Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM MURAMIDASE SERUM

Facility

$20.00

Service Code	CPT 85549
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

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	$16.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna of CA HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC SOM MURAMIDASE SERUM

Facility

$20.00

Service Code	CPT 85549
Hospital Charge Code	900911063
Hospital Revenue Code	305
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna of CA HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.00

HC SOM MYCOPHENOLIC ACID

Facility

$22.00

Service Code	CPT 80180 90
Hospital Charge Code	900910761
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 SOM MYCOPHENOLIC ACID

Facility

$22.00

Service Code	CPT 80180 90
Hospital Charge Code	900910761
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 SOM MYCOPHENOLIC ACID

Facility

$22.00

Service Code	CPT 80180
Hospital Charge Code	900910761
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 SOM MYCOPHENOLIC ACID

Facility

$22.00

Service Code	CPT 80180
Hospital Charge Code	900910761
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 SOM MYCOPLASMA PNEUMONIAE AB IGG

Facility

$10.40

Service Code	CPT 86738
Hospital Charge Code	900911589
Hospital Revenue Code	302
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$7.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.24
Rate for Payer: Aetna of CA Government/Medicare	$6.24
Rate for Payer: Cash Price	$4.68
Rate for Payer: Health Smart Auto/Commercial	$6.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.24
Rate for Payer: LLUH Dept of Risk Management WC	$5.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.80

HC SOM MYCOPLASMA PNEUMONIAE AB IGG

Facility

$10.40

Service Code	CPT 86738 90
Hospital Charge Code	900911589
Hospital Revenue Code	302
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$7.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.24
Rate for Payer: Aetna of CA Government/Medicare	$6.24
Rate for Payer: Cash Price	$4.68
Rate for Payer: Health Smart Auto/Commercial	$6.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.24
Rate for Payer: LLUH Dept of Risk Management WC	$5.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.80

HC SOM MYCOPLASMA PNEUMONIAE AB IGG

Facility

$10.40

Service Code	CPT 86738
Hospital Charge Code	900911589
Hospital Revenue Code	302
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$8.32
Rate for Payer: Cash Price	$4.68
Rate for Payer: Cigna of CA HMO/PPO	$8.32
Rate for Payer: Health Smart Auto/Commercial	$6.24
Rate for Payer: LLUH Dept of Risk Management WC	$5.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.80

HC SOM MYCOPLASMA PNEUMONIAE AB IGG

Facility

$10.40

Service Code	CPT 86738 90
Hospital Charge Code	900911589
Hospital Revenue Code	302
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$8.32
Rate for Payer: Cash Price	$4.68
Rate for Payer: Cigna of CA HMO/PPO	$8.32
Rate for Payer: Health Smart Auto/Commercial	$6.24
Rate for Payer: LLUH Dept of Risk Management WC	$5.72
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.80

HC SOM MYCOPLASMA PNEUMONIAE AB IGM

Facility

$10.41

Service Code	CPT 86738 90
Hospital Charge Code	900912639
Hospital Revenue Code	302
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$7.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.25
Rate for Payer: Aetna of CA Government/Medicare	$6.25
Rate for Payer: Cash Price	$4.68
Rate for Payer: Health Smart Auto/Commercial	$6.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.25
Rate for Payer: LLUH Dept of Risk Management WC	$5.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.81

HC SOM MYCOPLASMA PNEUMONIAE AB IGM

Facility

$10.41

Service Code	CPT 86738
Hospital Charge Code	900912639
Hospital Revenue Code	302
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$7.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.25
Rate for Payer: Aetna of CA Government/Medicare	$6.25
Rate for Payer: Cash Price	$4.68
Rate for Payer: Health Smart Auto/Commercial	$6.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.25
Rate for Payer: LLUH Dept of Risk Management WC	$5.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.81

HC SOM MYCOPLASMA PNEUMONIAE AB IGM

Facility

$10.41

Service Code	CPT 86738
Hospital Charge Code	900912639
Hospital Revenue Code	302
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$8.33
Rate for Payer: Cash Price	$4.68
Rate for Payer: Cigna of CA HMO/PPO	$8.33
Rate for Payer: Health Smart Auto/Commercial	$6.25
Rate for Payer: LLUH Dept of Risk Management WC	$5.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.81

HC SOM MYCOPLASMA PNEUMONIAE AB IGM

Facility

$10.41

Service Code	CPT 86738 90
Hospital Charge Code	900912639
Hospital Revenue Code	302
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$8.33
Rate for Payer: Cash Price	$4.68
Rate for Payer: Cigna of CA HMO/PPO	$8.33
Rate for Payer: Health Smart Auto/Commercial	$6.25
Rate for Payer: LLUH Dept of Risk Management WC	$5.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.81

HC SOM MYCO PNEUM DNA PCR

Facility

$175.00

Service Code	CPT 87581
Hospital Charge Code	900914442
Hospital Revenue Code	306
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$131.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM MYCO PNEUM DNA PCR

Facility

$175.00

Service Code	CPT 0100U 90
Hospital Charge Code	900914442
Hospital Revenue Code	306
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Cigna of CA HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM MYCO PNEUM DNA PCR

Facility

$175.00

Service Code	CPT 0100U 90
Hospital Charge Code	900914442
Hospital Revenue Code	306
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$131.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM MYCO PNEUM DNA PCR

Facility

$175.00

Service Code	CPT 87581
Hospital Charge Code	900914442
Hospital Revenue Code	306
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$78.75
Rate for Payer: Cigna of CA HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$131.25

HC SOM MYELOPEROXIDASE

Facility

$27.90

Service Code	CPT 83516 90
Hospital Charge Code	900910578
Hospital Revenue Code	302
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$22.32
Rate for Payer: Cash Price	$12.56
Rate for Payer: Cigna of CA HMO/PPO	$22.32
Rate for Payer: Health Smart Auto/Commercial	$16.74
Rate for Payer: LLUH Dept of Risk Management WC	$15.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.92

HC SOM MYELOPEROXIDASE

Facility

$27.90

Service Code	CPT 83516
Hospital Charge Code	900910578
Hospital Revenue Code	302
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$20.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.74
Rate for Payer: Aetna of CA Government/Medicare	$16.74
Rate for Payer: Cash Price	$12.56
Rate for Payer: Health Smart Auto/Commercial	$16.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.74
Rate for Payer: LLUH Dept of Risk Management WC	$15.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.92

HC SOM MYELOPEROXIDASE

Facility

$27.90

Service Code	CPT 83516 90
Hospital Charge Code	900910578
Hospital Revenue Code	302
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$20.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.74
Rate for Payer: Aetna of CA Government/Medicare	$16.74
Rate for Payer: Cash Price	$12.56
Rate for Payer: Health Smart Auto/Commercial	$16.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.74
Rate for Payer: LLUH Dept of Risk Management WC	$15.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.92

HC SOM MYELOPEROXIDASE

Facility

$27.90

Service Code	CPT 83516
Hospital Charge Code	900910578
Hospital Revenue Code	302
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$22.32
Rate for Payer: Cash Price	$12.56
Rate for Payer: Cigna of CA HMO/PPO	$22.32
Rate for Payer: Health Smart Auto/Commercial	$16.74
Rate for Payer: LLUH Dept of Risk Management WC	$15.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.92

HC SOM MYOGLOBIN URINE

Facility

$18.00

Service Code	CPT 83874 90
Hospital Charge Code	900910762
Hospital Revenue Code	301
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 SOM MYOGLOBIN URINE

Facility

$18.00

Service Code	CPT 83874 90
Hospital Charge Code	900910762
Hospital Revenue Code	301
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$14.40
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna of CA HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.50

Know your out-of-pocket cost for care.

All Charges