Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM LEPTOSPIRA IGM

Facility

$50.00

Service Code	CPT 86720
Hospital Charge Code	900911765
Hospital Revenue Code	302
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna of CA HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM LEPTOSPIRA IGM

Facility

$50.00

Service Code	CPT 86720
Hospital Charge Code	900911765
Hospital Revenue Code	302
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM LEPTOSPIRA IGM

Facility

$50.00

Service Code	CPT 86720 90
Hospital Charge Code	900911765
Hospital Revenue Code	302
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna of CA HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM LEPTOSPIRA IGM

Facility

$50.00

Service Code	CPT 86720 90
Hospital Charge Code	900911765
Hospital Revenue Code	302
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$37.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$37.50

HC SOM LEVETIRACETAM LEVEL

Facility

$14.50

Service Code	CPT 80177 90
Hospital Charge Code	900912530
Hospital Revenue Code	301
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$10.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.70
Rate for Payer: Aetna of CA Government/Medicare	$8.70
Rate for Payer: Cash Price	$6.53
Rate for Payer: Health Smart Auto/Commercial	$8.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.70
Rate for Payer: LLUH Dept of Risk Management WC	$7.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.88

HC SOM LEVETIRACETAM LEVEL

Facility

$14.50

Service Code	CPT 80177 90
Hospital Charge Code	900912530
Hospital Revenue Code	301
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$11.60
Rate for Payer: Cash Price	$6.53
Rate for Payer: Cigna of CA HMO/PPO	$11.60
Rate for Payer: Health Smart Auto/Commercial	$8.70
Rate for Payer: LLUH Dept of Risk Management WC	$7.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.88

HC SOM LEVETIRACETAM LEVEL

Facility

$14.50

Service Code	CPT 80177
Hospital Charge Code	900912530
Hospital Revenue Code	301
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$10.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.70
Rate for Payer: Aetna of CA Government/Medicare	$8.70
Rate for Payer: Cash Price	$6.53
Rate for Payer: Health Smart Auto/Commercial	$8.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.70
Rate for Payer: LLUH Dept of Risk Management WC	$7.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.88

HC SOM LEVETIRACETAM LEVEL

Facility

$14.50

Service Code	CPT 80177
Hospital Charge Code	900912530
Hospital Revenue Code	301
Min. Negotiated Rate	$7.98
Max. Negotiated Rate	$11.60
Rate for Payer: Cash Price	$6.53
Rate for Payer: Cigna of CA HMO/PPO	$11.60
Rate for Payer: Health Smart Auto/Commercial	$8.70
Rate for Payer: LLUH Dept of Risk Management WC	$7.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.88

HC SOM LIPASE BF

Facility

$17.00

Service Code	CPT 83690
Hospital Charge Code	900913938
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

HC SOM LIPASE BF

Facility

$25.00

Service Code	CPT 83690
Hospital Charge Code	900913938
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna of CA HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM LIPASE BF

Facility

$25.00

Service Code	CPT 83690 90
Hospital Charge Code	900913938
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Cigna of CA HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.75

HC SOM LIPASE RANDOM URINE

Facility

$67.10

Service Code	CPT 83690
Hospital Charge Code	900912532
Hospital Revenue Code	301
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$50.32
Rate for Payer: Health Smart Auto/Commercial	$40.26
Rate for Payer: Cash Price	$30.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.26
Rate for Payer: Aetna of CA Government/Medicare	$40.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.26
Rate for Payer: LLUH Dept of Risk Management WC	$36.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.32

HC SOM LIPASE RANDOM URINE

Facility

$67.10

Service Code	CPT 83690 90
Hospital Charge Code	900912532
Hospital Revenue Code	301
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$50.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.26
Rate for Payer: Aetna of CA Government/Medicare	$40.26
Rate for Payer: Cash Price	$30.20
Rate for Payer: Health Smart Auto/Commercial	$40.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.26
Rate for Payer: LLUH Dept of Risk Management WC	$36.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.32

HC SOM LIPASE RANDOM URINE

Facility

$67.10

Service Code	CPT 83690
Hospital Charge Code	900912532
Hospital Revenue Code	301
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$53.68
Rate for Payer: Cash Price	$30.20
Rate for Payer: Cigna of CA HMO/PPO	$53.68
Rate for Payer: Health Smart Auto/Commercial	$40.26
Rate for Payer: LLUH Dept of Risk Management WC	$36.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.32

HC SOM LIPASE RANDOM URINE

Facility

$67.10

Service Code	CPT 83690 90
Hospital Charge Code	900912532
Hospital Revenue Code	301
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$53.68
Rate for Payer: Cash Price	$30.20
Rate for Payer: Cigna of CA HMO/PPO	$53.68
Rate for Payer: Health Smart Auto/Commercial	$40.26
Rate for Payer: LLUH Dept of Risk Management WC	$36.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.32

HC SOM LIPOPROTEIN A

Facility

$14.65

Service Code	CPT 83695 90
Hospital Charge Code	900910756
Hospital Revenue Code	301
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$11.72
Rate for Payer: Health Smart Auto/Commercial	$8.79
Rate for Payer: Cash Price	$6.59
Rate for Payer: Cigna of CA HMO/PPO	$11.72
Rate for Payer: LLUH Dept of Risk Management WC	$8.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.99

HC SOM LIPOPROTEIN A

Facility

$14.65

Service Code	CPT 83695 90
Hospital Charge Code	900910756
Hospital Revenue Code	301
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$10.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.79
Rate for Payer: Aetna of CA Government/Medicare	$8.79
Rate for Payer: Cash Price	$6.59
Rate for Payer: Health Smart Auto/Commercial	$8.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.79
Rate for Payer: LLUH Dept of Risk Management WC	$8.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.99

HC SOM LIPOPROTEIN A

Facility

$14.65

Service Code	CPT 83695
Hospital Charge Code	900910756
Hospital Revenue Code	301
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$11.72
Rate for Payer: Cash Price	$6.59
Rate for Payer: Cigna of CA HMO/PPO	$11.72
Rate for Payer: Health Smart Auto/Commercial	$8.79
Rate for Payer: LLUH Dept of Risk Management WC	$8.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.99

HC SOM LIPOPROTEIN A

Facility

$14.65

Service Code	CPT 83695
Hospital Charge Code	900910756
Hospital Revenue Code	301
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$10.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.79
Rate for Payer: Aetna of CA Government/Medicare	$8.79
Rate for Payer: Cash Price	$6.59
Rate for Payer: Health Smart Auto/Commercial	$8.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.79
Rate for Payer: LLUH Dept of Risk Management WC	$8.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.99

HC SOM LYME DISEASE AB IGG

Facility

$15.00

Service Code	CPT 86617
Hospital Charge Code	900912569
Hospital Revenue Code	302
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Cigna of CA HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC SOM LYME DISEASE AB IGG

Facility

$15.00

Service Code	CPT 86617
Hospital Charge Code	900912569
Hospital Revenue Code	302
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 SOM LYME DISEASE AB IGG

Facility

$15.00

Service Code	CPT 86617 90
Hospital Charge Code	900912569
Hospital Revenue Code	302
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 SOM LYME DISEASE AB IGG

Facility

$15.00

Service Code	CPT 86617 90
Hospital Charge Code	900912569
Hospital Revenue Code	302
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Cigna of CA HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

HC SOM LYME DISEASE AB IGM

Facility

$15.00

Service Code	CPT 86617 90
Hospital Charge Code	900912696
Hospital Revenue Code	302
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 SOM LYME DISEASE AB IGM

Facility

$15.00

Service Code	CPT 86617 90
Hospital Charge Code	900912696
Hospital Revenue Code	302
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$6.75
Rate for Payer: Cigna of CA HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.25

Know your out-of-pocket cost for care.

All Charges