Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM MGLES 83519A

Facility

$126.40

Service Code	CPT 83519
Hospital Charge Code	900914809
Hospital Revenue Code	302
Min. Negotiated Rate	$69.52
Max. Negotiated Rate	$101.12
Rate for Payer: Cash Price	$126.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$101.12
Rate for Payer: Health Smart Auto/Commercial	$75.84
Rate for Payer: LLUH Dept of Risk Management WC	$69.52
Rate for Payer: Multiplan Commercial	$94.80

HC SOM MGLES 83519B

Facility

$126.40

Service Code	CPT 83519
Hospital Charge Code	900914811
Hospital Revenue Code	302
Min. Negotiated Rate	$69.52
Max. Negotiated Rate	$101.12
Rate for Payer: Cash Price	$126.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$101.12
Rate for Payer: Health Smart Auto/Commercial	$75.84
Rate for Payer: LLUH Dept of Risk Management WC	$69.52
Rate for Payer: Multiplan Commercial	$94.80

HC SOM MGLES 83519B

Facility

$126.40

Service Code	CPT 83519
Hospital Charge Code	900914811
Hospital Revenue Code	302
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$101.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.84
Rate for Payer: Aetna of CA Government/Medicare	$75.84
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$126.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$101.12
Rate for Payer: Health Smart Auto/Commercial	$75.84
Rate for Payer: Intervalley Health Plan Commercial	$18.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.84
Rate for Payer: LLUH Dept of Risk Management WC	$69.52
Rate for Payer: Multiplan Commercial	$94.80

HC SOM MGLES 83519C

Facility

$126.41

Service Code	CPT 83519
Hospital Charge Code	900914812
Hospital Revenue Code	302
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$101.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.85
Rate for Payer: Aetna of CA Government/Medicare	$75.85
Rate for Payer: Cash Price	$126.41
Rate for Payer: Cash Price	$126.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$101.13
Rate for Payer: Health Smart Auto/Commercial	$75.85
Rate for Payer: Intervalley Health Plan Commercial	$18.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.85
Rate for Payer: LLUH Dept of Risk Management WC	$69.53
Rate for Payer: Multiplan Commercial	$94.81

HC SOM MGLES 83519C

Facility

$126.41

Service Code	CPT 83519
Hospital Charge Code	900914812
Hospital Revenue Code	302
Min. Negotiated Rate	$69.53
Max. Negotiated Rate	$101.13
Rate for Payer: Cash Price	$126.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$101.13
Rate for Payer: Health Smart Auto/Commercial	$75.85
Rate for Payer: LLUH Dept of Risk Management WC	$69.53
Rate for Payer: Multiplan Commercial	$94.81

HC SOM MGLES 83519D

Facility

$126.40

Service Code	CPT 83519
Hospital Charge Code	900914813
Hospital Revenue Code	302
Min. Negotiated Rate	$69.52
Max. Negotiated Rate	$101.12
Rate for Payer: Cash Price	$126.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$101.12
Rate for Payer: Health Smart Auto/Commercial	$75.84
Rate for Payer: LLUH Dept of Risk Management WC	$69.52
Rate for Payer: Multiplan Commercial	$94.80

HC SOM MGLES 83519D

Facility

$126.40

Service Code	CPT 83519
Hospital Charge Code	900914813
Hospital Revenue Code	302
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$101.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.84
Rate for Payer: Aetna of CA Government/Medicare	$75.84
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$126.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$101.12
Rate for Payer: Health Smart Auto/Commercial	$75.84
Rate for Payer: Intervalley Health Plan Commercial	$18.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.84
Rate for Payer: LLUH Dept of Risk Management WC	$69.52
Rate for Payer: Multiplan Commercial	$94.80

HC SOM MGLES 83520

Facility

$121.17

Service Code	CPT 83520
Hospital Charge Code	900914810
Hospital Revenue Code	302
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$96.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.70
Rate for Payer: Aetna of CA Government/Medicare	$72.70
Rate for Payer: Cash Price	$121.17
Rate for Payer: Cash Price	$121.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$96.94
Rate for Payer: Health Smart Auto/Commercial	$72.70
Rate for Payer: Intervalley Health Plan Commercial	$17.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.70
Rate for Payer: LLUH Dept of Risk Management WC	$66.64
Rate for Payer: Multiplan Commercial	$90.88

HC SOM MGLES 83520

Facility

$121.17

Service Code	CPT 83520
Hospital Charge Code	900914810
Hospital Revenue Code	302
Min. Negotiated Rate	$66.64
Max. Negotiated Rate	$96.94
Rate for Payer: Cash Price	$121.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$96.94
Rate for Payer: Health Smart Auto/Commercial	$72.70
Rate for Payer: LLUH Dept of Risk Management WC	$66.64
Rate for Payer: Multiplan Commercial	$90.88

HC SOM MICROSPORIDIA CULTURE

Facility

$206.40

Service Code	CPT 87015
Hospital Charge Code	900912827
Hospital Revenue Code	306
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$165.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$123.84
Rate for Payer: Aetna of CA Government/Medicare	$123.84
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cash Price	$206.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$165.12
Rate for Payer: Health Smart Auto/Commercial	$123.84
Rate for Payer: Intervalley Health Plan Commercial	$6.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$123.84
Rate for Payer: LLUH Dept of Risk Management WC	$113.52
Rate for Payer: Multiplan Commercial	$154.80

HC SOM MICROSPORIDIA CULTURE

Facility

$206.40

Service Code	CPT 87015
Hospital Charge Code	900912827
Hospital Revenue Code	306
Min. Negotiated Rate	$113.52
Max. Negotiated Rate	$165.12
Rate for Payer: Cash Price	$206.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$165.12
Rate for Payer: Health Smart Auto/Commercial	$123.84
Rate for Payer: LLUH Dept of Risk Management WC	$113.52
Rate for Payer: Multiplan Commercial	$154.80

HC SOM MICROSPORIDIA DETECTION

Facility

$89.72

Service Code	CPT 87207
Hospital Charge Code	900911588
Hospital Revenue Code	306
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$71.78
Rate for Payer: Cash Price	$89.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.78
Rate for Payer: Health Smart Auto/Commercial	$53.83
Rate for Payer: LLUH Dept of Risk Management WC	$49.35
Rate for Payer: Multiplan Commercial	$67.29

HC SOM MICROSPORIDIA DETECTION

Facility

$89.72

Service Code	CPT 87207
Hospital Charge Code	900911588
Hospital Revenue Code	306
Min. Negotiated Rate	$5.99
Max. Negotiated Rate	$71.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.83
Rate for Payer: Aetna of CA Government/Medicare	$53.83
Rate for Payer: Cash Price	$89.72
Rate for Payer: Cash Price	$89.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.78
Rate for Payer: Health Smart Auto/Commercial	$53.83
Rate for Payer: Intervalley Health Plan Commercial	$5.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.83
Rate for Payer: LLUH Dept of Risk Management WC	$49.35
Rate for Payer: Multiplan Commercial	$67.29

HC SOM MILK PROCESSED IGE

Facility

$4.75

Service Code	CPT 86003
Hospital Charge Code	900914157
Hospital Revenue Code	302
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$5.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.85
Rate for Payer: Aetna of CA Government/Medicare	$2.85
Rate for Payer: Cash Price	$4.75
Rate for Payer: Cash Price	$4.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.80
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: Intervalley Health Plan Commercial	$5.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Commercial	$3.56

HC SOM MILK PROCESSED IGE

Facility

$4.75

Service Code	CPT 86003
Hospital Charge Code	900914157
Hospital Revenue Code	302
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.80
Rate for Payer: Cash Price	$4.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.80
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Commercial	$3.56

HC SOM MIRA VISTA HC HISTOPLASMA AG

Facility

$140.00

Service Code	CPT 87385
Hospital Charge Code	900913883
Hospital Revenue Code	306
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$112.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$112.00
Rate for Payer: Health Smart Auto/Commercial	$84.00
Rate for Payer: LLUH Dept of Risk Management WC	$77.00
Rate for Payer: Multiplan Commercial	$105.00

HC SOM MIRA VISTA HC HISTOPLASMA AG

Facility

$140.00

Service Code	CPT 87385
Hospital Charge Code	900913883
Hospital Revenue Code	306
Min. Negotiated Rate	$13.25
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$84.00
Rate for Payer: Aetna of CA Government/Medicare	$84.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$112.00
Rate for Payer: Health Smart Auto/Commercial	$84.00
Rate for Payer: Intervalley Health Plan Commercial	$13.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$84.00
Rate for Payer: LLUH Dept of Risk Management WC	$77.00
Rate for Payer: Multiplan Commercial	$105.00

HC SOM MITOCHONDRIAL ANTIBO

Facility

$10.82

Service Code	CPT 86381
Hospital Charge Code	900911178
Hospital Revenue Code	302
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$8.66
Rate for Payer: Cash Price	$10.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.66
Rate for Payer: Health Smart Auto/Commercial	$6.49
Rate for Payer: LLUH Dept of Risk Management WC	$5.95
Rate for Payer: Multiplan Commercial	$8.12

HC SOM MITOCHONDRIAL ANTIBO

Facility

$10.82

Service Code	CPT 86381
Hospital Charge Code	900911178
Hospital Revenue Code	302
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$25.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.49
Rate for Payer: Aetna of CA Government/Medicare	$6.49
Rate for Payer: Cash Price	$10.82
Rate for Payer: Cash Price	$10.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.66
Rate for Payer: Health Smart Auto/Commercial	$6.49
Rate for Payer: Intervalley Health Plan Commercial	$25.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.49
Rate for Payer: LLUH Dept of Risk Management WC	$5.95
Rate for Payer: Multiplan Commercial	$8.12

HC SOM MMRV 86735

Facility

$100.43

Service Code	CPT 86735
Hospital Charge Code	900914957
Hospital Revenue Code	302
Min. Negotiated Rate	$55.24
Max. Negotiated Rate	$80.34
Rate for Payer: Cash Price	$100.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.34
Rate for Payer: Health Smart Auto/Commercial	$60.26
Rate for Payer: LLUH Dept of Risk Management WC	$55.24
Rate for Payer: Multiplan Commercial	$75.32

HC SOM MMRV 86735

Facility

$100.43

Service Code	CPT 86735
Hospital Charge Code	900914957
Hospital Revenue Code	302
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$80.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.26
Rate for Payer: Aetna of CA Government/Medicare	$60.26
Rate for Payer: Cash Price	$100.43
Rate for Payer: Cash Price	$100.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.34
Rate for Payer: Health Smart Auto/Commercial	$60.26
Rate for Payer: Intervalley Health Plan Commercial	$13.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.26
Rate for Payer: LLUH Dept of Risk Management WC	$55.24
Rate for Payer: Multiplan Commercial	$75.32

HC SOM MMRV 86762

Facility

$70.05

Service Code	CPT 86762
Hospital Charge Code	900914958
Hospital Revenue Code	302
Min. Negotiated Rate	$38.53
Max. Negotiated Rate	$56.04
Rate for Payer: Cash Price	$70.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.04
Rate for Payer: Health Smart Auto/Commercial	$42.03
Rate for Payer: LLUH Dept of Risk Management WC	$38.53
Rate for Payer: Multiplan Commercial	$52.54

HC SOM MMRV 86762

Facility

$70.05

Service Code	CPT 86762
Hospital Charge Code	900914958
Hospital Revenue Code	302
Min. Negotiated Rate	$14.39
Max. Negotiated Rate	$56.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.03
Rate for Payer: Aetna of CA Government/Medicare	$42.03
Rate for Payer: Cash Price	$70.05
Rate for Payer: Cash Price	$70.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.04
Rate for Payer: Health Smart Auto/Commercial	$42.03
Rate for Payer: Intervalley Health Plan Commercial	$14.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.03
Rate for Payer: LLUH Dept of Risk Management WC	$38.53
Rate for Payer: Multiplan Commercial	$52.54

HC SOM MMRV 86765

Facility

$17.90

Service Code	CPT 86765
Hospital Charge Code	900914956
Hospital Revenue Code	302
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$14.32
Rate for Payer: Cash Price	$17.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.85
Rate for Payer: Multiplan Commercial	$13.43

HC SOM MMRV 86765

Facility

$17.90

Service Code	CPT 86765
Hospital Charge Code	900914956
Hospital Revenue Code	302
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$14.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.74
Rate for Payer: Aetna of CA Government/Medicare	$10.74
Rate for Payer: Cash Price	$17.90
Rate for Payer: Cash Price	$17.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: Intervalley Health Plan Commercial	$12.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.85
Rate for Payer: Multiplan Commercial	$13.43

Know your out-of-pocket cost for care.

All Charges