Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM TIAGABINE LEVEL

Facility

$88.66

Service Code	CPT 80199
Hospital Charge Code	900912716
Hospital Revenue Code	301
Min. Negotiated Rate	$48.76
Max. Negotiated Rate	$70.93
Rate for Payer: Cash Price	$88.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$70.93
Rate for Payer: Health Smart Auto/Commercial	$53.20
Rate for Payer: LLUH Dept of Risk Management WC	$48.76
Rate for Payer: Multiplan Commercial	$66.50

HC SOM TIAGABINE LEVEL

Facility

$88.66

Service Code	CPT 80199
Hospital Charge Code	900912716
Hospital Revenue Code	301
Min. Negotiated Rate	$27.11
Max. Negotiated Rate	$70.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.20
Rate for Payer: Aetna of CA Government/Medicare	$53.20
Rate for Payer: Cash Price	$88.66
Rate for Payer: Cash Price	$88.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$70.93
Rate for Payer: Health Smart Auto/Commercial	$53.20
Rate for Payer: Intervalley Health Plan Commercial	$27.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.20
Rate for Payer: LLUH Dept of Risk Management WC	$48.76
Rate for Payer: Multiplan Commercial	$66.50

HC SOM TISSUE CULTURE NEOPLASTIC

Facility

$325.00

Service Code	CPT 88291
Hospital Charge Code	900910765
Hospital Revenue Code	310
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$260.00
Rate for Payer: Cash Price	$325.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$260.00
Rate for Payer: Health Smart Auto/Commercial	$195.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Multiplan Commercial	$243.75

HC SOM TISSUE CULTURE NEOPLASTIC

Facility

$325.00

Service Code	CPT 88291
Hospital Charge Code	900910765
Hospital Revenue Code	310
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$195.00
Rate for Payer: Aetna of CA Government/Medicare	$195.00
Rate for Payer: Cash Price	$325.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$260.00
Rate for Payer: Health Smart Auto/Commercial	$195.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$195.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Multiplan Commercial	$243.75

HC SOM TISSUE TRANSGLT AB IGA

Facility

$14.75

Service Code	CPT 83516
Hospital Charge Code	900914110
Hospital Revenue Code	302
Min. Negotiated Rate	$8.11
Max. Negotiated Rate	$11.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.85
Rate for Payer: Aetna of CA Government/Medicare	$8.85
Rate for Payer: Cash Price	$14.75
Rate for Payer: Cash Price	$14.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.80
Rate for Payer: Health Smart Auto/Commercial	$8.85
Rate for Payer: Intervalley Health Plan Commercial	$11.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.85
Rate for Payer: LLUH Dept of Risk Management WC	$8.11
Rate for Payer: Multiplan Commercial	$11.06

HC SOM TISSUE TRANSGLT AB IGA

Facility

$14.75

Service Code	CPT 83516
Hospital Charge Code	900914110
Hospital Revenue Code	302
Min. Negotiated Rate	$8.11
Max. Negotiated Rate	$11.80
Rate for Payer: Cash Price	$14.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.80
Rate for Payer: Health Smart Auto/Commercial	$8.85
Rate for Payer: LLUH Dept of Risk Management WC	$8.11
Rate for Payer: Multiplan Commercial	$11.06

HC SOM TOPIRAMATE

Facility

$17.50

Service Code	CPT 80201
Hospital Charge Code	900910764
Hospital Revenue Code	301
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.50
Rate for Payer: Aetna of CA Government/Medicare	$10.50
Rate for Payer: Cash Price	$17.50
Rate for Payer: Cash Price	$17.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.00
Rate for Payer: Health Smart Auto/Commercial	$10.50
Rate for Payer: Intervalley Health Plan Commercial	$11.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.50
Rate for Payer: LLUH Dept of Risk Management WC	$9.62
Rate for Payer: Multiplan Commercial	$13.12

HC SOM TOPIRAMATE

Facility

$17.50

Service Code	CPT 80201
Hospital Charge Code	900910764
Hospital Revenue Code	301
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$14.00
Rate for Payer: Cash Price	$17.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.00
Rate for Payer: Health Smart Auto/Commercial	$10.50
Rate for Payer: LLUH Dept of Risk Management WC	$9.62
Rate for Payer: Multiplan Commercial	$13.12

HC SOM TOXOCARA AB

Facility

$40.00

Service Code	CPT 86682
Hospital Charge Code	900911594
Hospital Revenue Code	302
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.00
Rate for Payer: Aetna of CA Government/Medicare	$24.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: Intervalley Health Plan Commercial	$13.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Commercial	$30.00

HC SOM TOXOCARA AB

Facility

$40.00

Service Code	CPT 86682
Hospital Charge Code	900911594
Hospital Revenue Code	302
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$32.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Commercial	$30.00

HC SOM TOXOPLASMA AB CSF IGG

Facility

$87.36

Service Code	CPT 86777
Hospital Charge Code	900911346
Hospital Revenue Code	302
Min. Negotiated Rate	$48.05
Max. Negotiated Rate	$69.89
Rate for Payer: Cash Price	$87.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.89
Rate for Payer: Health Smart Auto/Commercial	$52.42
Rate for Payer: LLUH Dept of Risk Management WC	$48.05
Rate for Payer: Multiplan Commercial	$65.52

HC SOM TOXOPLASMA AB CSF IGG

Facility

$87.36

Service Code	CPT 86777
Hospital Charge Code	900911346
Hospital Revenue Code	302
Min. Negotiated Rate	$14.39
Max. Negotiated Rate	$69.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.42
Rate for Payer: Aetna of CA Government/Medicare	$52.42
Rate for Payer: Cash Price	$87.36
Rate for Payer: Cash Price	$87.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.89
Rate for Payer: Health Smart Auto/Commercial	$52.42
Rate for Payer: Intervalley Health Plan Commercial	$14.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.42
Rate for Payer: LLUH Dept of Risk Management WC	$48.05
Rate for Payer: Multiplan Commercial	$65.52

HC SOM TOXOPLASMA AB CSF IGM

Facility

$87.49

Service Code	CPT 86778
Hospital Charge Code	900914413
Hospital Revenue Code	302
Min. Negotiated Rate	$48.12
Max. Negotiated Rate	$69.99
Rate for Payer: Cash Price	$87.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.99
Rate for Payer: Health Smart Auto/Commercial	$52.49
Rate for Payer: LLUH Dept of Risk Management WC	$48.12
Rate for Payer: Multiplan Commercial	$65.62

HC SOM TOXOPLASMA AB CSF IGM

Facility

$87.49

Service Code	CPT 86778
Hospital Charge Code	900914413
Hospital Revenue Code	302
Min. Negotiated Rate	$14.41
Max. Negotiated Rate	$69.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.49
Rate for Payer: Aetna of CA Government/Medicare	$52.49
Rate for Payer: Cash Price	$87.49
Rate for Payer: Cash Price	$87.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.99
Rate for Payer: Health Smart Auto/Commercial	$52.49
Rate for Payer: Intervalley Health Plan Commercial	$14.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.49
Rate for Payer: LLUH Dept of Risk Management WC	$48.12
Rate for Payer: Multiplan Commercial	$65.62

HC SOM TPPA 86780

Facility

$37.51

Service Code	CPT 86780
Hospital Charge Code	900914807
Hospital Revenue Code	301
Min. Negotiated Rate	$13.24
Max. Negotiated Rate	$30.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.51
Rate for Payer: Aetna of CA Government/Medicare	$22.51
Rate for Payer: Cash Price	$37.51
Rate for Payer: Cash Price	$37.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.01
Rate for Payer: Health Smart Auto/Commercial	$22.51
Rate for Payer: Intervalley Health Plan Commercial	$13.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.51
Rate for Payer: LLUH Dept of Risk Management WC	$20.63
Rate for Payer: Multiplan Commercial	$28.13

HC SOM TPPA 86780

Facility

$37.51

Service Code	CPT 86780
Hospital Charge Code	900914807
Hospital Revenue Code	301
Min. Negotiated Rate	$20.63
Max. Negotiated Rate	$30.01
Rate for Payer: Cash Price	$37.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.01
Rate for Payer: Health Smart Auto/Commercial	$22.51
Rate for Payer: LLUH Dept of Risk Management WC	$20.63
Rate for Payer: Multiplan Commercial	$28.13

HC SOM TPPTL 82657

Facility

$25.86

Service Code	CPT 82657
Hospital Charge Code	900914893
Hospital Revenue Code	301
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$22.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.52
Rate for Payer: Aetna of CA Government/Medicare	$15.52
Rate for Payer: Cash Price	$25.86
Rate for Payer: Cash Price	$25.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.69
Rate for Payer: Health Smart Auto/Commercial	$15.52
Rate for Payer: Intervalley Health Plan Commercial	$22.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.52
Rate for Payer: LLUH Dept of Risk Management WC	$14.22
Rate for Payer: Multiplan Commercial	$19.39

HC SOM TPPTL 82657

Facility

$25.86

Service Code	CPT 82657
Hospital Charge Code	900914893
Hospital Revenue Code	301
Min. Negotiated Rate	$14.22
Max. Negotiated Rate	$20.69
Rate for Payer: Cash Price	$25.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.69
Rate for Payer: Health Smart Auto/Commercial	$15.52
Rate for Payer: LLUH Dept of Risk Management WC	$14.22
Rate for Payer: Multiplan Commercial	$19.39

HC SOM TRAM 83925

Facility

$45.00

Service Code	CPT 80373
Hospital Charge Code	900915271
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Commercial	$33.75

HC SOM TRAM 83925

Facility

$45.00

Service Code	CPT 80373
Hospital Charge Code	900915271
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Commercial	$33.75

HC SOM TRANSGLUTAMINASE AB IGG

Facility

$14.75

Service Code	CPT 83516
Hospital Charge Code	900912640
Hospital Revenue Code	302
Min. Negotiated Rate	$8.11
Max. Negotiated Rate	$11.80
Rate for Payer: Cash Price	$14.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.80
Rate for Payer: Health Smart Auto/Commercial	$8.85
Rate for Payer: LLUH Dept of Risk Management WC	$8.11
Rate for Payer: Multiplan Commercial	$11.06

HC SOM TRANSGLUTAMINASE AB IGG

Facility

$14.75

Service Code	CPT 83516
Hospital Charge Code	900912640
Hospital Revenue Code	302
Min. Negotiated Rate	$8.11
Max. Negotiated Rate	$11.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.85
Rate for Payer: Aetna of CA Government/Medicare	$8.85
Rate for Payer: Cash Price	$14.75
Rate for Payer: Cash Price	$14.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.80
Rate for Payer: Health Smart Auto/Commercial	$8.85
Rate for Payer: Intervalley Health Plan Commercial	$11.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.85
Rate for Payer: LLUH Dept of Risk Management WC	$8.11
Rate for Payer: Multiplan Commercial	$11.06

HC SOM TREE4 86003

Facility

$61.13

Service Code	CPT 86003
Hospital Charge Code	900914815
Hospital Revenue Code	302
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$48.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.68
Rate for Payer: Aetna of CA Government/Medicare	$36.68
Rate for Payer: Cash Price	$61.13
Rate for Payer: Cash Price	$61.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.90
Rate for Payer: Health Smart Auto/Commercial	$36.68
Rate for Payer: Intervalley Health Plan Commercial	$5.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.68
Rate for Payer: LLUH Dept of Risk Management WC	$33.62
Rate for Payer: Multiplan Commercial	$45.85

HC SOM TREE4 86003

Facility

$61.13

Service Code	CPT 86003
Hospital Charge Code	900914815
Hospital Revenue Code	302
Min. Negotiated Rate	$33.62
Max. Negotiated Rate	$48.90
Rate for Payer: Cash Price	$61.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.90
Rate for Payer: Health Smart Auto/Commercial	$36.68
Rate for Payer: LLUH Dept of Risk Management WC	$33.62
Rate for Payer: Multiplan Commercial	$45.85

HC SOM TRYPTASE

Facility

$37.70

Service Code	CPT 83520
Hospital Charge Code	900910734
Hospital Revenue Code	302
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$30.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.62
Rate for Payer: Aetna of CA Government/Medicare	$22.62
Rate for Payer: Cash Price	$37.70
Rate for Payer: Cash Price	$37.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.16
Rate for Payer: Health Smart Auto/Commercial	$22.62
Rate for Payer: Intervalley Health Plan Commercial	$17.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.62
Rate for Payer: LLUH Dept of Risk Management WC	$20.73
Rate for Payer: Multiplan Commercial	$28.27

Know your out-of-pocket cost for care.

All Charges