Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM PCDES GFAP IFA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915499
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 LGI1 IGG CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915494
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 LGI1 IGG CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915494
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 MGLUR1 AB IFA

Facility

$48.66

Service Code	CPT 86255
Hospital Charge Code	900915497
Hospital Revenue Code	300
Min. Negotiated Rate	$26.76
Max. Negotiated Rate	$38.93
Rate for Payer: Cash Price	$48.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.93
Rate for Payer: Health Smart Auto/Commercial	$29.20
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES MGLUR1 AB IFA

Facility

$48.66

Service Code	CPT 86255
Hospital Charge Code	900915497
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$38.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.20
Rate for Payer: Aetna of CA Government/Medicare	$29.20
Rate for Payer: Cash Price	$48.66
Rate for Payer: Cash Price	$48.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.93
Rate for Payer: Health Smart Auto/Commercial	$29.20
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.20
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES MOG FACS

Facility

$152.33

Service Code	CPT 86363
Hospital Charge Code	900915496
Hospital Revenue Code	300
Min. Negotiated Rate	$83.78
Max. Negotiated Rate	$121.86
Rate for Payer: Cash Price	$152.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$121.86
Rate for Payer: Health Smart Auto/Commercial	$91.40
Rate for Payer: LLUH Dept of Risk Management WC	$83.78
Rate for Payer: Multiplan Commercial	$114.25

HC SOM PCDES MOG FACS

Facility

$152.33

Service Code	CPT 86363
Hospital Charge Code	900915496
Hospital Revenue Code	300
Min. Negotiated Rate	$37.73
Max. Negotiated Rate	$121.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$91.40
Rate for Payer: Aetna of CA Government/Medicare	$91.40
Rate for Payer: Cash Price	$152.33
Rate for Payer: Cash Price	$152.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$121.86
Rate for Payer: Health Smart Auto/Commercial	$91.40
Rate for Payer: Intervalley Health Plan Commercial	$37.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$91.40
Rate for Payer: LLUH Dept of Risk Management WC	$83.78
Rate for Payer: Multiplan Commercial	$114.25

HC SOM PCDES NEUROCONDRIN IFA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915500
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 NEUROCONDRIN IFA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915500
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 NMDA-R AB CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915490
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 NMDA-R AB CBA

Facility

$48.65

Service Code	CPT 86255
Hospital Charge Code	900915490
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 NMO/AQP4 FACS

Facility

$152.34

Service Code	CPT 86053
Hospital Charge Code	900915493
Hospital Revenue Code	300
Min. Negotiated Rate	$37.73
Max. Negotiated Rate	$121.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$91.40
Rate for Payer: Aetna of CA Government/Medicare	$91.40
Rate for Payer: Cash Price	$152.34
Rate for Payer: Cash Price	$152.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$121.87
Rate for Payer: Health Smart Auto/Commercial	$91.40
Rate for Payer: Intervalley Health Plan Commercial	$37.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$91.40
Rate for Payer: LLUH Dept of Risk Management WC	$83.79
Rate for Payer: Multiplan Commercial	$114.25

HC SOM PCDES NMO/AQP4 FACS

Facility

$152.34

Service Code	CPT 86053
Hospital Charge Code	900915493
Hospital Revenue Code	300
Min. Negotiated Rate	$83.79
Max. Negotiated Rate	$121.87
Rate for Payer: Cash Price	$152.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$121.87
Rate for Payer: Health Smart Auto/Commercial	$91.40
Rate for Payer: LLUH Dept of Risk Management WC	$83.79
Rate for Payer: Multiplan Commercial	$114.25

HC SOM PCDES PCA-TR

Facility

$48.66

Service Code	CPT 86255
Hospital Charge Code	900915488
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$38.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.20
Rate for Payer: Aetna of CA Government/Medicare	$29.20
Rate for Payer: Cash Price	$48.66
Rate for Payer: Cash Price	$48.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.93
Rate for Payer: Health Smart Auto/Commercial	$29.20
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.20
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PCDES PCA-TR

Facility

$48.66

Service Code	CPT 86255
Hospital Charge Code	900915488
Hospital Revenue Code	300
Min. Negotiated Rate	$26.76
Max. Negotiated Rate	$38.93
Rate for Payer: Cash Price	$48.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.93
Rate for Payer: Health Smart Auto/Commercial	$29.20
Rate for Payer: LLUH Dept of Risk Management WC	$26.76
Rate for Payer: Multiplan Commercial	$36.49

HC SOM PENICILLIN G IGE

Facility

$4.75

Service Code	CPT 86003
Hospital Charge Code	900912843
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 PENICILLIN G IGE

Facility

$4.75

Service Code	CPT 86003
Hospital Charge Code	900912843
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 PENICILLIN V IGE

Facility

$4.75

Service Code	CPT 86003
Hospital Charge Code	900912842
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 PENICILLIN V IGE

Facility

$4.75

Service Code	CPT 86003
Hospital Charge Code	900912842
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 PHENCYCLIDINE CONFIRM, U

Facility

$61.00

Service Code	CPT 83992
Hospital Charge Code	900912920
Hospital Revenue Code	301
Min. Negotiated Rate	$33.55
Max. Negotiated Rate	$48.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.60
Rate for Payer: Aetna of CA Government/Medicare	$36.60
Rate for Payer: Cash Price	$61.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.80
Rate for Payer: Health Smart Auto/Commercial	$36.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.60
Rate for Payer: LLUH Dept of Risk Management WC	$33.55
Rate for Payer: Multiplan Commercial	$45.75

HC SOM PHENCYCLIDINE CONFIRM, U

Facility

$61.00

Service Code	CPT 83992
Hospital Charge Code	900912920
Hospital Revenue Code	301
Min. Negotiated Rate	$33.55
Max. Negotiated Rate	$48.80
Rate for Payer: Cash Price	$61.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.80
Rate for Payer: Health Smart Auto/Commercial	$36.60
Rate for Payer: LLUH Dept of Risk Management WC	$33.55
Rate for Payer: Multiplan Commercial	$45.75

HC SOM PHENOBARBITAL LEVEL

Facility

$23.99

Service Code	CPT 80184
Hospital Charge Code	900912658
Hospital Revenue Code	301
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$19.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.39
Rate for Payer: Aetna of CA Government/Medicare	$14.39
Rate for Payer: Cash Price	$23.99
Rate for Payer: Cash Price	$23.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.19
Rate for Payer: Health Smart Auto/Commercial	$14.39
Rate for Payer: Intervalley Health Plan Commercial	$15.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.39
Rate for Payer: LLUH Dept of Risk Management WC	$13.19
Rate for Payer: Multiplan Commercial	$17.99

HC SOM PHENOBARBITAL LEVEL

Facility

$23.99

Service Code	CPT 80184
Hospital Charge Code	900912658
Hospital Revenue Code	301
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$19.19
Rate for Payer: Cash Price	$23.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.19
Rate for Payer: Health Smart Auto/Commercial	$14.39
Rate for Payer: LLUH Dept of Risk Management WC	$13.19
Rate for Payer: Multiplan Commercial	$17.99

HC SOM PHI 2PROPSA

Facility

$29.20

Service Code	CPT 86316
Hospital Charge Code	900915520
Hospital Revenue Code	300
Min. Negotiated Rate	$16.06
Max. Negotiated Rate	$23.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.52
Rate for Payer: Aetna of CA Government/Medicare	$17.52
Rate for Payer: Cash Price	$29.20
Rate for Payer: Cash Price	$29.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.36
Rate for Payer: Health Smart Auto/Commercial	$17.52
Rate for Payer: Intervalley Health Plan Commercial	$20.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.52
Rate for Payer: LLUH Dept of Risk Management WC	$16.06
Rate for Payer: Multiplan Commercial	$21.90

HC SOM PHI 2PROPSA

Facility

$29.20

Service Code	CPT 86316
Hospital Charge Code	900915520
Hospital Revenue Code	300
Min. Negotiated Rate	$16.06
Max. Negotiated Rate	$23.36
Rate for Payer: Cash Price	$29.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.36
Rate for Payer: Health Smart Auto/Commercial	$17.52
Rate for Payer: LLUH Dept of Risk Management WC	$16.06
Rate for Payer: Multiplan Commercial	$21.90

Know your out-of-pocket cost for care.

All Charges