Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM CLOZAPINE LEVEL

Facility

$31.59

Service Code	CPT 80159
Hospital Charge Code	900911438
Hospital Revenue Code	301
Min. Negotiated Rate	$17.37
Max. Negotiated Rate	$25.27
Rate for Payer: Cash Price	$31.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.27
Rate for Payer: Health Smart Auto/Commercial	$18.95
Rate for Payer: LLUH Dept of Risk Management WC	$17.37
Rate for Payer: Multiplan Commercial	$23.69

HC SOM CMV PCR NON-BLOOD

Facility

$55.00

Service Code	CPT 87496
Hospital Charge Code	900912519
Hospital Revenue Code	306
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$44.00
Rate for Payer: Cash Price	$55.00
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: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Commercial	$41.25

HC SOM CMV PCR NON-BLOOD

Facility

$55.00

Service Code	CPT 87496
Hospital Charge Code	900912519
Hospital Revenue Code	306
Min. Negotiated Rate	$30.25
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	$55.00
Rate for Payer: Cash Price	$55.00
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	$35.09
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 SOM CMVQU 87497

Facility

$333.90

Service Code	CPT 87497
Hospital Charge Code	900915269
Hospital Revenue Code	306
Min. Negotiated Rate	$183.65
Max. Negotiated Rate	$267.12
Rate for Payer: Cash Price	$333.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$267.12
Rate for Payer: Health Smart Auto/Commercial	$200.34
Rate for Payer: LLUH Dept of Risk Management WC	$183.65
Rate for Payer: Multiplan Commercial	$250.43

HC SOM CMVQU 87497

Facility

$333.90

Service Code	CPT 87497
Hospital Charge Code	900915269
Hospital Revenue Code	306
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$267.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$200.34
Rate for Payer: Aetna of CA Government/Medicare	$200.34
Rate for Payer: Cash Price	$333.90
Rate for Payer: Cash Price	$333.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$267.12
Rate for Payer: Health Smart Auto/Commercial	$200.34
Rate for Payer: Intervalley Health Plan Commercial	$42.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$200.34
Rate for Payer: LLUH Dept of Risk Management WC	$183.65
Rate for Payer: Multiplan Commercial	$250.43

HC SOM COAG FACTOR VIII ASSAY

Facility

$75.32

Service Code	CPT 85240
Hospital Charge Code	900913969
Hospital Revenue Code	305
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$60.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.19
Rate for Payer: Aetna of CA Government/Medicare	$45.19
Rate for Payer: Cash Price	$75.32
Rate for Payer: Cash Price	$75.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.26
Rate for Payer: Health Smart Auto/Commercial	$45.19
Rate for Payer: Intervalley Health Plan Commercial	$17.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.19
Rate for Payer: LLUH Dept of Risk Management WC	$41.43
Rate for Payer: Multiplan Commercial	$56.49

HC SOM COAG FACTOR VIII ASSAY

Facility

$75.32

Service Code	CPT 85240
Hospital Charge Code	900913969
Hospital Revenue Code	305
Min. Negotiated Rate	$41.43
Max. Negotiated Rate	$60.26
Rate for Payer: Cash Price	$75.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.26
Rate for Payer: Health Smart Auto/Commercial	$45.19
Rate for Payer: LLUH Dept of Risk Management WC	$41.43
Rate for Payer: Multiplan Commercial	$56.49

HC SOM COAG FVIII INHIB SCREEN

Facility

$222.45

Service Code	CPT 85335
Hospital Charge Code	900913971
Hospital Revenue Code	305
Min. Negotiated Rate	$122.35
Max. Negotiated Rate	$177.96
Rate for Payer: Cash Price	$222.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.96
Rate for Payer: Health Smart Auto/Commercial	$133.47
Rate for Payer: LLUH Dept of Risk Management WC	$122.35
Rate for Payer: Multiplan Commercial	$166.84

HC SOM COAG FVIII INHIB SCREEN

Facility

$222.45

Service Code	CPT 85335
Hospital Charge Code	900913971
Hospital Revenue Code	305
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$177.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$133.47
Rate for Payer: Aetna of CA Government/Medicare	$133.47
Rate for Payer: Cash Price	$222.45
Rate for Payer: Cash Price	$222.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$177.96
Rate for Payer: Health Smart Auto/Commercial	$133.47
Rate for Payer: Intervalley Health Plan Commercial	$12.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$133.47
Rate for Payer: LLUH Dept of Risk Management WC	$122.35
Rate for Payer: Multiplan Commercial	$166.84

HC SOM COCCI AB IGG CSF BY CF

Facility

$12.00

Service Code	CPT 86635
Hospital Charge Code	900911338
Hospital Revenue Code	302
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$11.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Intervalley Health Plan Commercial	$11.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Commercial	$9.00

HC SOM COCCI AB IGG CSF BY CF

Facility

$12.00

Service Code	CPT 86635
Hospital Charge Code	900911338
Hospital Revenue Code	302
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.60
Rate for Payer: Cash Price	$12.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Commercial	$9.00

HC SOM COCCI AB IGG CSF BY ID

Facility

$13.00

Service Code	CPT 86635
Hospital Charge Code	900912666
Hospital Revenue Code	302
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$13.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

HC SOM COCCI AB IGG CSF BY ID

Facility

$13.00

Service Code	CPT 86635
Hospital Charge Code	900912666
Hospital Revenue Code	302
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$11.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.80
Rate for Payer: Aetna of CA Government/Medicare	$7.80
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: Intervalley Health Plan Commercial	$11.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

HC SOM COCCI AB IGM CSF BY ID

Facility

$13.00

Service Code	CPT 86635
Hospital Charge Code	900912665
Hospital Revenue Code	302
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$11.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.80
Rate for Payer: Aetna of CA Government/Medicare	$7.80
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: Intervalley Health Plan Commercial	$11.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

HC SOM COCCI AB IGM CSF BY ID

Facility

$13.00

Service Code	CPT 86635
Hospital Charge Code	900912665
Hospital Revenue Code	302
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$13.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

HC SOM COCCIDIOIDES AB IGG BY CF

Facility

$13.00

Service Code	CPT 86635
Hospital Charge Code	900912669
Hospital Revenue Code	302
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$13.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

HC SOM COCCIDIOIDES AB IGG BY CF

Facility

$13.00

Service Code	CPT 86635
Hospital Charge Code	900912669
Hospital Revenue Code	302
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$11.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.80
Rate for Payer: Aetna of CA Government/Medicare	$7.80
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: Intervalley Health Plan Commercial	$11.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

HC SOM COCCIDIOIDES AB IGG BY ID

Facility

$13.50

Service Code	CPT 86635
Hospital Charge Code	900911752
Hospital Revenue Code	302
Min. Negotiated Rate	$7.42
Max. Negotiated Rate	$10.80
Rate for Payer: Cash Price	$13.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.80
Rate for Payer: Health Smart Auto/Commercial	$8.10
Rate for Payer: LLUH Dept of Risk Management WC	$7.42
Rate for Payer: Multiplan Commercial	$10.12

HC SOM COCCIDIOIDES AB IGG BY ID

Facility

$13.50

Service Code	CPT 86635
Hospital Charge Code	900911752
Hospital Revenue Code	302
Min. Negotiated Rate	$7.42
Max. Negotiated Rate	$11.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.10
Rate for Payer: Aetna of CA Government/Medicare	$8.10
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cash Price	$13.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.80
Rate for Payer: Health Smart Auto/Commercial	$8.10
Rate for Payer: Intervalley Health Plan Commercial	$11.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.10
Rate for Payer: LLUH Dept of Risk Management WC	$7.42
Rate for Payer: Multiplan Commercial	$10.12

HC SOM COCCIDIOIDES AB IGM BY ID

Facility

$13.50

Service Code	CPT 86635
Hospital Charge Code	900912668
Hospital Revenue Code	302
Min. Negotiated Rate	$7.42
Max. Negotiated Rate	$10.80
Rate for Payer: Cash Price	$13.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.80
Rate for Payer: Health Smart Auto/Commercial	$8.10
Rate for Payer: LLUH Dept of Risk Management WC	$7.42
Rate for Payer: Multiplan Commercial	$10.12

HC SOM COCCIDIOIDES AB IGM BY ID

Facility

$13.50

Service Code	CPT 86635
Hospital Charge Code	900912668
Hospital Revenue Code	302
Min. Negotiated Rate	$7.42
Max. Negotiated Rate	$11.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.10
Rate for Payer: Aetna of CA Government/Medicare	$8.10
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cash Price	$13.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.80
Rate for Payer: Health Smart Auto/Commercial	$8.10
Rate for Payer: Intervalley Health Plan Commercial	$11.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.10
Rate for Payer: LLUH Dept of Risk Management WC	$7.42
Rate for Payer: Multiplan Commercial	$10.12

HC SOM COMPLEMENT C1Q

Facility

$25.00

Service Code	CPT 86160
Hospital Charge Code	900911109
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$18.75

HC SOM COMPLEMENT C1Q

Facility

$25.00

Service Code	CPT 86160
Hospital Charge Code	900911109
Hospital Revenue Code	302
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$20.00
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	$25.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Intervalley Health Plan Commercial	$12.00
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 Commercial	$18.75

HC SOM COMPLEMENT C1Q BINDING

Facility

$86.00

Service Code	CPT 86332
Hospital Charge Code	900911097
Hospital Revenue Code	302
Min. Negotiated Rate	$47.30
Max. Negotiated Rate	$68.80
Rate for Payer: Cash Price	$86.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.80
Rate for Payer: Health Smart Auto/Commercial	$51.60
Rate for Payer: LLUH Dept of Risk Management WC	$47.30
Rate for Payer: Multiplan Commercial	$64.50

HC SOM COMPLEMENT C1Q BINDING

Facility

$86.00

Service Code	CPT 86332
Hospital Charge Code	900911097
Hospital Revenue Code	302
Min. Negotiated Rate	$24.37
Max. Negotiated Rate	$68.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.60
Rate for Payer: Aetna of CA Government/Medicare	$51.60
Rate for Payer: Cash Price	$86.00
Rate for Payer: Cash Price	$86.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.80
Rate for Payer: Health Smart Auto/Commercial	$51.60
Rate for Payer: Intervalley Health Plan Commercial	$24.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.60
Rate for Payer: LLUH Dept of Risk Management WC	$47.30
Rate for Payer: Multiplan Commercial	$64.50

Know your out-of-pocket cost for care.

All Charges