Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM C. TRACHOMATIS IGM

Facility

$7.00

Service Code	CPT 86632
Hospital Charge Code	900912799
Hospital Revenue Code	302
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$5.60
Rate for Payer: Cash Price	$7.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.60
Rate for Payer: Health Smart Auto/Commercial	$4.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.85
Rate for Payer: Multiplan Commercial	$5.25

HC SOM C. TRACHOMATIS IGM

Facility

$7.00

Service Code	CPT 86632
Hospital Charge Code	900912799
Hospital Revenue Code	302
Min. Negotiated Rate	$3.85
Max. Negotiated Rate	$12.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.20
Rate for Payer: Aetna of CA Government/Medicare	$4.20
Rate for Payer: Cash Price	$7.00
Rate for Payer: Cash Price	$7.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.60
Rate for Payer: Health Smart Auto/Commercial	$4.20
Rate for Payer: Intervalley Health Plan Commercial	$12.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.20
Rate for Payer: LLUH Dept of Risk Management WC	$3.85
Rate for Payer: Multiplan Commercial	$5.25

HC SOM CYSTATIN C WITH EGFR, S

Facility

$37.23

Service Code	CPT 82610
Hospital Charge Code	900915362
Hospital Revenue Code	301
Min. Negotiated Rate	$18.52
Max. Negotiated Rate	$29.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.34
Rate for Payer: Aetna of CA Government/Medicare	$22.34
Rate for Payer: Cash Price	$37.23
Rate for Payer: Cash Price	$37.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.78
Rate for Payer: Health Smart Auto/Commercial	$22.34
Rate for Payer: Intervalley Health Plan Commercial	$18.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.34
Rate for Payer: LLUH Dept of Risk Management WC	$20.48
Rate for Payer: Multiplan Commercial	$27.92

HC SOM CYSTATIN C WITH EGFR, S

Facility

$37.23

Service Code	CPT 82610
Hospital Charge Code	900915362
Hospital Revenue Code	301
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$29.78
Rate for Payer: Cash Price	$37.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.78
Rate for Payer: Health Smart Auto/Commercial	$22.34
Rate for Payer: LLUH Dept of Risk Management WC	$20.48
Rate for Payer: Multiplan Commercial	$27.92

HC SOM CYSTICERCOSIS AB BLOOD

Facility

$30.00

Service Code	CPT 86682
Hospital Charge Code	900911763
Hospital Revenue Code	302
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Intervalley Health Plan Commercial	$13.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

HC SOM CYSTICERCOSIS AB BLOOD

Facility

$30.00

Service Code	CPT 86682
Hospital Charge Code	900911763
Hospital Revenue Code	302
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

HC SOM CYSTICERCOSIS AB CSF

Facility

$122.89

Service Code	CPT 86682
Hospital Charge Code	900911345
Hospital Revenue Code	302
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$98.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$73.73
Rate for Payer: Aetna of CA Government/Medicare	$73.73
Rate for Payer: Cash Price	$122.89
Rate for Payer: Cash Price	$122.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$98.31
Rate for Payer: Health Smart Auto/Commercial	$73.73
Rate for Payer: Intervalley Health Plan Commercial	$13.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$73.73
Rate for Payer: LLUH Dept of Risk Management WC	$67.59
Rate for Payer: Multiplan Commercial	$92.17

HC SOM CYSTICERCOSIS AB CSF

Facility

$122.89

Service Code	CPT 86682
Hospital Charge Code	900911345
Hospital Revenue Code	302
Min. Negotiated Rate	$67.59
Max. Negotiated Rate	$98.31
Rate for Payer: Cash Price	$122.89
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$98.31
Rate for Payer: Health Smart Auto/Commercial	$73.73
Rate for Payer: LLUH Dept of Risk Management WC	$67.59
Rate for Payer: Multiplan Commercial	$92.17

HC SOM CYSTIC FIBROSIS DNA

Facility

$168.38

Service Code	CPT 81220
Hospital Charge Code	900911481
Hospital Revenue Code	301
Min. Negotiated Rate	$92.61
Max. Negotiated Rate	$134.70
Rate for Payer: Cash Price	$168.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$134.70
Rate for Payer: Health Smart Auto/Commercial	$101.03
Rate for Payer: LLUH Dept of Risk Management WC	$92.61
Rate for Payer: Multiplan Commercial	$126.28

HC SOM CYSTIC FIBROSIS DNA

Facility

$168.38

Service Code	CPT 81220
Hospital Charge Code	900911481
Hospital Revenue Code	301
Min. Negotiated Rate	$92.61
Max. Negotiated Rate	$556.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$101.03
Rate for Payer: Aetna of CA Government/Medicare	$101.03
Rate for Payer: Cash Price	$168.38
Rate for Payer: Cash Price	$168.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$134.70
Rate for Payer: Health Smart Auto/Commercial	$101.03
Rate for Payer: Intervalley Health Plan Commercial	$556.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$101.03
Rate for Payer: LLUH Dept of Risk Management WC	$92.61
Rate for Payer: Multiplan Commercial	$126.28

HC SOM DCP 83951

Facility

$90.00

Service Code	CPT 83951
Hospital Charge Code	900914920
Hospital Revenue Code	305
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Commercial	$67.50

HC SOM DCP 83951

Facility

$90.00

Service Code	CPT 83951
Hospital Charge Code	900914920
Hospital Revenue Code	305
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.00
Rate for Payer: Aetna of CA Government/Medicare	$54.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: Intervalley Health Plan Commercial	$64.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.00
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Commercial	$67.50

HC SOM DENGUE FEVER AB IGG

Facility

$89.10

Service Code	CPT 86790
Hospital Charge Code	900911637
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$71.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.46
Rate for Payer: Aetna of CA Government/Medicare	$53.46
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cash Price	$89.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.28
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: Intervalley Health Plan Commercial	$12.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.01
Rate for Payer: Multiplan Commercial	$66.83

HC SOM DENGUE FEVER AB IGG

Facility

$89.10

Service Code	CPT 86790
Hospital Charge Code	900911637
Hospital Revenue Code	302
Min. Negotiated Rate	$49.01
Max. Negotiated Rate	$71.28
Rate for Payer: Cash Price	$89.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.28
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.01
Rate for Payer: Multiplan Commercial	$66.83

HC SOM DENGUE FEVER AB IGM

Facility

$89.10

Service Code	CPT 86790
Hospital Charge Code	900912614
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$71.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.46
Rate for Payer: Aetna of CA Government/Medicare	$53.46
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cash Price	$89.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.28
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: Intervalley Health Plan Commercial	$12.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.01
Rate for Payer: Multiplan Commercial	$66.83

HC SOM DENGUE FEVER AB IGM

Facility

$89.10

Service Code	CPT 86790
Hospital Charge Code	900912614
Hospital Revenue Code	302
Min. Negotiated Rate	$49.01
Max. Negotiated Rate	$71.28
Rate for Payer: Cash Price	$89.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.28
Rate for Payer: Health Smart Auto/Commercial	$53.46
Rate for Payer: LLUH Dept of Risk Management WC	$49.01
Rate for Payer: Multiplan Commercial	$66.83

HC SOM DESMOGLEIN 1

Facility

$55.00

Service Code	CPT 83516
Hospital Charge Code	900914423
Hospital Revenue Code	301
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 DESMOGLEIN 1

Facility

$55.00

Service Code	CPT 83516
Hospital Charge Code	900914423
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
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	$11.53
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 DESYREL (TRAZODONE)

Facility

$70.25

Service Code	CPT 80338
Hospital Charge Code	900911223
Hospital Revenue Code	301
Min. Negotiated Rate	$38.64
Max. Negotiated Rate	$56.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.15
Rate for Payer: Aetna of CA Government/Medicare	$42.15
Rate for Payer: Cash Price	$70.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.20
Rate for Payer: Health Smart Auto/Commercial	$42.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.15
Rate for Payer: LLUH Dept of Risk Management WC	$38.64
Rate for Payer: Multiplan Commercial	$52.69

HC SOM DESYREL (TRAZODONE)

Facility

$70.25

Service Code	CPT 80338
Hospital Charge Code	900911223
Hospital Revenue Code	301
Min. Negotiated Rate	$38.64
Max. Negotiated Rate	$56.20
Rate for Payer: Cash Price	$70.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.20
Rate for Payer: Health Smart Auto/Commercial	$42.15
Rate for Payer: LLUH Dept of Risk Management WC	$38.64
Rate for Payer: Multiplan Commercial	$52.69

HC SOM DHEA

Facility

$18.58

Service Code	CPT 82626
Hospital Charge Code	900911115
Hospital Revenue Code	302
Min. Negotiated Rate	$10.22
Max. Negotiated Rate	$25.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.15
Rate for Payer: Aetna of CA Government/Medicare	$11.15
Rate for Payer: Cash Price	$18.58
Rate for Payer: Cash Price	$18.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.86
Rate for Payer: Health Smart Auto/Commercial	$11.15
Rate for Payer: Intervalley Health Plan Commercial	$25.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.15
Rate for Payer: LLUH Dept of Risk Management WC	$10.22
Rate for Payer: Multiplan Commercial	$13.94

HC SOM DHEA

Facility

$18.58

Service Code	CPT 82626
Hospital Charge Code	900911115
Hospital Revenue Code	302
Min. Negotiated Rate	$10.22
Max. Negotiated Rate	$14.86
Rate for Payer: Cash Price	$18.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.86
Rate for Payer: Health Smart Auto/Commercial	$11.15
Rate for Payer: LLUH Dept of Risk Management WC	$10.22
Rate for Payer: Multiplan Commercial	$13.94

HC SOM DIAZEPAM (VALIUM)

Facility

$266.68

Service Code	CPT 80346
Hospital Charge Code	900911088
Hospital Revenue Code	301
Min. Negotiated Rate	$146.67
Max. Negotiated Rate	$213.34
Rate for Payer: Cash Price	$266.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$213.34
Rate for Payer: Health Smart Auto/Commercial	$160.01
Rate for Payer: LLUH Dept of Risk Management WC	$146.67
Rate for Payer: Multiplan Commercial	$200.01

HC SOM DIAZEPAM (VALIUM)

Facility

$266.68

Service Code	CPT 80346
Hospital Charge Code	900911088
Hospital Revenue Code	301
Min. Negotiated Rate	$146.67
Max. Negotiated Rate	$213.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$160.01
Rate for Payer: Aetna of CA Government/Medicare	$160.01
Rate for Payer: Cash Price	$266.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$213.34
Rate for Payer: Health Smart Auto/Commercial	$160.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$160.01
Rate for Payer: LLUH Dept of Risk Management WC	$146.67
Rate for Payer: Multiplan Commercial	$200.01

HC SOM DIHYDROTESTERONE

Facility

$41.00

Service Code	CPT 82642
Hospital Charge Code	900911013
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$32.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.60
Rate for Payer: Aetna of CA Government/Medicare	$24.60
Rate for Payer: Cash Price	$41.00
Rate for Payer: Cash Price	$41.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.80
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: Intervalley Health Plan Commercial	$29.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Commercial	$30.75

Know your out-of-pocket cost for care.

All Charges