Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM HEPATITIS BE AB

Facility

$12.00

Service Code	CPT 86707
Hospital Charge Code	900911195
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 HEPATITIS BE AB

Facility

$12.00

Service Code	CPT 86707
Hospital Charge Code	900911195
Hospital Revenue Code	302
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$11.57
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	$11.57
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 HEPATITIS D ANTIBODY

Facility

$60.00

Service Code	CPT 86692
Hospital Charge Code	900910354
Hospital Revenue Code	302
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$48.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.00
Rate for Payer: Health Smart Auto/Commercial	$36.00
Rate for Payer: LLUH Dept of Risk Management WC	$33.00
Rate for Payer: Multiplan Commercial	$45.00

HC SOM HEPATITIS D ANTIBODY

Facility

$60.00

Service Code	CPT 86692
Hospital Charge Code	900910354
Hospital Revenue Code	302
Min. Negotiated Rate	$17.16
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.00
Rate for Payer: Aetna of CA Government/Medicare	$36.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.00
Rate for Payer: Health Smart Auto/Commercial	$36.00
Rate for Payer: Intervalley Health Plan Commercial	$17.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.00
Rate for Payer: LLUH Dept of Risk Management WC	$33.00
Rate for Payer: Multiplan Commercial	$45.00

HC SOM HHEMO 81256

Facility

$70.98

Service Code	CPT 81256
Hospital Charge Code	900914875
Hospital Revenue Code	309
Min. Negotiated Rate	$39.04
Max. Negotiated Rate	$56.78
Rate for Payer: Cash Price	$70.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.78
Rate for Payer: Health Smart Auto/Commercial	$42.59
Rate for Payer: LLUH Dept of Risk Management WC	$39.04
Rate for Payer: Multiplan Commercial	$53.23

HC SOM HHEMO 81256

Facility

$70.98

Service Code	CPT 81256
Hospital Charge Code	900914875
Hospital Revenue Code	309
Min. Negotiated Rate	$39.04
Max. Negotiated Rate	$65.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.59
Rate for Payer: Aetna of CA Government/Medicare	$42.59
Rate for Payer: Cash Price	$70.98
Rate for Payer: Cash Price	$70.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.78
Rate for Payer: Health Smart Auto/Commercial	$42.59
Rate for Payer: Intervalley Health Plan Commercial	$65.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.59
Rate for Payer: LLUH Dept of Risk Management WC	$39.04
Rate for Payer: Multiplan Commercial	$53.23

HC SOM HISTOPLASMA AB IMMUNODIFFUSION

Facility

$25.56

Service Code	CPT 86698
Hospital Charge Code	900912643
Hospital Revenue Code	302
Min. Negotiated Rate	$14.06
Max. Negotiated Rate	$20.45
Rate for Payer: Cash Price	$25.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.45
Rate for Payer: Health Smart Auto/Commercial	$15.34
Rate for Payer: LLUH Dept of Risk Management WC	$14.06
Rate for Payer: Multiplan Commercial	$19.17

HC SOM HISTOPLASMA AB IMMUNODIFFUSION

Facility

$25.56

Service Code	CPT 86698
Hospital Charge Code	900912643
Hospital Revenue Code	302
Min. Negotiated Rate	$13.79
Max. Negotiated Rate	$20.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.34
Rate for Payer: Aetna of CA Government/Medicare	$15.34
Rate for Payer: Cash Price	$25.56
Rate for Payer: Cash Price	$25.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.45
Rate for Payer: Health Smart Auto/Commercial	$15.34
Rate for Payer: Intervalley Health Plan Commercial	$13.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.34
Rate for Payer: LLUH Dept of Risk Management WC	$14.06
Rate for Payer: Multiplan Commercial	$19.17

HC SOM HISTOPLASMA/BLASTOMYCES PCR

Facility

$144.56

Service Code	CPT 87798
Hospital Charge Code	900915469
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$115.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$86.74
Rate for Payer: Aetna of CA Government/Medicare	$86.74
Rate for Payer: Cash Price	$144.56
Rate for Payer: Cash Price	$144.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$115.65
Rate for Payer: Health Smart Auto/Commercial	$86.74
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$86.74
Rate for Payer: LLUH Dept of Risk Management WC	$79.51
Rate for Payer: Multiplan Commercial	$108.42

HC SOM HISTOPLASMA/BLASTOMYCES PCR

Facility

$144.56

Service Code	CPT 87798
Hospital Charge Code	900915469
Hospital Revenue Code	300
Min. Negotiated Rate	$79.51
Max. Negotiated Rate	$115.65
Rate for Payer: Cash Price	$144.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$115.65
Rate for Payer: Health Smart Auto/Commercial	$86.74
Rate for Payer: LLUH Dept of Risk Management WC	$79.51
Rate for Payer: Multiplan Commercial	$108.42

HC SOM HIV-1 PROVIRAL DNA

Facility

$50.27

Service Code	CPT 87535
Hospital Charge Code	900914170
Hospital Revenue Code	309
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$40.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.16
Rate for Payer: Aetna of CA Government/Medicare	$30.16
Rate for Payer: Cash Price	$50.27
Rate for Payer: Cash Price	$50.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.22
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Commercial	$37.70

HC SOM HIV-1 PROVIRAL DNA

Facility

$50.27

Service Code	CPT 87535
Hospital Charge Code	900914170
Hospital Revenue Code	309
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$40.22
Rate for Payer: Cash Price	$50.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.22
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Commercial	$37.70

HC SOM HIV 2 CONFIRM

Facility

$65.00

Service Code	CPT 86702
Hospital Charge Code	900911352
Hospital Revenue Code	302
Min. Negotiated Rate	$13.52
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.00
Rate for Payer: Aetna of CA Government/Medicare	$39.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.00
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: Intervalley Health Plan Commercial	$13.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Commercial	$48.75

HC SOM HIV 2 CONFIRM

Facility

$57.80

Service Code	CPT 86702
Hospital Charge Code	900911352
Hospital Revenue Code	302
Min. Negotiated Rate	$31.79
Max. Negotiated Rate	$46.24
Rate for Payer: Cash Price	$57.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$46.24
Rate for Payer: Health Smart Auto/Commercial	$34.68
Rate for Payer: LLUH Dept of Risk Management WC	$31.79
Rate for Payer: Multiplan Commercial	$43.35

HC SOM HIV DNA (PCR)

Facility

$85.00

Service Code	CPT 87536
Hospital Charge Code	900911055
Hospital Revenue Code	306
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$85.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.00
Rate for Payer: Aetna of CA Government/Medicare	$51.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.00
Rate for Payer: Health Smart Auto/Commercial	$51.00
Rate for Payer: Intervalley Health Plan Commercial	$85.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.00
Rate for Payer: LLUH Dept of Risk Management WC	$46.75
Rate for Payer: Multiplan Commercial	$63.75

HC SOM HIV DNA (PCR)

Facility

$85.00

Service Code	CPT 87536
Hospital Charge Code	900911055
Hospital Revenue Code	306
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$68.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.00
Rate for Payer: Health Smart Auto/Commercial	$51.00
Rate for Payer: LLUH Dept of Risk Management WC	$46.75
Rate for Payer: Multiplan Commercial	$63.75

HC SOM HOMOCYSTEINE

Facility

$17.92

Service Code	CPT 83090
Hospital Charge Code	900911404
Hospital Revenue Code	301
Min. Negotiated Rate	$9.86
Max. Negotiated Rate	$17.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.75
Rate for Payer: Aetna of CA Government/Medicare	$10.75
Rate for Payer: Cash Price	$17.92
Rate for Payer: Cash Price	$17.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.34
Rate for Payer: Health Smart Auto/Commercial	$10.75
Rate for Payer: Intervalley Health Plan Commercial	$17.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.75
Rate for Payer: LLUH Dept of Risk Management WC	$9.86
Rate for Payer: Multiplan Commercial	$13.44

HC SOM HOMOCYSTEINE

Facility

$17.92

Service Code	CPT 83090
Hospital Charge Code	900911404
Hospital Revenue Code	301
Min. Negotiated Rate	$9.86
Max. Negotiated Rate	$14.34
Rate for Payer: Cash Price	$17.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.34
Rate for Payer: Health Smart Auto/Commercial	$10.75
Rate for Payer: LLUH Dept of Risk Management WC	$9.86
Rate for Payer: Multiplan Commercial	$13.44

HC SOM HPV

Facility

$45.00

Service Code	CPT 87624
Hospital Charge Code	900915272
Hospital Revenue Code	306
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 HPV

Facility

$45.00

Service Code	CPT 87624
Hospital Charge Code	900915272
Hospital Revenue Code	306
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: 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: Intervalley Health Plan Commercial	$35.09
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 HROMOSOME ANALYSIS AMNIO

Facility

$400.00

Service Code	CPT 88291
Hospital Charge Code	900910739
Hospital Revenue Code	310
Min. Negotiated Rate	$220.00
Max. Negotiated Rate	$320.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$320.00
Rate for Payer: Health Smart Auto/Commercial	$240.00
Rate for Payer: LLUH Dept of Risk Management WC	$220.00
Rate for Payer: Multiplan Commercial	$300.00

HC SOM HROMOSOME ANALYSIS AMNIO

Facility

$400.00

Service Code	CPT 88291
Hospital Charge Code	900910739
Hospital Revenue Code	310
Min. Negotiated Rate	$220.00
Max. Negotiated Rate	$320.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$240.00
Rate for Payer: Aetna of CA Government/Medicare	$240.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$320.00
Rate for Payer: Health Smart Auto/Commercial	$240.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$240.00
Rate for Payer: LLUH Dept of Risk Management WC	$220.00
Rate for Payer: Multiplan Commercial	$300.00

HC SOM HSV AB SCREEN, IGM,S EIA

Facility

$15.92

Service Code	CPT 86694
Hospital Charge Code	900914087
Hospital Revenue Code	302
Min. Negotiated Rate	$8.76
Max. Negotiated Rate	$12.74
Rate for Payer: Cash Price	$15.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.74
Rate for Payer: Health Smart Auto/Commercial	$9.55
Rate for Payer: LLUH Dept of Risk Management WC	$8.76
Rate for Payer: Multiplan Commercial	$11.94

HC SOM HSV AB SCREEN, IGM,S EIA

Facility

$15.92

Service Code	CPT 86694
Hospital Charge Code	900914087
Hospital Revenue Code	302
Min. Negotiated Rate	$8.76
Max. Negotiated Rate	$14.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.55
Rate for Payer: Aetna of CA Government/Medicare	$9.55
Rate for Payer: Cash Price	$15.92
Rate for Payer: Cash Price	$15.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.74
Rate for Payer: Health Smart Auto/Commercial	$9.55
Rate for Payer: Intervalley Health Plan Commercial	$14.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.55
Rate for Payer: LLUH Dept of Risk Management WC	$8.76
Rate for Payer: Multiplan Commercial	$11.94

HC SOM HSV TYPE 1 AB, IGG, S

Facility

$11.75

Service Code	CPT 86695
Hospital Charge Code	900914085
Hospital Revenue Code	302
Min. Negotiated Rate	$6.46
Max. Negotiated Rate	$9.40
Rate for Payer: Cash Price	$11.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.40
Rate for Payer: Health Smart Auto/Commercial	$7.05
Rate for Payer: LLUH Dept of Risk Management WC	$6.46
Rate for Payer: Multiplan Commercial	$8.81

Know your out-of-pocket cost for care.

All Charges