Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM ASPERGILLUS AG BAL

Facility

$20.00

Service Code	CPT 87305
Hospital Charge Code	900915471
Hospital Revenue Code	300
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$15.00

HC SOM ASPERGILLUS(GALACT)ANTIGEN

Facility

$20.00

Service Code	CPT 87305
Hospital Charge Code	900912574
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$15.00

HC SOM ASPERGILLUS(GALACT)ANTIGEN

Facility

$20.00

Service Code	CPT 87305
Hospital Charge Code	900912574
Hospital Revenue Code	302
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
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	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Intervalley Health Plan Commercial	$11.98
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 Commercial	$15.00

HC SOM ATIVAN

Facility

$73.59

Service Code	CPT 80346
Hospital Charge Code	900911456
Hospital Revenue Code	301
Min. Negotiated Rate	$40.47
Max. Negotiated Rate	$58.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.15
Rate for Payer: Aetna of CA Government/Medicare	$44.15
Rate for Payer: Cash Price	$73.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$58.87
Rate for Payer: Health Smart Auto/Commercial	$44.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.15
Rate for Payer: LLUH Dept of Risk Management WC	$40.47
Rate for Payer: Multiplan Commercial	$55.19

HC SOM ATIVAN

Facility

$73.59

Service Code	CPT 80346
Hospital Charge Code	900911456
Hospital Revenue Code	301
Min. Negotiated Rate	$40.47
Max. Negotiated Rate	$58.87
Rate for Payer: Cash Price	$73.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$58.87
Rate for Payer: Health Smart Auto/Commercial	$44.15
Rate for Payer: LLUH Dept of Risk Management WC	$40.47
Rate for Payer: Multiplan Commercial	$55.19

HC SOM BACLOFEN 83789

Facility

$319.00

Service Code	CPT 83789
Hospital Charge Code	900915259
Hospital Revenue Code	301
Min. Negotiated Rate	$175.45
Max. Negotiated Rate	$255.20
Rate for Payer: Cash Price	$319.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$255.20
Rate for Payer: Health Smart Auto/Commercial	$191.40
Rate for Payer: LLUH Dept of Risk Management WC	$175.45
Rate for Payer: Multiplan Commercial	$239.25

HC SOM BACLOFEN 83789

Facility

$319.00

Service Code	CPT 83789
Hospital Charge Code	900915259
Hospital Revenue Code	301
Min. Negotiated Rate	$24.11
Max. Negotiated Rate	$255.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$191.40
Rate for Payer: Aetna of CA Government/Medicare	$191.40
Rate for Payer: Cash Price	$319.00
Rate for Payer: Cash Price	$319.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$255.20
Rate for Payer: Health Smart Auto/Commercial	$191.40
Rate for Payer: Intervalley Health Plan Commercial	$24.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$191.40
Rate for Payer: LLUH Dept of Risk Management WC	$175.45
Rate for Payer: Multiplan Commercial	$239.25

HC SOM BARBITURATE CONFIRM, U

Facility

$61.25

Service Code	CPT 80345
Hospital Charge Code	900912916
Hospital Revenue Code	301
Min. Negotiated Rate	$33.69
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.75
Rate for Payer: Aetna of CA Government/Medicare	$36.75
Rate for Payer: Cash Price	$61.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$49.00
Rate for Payer: Health Smart Auto/Commercial	$36.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.75
Rate for Payer: LLUH Dept of Risk Management WC	$33.69
Rate for Payer: Multiplan Commercial	$45.94

HC SOM BARBITURATE CONFIRM, U

Facility

$61.25

Service Code	CPT 80345
Hospital Charge Code	900912916
Hospital Revenue Code	301
Min. Negotiated Rate	$33.69
Max. Negotiated Rate	$49.00
Rate for Payer: Cash Price	$61.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$49.00
Rate for Payer: Health Smart Auto/Commercial	$36.75
Rate for Payer: LLUH Dept of Risk Management WC	$33.69
Rate for Payer: Multiplan Commercial	$45.94

HC SOM BARTONELLA HENSELAE AB IGG

Facility

$9.83

Service Code	CPT 86611
Hospital Charge Code	900911386
Hospital Revenue Code	302
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$7.86
Rate for Payer: Cash Price	$9.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.86
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Commercial	$7.37

HC SOM BARTONELLA HENSELAE AB IGG

Facility

$9.83

Service Code	CPT 86611
Hospital Charge Code	900911386
Hospital Revenue Code	302
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$10.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.90
Rate for Payer: Aetna of CA Government/Medicare	$5.90
Rate for Payer: Cash Price	$9.83
Rate for Payer: Cash Price	$9.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.86
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: Intervalley Health Plan Commercial	$10.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Commercial	$7.37

HC SOM BARTONELLA HENSELAE AB IGM

Facility

$9.83

Service Code	CPT 86611
Hospital Charge Code	900912690
Hospital Revenue Code	302
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$10.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.90
Rate for Payer: Aetna of CA Government/Medicare	$5.90
Rate for Payer: Cash Price	$9.83
Rate for Payer: Cash Price	$9.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.86
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: Intervalley Health Plan Commercial	$10.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Commercial	$7.37

HC SOM BARTONELLA HENSELAE AB IGM

Facility

$9.83

Service Code	CPT 86611
Hospital Charge Code	900912690
Hospital Revenue Code	302
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$7.86
Rate for Payer: Cash Price	$9.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.86
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Commercial	$7.37

HC SOM BARTONELLA QUINTANA AB IGG

Facility

$9.83

Service Code	CPT 86611
Hospital Charge Code	900912691
Hospital Revenue Code	302
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$10.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.90
Rate for Payer: Aetna of CA Government/Medicare	$5.90
Rate for Payer: Cash Price	$9.83
Rate for Payer: Cash Price	$9.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.86
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: Intervalley Health Plan Commercial	$10.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Commercial	$7.37

HC SOM BARTONELLA QUINTANA AB IGG

Facility

$9.83

Service Code	CPT 86611
Hospital Charge Code	900912691
Hospital Revenue Code	302
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$7.86
Rate for Payer: Cash Price	$9.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.86
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Commercial	$7.37

HC SOM BARTONELLA QUINTANA AB IGM

Facility

$9.83

Service Code	CPT 86611
Hospital Charge Code	900912692
Hospital Revenue Code	302
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$10.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.90
Rate for Payer: Aetna of CA Government/Medicare	$5.90
Rate for Payer: Cash Price	$9.83
Rate for Payer: Cash Price	$9.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.86
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: Intervalley Health Plan Commercial	$10.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Commercial	$7.37

HC SOM BARTONELLA QUINTANA AB IGM

Facility

$9.83

Service Code	CPT 86611
Hospital Charge Code	900912692
Hospital Revenue Code	302
Min. Negotiated Rate	$5.41
Max. Negotiated Rate	$7.86
Rate for Payer: Cash Price	$9.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.86
Rate for Payer: Health Smart Auto/Commercial	$5.90
Rate for Payer: LLUH Dept of Risk Management WC	$5.41
Rate for Payer: Multiplan Commercial	$7.37

HC SOM B-CELL LYMPH FISH INTERP

Facility

$254.50

Service Code	CPT 88291
Hospital Charge Code	900914116
Hospital Revenue Code	310
Min. Negotiated Rate	$139.97
Max. Negotiated Rate	$203.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$152.70
Rate for Payer: Aetna of CA Government/Medicare	$152.70
Rate for Payer: Cash Price	$254.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$203.60
Rate for Payer: Health Smart Auto/Commercial	$152.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$152.70
Rate for Payer: LLUH Dept of Risk Management WC	$139.97
Rate for Payer: Multiplan Commercial	$190.88

HC SOM B-CELL LYMPH FISH INTERP

Facility

$254.50

Service Code	CPT 88291
Hospital Charge Code	900914116
Hospital Revenue Code	310
Min. Negotiated Rate	$139.97
Max. Negotiated Rate	$203.60
Rate for Payer: Cash Price	$254.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$203.60
Rate for Payer: Health Smart Auto/Commercial	$152.70
Rate for Payer: LLUH Dept of Risk Management WC	$139.97
Rate for Payer: Multiplan Commercial	$190.88

HC SOM BCR ABL MUTAT ASPE

Facility

$435.08

Service Code	CPT 81403
Hospital Charge Code	900914536
Hospital Revenue Code	309
Min. Negotiated Rate	$239.29
Max. Negotiated Rate	$348.06
Rate for Payer: Cash Price	$435.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$348.06
Rate for Payer: Health Smart Auto/Commercial	$261.05
Rate for Payer: LLUH Dept of Risk Management WC	$239.29
Rate for Payer: Multiplan Commercial	$326.31

HC SOM BCR ABL MUTAT ASPE

Facility

$435.08

Service Code	CPT 81403
Hospital Charge Code	900914536
Hospital Revenue Code	309
Min. Negotiated Rate	$185.20
Max. Negotiated Rate	$348.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$261.05
Rate for Payer: Aetna of CA Government/Medicare	$261.05
Rate for Payer: Cash Price	$435.08
Rate for Payer: Cash Price	$435.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$348.06
Rate for Payer: Health Smart Auto/Commercial	$261.05
Rate for Payer: Intervalley Health Plan Commercial	$185.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$261.05
Rate for Payer: LLUH Dept of Risk Management WC	$239.29
Rate for Payer: Multiplan Commercial	$326.31

HC SOM BENZODIAZEPINE CONFIRM, U

Facility

$36.96

Service Code	CPT 80346
Hospital Charge Code	900912915
Hospital Revenue Code	301
Min. Negotiated Rate	$20.33
Max. Negotiated Rate	$29.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.18
Rate for Payer: Aetna of CA Government/Medicare	$22.18
Rate for Payer: Cash Price	$36.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.57
Rate for Payer: Health Smart Auto/Commercial	$22.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.18
Rate for Payer: LLUH Dept of Risk Management WC	$20.33
Rate for Payer: Multiplan Commercial	$27.72

HC SOM BENZODIAZEPINE CONFIRM, U

Facility

$36.96

Service Code	CPT 80346
Hospital Charge Code	900912915
Hospital Revenue Code	301
Min. Negotiated Rate	$20.33
Max. Negotiated Rate	$29.57
Rate for Payer: Cash Price	$36.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.57
Rate for Payer: Health Smart Auto/Commercial	$22.18
Rate for Payer: LLUH Dept of Risk Management WC	$20.33
Rate for Payer: Multiplan Commercial	$27.72

HC SOM BETA 2 MICROGLOBULIN CSF

Facility

$220.67

Service Code	CPT 82232
Hospital Charge Code	900911369
Hospital Revenue Code	301
Min. Negotiated Rate	$121.37
Max. Negotiated Rate	$176.54
Rate for Payer: Cash Price	$220.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$176.54
Rate for Payer: Health Smart Auto/Commercial	$132.40
Rate for Payer: LLUH Dept of Risk Management WC	$121.37
Rate for Payer: Multiplan Commercial	$165.50

HC SOM BETA 2 MICROGLOBULIN CSF

Facility

$220.67

Service Code	CPT 82232
Hospital Charge Code	900911369
Hospital Revenue Code	301
Min. Negotiated Rate	$16.18
Max. Negotiated Rate	$176.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$132.40
Rate for Payer: Aetna of CA Government/Medicare	$132.40
Rate for Payer: Cash Price	$220.67
Rate for Payer: Cash Price	$220.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$176.54
Rate for Payer: Health Smart Auto/Commercial	$132.40
Rate for Payer: Intervalley Health Plan Commercial	$16.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$132.40
Rate for Payer: LLUH Dept of Risk Management WC	$121.37
Rate for Payer: Multiplan Commercial	$165.50

Know your out-of-pocket cost for care.

All Charges