Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM PARVOVIRUS B19 AB IGG

Facility

$11.23

Service Code	CPT 86747
Hospital Charge Code	900912538
Hospital Revenue Code	302
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$11.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Commercial	$8.42

HC SOM PARVOVIRUS B19 AB IGG

Facility

$11.23

Service Code	CPT 86747
Hospital Charge Code	900912538
Hospital Revenue Code	302
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$15.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.74
Rate for Payer: Aetna of CA Government/Medicare	$6.74
Rate for Payer: Cash Price	$11.23
Rate for Payer: Cash Price	$11.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: Intervalley Health Plan Commercial	$15.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Commercial	$8.42

HC SOM PARVOVIRUS B19 AB IGM

Facility

$11.23

Service Code	CPT 86747
Hospital Charge Code	900912694
Hospital Revenue Code	302
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$15.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.74
Rate for Payer: Aetna of CA Government/Medicare	$6.74
Rate for Payer: Cash Price	$11.23
Rate for Payer: Cash Price	$11.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: Intervalley Health Plan Commercial	$15.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Commercial	$8.42

HC SOM PARVOVIRUS B19 AB IGM

Facility

$11.23

Service Code	CPT 86747
Hospital Charge Code	900912694
Hospital Revenue Code	302
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$11.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Commercial	$8.42

HC SOM PARVOVIRUS B19 PCR BF

Facility

$41.48

Service Code	CPT 87798
Hospital Charge Code	900912782
Hospital Revenue Code	306
Min. Negotiated Rate	$22.81
Max. Negotiated Rate	$33.18
Rate for Payer: Cash Price	$41.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.18
Rate for Payer: Health Smart Auto/Commercial	$24.89
Rate for Payer: LLUH Dept of Risk Management WC	$22.81
Rate for Payer: Multiplan Commercial	$31.11

HC SOM PARVOVIRUS B19 PCR BF

Facility

$41.48

Service Code	CPT 87798
Hospital Charge Code	900912782
Hospital Revenue Code	306
Min. Negotiated Rate	$22.81
Max. Negotiated Rate	$35.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.89
Rate for Payer: Aetna of CA Government/Medicare	$24.89
Rate for Payer: Cash Price	$41.48
Rate for Payer: Cash Price	$41.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.18
Rate for Payer: Health Smart Auto/Commercial	$24.89
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.89
Rate for Payer: LLUH Dept of Risk Management WC	$22.81
Rate for Payer: Multiplan Commercial	$31.11

HC SOM PARVOVIRUS PCR

Facility

$41.48

Service Code	CPT 87798
Hospital Charge Code	900911590
Hospital Revenue Code	306
Min. Negotiated Rate	$22.81
Max. Negotiated Rate	$35.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.89
Rate for Payer: Aetna of CA Government/Medicare	$24.89
Rate for Payer: Cash Price	$41.48
Rate for Payer: Cash Price	$41.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.18
Rate for Payer: Health Smart Auto/Commercial	$24.89
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.89
Rate for Payer: LLUH Dept of Risk Management WC	$22.81
Rate for Payer: Multiplan Commercial	$31.11

HC SOM PARVOVIRUS PCR

Facility

$41.48

Service Code	CPT 87798
Hospital Charge Code	900911590
Hospital Revenue Code	306
Min. Negotiated Rate	$22.81
Max. Negotiated Rate	$33.18
Rate for Payer: Cash Price	$41.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.18
Rate for Payer: Health Smart Auto/Commercial	$24.89
Rate for Payer: LLUH Dept of Risk Management WC	$22.81
Rate for Payer: Multiplan Commercial	$31.11

HC SOM PCA3 U

Facility

$500.00

Service Code	CPT 81479
Hospital Charge Code	900913905
Hospital Revenue Code	309
Min. Negotiated Rate	$275.00
Max. Negotiated Rate	$400.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$400.00
Rate for Payer: Health Smart Auto/Commercial	$300.00
Rate for Payer: LLUH Dept of Risk Management WC	$275.00
Rate for Payer: Multiplan Commercial	$375.00

HC SOM PCA3 U

Facility

$500.00

Service Code	CPT 81479
Hospital Charge Code	900913905
Hospital Revenue Code	309
Min. Negotiated Rate	$275.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$300.00
Rate for Payer: Aetna of CA Government/Medicare	$300.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$400.00
Rate for Payer: Health Smart Auto/Commercial	$300.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$300.00
Rate for Payer: LLUH Dept of Risk Management WC	$275.00
Rate for Payer: Multiplan Commercial	$375.00

HC SOM PCDEC AMPA-R AB CBA

Facility

$50.19

Service Code	CPT 86255
Hospital Charge Code	900915486
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$40.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.11
Rate for Payer: Aetna of CA Government/Medicare	$30.11
Rate for Payer: Cash Price	$50.19
Rate for Payer: Cash Price	$50.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.15
Rate for Payer: Health Smart Auto/Commercial	$30.11
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.11
Rate for Payer: LLUH Dept of Risk Management WC	$27.60
Rate for Payer: Multiplan Commercial	$37.64

HC SOM PCDEC AMPA-R AB CBA

Facility

$50.19

Service Code	CPT 86255
Hospital Charge Code	900915486
Hospital Revenue Code	300
Min. Negotiated Rate	$27.60
Max. Negotiated Rate	$40.15
Rate for Payer: Cash Price	$50.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.15
Rate for Payer: Health Smart Auto/Commercial	$30.11
Rate for Payer: LLUH Dept of Risk Management WC	$27.60
Rate for Payer: Multiplan Commercial	$37.64

HC SOM PCDES AMPA-R AB CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915491
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$38.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.19
Rate for Payer: Aetna of CA Government/Medicare	$29.19
Rate for Payer: Cash Price	$48.65
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES AMPA-R AB CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915491
Hospital Revenue Code	300
Min. Negotiated Rate	$26.76
Max. Negotiated Rate	$38.92
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES ANNA1

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915489
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$38.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.19
Rate for Payer: Aetna of CA Government/Medicare	$29.19
Rate for Payer: Cash Price	$48.65
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES ANNA1

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915489
Hospital Revenue Code	300
Min. Negotiated Rate	$26.76
Max. Negotiated Rate	$38.92
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES CASPR2 IGG CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915495
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$38.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.19
Rate for Payer: Aetna of CA Government/Medicare	$29.19
Rate for Payer: Cash Price	$48.65
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES CASPR2 IGG CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915495
Hospital Revenue Code	300
Min. Negotiated Rate	$26.76
Max. Negotiated Rate	$38.92
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES DPPX AB CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915498
Hospital Revenue Code	300
Min. Negotiated Rate	$26.76
Max. Negotiated Rate	$38.92
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES DPPX AB CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915498
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$38.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.19
Rate for Payer: Aetna of CA Government/Medicare	$29.19
Rate for Payer: Cash Price	$48.65
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES GABA-B-R AB CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915492
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$38.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.19
Rate for Payer: Aetna of CA Government/Medicare	$29.19
Rate for Payer: Cash Price	$48.65
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES GABA-B-R AB CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915492
Hospital Revenue Code	300
Min. Negotiated Rate	$26.76
Max. Negotiated Rate	$38.92
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES GAD65 AB

Facility

$95.16

Service Code	CPT 86341
Hospital Charge Code	900915487
Hospital Revenue Code	300
Min. Negotiated Rate	$23.57
Max. Negotiated Rate	$76.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.10
Rate for Payer: Aetna of CA Government/Medicare	$57.10
Rate for Payer: Cash Price	$95.16
Rate for Payer: Cash Price	$95.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.13
Rate for Payer: Health Smart Auto/Commercial	$57.10
Rate for Payer: Intervalley Health Plan Commercial	$23.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.10
Rate for Payer: LLUH Dept of Risk Management WC	$52.34
Rate for Payer: Multiplan Commercial	$71.37

HC SOM PCDES GAD65 AB

Facility

$95.16

Service Code	CPT 86341
Hospital Charge Code	900915487
Hospital Revenue Code	300
Min. Negotiated Rate	$52.34
Max. Negotiated Rate	$76.13
Rate for Payer: Cash Price	$95.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.13
Rate for Payer: Health Smart Auto/Commercial	$57.10
Rate for Payer: LLUH Dept of Risk Management WC	$52.34
Rate for Payer: Multiplan Commercial	$71.37

HC SOM PCDES GFAP IFA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915499
Hospital Revenue Code	300
Min. Negotiated Rate	$26.76
Max. Negotiated Rate	$38.92
Rate for Payer: Cash Price	$48.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.92
Rate for Payer: Health Smart Auto/Commercial	$29.19
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

Know your out-of-pocket cost for care.

All Charges