Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC EBNA IGG

Facility

$70.00

Service Code	CPT 86664
Hospital Charge Code	900913537
Hospital Revenue Code	302
Min. Negotiated Rate	$15.29
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.00
Rate for Payer: Aetna of CA Government/Medicare	$42.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cash Price	$31.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.00
Rate for Payer: Health Smart Auto/Commercial	$42.00
Rate for Payer: Intervalley Health Plan Commercial	$15.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.00
Rate for Payer: LLUH Dept of Risk Management WC	$38.50
Rate for Payer: Multiplan Commercial	$52.50

HC EBNA IGG

Facility

$270.00

Service Code	CPT 86664
Hospital Charge Code	900913537
Hospital Revenue Code	302
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$216.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$216.00
Rate for Payer: Health Smart Auto/Commercial	$162.00
Rate for Payer: LLUH Dept of Risk Management WC	$148.50
Rate for Payer: Multiplan Commercial	$202.50

HC EBV IGG EARLY AB

Facility

$92.00

Service Code	CPT 86663
Hospital Charge Code	900913538
Hospital Revenue Code	302
Min. Negotiated Rate	$50.60
Max. Negotiated Rate	$73.60
Rate for Payer: Cash Price	$41.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$73.60
Rate for Payer: Health Smart Auto/Commercial	$55.20
Rate for Payer: LLUH Dept of Risk Management WC	$50.60
Rate for Payer: Multiplan Commercial	$69.00

HC EBV IGG EARLY AB

Facility

$55.00

Service Code	CPT 86663
Hospital Charge Code	900913538
Hospital Revenue Code	302
Min. Negotiated Rate	$13.12
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.00
Rate for Payer: Aetna of CA Government/Medicare	$33.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Cash Price	$24.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Intervalley Health Plan Commercial	$13.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Commercial	$41.25

HC EBV PCR

Facility

$277.00

Service Code	CPT 87799
Hospital Charge Code	900912315
Hospital Revenue Code	300
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$221.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$166.20
Rate for Payer: Aetna of CA Government/Medicare	$166.20
Rate for Payer: Cash Price	$124.65
Rate for Payer: Cash Price	$124.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$221.60
Rate for Payer: Health Smart Auto/Commercial	$166.20
Rate for Payer: Intervalley Health Plan Commercial	$42.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$166.20
Rate for Payer: LLUH Dept of Risk Management WC	$152.35
Rate for Payer: Multiplan Commercial	$207.75

HC EBV PCR

Facility

$593.00

Service Code	CPT 87799
Hospital Charge Code	900912315
Hospital Revenue Code	300
Min. Negotiated Rate	$326.15
Max. Negotiated Rate	$474.40
Rate for Payer: Cash Price	$266.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$474.40
Rate for Payer: Health Smart Auto/Commercial	$355.80
Rate for Payer: LLUH Dept of Risk Management WC	$326.15
Rate for Payer: Multiplan Commercial	$444.75

HC EBV-VCA IGG/IGM

Facility

$270.00

Service Code	CPT 86665
Hospital Charge Code	900913535
Hospital Revenue Code	302
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$216.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$216.00
Rate for Payer: Health Smart Auto/Commercial	$162.00
Rate for Payer: LLUH Dept of Risk Management WC	$148.50
Rate for Payer: Multiplan Commercial	$202.50

HC EBV-VCA IGG/IGM

Facility

$76.00

Service Code	CPT 86665
Hospital Charge Code	900913535
Hospital Revenue Code	302
Min. Negotiated Rate	$18.14
Max. Negotiated Rate	$60.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.60
Rate for Payer: Aetna of CA Government/Medicare	$45.60
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cash Price	$34.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.80
Rate for Payer: Health Smart Auto/Commercial	$45.60
Rate for Payer: Intervalley Health Plan Commercial	$18.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.60
Rate for Payer: LLUH Dept of Risk Management WC	$41.80
Rate for Payer: Multiplan Commercial	$57.00

HC ED FAMILY THERAPY WITH PATIENT

Facility

$553.00

Service Code	CPT 90847
Hospital Charge Code	907804116
Hospital Revenue Code	905
Min. Negotiated Rate	$120.20
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$504.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Blue Shield of California Commercial	$349.00
Rate for Payer: Cash Price	$248.85
Rate for Payer: Cash Price	$248.85
Rate for Payer: Cash Price	$248.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$316.00
Rate for Payer: Health Smart Auto/Commercial	$426.00
Rate for Payer: Intervalley Health Plan Commercial	$520.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$330.00
Rate for Payer: LLUH Dept of Risk Management WC	$304.15
Rate for Payer: Magellan Commercial	$500.00
Rate for Payer: Managed Health Network (MHN) Commercial	$456.00
Rate for Payer: Mary Free Bed Workers' Compensation	$120.20
Rate for Payer: Multiplan Commercial	$414.75
Rate for Payer: US Behavioral Health Commercial/Medicare	$318.08

HC ED FAMILY THERAPY WITH PATIENT

Facility

$553.00

Service Code	CPT 90847
Hospital Charge Code	907804116
Hospital Revenue Code	905
Min. Negotiated Rate	$304.15
Max. Negotiated Rate	$652.36
Rate for Payer: Cash Price	$248.85
Rate for Payer: Cash Price	$248.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$442.40
Rate for Payer: Health Smart Auto/Commercial	$331.80
Rate for Payer: LLUH Dept of Risk Management WC	$304.15
Rate for Payer: Mary Free Bed Workers' Compensation	$652.36
Rate for Payer: Multiplan Commercial	$414.75

HC ED INDIV BRIEF THERAPY

Facility

$404.00

Service Code	CPT 90832
Hospital Charge Code	907804117
Hospital Revenue Code	914
Min. Negotiated Rate	$222.20
Max. Negotiated Rate	$323.20
Rate for Payer: Cash Price	$181.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$323.20
Rate for Payer: Health Smart Auto/Commercial	$242.40
Rate for Payer: LLUH Dept of Risk Management WC	$222.20
Rate for Payer: Multiplan Commercial	$303.00

HC ED INDIV BRIEF THERAPY

Facility

$404.00

Service Code	CPT 90832
Hospital Charge Code	907804117
Hospital Revenue Code	914
Min. Negotiated Rate	$81.95
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$102.00
Rate for Payer: Aetna of CA Government/Medicare	$102.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cash Price	$181.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$323.20
Rate for Payer: Health Smart Auto/Commercial	$242.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$242.40
Rate for Payer: LLUH Dept of Risk Management WC	$222.20
Rate for Payer: Mary Free Bed Workers' Compensation	$81.95
Rate for Payer: Multiplan Commercial	$303.00

HC ED INDIV THERAPY

Facility

$512.00

Service Code	CPT 90834
Hospital Charge Code	907804118
Hospital Revenue Code	905
Min. Negotiated Rate	$281.60
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$504.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Blue Shield of California Commercial	$349.00
Rate for Payer: Cash Price	$230.40
Rate for Payer: Cash Price	$230.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$316.00
Rate for Payer: Health Smart Auto/Commercial	$426.00
Rate for Payer: Intervalley Health Plan Commercial	$520.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$330.00
Rate for Payer: LLUH Dept of Risk Management WC	$281.60
Rate for Payer: Magellan Commercial	$500.00
Rate for Payer: Managed Health Network (MHN) Commercial	$456.00
Rate for Payer: Multiplan Commercial	$384.00
Rate for Payer: US Behavioral Health Commercial/Medicare	$318.08

HC ED INDIV THERAPY

Facility

$512.00

Service Code	CPT 90834
Hospital Charge Code	907804118
Hospital Revenue Code	905
Min. Negotiated Rate	$281.60
Max. Negotiated Rate	$652.36
Rate for Payer: Cash Price	$230.40
Rate for Payer: Cash Price	$230.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$409.60
Rate for Payer: Health Smart Auto/Commercial	$307.20
Rate for Payer: LLUH Dept of Risk Management WC	$281.60
Rate for Payer: Mary Free Bed Workers' Compensation	$652.36
Rate for Payer: Multiplan Commercial	$384.00

HC ED INTENSIVE OUT (ADOL)

Facility

$796.00

Service Code	CPT 90853
Hospital Charge Code	907300015
Hospital Revenue Code	905
Min. Negotiated Rate	$437.80
Max. Negotiated Rate	$652.36
Rate for Payer: Cash Price	$358.20
Rate for Payer: Cash Price	$358.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$636.80
Rate for Payer: Health Smart Auto/Commercial	$477.60
Rate for Payer: LLUH Dept of Risk Management WC	$437.80
Rate for Payer: Mary Free Bed Workers' Compensation	$652.36
Rate for Payer: Multiplan Commercial	$597.00

HC ED INTENSIVE OUT (ADOL)

Facility

$796.00

Service Code	CPT 90853
Hospital Charge Code	907300015
Hospital Revenue Code	905
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$597.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$504.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Blue Shield of California Commercial	$349.00
Rate for Payer: Cash Price	$358.20
Rate for Payer: Cash Price	$358.20
Rate for Payer: Cash Price	$358.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$316.00
Rate for Payer: Health Smart Auto/Commercial	$426.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$364.00
Rate for Payer: Intervalley Health Plan Commercial	$520.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$330.00
Rate for Payer: LLUH Dept of Risk Management WC	$437.80
Rate for Payer: Magellan Commercial	$500.00
Rate for Payer: Managed Health Network (MHN) Commercial	$456.00
Rate for Payer: Mary Free Bed Workers' Compensation	$44.80
Rate for Payer: Multiplan Commercial	$597.00
Rate for Payer: US Behavioral Health Commercial/Medicare	$318.08

HC ED INTERACTIVE GROUP THERAPY

Facility

$443.00

Service Code	CPT 90853
Hospital Charge Code	907804101
Hospital Revenue Code	912
Min. Negotiated Rate	$243.65
Max. Negotiated Rate	$703.72
Rate for Payer: Cash Price	$199.35
Rate for Payer: Cash Price	$199.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$354.40
Rate for Payer: Health Smart Auto/Commercial	$265.80
Rate for Payer: LLUH Dept of Risk Management WC	$243.65
Rate for Payer: Mary Free Bed Workers' Compensation	$703.72
Rate for Payer: Multiplan Commercial	$332.25

HC ED INTERACTIVE GROUP THERAPY

Facility

$443.00

Service Code	CPT 90853
Hospital Charge Code	907804101
Hospital Revenue Code	912
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$769.00
Rate for Payer: Aetna of CA Government/Medicare	$55.76
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$600.00
Rate for Payer: Blue Shield of California Commercial	$569.00
Rate for Payer: Cash Price	$199.35
Rate for Payer: Cash Price	$199.35
Rate for Payer: Cash Price	$199.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$594.00
Rate for Payer: Health Smart Auto/Commercial	$616.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$510.00
Rate for Payer: Intervalley Health Plan Commercial	$720.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$588.00
Rate for Payer: LLUH Dept of Risk Management WC	$243.65
Rate for Payer: Magellan Commercial	$825.00
Rate for Payer: Managed Health Network (MHN) Commercial	$716.00
Rate for Payer: Mary Free Bed Workers' Compensation	$44.80
Rate for Payer: Multiplan Commercial	$332.25
Rate for Payer: US Behavioral Health Commercial/Medicare	$516.13

HC ED OT TASK GROUP

Facility

$359.00

Service Code	CPT 90853
Hospital Charge Code	907804115
Hospital Revenue Code	912
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$769.00
Rate for Payer: Aetna of CA Government/Medicare	$55.76
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$600.00
Rate for Payer: Blue Shield of California Commercial	$569.00
Rate for Payer: Cash Price	$161.55
Rate for Payer: Cash Price	$161.55
Rate for Payer: Cash Price	$161.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$594.00
Rate for Payer: Health Smart Auto/Commercial	$616.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$510.00
Rate for Payer: Intervalley Health Plan Commercial	$720.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$588.00
Rate for Payer: LLUH Dept of Risk Management WC	$197.45
Rate for Payer: Magellan Commercial	$825.00
Rate for Payer: Managed Health Network (MHN) Commercial	$716.00
Rate for Payer: Mary Free Bed Workers' Compensation	$44.80
Rate for Payer: Multiplan Commercial	$269.25
Rate for Payer: US Behavioral Health Commercial/Medicare	$516.13

HC ED OT TASK GROUP

Facility

$359.00

Service Code	CPT 90853
Hospital Charge Code	907804115
Hospital Revenue Code	912
Min. Negotiated Rate	$197.45
Max. Negotiated Rate	$703.72
Rate for Payer: Cash Price	$161.55
Rate for Payer: Cash Price	$161.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$287.20
Rate for Payer: Health Smart Auto/Commercial	$215.40
Rate for Payer: LLUH Dept of Risk Management WC	$197.45
Rate for Payer: Mary Free Bed Workers' Compensation	$703.72
Rate for Payer: Multiplan Commercial	$269.25

HC EDUCATION ED MENTAL HEALTH

Facility

$385.00

Service Code	CPT 90853
Hospital Charge Code	907804100
Hospital Revenue Code	942
Min. Negotiated Rate	$211.75
Max. Negotiated Rate	$308.00
Rate for Payer: Cash Price	$173.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$308.00
Rate for Payer: Health Smart Auto/Commercial	$231.00
Rate for Payer: LLUH Dept of Risk Management WC	$211.75
Rate for Payer: Multiplan Commercial	$288.75

HC EDUCATION ED MENTAL HEALTH

Facility

$385.00

Service Code	CPT 90853
Hospital Charge Code	907804100
Hospital Revenue Code	942
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$308.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.76
Rate for Payer: Aetna of CA Government/Medicare	$55.76
Rate for Payer: Cash Price	$173.25
Rate for Payer: Cash Price	$173.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$308.00
Rate for Payer: Health Smart Auto/Commercial	$231.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$231.00
Rate for Payer: LLUH Dept of Risk Management WC	$211.75
Rate for Payer: Mary Free Bed Workers' Compensation	$44.80
Rate for Payer: Multiplan Commercial	$288.75

HC EDUCATION MENTAL HEALTH

Facility

$374.00

Service Code	CPT 90853
Hospital Charge Code	907804065
Hospital Revenue Code	912
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$769.00
Rate for Payer: Aetna of CA Government/Medicare	$55.76
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$600.00
Rate for Payer: Blue Shield of California Commercial	$569.00
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cash Price	$168.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$594.00
Rate for Payer: Health Smart Auto/Commercial	$616.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$510.00
Rate for Payer: Intervalley Health Plan Commercial	$720.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$588.00
Rate for Payer: LLUH Dept of Risk Management WC	$205.70
Rate for Payer: Magellan Commercial	$825.00
Rate for Payer: Managed Health Network (MHN) Commercial	$716.00
Rate for Payer: Mary Free Bed Workers' Compensation	$44.80
Rate for Payer: Multiplan Commercial	$280.50
Rate for Payer: US Behavioral Health Commercial/Medicare	$516.13

HC EDUCATION MENTAL HEALTH

Facility

$374.00

Service Code	CPT 90853
Hospital Charge Code	907804065
Hospital Revenue Code	912
Min. Negotiated Rate	$205.70
Max. Negotiated Rate	$703.72
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cash Price	$168.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$299.20
Rate for Payer: Health Smart Auto/Commercial	$224.40
Rate for Payer: LLUH Dept of Risk Management WC	$205.70
Rate for Payer: Mary Free Bed Workers' Compensation	$703.72
Rate for Payer: Multiplan Commercial	$280.50

HC EEG,AWAKE/DROWSY

Facility

$2,957.00

Service Code	CPT 95816
Hospital Charge Code	900600228
Hospital Revenue Code	740
Min. Negotiated Rate	$1,626.35
Max. Negotiated Rate	$2,365.60
Rate for Payer: Cash Price	$1,330.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,365.60
Rate for Payer: Health Smart Auto/Commercial	$1,774.20
Rate for Payer: LLUH Dept of Risk Management WC	$1,626.35
Rate for Payer: Multiplan Commercial	$2,217.75

Know your out-of-pocket cost for care.

All Charges