Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$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 14 (14)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912853
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 14 (14)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912853
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 15B (54)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912863
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 15B (54)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912863
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 17F (17)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912854
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 17F (17)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912854
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 18C (56)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912864
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 18C (56)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912864
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 19A (57)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912865
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 19A (57)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912865
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 19F (19)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912855
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 19F (19)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912855
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 20 (20)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912856
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 20 (20)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912856
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 2 (2)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912846
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 2 (2)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912846
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 22F (22)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912857
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 22F (22)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912857
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 23F (23)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912858
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 23F (23)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912858
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 3 (3)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912847
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 3 (3)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912847
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 33F (70)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912867
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 33F (70)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912867
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

Know your out-of-pocket cost for care.

All Charges