Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM STREP PNEUMO SEROTYPE 4 (4)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912848
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 4 (4)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912848
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 5 (5)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912849
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 5 (5)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912849
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 6B (26)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912859
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 6B (26)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912859
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 7F (51)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912862
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 7F (51)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912862
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 8 (8)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912850
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 8 (8)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912850
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 9N (9)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912851
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 9N (9)

Facility

$4.00

Service Code	CPT 86317
Hospital Charge Code	900912851
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 9V (68)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912866
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 9V (68)

Facility

$5.00

Service Code	CPT 86317
Hospital Charge Code	900912866
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 STREPTOCOCCAL ABS

Facility

$9.91

Service Code	CPT 86215
Hospital Charge Code	900911155
Hospital Revenue Code	302
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$13.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.95
Rate for Payer: Aetna of CA Government/Medicare	$5.95
Rate for Payer: Cash Price	$9.91
Rate for Payer: Cash Price	$9.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.93
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: Intervalley Health Plan Commercial	$13.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Commercial	$7.43

HC SOM STREPTOCOCCAL ABS

Facility

$9.91

Service Code	CPT 86215
Hospital Charge Code	900911155
Hospital Revenue Code	302
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.93
Rate for Payer: Cash Price	$9.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.93
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Commercial	$7.43

HC SOM STREPTOCOCCAL ABS, SNTISTREP-O

Facility

$10.00

Service Code	CPT 86060
Hospital Charge Code	900912820
Hospital Revenue Code	302
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Cash Price	$10.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.00
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Commercial	$7.50

HC SOM STREPTOCOCCAL ABS, SNTISTREP-O

Facility

$10.00

Service Code	CPT 86060
Hospital Charge Code	900912820
Hospital Revenue Code	302
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.00
Rate for Payer: Aetna of CA Government/Medicare	$6.00
Rate for Payer: Cash Price	$10.00
Rate for Payer: Cash Price	$10.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.00
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Intervalley Health Plan Commercial	$7.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Commercial	$7.50

HC SOM SULFA DRUGS

Facility

$55.00

Service Code	CPT 80299
Hospital Charge Code	900911100
Hospital Revenue Code	301
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 SULFA DRUGS

Facility

$55.00

Service Code	CPT 80299
Hospital Charge Code	900911100
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
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	$18.64
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 TCP 86359

Facility

$115.35

Service Code	CPT 86359
Hospital Charge Code	900914880
Hospital Revenue Code	309
Min. Negotiated Rate	$37.73
Max. Negotiated Rate	$92.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$69.21
Rate for Payer: Aetna of CA Government/Medicare	$69.21
Rate for Payer: Cash Price	$115.35
Rate for Payer: Cash Price	$115.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$92.28
Rate for Payer: Health Smart Auto/Commercial	$69.21
Rate for Payer: Intervalley Health Plan Commercial	$37.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$69.21
Rate for Payer: LLUH Dept of Risk Management WC	$63.44
Rate for Payer: Multiplan Commercial	$86.51

HC SOM TCP 86359

Facility

$115.35

Service Code	CPT 86359
Hospital Charge Code	900914880
Hospital Revenue Code	309
Min. Negotiated Rate	$63.44
Max. Negotiated Rate	$92.28
Rate for Payer: Cash Price	$115.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$92.28
Rate for Payer: Health Smart Auto/Commercial	$69.21
Rate for Payer: LLUH Dept of Risk Management WC	$63.44
Rate for Payer: Multiplan Commercial	$86.51

HC SOM TCP 86361

Facility

$81.87

Service Code	CPT 86361
Hospital Charge Code	900914881
Hospital Revenue Code	309
Min. Negotiated Rate	$26.78
Max. Negotiated Rate	$65.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.12
Rate for Payer: Aetna of CA Government/Medicare	$49.12
Rate for Payer: Cash Price	$81.87
Rate for Payer: Cash Price	$81.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$65.50
Rate for Payer: Health Smart Auto/Commercial	$49.12
Rate for Payer: Intervalley Health Plan Commercial	$26.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.12
Rate for Payer: LLUH Dept of Risk Management WC	$45.03
Rate for Payer: Multiplan Commercial	$61.40

HC SOM TCP 86361

Facility

$81.87

Service Code	CPT 86361
Hospital Charge Code	900914881
Hospital Revenue Code	309
Min. Negotiated Rate	$45.03
Max. Negotiated Rate	$65.50
Rate for Payer: Cash Price	$81.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$65.50
Rate for Payer: Health Smart Auto/Commercial	$49.12
Rate for Payer: LLUH Dept of Risk Management WC	$45.03
Rate for Payer: Multiplan Commercial	$61.40

HC SOM TCP 88184

Facility

$199.38

Service Code	CPT 88184
Hospital Charge Code	900914882
Hospital Revenue Code	309
Min. Negotiated Rate	$109.66
Max. Negotiated Rate	$159.50
Rate for Payer: Cash Price	$199.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$159.50
Rate for Payer: Health Smart Auto/Commercial	$119.63
Rate for Payer: LLUH Dept of Risk Management WC	$109.66
Rate for Payer: Multiplan Commercial	$149.53

Know your out-of-pocket cost for care.

All Charges