Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$13.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.05
Rate for Payer: Aetna of CA Government/Medicare	$7.05
Rate for Payer: Cash Price	$11.75
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: Intervalley Health Plan Commercial	$13.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.05
Rate for Payer: LLUH Dept of Risk Management WC	$6.46
Rate for Payer: Multiplan Commercial	$8.81

HC SOM HSV TYPE 2 AB, IGG, S

Facility

$17.25

Service Code	CPT 86696
Hospital Charge Code	900914086
Hospital Revenue Code	302
Min. Negotiated Rate	$9.49
Max. Negotiated Rate	$13.80
Rate for Payer: Cash Price	$17.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.80
Rate for Payer: Health Smart Auto/Commercial	$10.35
Rate for Payer: LLUH Dept of Risk Management WC	$9.49
Rate for Payer: Multiplan Commercial	$12.94

HC SOM HSV TYPE 2 AB, IGG, S

Facility

$17.25

Service Code	CPT 86696
Hospital Charge Code	900914086
Hospital Revenue Code	302
Min. Negotiated Rate	$9.49
Max. Negotiated Rate	$19.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.35
Rate for Payer: Aetna of CA Government/Medicare	$10.35
Rate for Payer: Cash Price	$17.25
Rate for Payer: Cash Price	$17.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.80
Rate for Payer: Health Smart Auto/Commercial	$10.35
Rate for Payer: Intervalley Health Plan Commercial	$19.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.35
Rate for Payer: LLUH Dept of Risk Management WC	$9.49
Rate for Payer: Multiplan Commercial	$12.94

HC SOM HTGFN 84432

Facility

$163.88

Service Code	CPT 84432
Hospital Charge Code	900914871
Hospital Revenue Code	302
Min. Negotiated Rate	$16.06
Max. Negotiated Rate	$131.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$98.33
Rate for Payer: Aetna of CA Government/Medicare	$98.33
Rate for Payer: Cash Price	$163.88
Rate for Payer: Cash Price	$163.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$131.10
Rate for Payer: Health Smart Auto/Commercial	$98.33
Rate for Payer: Intervalley Health Plan Commercial	$16.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$98.33
Rate for Payer: LLUH Dept of Risk Management WC	$90.13
Rate for Payer: Multiplan Commercial	$122.91

HC SOM HTGFN 84432

Facility

$163.88

Service Code	CPT 84432
Hospital Charge Code	900914871
Hospital Revenue Code	302
Min. Negotiated Rate	$90.13
Max. Negotiated Rate	$131.10
Rate for Payer: Cash Price	$163.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$131.10
Rate for Payer: Health Smart Auto/Commercial	$98.33
Rate for Payer: LLUH Dept of Risk Management WC	$90.13
Rate for Payer: Multiplan Commercial	$122.91

HC SOM HTLV AB CONFIRM

Facility

$130.00

Service Code	CPT 86689
Hospital Charge Code	900912880
Hospital Revenue Code	302
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$104.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$104.00
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Commercial	$97.50

HC SOM HTLV AB CONFIRM

Facility

$130.00

Service Code	CPT 86689
Hospital Charge Code	900912880
Hospital Revenue Code	302
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$104.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$78.00
Rate for Payer: Aetna of CA Government/Medicare	$78.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$104.00
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: Intervalley Health Plan Commercial	$19.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Commercial	$97.50

HC SOM HTLV AB SCREEN

Facility

$12.88

Service Code	CPT 86790
Hospital Charge Code	900911034
Hospital Revenue Code	302
Min. Negotiated Rate	$7.08
Max. Negotiated Rate	$10.30
Rate for Payer: Cash Price	$12.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.30
Rate for Payer: Health Smart Auto/Commercial	$7.73
Rate for Payer: LLUH Dept of Risk Management WC	$7.08
Rate for Payer: Multiplan Commercial	$9.66

HC SOM HTLV AB SCREEN

Facility

$12.88

Service Code	CPT 86790
Hospital Charge Code	900911034
Hospital Revenue Code	302
Min. Negotiated Rate	$7.08
Max. Negotiated Rate	$12.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.73
Rate for Payer: Aetna of CA Government/Medicare	$7.73
Rate for Payer: Cash Price	$12.88
Rate for Payer: Cash Price	$12.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.30
Rate for Payer: Health Smart Auto/Commercial	$7.73
Rate for Payer: Intervalley Health Plan Commercial	$12.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.73
Rate for Payer: LLUH Dept of Risk Management WC	$7.08
Rate for Payer: Multiplan Commercial	$9.66

HC SOM HUMAN HERPESVIRUS-6 PCR

Facility

$200.00

Service Code	CPT 87533
Hospital Charge Code	900912711
Hospital Revenue Code	306
Min. Negotiated Rate	$41.76
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: 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: Intervalley Health Plan Commercial	$41.76
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 HUMAN HERPESVIRUS-6 PCR

Facility

$200.00

Service Code	CPT 87533
Hospital Charge Code	900912711
Hospital Revenue Code	306
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 HYPOGLYCEMIC AGENT SCREEN

Facility

$90.00

Service Code	CPT 80377
Hospital Charge Code	900912528
Hospital Revenue Code	301
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Health Smart Auto/Commercial	$54.00
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 HYPOGLYCEMIC AGENT SCREEN

Facility

$90.00

Service Code	CPT 80377
Hospital Charge Code	900912528
Hospital Revenue Code	301
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 IA2 AB

Facility

$55.00

Service Code	CPT 86341
Hospital Charge Code	900914354
Hospital Revenue Code	302
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 IA2 AB

Facility

$55.00

Service Code	CPT 86341
Hospital Charge Code	900914354
Hospital Revenue Code	302
Min. Negotiated Rate	$23.57
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	$23.57
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 IGA SUBCLASSES IGA 1

Facility

$66.00

Service Code	CPT 82787
Hospital Charge Code	900912703
Hospital Revenue Code	301
Min. Negotiated Rate	$36.30
Max. Negotiated Rate	$52.80
Rate for Payer: Cash Price	$66.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.80
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Commercial	$49.50

HC SOM IGA SUBCLASSES IGA 1

Facility

$66.00

Service Code	CPT 82787
Hospital Charge Code	900912703
Hospital Revenue Code	301
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$52.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.60
Rate for Payer: Aetna of CA Government/Medicare	$39.60
Rate for Payer: Cash Price	$66.00
Rate for Payer: Cash Price	$66.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.80
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: Intervalley Health Plan Commercial	$8.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.60
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Commercial	$49.50

HC SOM IGA SUBCLASSES IGA 2

Facility

$67.00

Service Code	CPT 82787
Hospital Charge Code	900912704
Hospital Revenue Code	301
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$53.60
Rate for Payer: Cash Price	$67.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.60
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Commercial	$50.25

HC SOM IGA SUBCLASSES IGA 2

Facility

$67.00

Service Code	CPT 82787
Hospital Charge Code	900912704
Hospital Revenue Code	301
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$53.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.20
Rate for Payer: Aetna of CA Government/Medicare	$40.20
Rate for Payer: Cash Price	$67.00
Rate for Payer: Cash Price	$67.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.60
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: Intervalley Health Plan Commercial	$8.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Commercial	$50.25

HC SOM IGA SUBCLASSES TOTAL IGA

Facility

$67.00

Service Code	CPT 82784
Hospital Charge Code	900912705
Hospital Revenue Code	301
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$53.60
Rate for Payer: Cash Price	$67.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.60
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Commercial	$50.25

HC SOM IGA SUBCLASSES TOTAL IGA

Facility

$67.00

Service Code	CPT 82784
Hospital Charge Code	900912705
Hospital Revenue Code	301
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$53.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.20
Rate for Payer: Aetna of CA Government/Medicare	$40.20
Rate for Payer: Cash Price	$67.00
Rate for Payer: Cash Price	$67.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.60
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: Intervalley Health Plan Commercial	$9.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Commercial	$50.25

HC SOM IGF-BP3

Facility

$17.27

Service Code	CPT 83520
Hospital Charge Code	900911428
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$13.82
Rate for Payer: Cash Price	$17.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.82
Rate for Payer: Health Smart Auto/Commercial	$10.36
Rate for Payer: LLUH Dept of Risk Management WC	$9.50
Rate for Payer: Multiplan Commercial	$12.95

HC SOM IGF-BP3

Facility

$17.27

Service Code	CPT 83520
Hospital Charge Code	900911428
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$17.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.36
Rate for Payer: Aetna of CA Government/Medicare	$10.36
Rate for Payer: Cash Price	$17.27
Rate for Payer: Cash Price	$17.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.82
Rate for Payer: Health Smart Auto/Commercial	$10.36
Rate for Payer: Intervalley Health Plan Commercial	$17.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.36
Rate for Payer: LLUH Dept of Risk Management WC	$9.50
Rate for Payer: Multiplan Commercial	$12.95

HC SOM IGG FRAC. TOTAL IGG

Facility

$6.00

Service Code	CPT 82784
Hospital Charge Code	900912808
Hospital Revenue Code	302
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$9.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$6.00
Rate for Payer: Cash Price	$6.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Intervalley Health Plan Commercial	$9.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

HC SOM IGG FRAC. TOTAL IGG

Facility

$6.00

Service Code	CPT 82784
Hospital Charge Code	900912808
Hospital Revenue Code	302
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$6.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

Know your out-of-pocket cost for care.

All Charges