Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM LYME DISEASE AB IGM

Facility

$15.00

Service Code	CPT 86617
Hospital Charge Code	900912696
Hospital Revenue Code	302
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$15.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Intervalley Health Plan Commercial	$15.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Commercial	$11.25

HC SOM LYME DISEASE AB SERUM

Facility

$16.30

Service Code	CPT 86618
Hospital Charge Code	900912568
Hospital Revenue Code	302
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$13.04
Rate for Payer: Cash Price	$16.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.04
Rate for Payer: Health Smart Auto/Commercial	$9.78
Rate for Payer: LLUH Dept of Risk Management WC	$8.96
Rate for Payer: Multiplan Commercial	$12.22

HC SOM LYME DISEASE AB SERUM

Facility

$16.30

Service Code	CPT 86618
Hospital Charge Code	900912568
Hospital Revenue Code	302
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$17.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.78
Rate for Payer: Aetna of CA Government/Medicare	$9.78
Rate for Payer: Cash Price	$16.30
Rate for Payer: Cash Price	$16.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.04
Rate for Payer: Health Smart Auto/Commercial	$9.78
Rate for Payer: Intervalley Health Plan Commercial	$17.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.78
Rate for Payer: LLUH Dept of Risk Management WC	$8.96
Rate for Payer: Multiplan Commercial	$12.22

HC SOM MAGNESIUM RANDOM UR

Facility

$7.41

Service Code	CPT 83735
Hospital Charge Code	900913941
Hospital Revenue Code	301
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$6.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.45
Rate for Payer: Aetna of CA Government/Medicare	$4.45
Rate for Payer: Cash Price	$7.41
Rate for Payer: Cash Price	$7.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.93
Rate for Payer: Health Smart Auto/Commercial	$4.45
Rate for Payer: Intervalley Health Plan Commercial	$6.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.45
Rate for Payer: LLUH Dept of Risk Management WC	$4.08
Rate for Payer: Multiplan Commercial	$5.56

HC SOM MAGNESIUM RANDOM UR

Facility

$7.41

Service Code	CPT 83735
Hospital Charge Code	900913941
Hospital Revenue Code	301
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$5.93
Rate for Payer: Cash Price	$7.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.93
Rate for Payer: Health Smart Auto/Commercial	$4.45
Rate for Payer: LLUH Dept of Risk Management WC	$4.08
Rate for Payer: Multiplan Commercial	$5.56

HC SOM MAGNESIUM, URINE

Facility

$22.00

Service Code	CPT 83735
Hospital Charge Code	900910757
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$22.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Commercial	$16.50

HC SOM MAGNESIUM, URINE

Facility

$22.00

Service Code	CPT 83735
Hospital Charge Code	900910757
Hospital Revenue Code	301
Min. Negotiated Rate	$6.70
Max. Negotiated Rate	$17.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.20
Rate for Payer: Aetna of CA Government/Medicare	$13.20
Rate for Payer: Cash Price	$22.00
Rate for Payer: Cash Price	$22.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Intervalley Health Plan Commercial	$6.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Commercial	$16.50

HC SOM MANGANESE

Facility

$26.65

Service Code	CPT 83785
Hospital Charge Code	900911066
Hospital Revenue Code	301
Min. Negotiated Rate	$14.66
Max. Negotiated Rate	$21.32
Rate for Payer: Cash Price	$26.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.32
Rate for Payer: Health Smart Auto/Commercial	$15.99
Rate for Payer: LLUH Dept of Risk Management WC	$14.66
Rate for Payer: Multiplan Commercial	$19.99

HC SOM MANGANESE

Facility

$26.65

Service Code	CPT 83785
Hospital Charge Code	900911066
Hospital Revenue Code	301
Min. Negotiated Rate	$14.66
Max. Negotiated Rate	$26.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.99
Rate for Payer: Aetna of CA Government/Medicare	$15.99
Rate for Payer: Cash Price	$26.65
Rate for Payer: Cash Price	$26.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.32
Rate for Payer: Health Smart Auto/Commercial	$15.99
Rate for Payer: Intervalley Health Plan Commercial	$26.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.99
Rate for Payer: LLUH Dept of Risk Management WC	$14.66
Rate for Payer: Multiplan Commercial	$19.99

HC SOM MCLON IFE U

Facility

$28.86

Service Code	CPT 86335
Hospital Charge Code	900912768
Hospital Revenue Code	301
Min. Negotiated Rate	$15.87
Max. Negotiated Rate	$23.09
Rate for Payer: Cash Price	$28.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.09
Rate for Payer: Health Smart Auto/Commercial	$17.32
Rate for Payer: LLUH Dept of Risk Management WC	$15.87
Rate for Payer: Multiplan Commercial	$21.64

HC SOM MCLON IFE U

Facility

$28.86

Service Code	CPT 86335
Hospital Charge Code	900912768
Hospital Revenue Code	301
Min. Negotiated Rate	$15.87
Max. Negotiated Rate	$29.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.32
Rate for Payer: Aetna of CA Government/Medicare	$17.32
Rate for Payer: Cash Price	$28.86
Rate for Payer: Cash Price	$28.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.09
Rate for Payer: Health Smart Auto/Commercial	$17.32
Rate for Payer: Intervalley Health Plan Commercial	$29.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.32
Rate for Payer: LLUH Dept of Risk Management WC	$15.87
Rate for Payer: Multiplan Commercial	$21.64

HC SOM MCLON PROT ELEC. U

Facility

$17.53

Service Code	CPT 84166
Hospital Charge Code	900912767
Hospital Revenue Code	301
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$17.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.52
Rate for Payer: Aetna of CA Government/Medicare	$10.52
Rate for Payer: Cash Price	$17.53
Rate for Payer: Cash Price	$17.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.02
Rate for Payer: Health Smart Auto/Commercial	$10.52
Rate for Payer: Intervalley Health Plan Commercial	$17.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.52
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Commercial	$13.15

HC SOM MCLON PROT ELEC. U

Facility

$17.53

Service Code	CPT 84166
Hospital Charge Code	900912767
Hospital Revenue Code	301
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$14.02
Rate for Payer: Cash Price	$17.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.02
Rate for Payer: Health Smart Auto/Commercial	$10.52
Rate for Payer: LLUH Dept of Risk Management WC	$9.64
Rate for Payer: Multiplan Commercial	$13.15

HC SOM MCLON T. PROT U

Facility

$3.61

Service Code	CPT 84156
Hospital Charge Code	900912765
Hospital Revenue Code	301
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$3.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.17
Rate for Payer: Aetna of CA Government/Medicare	$2.17
Rate for Payer: Cash Price	$3.61
Rate for Payer: Cash Price	$3.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.89
Rate for Payer: Health Smart Auto/Commercial	$2.17
Rate for Payer: Intervalley Health Plan Commercial	$3.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.99
Rate for Payer: Multiplan Commercial	$2.71

HC SOM MCLON T. PROT U

Facility

$3.61

Service Code	CPT 84156
Hospital Charge Code	900912765
Hospital Revenue Code	301
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$2.89
Rate for Payer: Cash Price	$3.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.89
Rate for Payer: Health Smart Auto/Commercial	$2.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.99
Rate for Payer: Multiplan Commercial	$2.71

HC SOM MEASLES AB CSF IGG

Facility

$22.50

Service Code	CPT 86765
Hospital Charge Code	900911355
Hospital Revenue Code	302
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$18.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.00
Rate for Payer: Health Smart Auto/Commercial	$13.50
Rate for Payer: LLUH Dept of Risk Management WC	$12.38
Rate for Payer: Multiplan Commercial	$16.88

HC SOM MEASLES AB CSF IGG

Facility

$22.50

Service Code	CPT 86765
Hospital Charge Code	900911355
Hospital Revenue Code	302
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.50
Rate for Payer: Aetna of CA Government/Medicare	$13.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.00
Rate for Payer: Health Smart Auto/Commercial	$13.50
Rate for Payer: Intervalley Health Plan Commercial	$12.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.50
Rate for Payer: LLUH Dept of Risk Management WC	$12.38
Rate for Payer: Multiplan Commercial	$16.88

HC SOM MEASLES AB IGM CSF

Facility

$22.50

Service Code	CPT 86765
Hospital Charge Code	900912655
Hospital Revenue Code	302
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.50
Rate for Payer: Aetna of CA Government/Medicare	$13.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.00
Rate for Payer: Health Smart Auto/Commercial	$13.50
Rate for Payer: Intervalley Health Plan Commercial	$12.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.50
Rate for Payer: LLUH Dept of Risk Management WC	$12.38
Rate for Payer: Multiplan Commercial	$16.88

HC SOM MEASLES AB IGM CSF

Facility

$22.50

Service Code	CPT 86765
Hospital Charge Code	900912655
Hospital Revenue Code	302
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$18.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.00
Rate for Payer: Health Smart Auto/Commercial	$13.50
Rate for Payer: LLUH Dept of Risk Management WC	$12.38
Rate for Payer: Multiplan Commercial	$16.88

HC SOM MECONIUM AMPHETAMINE CONFIRM

Facility

$35.08

Service Code	CPT 80324
Hospital Charge Code	900912830
Hospital Revenue Code	301
Min. Negotiated Rate	$19.29
Max. Negotiated Rate	$28.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.05
Rate for Payer: Aetna of CA Government/Medicare	$21.05
Rate for Payer: Cash Price	$35.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.06
Rate for Payer: Health Smart Auto/Commercial	$21.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.05
Rate for Payer: LLUH Dept of Risk Management WC	$19.29
Rate for Payer: Multiplan Commercial	$26.31

HC SOM MECONIUM AMPHETAMINE CONFIRM

Facility

$35.08

Service Code	CPT 80324
Hospital Charge Code	900912830
Hospital Revenue Code	301
Min. Negotiated Rate	$19.29
Max. Negotiated Rate	$28.06
Rate for Payer: Cash Price	$35.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.06
Rate for Payer: Health Smart Auto/Commercial	$21.05
Rate for Payer: LLUH Dept of Risk Management WC	$19.29
Rate for Payer: Multiplan Commercial	$26.31

HC SOM MECONIUM COCAINE CONFIRM

Facility

$96.01

Service Code	CPT 80353
Hospital Charge Code	900912832
Hospital Revenue Code	301
Min. Negotiated Rate	$52.81
Max. Negotiated Rate	$76.81
Rate for Payer: Cash Price	$96.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.81
Rate for Payer: Health Smart Auto/Commercial	$57.61
Rate for Payer: LLUH Dept of Risk Management WC	$52.81
Rate for Payer: Multiplan Commercial	$72.01

HC SOM MECONIUM COCAINE CONFIRM

Facility

$96.01

Service Code	CPT 80353
Hospital Charge Code	900912832
Hospital Revenue Code	301
Min. Negotiated Rate	$52.81
Max. Negotiated Rate	$76.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.61
Rate for Payer: Aetna of CA Government/Medicare	$57.61
Rate for Payer: Cash Price	$96.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.81
Rate for Payer: Health Smart Auto/Commercial	$57.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.61
Rate for Payer: LLUH Dept of Risk Management WC	$52.81
Rate for Payer: Multiplan Commercial	$72.01

HC SOM MECONIUM METHAMPHETAMINE CONF

Facility

$23.42

Service Code	CPT 80359
Hospital Charge Code	900912831
Hospital Revenue Code	301
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$18.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.05
Rate for Payer: Aetna of CA Government/Medicare	$14.05
Rate for Payer: Cash Price	$23.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.74
Rate for Payer: Health Smart Auto/Commercial	$14.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.05
Rate for Payer: LLUH Dept of Risk Management WC	$12.88
Rate for Payer: Multiplan Commercial	$17.57

HC SOM MECONIUM METHAMPHETAMINE CONF

Facility

$23.42

Service Code	CPT 80359
Hospital Charge Code	900912831
Hospital Revenue Code	301
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$18.74
Rate for Payer: Cash Price	$23.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.74
Rate for Payer: Health Smart Auto/Commercial	$14.05
Rate for Payer: LLUH Dept of Risk Management WC	$12.88
Rate for Payer: Multiplan Commercial	$17.57

Know your out-of-pocket cost for care.

All Charges