Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM SMOOTH MUSCLE AB TITER REFLEX

Facility

$16.93

Service Code	CPT 86015
Hospital Charge Code	900915437
Hospital Revenue Code	300
Min. Negotiated Rate	$9.31
Max. Negotiated Rate	$13.54
Rate for Payer: Cash Price	$16.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.54
Rate for Payer: Health Smart Auto/Commercial	$10.16
Rate for Payer: LLUH Dept of Risk Management WC	$9.31
Rate for Payer: Multiplan Commercial	$12.70

HC SOM SMOOTH MUSCLE AB TITER REFLEX

Facility

$16.93

Service Code	CPT 86015
Hospital Charge Code	900915437
Hospital Revenue Code	300
Min. Negotiated Rate	$9.31
Max. Negotiated Rate	$13.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.16
Rate for Payer: Aetna of CA Government/Medicare	$10.16
Rate for Payer: Cash Price	$16.93
Rate for Payer: Cash Price	$16.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.54
Rate for Payer: Health Smart Auto/Commercial	$10.16
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.16
Rate for Payer: LLUH Dept of Risk Management WC	$9.31
Rate for Payer: Multiplan Commercial	$12.70

HC SOM SOMATOSTATIN

Facility

$245.00

Service Code	CPT 84307
Hospital Charge Code	900911327
Hospital Revenue Code	301
Min. Negotiated Rate	$18.28
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$147.00
Rate for Payer: Aetna of CA Government/Medicare	$147.00
Rate for Payer: Cash Price	$245.00
Rate for Payer: Cash Price	$245.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$196.00
Rate for Payer: Health Smart Auto/Commercial	$147.00
Rate for Payer: Intervalley Health Plan Commercial	$18.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$147.00
Rate for Payer: LLUH Dept of Risk Management WC	$134.75
Rate for Payer: Multiplan Commercial	$183.75

HC SOM SOMATOSTATIN

Facility

$245.00

Service Code	CPT 84307
Hospital Charge Code	900911327
Hospital Revenue Code	301
Min. Negotiated Rate	$134.75
Max. Negotiated Rate	$196.00
Rate for Payer: Cash Price	$245.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$196.00
Rate for Payer: Health Smart Auto/Commercial	$147.00
Rate for Payer: LLUH Dept of Risk Management WC	$134.75
Rate for Payer: Multiplan Commercial	$183.75

HC SOM SOTALOL

Facility

$82.23

Service Code	CPT 80299
Hospital Charge Code	900910789
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$65.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.34
Rate for Payer: Aetna of CA Government/Medicare	$49.34
Rate for Payer: Cash Price	$82.23
Rate for Payer: Cash Price	$82.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$65.78
Rate for Payer: Health Smart Auto/Commercial	$49.34
Rate for Payer: Intervalley Health Plan Commercial	$18.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.34
Rate for Payer: LLUH Dept of Risk Management WC	$45.23
Rate for Payer: Multiplan Commercial	$61.67

HC SOM SOTALOL

Facility

$82.23

Service Code	CPT 80299
Hospital Charge Code	900910789
Hospital Revenue Code	301
Min. Negotiated Rate	$45.23
Max. Negotiated Rate	$65.78
Rate for Payer: Cash Price	$82.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$65.78
Rate for Payer: Health Smart Auto/Commercial	$49.34
Rate for Payer: LLUH Dept of Risk Management WC	$45.23
Rate for Payer: Multiplan Commercial	$61.67

HC SOM SPCL HC COAG INTERPRETATION

Facility

$36.00

Service Code	CPT 85390
Hospital Charge Code	900913972
Hospital Revenue Code	305
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$28.80
Rate for Payer: Cash Price	$36.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Commercial	$27.00

HC SOM SPCL HC COAG INTERPRETATION

Facility

$36.00

Service Code	CPT 85390
Hospital Charge Code	900913972
Hospital Revenue Code	305
Min. Negotiated Rate	$15.48
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.60
Rate for Payer: Aetna of CA Government/Medicare	$21.60
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: Intervalley Health Plan Commercial	$15.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Commercial	$27.00

HC SOM SPN 87206

Facility

$48.68

Service Code	CPT 87206
Hospital Charge Code	900914919
Hospital Revenue Code	306
Min. Negotiated Rate	$26.77
Max. Negotiated Rate	$38.94
Rate for Payer: Cash Price	$48.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.94
Rate for Payer: Health Smart Auto/Commercial	$29.21
Rate for Payer: LLUH Dept of Risk Management WC	$26.77
Rate for Payer: Multiplan Commercial	$36.51

HC SOM SPN 87206

Facility

$48.68

Service Code	CPT 87206
Hospital Charge Code	900914919
Hospital Revenue Code	306
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$38.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.21
Rate for Payer: Aetna of CA Government/Medicare	$29.21
Rate for Payer: Cash Price	$48.68
Rate for Payer: Cash Price	$48.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.94
Rate for Payer: Health Smart Auto/Commercial	$29.21
Rate for Payer: Intervalley Health Plan Commercial	$5.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.21
Rate for Payer: LLUH Dept of Risk Management WC	$26.77
Rate for Payer: Multiplan Commercial	$36.51

HC SOM SSDNA 86226

Facility

$55.00

Service Code	CPT 86226
Hospital Charge Code	900914817
Hospital Revenue Code	302
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$44.00
Rate for Payer: Cash Price	$55.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Commercial	$41.25

HC SOM SSDNA 86226

Facility

$55.00

Service Code	CPT 86226
Hospital Charge Code	900914817
Hospital Revenue Code	302
Min. Negotiated Rate	$12.11
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.00
Rate for Payer: Aetna of CA Government/Medicare	$33.00
Rate for Payer: Cash Price	$55.00
Rate for Payer: Cash Price	$55.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Intervalley Health Plan Commercial	$12.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Commercial	$41.25

HC SOM ST LOUIS ENCEPH AB IGM

Facility

$25.00

Service Code	CPT 86653
Hospital Charge Code	900912812
Hospital Revenue Code	302
Min. Negotiated Rate	$13.19
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	$13.19
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 ST LOUIS ENCEPH AB IGM

Facility

$25.00

Service Code	CPT 86653
Hospital Charge Code	900912812
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 ST LOUIS ENCEPHALITIS AB IGG

Facility

$25.00

Service Code	CPT 86653
Hospital Charge Code	900911336
Hospital Revenue Code	302
Min. Negotiated Rate	$13.19
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	$13.19
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 ST LOUIS ENCEPHALITIS AB IGG

Facility

$25.00

Service Code	CPT 86653
Hospital Charge Code	900911336
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 STONE ANALYSIS

Facility

$16.63

Service Code	CPT 82365
Hospital Charge Code	900911025
Hospital Revenue Code	301
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$13.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.98
Rate for Payer: Aetna of CA Government/Medicare	$9.98
Rate for Payer: Cash Price	$16.63
Rate for Payer: Cash Price	$16.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.30
Rate for Payer: Health Smart Auto/Commercial	$9.98
Rate for Payer: Intervalley Health Plan Commercial	$12.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.98
Rate for Payer: LLUH Dept of Risk Management WC	$9.15
Rate for Payer: Multiplan Commercial	$12.47

HC SOM STONE ANALYSIS

Facility

$16.63

Service Code	CPT 82365
Hospital Charge Code	900911025
Hospital Revenue Code	301
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$13.30
Rate for Payer: Cash Price	$16.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.30
Rate for Payer: Health Smart Auto/Commercial	$9.98
Rate for Payer: LLUH Dept of Risk Management WC	$9.15
Rate for Payer: Multiplan Commercial	$12.47

HC SOM STREP PNEUMO SEROTYPE 10A (34)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912860
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$14.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.00
Rate for Payer: Aetna of CA Government/Medicare	$3.00
Rate for Payer: Cash Price	$5.00
Rate for Payer: Cash Price	$5.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: Intervalley Health Plan Commercial	$14.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Commercial	$3.75

HC SOM STREP PNEUMO SEROTYPE 10A (34)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912860
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Commercial	$3.75

HC SOM STREP PNEUMO SEROTYPE 1 (1)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912845
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$14.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Intervalley Health Plan Commercial	$14.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Commercial	$3.00

HC SOM STREP PNEUMO SEROTYPE 1 (1)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912845
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.20
Rate for Payer: Cash Price	$4.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Commercial	$3.00

HC SOM STREP PNEUMO SEROTYPE 11A (43)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912861
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Commercial	$3.75

HC SOM STREP PNEUMO SEROTYPE 11A (43)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912861
Hospital Revenue Code	302
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$14.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.00
Rate for Payer: Aetna of CA Government/Medicare	$3.00
Rate for Payer: Cash Price	$5.00
Rate for Payer: Cash Price	$5.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.00
Rate for Payer: Health Smart Auto/Commercial	$3.00
Rate for Payer: Intervalley Health Plan Commercial	$14.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.00
Rate for Payer: LLUH Dept of Risk Management WC	$2.75
Rate for Payer: Multiplan Commercial	$3.75

HC SOM STREP PNEUMO SEROTYPE 12F (12)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912852
Hospital Revenue Code	302
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$14.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.40
Rate for Payer: Aetna of CA Government/Medicare	$2.40
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.20
Rate for Payer: Health Smart Auto/Commercial	$2.40
Rate for Payer: Intervalley Health Plan Commercial	$14.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.40
Rate for Payer: LLUH Dept of Risk Management WC	$2.20
Rate for Payer: Multiplan Commercial	$3.00

Know your out-of-pocket cost for care.

All Charges