto/Commercial	$98.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$98.33
Rate for Payer: LLUH Dept of Risk Management WC	$90.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$122.91

HC SOM HTGFN 84432

Facility

$163.88

Service Code	CPT 84432
Hospital Charge Code	900914871
Hospital Revenue Code	302
Min. Negotiated Rate	$90.13
Max. Negotiated Rate	$122.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$98.33
Rate for Payer: Aetna of CA Government/Medicare	$98.33
Rate for Payer: Cash Price	$73.75
Rate for Payer: Health Smart Auto/Commercial	$98.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$98.33
Rate for Payer: LLUH Dept of Risk Management WC	$90.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$122.91

HC SOM HTGFN 84432

Facility

$163.88

Service Code	CPT 84432
Hospital Charge Code	900914871
Hospital Revenue Code	302
Min. Negotiated Rate	$90.13
Max. Negotiated Rate	$131.10
Rate for Payer: Cash Price	$73.75
Rate for Payer: Cigna of CA HMO/PPO	$131.10
Rate for Payer: Health Smart Auto/Commercial	$98.33
Rate for Payer: LLUH Dept of Risk Management WC	$90.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$122.91

HC SOM HTGFN 84432

Facility

$163.88

Service Code	CPT 84432 90
Hospital Charge Code	900914871
Hospital Revenue Code	302
Min. Negotiated Rate	$90.13
Max. Negotiated Rate	$131.10
Rate for Payer: Cash Price	$73.75
Rate for Payer: Cigna of CA HMO/PPO	$131.10
Rate for Payer: Health Smart Auto/Commercial	$98.33
Rate for Payer: LLUH Dept of Risk Management WC	$90.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$122.91

HC SOM HTLV AB CONFIRM

Facility

$130.00

Service Code	CPT 86689 90
Hospital Charge Code	900912880
Hospital Revenue Code	302
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$97.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$78.00
Rate for Payer: Aetna of CA Government/Medicare	$78.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$97.50

HC SOM HTLV AB CONFIRM

Facility

$130.00

Service Code	CPT 86689
Hospital Charge Code	900912880
Hospital Revenue Code	302
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$97.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$78.00
Rate for Payer: Aetna of CA Government/Medicare	$78.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$97.50

HC SOM HTLV AB CONFIRM

Facility

$130.00

Service Code	CPT 86689 90
Hospital Charge Code	900912880
Hospital Revenue Code	302
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$104.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna of CA HMO/PPO	$104.00
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$97.50

HC SOM HTLV AB CONFIRM

Facility

$130.00

Service Code	CPT 86689
Hospital Charge Code	900912880
Hospital Revenue Code	302
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$104.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna of CA HMO/PPO	$104.00
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$97.50

HC SOM HTLV AB SCREEN

Facility

$12.88

Service Code	CPT 86790
Hospital Charge Code	900911034
Hospital Revenue Code	302
Min. Negotiated Rate	$7.08
Max. Negotiated Rate	$9.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.73
Rate for Payer: Aetna of CA Government/Medicare	$7.73
Rate for Payer: Cash Price	$5.80
Rate for Payer: Health Smart Auto/Commercial	$7.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.73
Rate for Payer: LLUH Dept of Risk Management WC	$7.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.66

HC SOM HTLV AB SCREEN

Facility

$12.88

Service Code	CPT 86790
Hospital Charge Code	900911034
Hospital Revenue Code	302
Min. Negotiated Rate	$7.08
Max. Negotiated Rate	$10.30
Rate for Payer: Cash Price	$5.80
Rate for Payer: Cigna of CA HMO/PPO	$10.30
Rate for Payer: Health Smart Auto/Commercial	$7.73
Rate for Payer: LLUH Dept of Risk Management WC	$7.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.66

HC SOM HTLV AB SCREEN

Facility

$12.88

Service Code	CPT 86790 90
Hospital Charge Code	900911034
Hospital Revenue Code	302
Min. Negotiated Rate	$7.08
Max. Negotiated Rate	$9.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.73
Rate for Payer: Aetna of CA Government/Medicare	$7.73
Rate for Payer: Cash Price	$5.80
Rate for Payer: Health Smart Auto/Commercial	$7.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.73
Rate for Payer: LLUH Dept of Risk Management WC	$7.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.66

HC SOM HTLV AB SCREEN

Facility

$12.88

Service Code	CPT 86790 90
Hospital Charge Code	900911034
Hospital Revenue Code	302
Min. Negotiated Rate	$7.08
Max. Negotiated Rate	$10.30
Rate for Payer: Cash Price	$5.80
Rate for Payer: Cigna of CA HMO/PPO	$10.30
Rate for Payer: Health Smart Auto/Commercial	$7.73
Rate for Payer: LLUH Dept of Risk Management WC	$7.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.66

HC SOM HUMAN HERPESVIRUS-6 PCR

Facility

$75.00

Service Code	CPT 87532 90
Hospital Charge Code	900912711
Hospital Revenue Code	306
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Cigna of CA HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM HUMAN HERPESVIRUS-6 PCR

Facility

$75.00

Service Code	CPT 87532 90
Hospital Charge Code	900912711
Hospital Revenue Code	306
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$56.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM HUMAN HERPESVIRUS-6 PCR

Facility

$75.00

Service Code	CPT 87532
Hospital Charge Code	900912711
Hospital Revenue Code	306
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Cigna of CA HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM HUMAN HERPESVIRUS-6 PCR

Facility

$75.00

Service Code	CPT 87532
Hospital Charge Code	900912711
Hospital Revenue Code	306
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$56.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$33.75
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$56.25

HC SOM HYPOGLYCEMIC AGENT SCREEN

Facility

$90.00

Service Code	CPT 80377 90
Hospital Charge Code	900912528
Hospital Revenue Code	301
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna of CA HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.50

HC SOM HYPOGLYCEMIC AGENT SCREEN

Facility

$90.00

Service Code	CPT 80377
Hospital Charge Code	900912528
Hospital Revenue Code	301
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna of CA HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$67.50

Know your out-of-pocket cost for care.

All Charges