Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM MMRV 86787

Facility

$29.73

Service Code	CPT 86787
Hospital Charge Code	900914959
Hospital Revenue Code	302
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$23.78
Rate for Payer: Cash Price	$29.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.78
Rate for Payer: Health Smart Auto/Commercial	$17.84
Rate for Payer: LLUH Dept of Risk Management WC	$16.35
Rate for Payer: Multiplan Commercial	$22.30

HC SOM MMRV 86787

Facility

$29.73

Service Code	CPT 86787
Hospital Charge Code	900914959
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$23.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.84
Rate for Payer: Aetna of CA Government/Medicare	$17.84
Rate for Payer: Cash Price	$29.73
Rate for Payer: Cash Price	$29.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.78
Rate for Payer: Health Smart Auto/Commercial	$17.84
Rate for Payer: Intervalley Health Plan Commercial	$12.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.84
Rate for Payer: LLUH Dept of Risk Management WC	$16.35
Rate for Payer: Multiplan Commercial	$22.30

HC SOM MOGS FACS

Facility

$450.00

Service Code	CPT 86363
Hospital Charge Code	900915461
Hospital Revenue Code	300
Min. Negotiated Rate	$247.50
Max. Negotiated Rate	$360.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$360.00
Rate for Payer: Health Smart Auto/Commercial	$270.00
Rate for Payer: LLUH Dept of Risk Management WC	$247.50
Rate for Payer: Multiplan Commercial	$337.50

HC SOM MOGS FACS

Facility

$450.00

Service Code	CPT 86363
Hospital Charge Code	900915461
Hospital Revenue Code	300
Min. Negotiated Rate	$37.73
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$270.00
Rate for Payer: Aetna of CA Government/Medicare	$270.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$360.00
Rate for Payer: Health Smart Auto/Commercial	$270.00
Rate for Payer: Intervalley Health Plan Commercial	$37.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$270.00
Rate for Payer: LLUH Dept of Risk Management WC	$247.50
Rate for Payer: Multiplan Commercial	$337.50

HC SOM MOGS FACS TITER

Facility

$75.00

Service Code	CPT 86363
Hospital Charge Code	900915462
Hospital Revenue Code	300
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Commercial	$56.25

HC SOM MOGS FACS TITER

Facility

$75.00

Service Code	CPT 86363
Hospital Charge Code	900915462
Hospital Revenue Code	300
Min. Negotiated Rate	$37.73
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Intervalley Health Plan Commercial	$37.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Commercial	$56.25

HC SOM M PNEUMONIAE AB IGM S IFA

Facility

$47.00

Service Code	CPT 86738
Hospital Charge Code	900913940
Hospital Revenue Code	302
Min. Negotiated Rate	$13.24
Max. Negotiated Rate	$37.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.20
Rate for Payer: Aetna of CA Government/Medicare	$28.20
Rate for Payer: Cash Price	$47.00
Rate for Payer: Cash Price	$47.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.60
Rate for Payer: Health Smart Auto/Commercial	$28.20
Rate for Payer: Intervalley Health Plan Commercial	$13.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.20
Rate for Payer: LLUH Dept of Risk Management WC	$25.85
Rate for Payer: Multiplan Commercial	$35.25

HC SOM M PNEUMONIAE AB IGM S IFA

Facility

$47.00

Service Code	CPT 86738
Hospital Charge Code	900913940
Hospital Revenue Code	302
Min. Negotiated Rate	$25.85
Max. Negotiated Rate	$37.60
Rate for Payer: Cash Price	$47.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.60
Rate for Payer: Health Smart Auto/Commercial	$28.20
Rate for Payer: LLUH Dept of Risk Management WC	$25.85
Rate for Payer: Multiplan Commercial	$35.25

HC SOM M PNEUMONIAE PCR

Facility

$175.00

Service Code	CPT 87581
Hospital Charge Code	900915468
Hospital Revenue Code	300
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Commercial	$131.25

HC SOM M PNEUMONIAE PCR

Facility

$175.00

Service Code	CPT 87581
Hospital Charge Code	900915468
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Commercial	$131.25

HC SOM MTB PCR COMPLEX SPUTUM

Facility

$243.39

Service Code	CPT 87798
Hospital Charge Code	900915433
Hospital Revenue Code	300
Min. Negotiated Rate	$133.86
Max. Negotiated Rate	$194.71
Rate for Payer: Cash Price	$243.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$194.71
Rate for Payer: Health Smart Auto/Commercial	$146.03
Rate for Payer: LLUH Dept of Risk Management WC	$133.86
Rate for Payer: Multiplan Commercial	$182.54

HC SOM MTB PCR COMPLEX SPUTUM

Facility

$243.39

Service Code	CPT 87798
Hospital Charge Code	900915433
Hospital Revenue Code	300
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$194.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$146.03
Rate for Payer: Aetna of CA Government/Medicare	$146.03
Rate for Payer: Cash Price	$243.39
Rate for Payer: Cash Price	$243.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$194.71
Rate for Payer: Health Smart Auto/Commercial	$146.03
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$146.03
Rate for Payer: LLUH Dept of Risk Management WC	$133.86
Rate for Payer: Multiplan Commercial	$182.54

HC SOM MTB PCR SPUTUM

Facility

$289.11

Service Code	CPT 87556
Hospital Charge Code	900915432
Hospital Revenue Code	300
Min. Negotiated Rate	$41.68
Max. Negotiated Rate	$231.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$173.47
Rate for Payer: Aetna of CA Government/Medicare	$173.47
Rate for Payer: Cash Price	$289.11
Rate for Payer: Cash Price	$289.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$231.29
Rate for Payer: Health Smart Auto/Commercial	$173.47
Rate for Payer: Intervalley Health Plan Commercial	$41.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$173.47
Rate for Payer: LLUH Dept of Risk Management WC	$159.01
Rate for Payer: Multiplan Commercial	$216.83

HC SOM MTB PCR SPUTUM

Facility

$289.11

Service Code	CPT 87556
Hospital Charge Code	900915432
Hospital Revenue Code	300
Min. Negotiated Rate	$159.01
Max. Negotiated Rate	$231.29
Rate for Payer: Cash Price	$289.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$231.29
Rate for Payer: Health Smart Auto/Commercial	$173.47
Rate for Payer: LLUH Dept of Risk Management WC	$159.01
Rate for Payer: Multiplan Commercial	$216.83

HC SOM M. TUBERCULOSIS PCR

Facility

$75.00

Service Code	CPT 87556
Hospital Charge Code	900912875
Hospital Revenue Code	306
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Commercial	$56.25

HC SOM M. TUBERCULOSIS PCR

Facility

$75.00

Service Code	CPT 87556
Hospital Charge Code	900912875
Hospital Revenue Code	306
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Intervalley Health Plan Commercial	$41.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Commercial	$56.25

HC SOM MUMPS AB IGG CSF

Facility

$25.00

Service Code	CPT 86735
Hospital Charge Code	900911356
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

HC SOM MUMPS AB IGG CSF

Facility

$25.00

Service Code	CPT 86735
Hospital Charge Code	900911356
Hospital Revenue Code	302
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Intervalley Health Plan Commercial	$13.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

HC SOM MUMPS AB IGM CSF

Facility

$25.00

Service Code	CPT 86735
Hospital Charge Code	900912679
Hospital Revenue Code	302
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Intervalley Health Plan Commercial	$13.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

HC SOM MUMPS AB IGM CSF

Facility

$25.00

Service Code	CPT 86735
Hospital Charge Code	900912679
Hospital Revenue Code	302
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

HC SOM MURAMIDASE SERUM

Facility

$20.00

Service Code	CPT 85549
Hospital Charge Code	900911063
Hospital Revenue Code	305
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC SOM MURAMIDASE SERUM

Facility

$20.00

Service Code	CPT 85549
Hospital Charge Code	900911063
Hospital Revenue Code	305
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$18.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Intervalley Health Plan Commercial	$18.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC SOM MYCOPHENOLIC ACID

Facility

$22.00

Service Code	CPT 80180
Hospital Charge Code	900910761
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$18.05
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	$18.05
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 MYCOPHENOLIC ACID

Facility

$22.00

Service Code	CPT 80180
Hospital Charge Code	900910761
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 MYCOPLASMA PNEUMONIAE AB IGG

Facility

$10.40

Service Code	CPT 86738
Hospital Charge Code	900911589
Hospital Revenue Code	302
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$8.32
Rate for Payer: Cash Price	$10.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.32
Rate for Payer: Health Smart Auto/Commercial	$6.24
Rate for Payer: LLUH Dept of Risk Management WC	$5.72
Rate for Payer: Multiplan Commercial	$7.80

Know your out-of-pocket cost for care.

All Charges