Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM WESTERN EQUINE ENCEPH AB IGM

Facility

$25.00

Service Code	CPT 86654 90
Hospital Charge Code	900912651
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 WESTERN EQUINE ENCEPH AB IGM

Facility

$25.00

Service Code	CPT 86654
Hospital Charge Code	900912651
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 WESTERN EQUINE ENCEPH AB IGM

Facility

$25.00

Service Code	CPT 86654
Hospital Charge Code	900912651
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 WESTERN EQUINE ENCEPH AB IGM

Facility

$25.00

Service Code	CPT 86654 90
Hospital Charge Code	900912651
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 WEST NILE VIRUS AB

Facility

$18.39

Service Code	CPT 86788
Hospital Charge Code	900912544
Hospital Revenue Code	302
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$14.71
Rate for Payer: Cash Price	$8.28
Rate for Payer: Cigna of CA HMO/PPO	$14.71
Rate for Payer: Health Smart Auto/Commercial	$11.03
Rate for Payer: LLUH Dept of Risk Management WC	$10.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.79

HC SOM WEST NILE VIRUS AB

Facility

$18.39

Service Code	CPT 86788
Hospital Charge Code	900912544
Hospital Revenue Code	302
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$13.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.03
Rate for Payer: Aetna of CA Government/Medicare	$11.03
Rate for Payer: Cash Price	$8.28
Rate for Payer: Health Smart Auto/Commercial	$11.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.03
Rate for Payer: LLUH Dept of Risk Management WC	$10.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.79

HC SOM WEST NILE VIRUS AB

Facility

$18.39

Service Code	CPT 86788 90
Hospital Charge Code	900912544
Hospital Revenue Code	302
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$14.71
Rate for Payer: Cash Price	$8.28
Rate for Payer: Cigna of CA HMO/PPO	$14.71
Rate for Payer: Health Smart Auto/Commercial	$11.03
Rate for Payer: LLUH Dept of Risk Management WC	$10.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.79

HC SOM WEST NILE VIRUS AB

Facility

$18.39

Service Code	CPT 86788 90
Hospital Charge Code	900912544
Hospital Revenue Code	302
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$13.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.03
Rate for Payer: Aetna of CA Government/Medicare	$11.03
Rate for Payer: Cash Price	$8.28
Rate for Payer: Health Smart Auto/Commercial	$11.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.03
Rate for Payer: LLUH Dept of Risk Management WC	$10.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.79

HC SOM WEST NILE VIRUS AB IGG CSF

Facility

$15.66

Service Code	CPT 86789 90
Hospital Charge Code	900912603
Hospital Revenue Code	302
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$11.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.40
Rate for Payer: Aetna of CA Government/Medicare	$9.40
Rate for Payer: Cash Price	$7.05
Rate for Payer: Health Smart Auto/Commercial	$9.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.40
Rate for Payer: LLUH Dept of Risk Management WC	$8.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.74

HC SOM WEST NILE VIRUS AB IGG CSF

Facility

$15.66

Service Code	CPT 86789 90
Hospital Charge Code	900912603
Hospital Revenue Code	302
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$7.05
Rate for Payer: Cigna of CA HMO/PPO	$12.53
Rate for Payer: Health Smart Auto/Commercial	$9.40
Rate for Payer: LLUH Dept of Risk Management WC	$8.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.74

HC SOM WEST NILE VIRUS AB IGG CSF

Facility

$15.66

Service Code	CPT 86789
Hospital Charge Code	900912603
Hospital Revenue Code	302
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$7.05
Rate for Payer: Cigna of CA HMO/PPO	$12.53
Rate for Payer: Health Smart Auto/Commercial	$9.40
Rate for Payer: LLUH Dept of Risk Management WC	$8.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.74

HC SOM WEST NILE VIRUS AB IGG CSF

Facility

$15.66

Service Code	CPT 86789
Hospital Charge Code	900912603
Hospital Revenue Code	302
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$11.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.40
Rate for Payer: Aetna of CA Government/Medicare	$9.40
Rate for Payer: Cash Price	$7.05
Rate for Payer: Health Smart Auto/Commercial	$9.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.40
Rate for Payer: LLUH Dept of Risk Management WC	$8.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.74

HC SOM WEST NILE VIRUS AB IGM

Facility

$15.71

Service Code	CPT 86789
Hospital Charge Code	900912602
Hospital Revenue Code	302
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$12.57
Rate for Payer: Cash Price	$7.07
Rate for Payer: Cigna of CA HMO/PPO	$12.57
Rate for Payer: Health Smart Auto/Commercial	$9.43
Rate for Payer: LLUH Dept of Risk Management WC	$8.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.78

HC SOM WEST NILE VIRUS AB IGM

Facility

$15.71

Service Code	CPT 86789 90
Hospital Charge Code	900912602
Hospital Revenue Code	302
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$11.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.43
Rate for Payer: Aetna of CA Government/Medicare	$9.43
Rate for Payer: Cash Price	$7.07
Rate for Payer: Health Smart Auto/Commercial	$9.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.43
Rate for Payer: LLUH Dept of Risk Management WC	$8.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.78

HC SOM WEST NILE VIRUS AB IGM

Facility

$15.71

Service Code	CPT 86789
Hospital Charge Code	900912602
Hospital Revenue Code	302
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$11.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.43
Rate for Payer: Aetna of CA Government/Medicare	$9.43
Rate for Payer: Cash Price	$7.07
Rate for Payer: Health Smart Auto/Commercial	$9.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.43
Rate for Payer: LLUH Dept of Risk Management WC	$8.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.78

HC SOM WEST NILE VIRUS AB IGM

Facility

$15.71

Service Code	CPT 86789 90
Hospital Charge Code	900912602
Hospital Revenue Code	302
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$12.57
Rate for Payer: Cash Price	$7.07
Rate for Payer: Cigna of CA HMO/PPO	$12.57
Rate for Payer: Health Smart Auto/Commercial	$9.43
Rate for Payer: LLUH Dept of Risk Management WC	$8.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.78

HC SOM WEST NILE VIRUS AB IGM CSF

Facility

$18.34

Service Code	CPT 86788
Hospital Charge Code	900912164
Hospital Revenue Code	302
Min. Negotiated Rate	$10.09
Max. Negotiated Rate	$14.67
Rate for Payer: Cash Price	$8.25
Rate for Payer: Cigna of CA HMO/PPO	$14.67
Rate for Payer: Health Smart Auto/Commercial	$11.00
Rate for Payer: LLUH Dept of Risk Management WC	$10.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.76

HC SOM WEST NILE VIRUS AB IGM CSF

Facility

$18.34

Service Code	CPT 86788 90
Hospital Charge Code	900912164
Hospital Revenue Code	302
Min. Negotiated Rate	$10.09
Max. Negotiated Rate	$14.67
Rate for Payer: Cash Price	$8.25
Rate for Payer: Cigna of CA HMO/PPO	$14.67
Rate for Payer: Health Smart Auto/Commercial	$11.00
Rate for Payer: LLUH Dept of Risk Management WC	$10.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.76

HC SOM WEST NILE VIRUS AB IGM CSF

Facility

$18.34

Service Code	CPT 86788
Hospital Charge Code	900912164
Hospital Revenue Code	302
Min. Negotiated Rate	$10.09
Max. Negotiated Rate	$13.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.00
Rate for Payer: Aetna of CA Government/Medicare	$11.00
Rate for Payer: Cash Price	$8.25
Rate for Payer: Health Smart Auto/Commercial	$11.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.00
Rate for Payer: LLUH Dept of Risk Management WC	$10.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.76

HC SOM WEST NILE VIRUS AB IGM CSF

Facility

$18.34

Service Code	CPT 86788 90
Hospital Charge Code	900912164
Hospital Revenue Code	302
Min. Negotiated Rate	$10.09
Max. Negotiated Rate	$13.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.00
Rate for Payer: Aetna of CA Government/Medicare	$11.00
Rate for Payer: Cash Price	$8.25
Rate for Payer: Health Smart Auto/Commercial	$11.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.00
Rate for Payer: LLUH Dept of Risk Management WC	$10.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.76

HC SOM WEST NILE VIRUS PCR

Facility

$84.00

Service Code	CPT 87798 90
Hospital Charge Code	900912543
Hospital Revenue Code	306
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$67.20
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna of CA HMO/PPO	$67.20
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.00

HC SOM WEST NILE VIRUS PCR

Facility

$84.00

Service Code	CPT 87798
Hospital Charge Code	900912543
Hospital Revenue Code	306
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.40
Rate for Payer: Aetna of CA Government/Medicare	$50.40
Rate for Payer: Cash Price	$37.80
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.00

HC SOM WEST NILE VIRUS PCR

Facility

$84.00

Service Code	CPT 87798
Hospital Charge Code	900912543
Hospital Revenue Code	306
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$67.20
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna of CA HMO/PPO	$67.20
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.00

HC SOM WEST NILE VIRUS PCR

Facility

$84.00

Service Code	CPT 87798 90
Hospital Charge Code	900912543
Hospital Revenue Code	306
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.40
Rate for Payer: Aetna of CA Government/Medicare	$50.40
Rate for Payer: Cash Price	$37.80
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.00

HC SOM WEST NILE VIRUS PCR (CSF)

Facility

$84.00

Service Code	CPT 87798 90
Hospital Charge Code	900912764
Hospital Revenue Code	306
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.40
Rate for Payer: Aetna of CA Government/Medicare	$50.40
Rate for Payer: Cash Price	$37.80
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.00

Know your out-of-pocket cost for care.

All Charges