Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM STREP PNEUMO SEROTYPE 6B (26)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912859
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

HC SOM STREP PNEUMO SEROTYPE 7F (51)

Facility

$5.00

Service Code	CPT 86317 90
Hospital Charge Code	900912862
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cigna of CA HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

HC SOM STREP PNEUMO SEROTYPE 7F (51)

Facility

$5.00

Service Code	CPT 86317 90
Hospital Charge Code	900912862
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.00
Rate for Payer: Aetna of CA Government/Medicare	$3.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

HC SOM STREP PNEUMO SEROTYPE 7F (51)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912862
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.00
Rate for Payer: Aetna of CA Government/Medicare	$3.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

HC SOM STREP PNEUMO SEROTYPE 7F (51)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912862
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cigna of CA HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

HC SOM STREP PNEUMO SEROTYPE 8 (8)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912850
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

HC SOM STREP PNEUMO SEROTYPE 8 (8)

Facility

$4.00

Service Code	CPT 86317 90
Hospital Charge Code	900912850
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

HC SOM STREP PNEUMO SEROTYPE 8 (8)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912850
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cigna of CA HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

HC SOM STREP PNEUMO SEROTYPE 8 (8)

Facility

$4.00

Service Code	CPT 86317 90
Hospital Charge Code	900912850
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cigna of CA HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

HC SOM STREP PNEUMO SEROTYPE 9N (9)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912851
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cigna of CA HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

HC SOM STREP PNEUMO SEROTYPE 9N (9)

Facility

$4.00

Service Code	CPT 86317 90
Hospital Charge Code	900912851
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

HC SOM STREP PNEUMO SEROTYPE 9N (9)

Facility

$4.00

Service Code	CPT 86317 90
Hospital Charge Code	900912851
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cigna of CA HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

HC SOM STREP PNEUMO SEROTYPE 9N (9)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912851
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.00

HC SOM STREP PNEUMO SEROTYPE 9V (68)

Facility

$5.00

Service Code	CPT 86317 90
Hospital Charge Code	900912866
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.00
Rate for Payer: Aetna of CA Government/Medicare	$3.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

HC SOM STREP PNEUMO SEROTYPE 9V (68)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912866
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.00
Rate for Payer: Aetna of CA Government/Medicare	$3.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

HC SOM STREP PNEUMO SEROTYPE 9V (68)

Facility

$5.00

Service Code	CPT 86317 90
Hospital Charge Code	900912866
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cigna of CA HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

HC SOM STREP PNEUMO SEROTYPE 9V (68)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912866
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$2.25
Rate for Payer: Cigna of CA HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.75

HC SOM STREPTOCOCCAL ABS

Facility

$9.91

Service Code	CPT 86215
Hospital Charge Code	900911155
Hospital Revenue Code	302
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.93
Rate for Payer: Cash Price	$4.46
Rate for Payer: Cigna of CA HMO/PPO	$7.93
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.43

HC SOM STREPTOCOCCAL ABS

Facility

$9.91

Service Code	CPT 86215
Hospital Charge Code	900911155
Hospital Revenue Code	302
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.95
Rate for Payer: Aetna of CA Government/Medicare	$5.95
Rate for Payer: Cash Price	$4.46
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.43

HC SOM STREPTOCOCCAL ABS

Facility

$9.91

Service Code	CPT 86215 90
Hospital Charge Code	900911155
Hospital Revenue Code	302
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.95
Rate for Payer: Aetna of CA Government/Medicare	$5.95
Rate for Payer: Cash Price	$4.46
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.43

HC SOM STREPTOCOCCAL ABS

Facility

$9.91

Service Code	CPT 86215 90
Hospital Charge Code	900911155
Hospital Revenue Code	302
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.93
Rate for Payer: Cash Price	$4.46
Rate for Payer: Cigna of CA HMO/PPO	$7.93
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.43

HC SOM STREPTOCOCCAL ABS, SNTISTREP-O

Facility

$10.00

Service Code	CPT 86060
Hospital Charge Code	900912820
Hospital Revenue Code	302
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna of CA HMO/PPO	$8.00
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

HC SOM STREPTOCOCCAL ABS, SNTISTREP-O

Facility

$10.00

Service Code	CPT 86060
Hospital Charge Code	900912820
Hospital Revenue Code	302
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.00
Rate for Payer: Aetna of CA Government/Medicare	$6.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

HC SOM STREPTOCOCCAL ABS, SNTISTREP-O

Facility

$10.00

Service Code	CPT 86060 90
Hospital Charge Code	900912820
Hospital Revenue Code	302
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.00
Rate for Payer: Aetna of CA Government/Medicare	$6.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

HC SOM STREPTOCOCCAL ABS, SNTISTREP-O

Facility

$10.00

Service Code	CPT 86060 90
Hospital Charge Code	900912820
Hospital Revenue Code	302
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna of CA HMO/PPO	$8.00
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

Know your out-of-pocket cost for care.

All Charges