Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM FELBAMATE S

Facility

$21.17

Service Code	CPT 80167
Hospital Charge Code	900914198
Hospital Revenue Code	301
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$18.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.70
Rate for Payer: Aetna of CA Government/Medicare	$12.70
Rate for Payer: Cash Price	$21.17
Rate for Payer: Cash Price	$21.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.94
Rate for Payer: Health Smart Auto/Commercial	$12.70
Rate for Payer: Intervalley Health Plan Commercial	$18.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.70
Rate for Payer: LLUH Dept of Risk Management WC	$11.64
Rate for Payer: Multiplan Commercial	$15.88

HC SOM FENTU

Facility

$45.00

Service Code	CPT 80354
Hospital Charge Code	900915270
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Commercial	$33.75

HC SOM FENTU

Facility

$45.00

Service Code	CPT 80354
Hospital Charge Code	900915270
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Commercial	$33.75

HC SOM FESC 83789

Facility

$136.00

Service Code	CPT 83789
Hospital Charge Code	900914814
Hospital Revenue Code	301
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$108.80
Rate for Payer: Cash Price	$136.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$108.80
Rate for Payer: Health Smart Auto/Commercial	$81.60
Rate for Payer: LLUH Dept of Risk Management WC	$74.80
Rate for Payer: Multiplan Commercial	$102.00

HC SOM FESC 83789

Facility

$136.00

Service Code	CPT 83789
Hospital Charge Code	900914814
Hospital Revenue Code	301
Min. Negotiated Rate	$24.11
Max. Negotiated Rate	$108.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$81.60
Rate for Payer: Aetna of CA Government/Medicare	$81.60
Rate for Payer: Cash Price	$136.00
Rate for Payer: Cash Price	$136.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$108.80
Rate for Payer: Health Smart Auto/Commercial	$81.60
Rate for Payer: Intervalley Health Plan Commercial	$24.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$81.60
Rate for Payer: LLUH Dept of Risk Management WC	$74.80
Rate for Payer: Multiplan Commercial	$102.00

HC SOM FHBG 87912

Facility

$375.00

Service Code	CPT 87912
Hospital Charge Code	900914883
Hospital Revenue Code	306
Min. Negotiated Rate	$206.25
Max. Negotiated Rate	$300.00
Rate for Payer: Cash Price	$375.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$300.00
Rate for Payer: Health Smart Auto/Commercial	$225.00
Rate for Payer: LLUH Dept of Risk Management WC	$206.25
Rate for Payer: Multiplan Commercial	$281.25

HC SOM FHBG 87912

Facility

$375.00

Service Code	CPT 87912
Hospital Charge Code	900914883
Hospital Revenue Code	306
Min. Negotiated Rate	$206.25
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$225.00
Rate for Payer: Aetna of CA Government/Medicare	$225.00
Rate for Payer: Cash Price	$375.00
Rate for Payer: Cash Price	$375.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$300.00
Rate for Payer: Health Smart Auto/Commercial	$225.00
Rate for Payer: Intervalley Health Plan Commercial	$257.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$225.00
Rate for Payer: LLUH Dept of Risk Management WC	$206.25
Rate for Payer: Multiplan Commercial	$281.25

HC SOM FIAIA 82397

Facility

$186.25

Service Code	CPT 82397
Hospital Charge Code	900915258
Hospital Revenue Code	301
Min. Negotiated Rate	$14.12
Max. Negotiated Rate	$149.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$111.75
Rate for Payer: Aetna of CA Government/Medicare	$111.75
Rate for Payer: Cash Price	$186.25
Rate for Payer: Cash Price	$186.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$149.00
Rate for Payer: Health Smart Auto/Commercial	$111.75
Rate for Payer: Intervalley Health Plan Commercial	$14.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$111.75
Rate for Payer: LLUH Dept of Risk Management WC	$102.44
Rate for Payer: Multiplan Commercial	$139.69

HC SOM FIAIA 82397

Facility

$186.25

Service Code	CPT 82397
Hospital Charge Code	900915258
Hospital Revenue Code	301
Min. Negotiated Rate	$102.44
Max. Negotiated Rate	$149.00
Rate for Payer: Cash Price	$186.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$149.00
Rate for Payer: Health Smart Auto/Commercial	$111.75
Rate for Payer: LLUH Dept of Risk Management WC	$102.44
Rate for Payer: Multiplan Commercial	$139.69

HC SOM FIDQL 86331

Facility

$59.00

Service Code	CPT 86331
Hospital Charge Code	900914249
Hospital Revenue Code	302
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$47.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.40
Rate for Payer: Aetna of CA Government/Medicare	$35.40
Rate for Payer: Cash Price	$59.00
Rate for Payer: Cash Price	$59.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.20
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: Intervalley Health Plan Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.40
Rate for Payer: LLUH Dept of Risk Management WC	$32.45
Rate for Payer: Multiplan Commercial	$44.25

HC SOM FIDQL 86331

Facility

$59.00

Service Code	CPT 86331
Hospital Charge Code	900914249
Hospital Revenue Code	302
Min. Negotiated Rate	$32.45
Max. Negotiated Rate	$47.20
Rate for Payer: Cash Price	$59.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.20
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: LLUH Dept of Risk Management WC	$32.45
Rate for Payer: Multiplan Commercial	$44.25

HC SOM FISH AML LOCUS ANOMALIES

Facility

$350.00

Service Code	CPT 88291
Hospital Charge Code	900912611
Hospital Revenue Code	310
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Commercial	$262.50

HC SOM FISH AML LOCUS ANOMALIES

Facility

$350.00

Service Code	CPT 88291
Hospital Charge Code	900912611
Hospital Revenue Code	310
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$210.00
Rate for Payer: Aetna of CA Government/Medicare	$210.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Commercial	$262.50

HC SOM FISH B ALL

Facility

$170.30

Service Code	CPT 88291
Hospital Charge Code	900912609
Hospital Revenue Code	310
Min. Negotiated Rate	$93.67
Max. Negotiated Rate	$136.24
Rate for Payer: Cash Price	$170.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$136.24
Rate for Payer: Health Smart Auto/Commercial	$102.18
Rate for Payer: LLUH Dept of Risk Management WC	$93.67
Rate for Payer: Multiplan Commercial	$127.72

HC SOM FISH B ALL

Facility

$170.30

Service Code	CPT 88291
Hospital Charge Code	900912609
Hospital Revenue Code	310
Min. Negotiated Rate	$93.67
Max. Negotiated Rate	$136.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$102.18
Rate for Payer: Aetna of CA Government/Medicare	$102.18
Rate for Payer: Cash Price	$170.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$136.24
Rate for Payer: Health Smart Auto/Commercial	$102.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$102.18
Rate for Payer: LLUH Dept of Risk Management WC	$93.67
Rate for Payer: Multiplan Commercial	$127.72

HC SOM FISH DIGEORGE VELO-CARDIO-FACL

Facility

$200.00

Service Code	CPT 88291
Hospital Charge Code	900910684
Hospital Revenue Code	310
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Commercial	$150.00

HC SOM FISH DIGEORGE VELO-CARDIO-FACL

Facility

$200.00

Service Code	CPT 88291
Hospital Charge Code	900910684
Hospital Revenue Code	310
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$120.00
Rate for Payer: Aetna of CA Government/Medicare	$120.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Commercial	$150.00

HC SOM FISH FOR CLL

Facility

$350.00

Service Code	CPT 88291
Hospital Charge Code	900910707
Hospital Revenue Code	310
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Commercial	$262.50

HC SOM FISH FOR CLL

Facility

$350.00

Service Code	CPT 88291
Hospital Charge Code	900910707
Hospital Revenue Code	310
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$210.00
Rate for Payer: Aetna of CA Government/Medicare	$210.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Commercial	$262.50

HC SOM FISH MDS LOCUS ANOMALIES

Facility

$150.00

Service Code	CPT 88291
Hospital Charge Code	900912610
Hospital Revenue Code	310
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$120.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Commercial	$112.50

HC SOM FISH MDS LOCUS ANOMALIES

Facility

$150.00

Service Code	CPT 88291
Hospital Charge Code	900912610
Hospital Revenue Code	310
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.00
Rate for Payer: Aetna of CA Government/Medicare	$90.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Commercial	$112.50

HC SOM FISH NEWBORN ANEUPLOIDY DETECT

Facility

$200.00

Service Code	CPT 88291
Hospital Charge Code	900910685
Hospital Revenue Code	310
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$120.00
Rate for Payer: Aetna of CA Government/Medicare	$120.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Commercial	$150.00

HC SOM FISH NEWBORN ANEUPLOIDY DETECT

Facility

$200.00

Service Code	CPT 88291
Hospital Charge Code	900910685
Hospital Revenue Code	310
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Commercial	$150.00

HC SOM FISH PRENATAL ANEUPLOIDY DETEC

Facility

$225.00

Service Code	CPT 88291
Hospital Charge Code	900910689
Hospital Revenue Code	310
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$135.00
Rate for Payer: Aetna of CA Government/Medicare	$135.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$180.00
Rate for Payer: Health Smart Auto/Commercial	$135.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$135.00
Rate for Payer: LLUH Dept of Risk Management WC	$123.75
Rate for Payer: Multiplan Commercial	$168.75

HC SOM FISH PRENATAL ANEUPLOIDY DETEC

Facility

$225.00

Service Code	CPT 88291
Hospital Charge Code	900910689
Hospital Revenue Code	310
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$180.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$180.00
Rate for Payer: Health Smart Auto/Commercial	$135.00
Rate for Payer: LLUH Dept of Risk Management WC	$123.75
Rate for Payer: Multiplan Commercial	$168.75

Know your out-of-pocket cost for care.

All Charges