Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM M PNEUMONIAE AB IGM S IFA

Facility

$47.00

Service Code	CPT 86738 90
Hospital Charge Code	900913940
Hospital Revenue Code	302
Min. Negotiated Rate	$25.85
Max. Negotiated Rate	$35.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.20
Rate for Payer: Aetna of CA Government/Medicare	$28.20
Rate for Payer: Cash Price	$21.15
Rate for Payer: Health Smart Auto/Commercial	$28.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.20
Rate for Payer: LLUH Dept of Risk Management WC	$25.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.25

HC SOM M PNEUMONIAE AB IGM S IFA

Facility

$47.00

Service Code	CPT 86738
Hospital Charge Code	900913940
Hospital Revenue Code	302
Min. Negotiated Rate	$25.85
Max. Negotiated Rate	$37.60
Rate for Payer: Cash Price	$21.15
Rate for Payer: Cigna of CA HMO/PPO	$37.60
Rate for Payer: Health Smart Auto/Commercial	$28.20
Rate for Payer: LLUH Dept of Risk Management WC	$25.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.25

HC SOM M PNEUMONIAE AB IGM S IFA

Facility

$47.00

Service Code	CPT 86738 90
Hospital Charge Code	900913940
Hospital Revenue Code	302
Min. Negotiated Rate	$25.85
Max. Negotiated Rate	$37.60
Rate for Payer: Cash Price	$21.15
Rate for Payer: Cigna of CA HMO/PPO	$37.60
Rate for Payer: Health Smart Auto/Commercial	$28.20
Rate for Payer: LLUH Dept of Risk Management WC	$25.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.25

HC SOM M PNEUMONIAE AB IGM S IFA

Facility

$47.00

Service Code	CPT 86738
Hospital Charge Code	900913940
Hospital Revenue Code	302
Min. Negotiated Rate	$25.85
Max. Negotiated Rate	$35.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.20
Rate for Payer: Aetna of CA Government/Medicare	$28.20
Rate for Payer: Cash Price	$21.15
Rate for Payer: Health Smart Auto/Commercial	$28.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.20
Rate for Payer: LLUH Dept of Risk Management WC	$25.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$35.25

HC SOM MTB PCR COMPLEX SPUTUM

Facility

$243.39

Service Code	CPT 87798
Hospital Charge Code	900915433
Hospital Revenue Code	300
Min. Negotiated Rate	$133.86
Max. Negotiated Rate	$194.71
Rate for Payer: Cash Price	$109.53
Rate for Payer: Cigna of CA HMO/PPO	$194.71
Rate for Payer: Health Smart Auto/Commercial	$146.03
Rate for Payer: LLUH Dept of Risk Management WC	$133.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$182.54

HC SOM MTB PCR COMPLEX SPUTUM

Facility

$243.39

Service Code	CPT 87798 90
Hospital Charge Code	900915433
Hospital Revenue Code	300
Min. Negotiated Rate	$133.86
Max. Negotiated Rate	$194.71
Rate for Payer: Cash Price	$109.53
Rate for Payer: Cigna of CA HMO/PPO	$194.71
Rate for Payer: Health Smart Auto/Commercial	$146.03
Rate for Payer: LLUH Dept of Risk Management WC	$133.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$182.54

HC SOM MTB PCR COMPLEX SPUTUM

Facility

$243.39

Service Code	CPT 87798 90
Hospital Charge Code	900915433
Hospital Revenue Code	300
Min. Negotiated Rate	$133.86
Max. Negotiated Rate	$182.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$146.03
Rate for Payer: Aetna of CA Government/Medicare	$146.03
Rate for Payer: Cash Price	$109.53
Rate for Payer: Health Smart Auto/Commercial	$146.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$146.03
Rate for Payer: LLUH Dept of Risk Management WC	$133.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$182.54

HC SOM MTB PCR COMPLEX SPUTUM

Facility

$243.39

Service Code	CPT 87798
Hospital Charge Code	900915433
Hospital Revenue Code	300
Min. Negotiated Rate	$133.86
Max. Negotiated Rate	$182.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$146.03
Rate for Payer: Aetna of CA Government/Medicare	$146.03
Rate for Payer: Cash Price	$109.53
Rate for Payer: Health Smart Auto/Commercial	$146.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$146.03
Rate for Payer: LLUH Dept of Risk Management WC	$133.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$182.54

HC SOM MTB PCR SPUTUM

Facility

$289.11

Service Code	CPT 87556 90
Hospital Charge Code	900915432
Hospital Revenue Code	300
Min. Negotiated Rate	$159.01
Max. Negotiated Rate	$216.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$173.47
Rate for Payer: Aetna of CA Government/Medicare	$173.47
Rate for Payer: Cash Price	$130.10
Rate for Payer: Health Smart Auto/Commercial	$173.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$173.47
Rate for Payer: LLUH Dept of Risk Management WC	$159.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$216.83

HC SOM MTB PCR SPUTUM

Facility

$289.11

Service Code	CPT 87556
Hospital Charge Code	900915432
Hospital Revenue Code	300
Min. Negotiated Rate	$159.01
Max. Negotiated Rate	$216.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$173.47
Rate for Payer: Aetna of CA Government/Medicare	$173.47
Rate for Payer: Cash Price	$130.10
Rate for Payer: Health Smart Auto/Commercial	$173.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$173.47
Rate for Payer: LLUH Dept of Risk Management WC	$159.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$216.83

HC SOM MTB PCR SPUTUM

Facility

$289.11

Service Code	CPT 87556 90
Hospital Charge Code	900915432
Hospital Revenue Code	300
Min. Negotiated Rate	$159.01
Max. Negotiated Rate	$231.29
Rate for Payer: Cash Price	$130.10
Rate for Payer: Cigna of CA HMO/PPO	$231.29
Rate for Payer: Health Smart Auto/Commercial	$173.47
Rate for Payer: LLUH Dept of Risk Management WC	$159.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$216.83

HC SOM MTB PCR SPUTUM

Facility

$289.11

Service Code	CPT 87556
Hospital Charge Code	900915432
Hospital Revenue Code	300
Min. Negotiated Rate	$159.01
Max. Negotiated Rate	$231.29
Rate for Payer: Health Smart Auto/Commercial	$173.47
Rate for Payer: Cash Price	$130.10
Rate for Payer: Cigna of CA HMO/PPO	$231.29
Rate for Payer: LLUH Dept of Risk Management WC	$159.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$216.83

HC SOM M. TUBERCULOSIS PCR

Facility

$75.00

Service Code	CPT 87556 90
Hospital Charge Code	900912875
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 M. TUBERCULOSIS PCR

Facility

$75.00

Service Code	CPT 87556
Hospital Charge Code	900912875
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 M. TUBERCULOSIS PCR

Facility

$75.00

Service Code	CPT 87556
Hospital Charge Code	900912875
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 M. TUBERCULOSIS PCR

Facility

$75.00

Service Code	CPT 87556 90
Hospital Charge Code	900912875
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 MUMPS AB IGG CSF

Facility

$25.00

Service Code	CPT 86735
Hospital Charge Code	900911356
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 MUMPS AB IGG CSF

Facility

$25.00

Service Code	CPT 86735 90
Hospital Charge Code	900911356
Hospital Revenue Code	302
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 MUMPS AB IGG CSF

Facility

$25.00

Service Code	CPT 86735
Hospital Charge Code	900911356
Hospital Revenue Code	302
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 MUMPS AB IGG CSF

Facility

$25.00

Service Code	CPT 86735 90
Hospital Charge Code	900911356
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 MUMPS AB IGM CSF

Facility

$25.00

Service Code	CPT 86735 90
Hospital Charge Code	900912679
Hospital Revenue Code	302
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 MUMPS AB IGM CSF

Facility

$25.00

Service Code	CPT 86735
Hospital Charge Code	900912679
Hospital Revenue Code	302
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 MUMPS AB IGM CSF

Facility

$25.00

Service Code	CPT 86735 90
Hospital Charge Code	900912679
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 MUMPS AB IGM CSF

Facility

$25.00

Service Code	CPT 86735
Hospital Charge Code	900912679
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$11.25
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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 MURAMIDASE SERUM

Facility

$20.00

Service Code	CPT 85549 90
Hospital Charge Code	900911063
Hospital Revenue Code	305
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

Know your out-of-pocket cost for care.

All Charges