Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM WEST NILE VIRUS AB IGG CSF

Facility

$15.66

Service Code	CPT 86789
Hospital Charge Code	900912603
Hospital Revenue Code	302
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$14.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.40
Rate for Payer: Aetna of CA Government/Medicare	$9.40
Rate for Payer: Cash Price	$15.66
Rate for Payer: Cash Price	$15.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.53
Rate for Payer: Health Smart Auto/Commercial	$9.40
Rate for Payer: Intervalley Health Plan Commercial	$14.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.40
Rate for Payer: LLUH Dept of Risk Management WC	$8.61
Rate for Payer: Multiplan Commercial	$11.74

HC SOM WEST NILE VIRUS AB IGM

Facility

$15.71

Service Code	CPT 86789
Hospital Charge Code	900912602
Hospital Revenue Code	302
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$12.57
Rate for Payer: Cash Price	$15.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.57
Rate for Payer: Health Smart Auto/Commercial	$9.43
Rate for Payer: LLUH Dept of Risk Management WC	$8.64
Rate for Payer: Multiplan Commercial	$11.78

HC SOM WEST NILE VIRUS AB IGM

Facility

$15.71

Service Code	CPT 86789
Hospital Charge Code	900912602
Hospital Revenue Code	302
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$14.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.43
Rate for Payer: Aetna of CA Government/Medicare	$9.43
Rate for Payer: Cash Price	$15.71
Rate for Payer: Cash Price	$15.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.57
Rate for Payer: Health Smart Auto/Commercial	$9.43
Rate for Payer: Intervalley Health Plan Commercial	$14.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.43
Rate for Payer: LLUH Dept of Risk Management WC	$8.64
Rate for Payer: Multiplan Commercial	$11.78

HC SOM WEST NILE VIRUS AB IGM CSF

Facility

$18.34

Service Code	CPT 86788
Hospital Charge Code	900912164
Hospital Revenue Code	302
Min. Negotiated Rate	$10.09
Max. Negotiated Rate	$16.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.00
Rate for Payer: Aetna of CA Government/Medicare	$11.00
Rate for Payer: Cash Price	$18.34
Rate for Payer: Cash Price	$18.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.67
Rate for Payer: Health Smart Auto/Commercial	$11.00
Rate for Payer: Intervalley Health Plan Commercial	$16.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.00
Rate for Payer: LLUH Dept of Risk Management WC	$10.09
Rate for Payer: Multiplan Commercial	$13.76

HC SOM WEST NILE VIRUS AB IGM CSF

Facility

$18.34

Service Code	CPT 86788
Hospital Charge Code	900912164
Hospital Revenue Code	302
Min. Negotiated Rate	$10.09
Max. Negotiated Rate	$14.67
Rate for Payer: Cash Price	$18.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.67
Rate for Payer: Health Smart Auto/Commercial	$11.00
Rate for Payer: LLUH Dept of Risk Management WC	$10.09
Rate for Payer: Multiplan Commercial	$13.76

HC SOM WEST NILE VIRUS PCR

Facility

$84.00

Service Code	CPT 87798
Hospital Charge Code	900912543
Hospital Revenue Code	306
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$67.20
Rate for Payer: Cash Price	$84.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.20
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Commercial	$63.00

HC SOM WEST NILE VIRUS PCR

Facility

$84.00

Service Code	CPT 87798
Hospital Charge Code	900912543
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$67.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.40
Rate for Payer: Aetna of CA Government/Medicare	$50.40
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$84.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.20
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Commercial	$63.00

HC SOM WEST NILE VIRUS PCR (CSF)

Facility

$84.00

Service Code	CPT 87798
Hospital Charge Code	900912764
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$67.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.40
Rate for Payer: Aetna of CA Government/Medicare	$50.40
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cash Price	$84.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.20
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Commercial	$63.00

HC SOM WEST NILE VIRUS PCR (CSF)

Facility

$84.00

Service Code	CPT 87798
Hospital Charge Code	900912764
Hospital Revenue Code	306
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$67.20
Rate for Payer: Cash Price	$84.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.20
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: Multiplan Commercial	$63.00

HC SOM ZINC

Facility

$12.17

Service Code	CPT 84630
Hospital Charge Code	900911152
Hospital Revenue Code	301
Min. Negotiated Rate	$6.69
Max. Negotiated Rate	$11.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.30
Rate for Payer: Aetna of CA Government/Medicare	$7.30
Rate for Payer: Cash Price	$12.17
Rate for Payer: Cash Price	$12.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.74
Rate for Payer: Health Smart Auto/Commercial	$7.30
Rate for Payer: Intervalley Health Plan Commercial	$11.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.30
Rate for Payer: LLUH Dept of Risk Management WC	$6.69
Rate for Payer: Multiplan Commercial	$9.13

HC SOM ZINC

Facility

$12.17

Service Code	CPT 84630
Hospital Charge Code	900911152
Hospital Revenue Code	301
Min. Negotiated Rate	$6.69
Max. Negotiated Rate	$9.74
Rate for Payer: Cash Price	$12.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.74
Rate for Payer: Health Smart Auto/Commercial	$7.30
Rate for Payer: LLUH Dept of Risk Management WC	$6.69
Rate for Payer: Multiplan Commercial	$9.13

HC SOM ZINC TRANSPORTER 8 AUTOAB

Facility

$150.00

Service Code	CPT 86341
Hospital Charge Code	900915260
Hospital Revenue Code	302
Min. Negotiated Rate	$23.57
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.00
Rate for Payer: Aetna of CA Government/Medicare	$90.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: Intervalley Health Plan Commercial	$23.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Commercial	$112.50

HC SOM ZINC TRANSPORTER 8 AUTOAB

Facility

$150.00

Service Code	CPT 86341
Hospital Charge Code	900915260
Hospital Revenue Code	302
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$120.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Commercial	$112.50

HC SOM ZINC URINE

Facility

$185.52

Service Code	CPT 84630
Hospital Charge Code	900911153
Hospital Revenue Code	301
Min. Negotiated Rate	$11.39
Max. Negotiated Rate	$148.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$111.31
Rate for Payer: Aetna of CA Government/Medicare	$111.31
Rate for Payer: Cash Price	$185.52
Rate for Payer: Cash Price	$185.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$148.42
Rate for Payer: Health Smart Auto/Commercial	$111.31
Rate for Payer: Intervalley Health Plan Commercial	$11.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$111.31
Rate for Payer: LLUH Dept of Risk Management WC	$102.04
Rate for Payer: Multiplan Commercial	$139.14

HC SOM ZINC URINE

Facility

$185.52

Service Code	CPT 84630
Hospital Charge Code	900911153
Hospital Revenue Code	301
Min. Negotiated Rate	$102.04
Max. Negotiated Rate	$148.42
Rate for Payer: Cash Price	$185.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$148.42
Rate for Payer: Health Smart Auto/Commercial	$111.31
Rate for Payer: LLUH Dept of Risk Management WC	$102.04
Rate for Payer: Multiplan Commercial	$139.14

HC SOM ZONISAMIDE LEVEL

Facility

$39.85

Service Code	CPT 80203
Hospital Charge Code	900912714
Hospital Revenue Code	301
Min. Negotiated Rate	$21.92
Max. Negotiated Rate	$31.88
Rate for Payer: Cash Price	$39.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.88
Rate for Payer: Health Smart Auto/Commercial	$23.91
Rate for Payer: LLUH Dept of Risk Management WC	$21.92
Rate for Payer: Multiplan Commercial	$29.89

HC SOM ZONISAMIDE LEVEL

Facility

$39.85

Service Code	CPT 80203
Hospital Charge Code	900912714
Hospital Revenue Code	301
Min. Negotiated Rate	$13.25
Max. Negotiated Rate	$31.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.91
Rate for Payer: Aetna of CA Government/Medicare	$23.91
Rate for Payer: Cash Price	$39.85
Rate for Payer: Cash Price	$39.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.88
Rate for Payer: Health Smart Auto/Commercial	$23.91
Rate for Payer: Intervalley Health Plan Commercial	$13.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.91
Rate for Payer: LLUH Dept of Risk Management WC	$21.92
Rate for Payer: Multiplan Commercial	$29.89

HC SOP CELIAC PLUS

Facility

$127.50

Service Code	CPT 88346
Hospital Charge Code	900914910
Hospital Revenue Code	309
Min. Negotiated Rate	$70.12
Max. Negotiated Rate	$102.00
Rate for Payer: Cash Price	$57.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$102.00
Rate for Payer: Health Smart Auto/Commercial	$76.50
Rate for Payer: LLUH Dept of Risk Management WC	$70.12
Rate for Payer: Multiplan Commercial	$95.62

HC SOP CELIAC PLUS

Facility

$127.50

Service Code	CPT 88346
Hospital Charge Code	900914910
Hospital Revenue Code	309
Min. Negotiated Rate	$70.12
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$76.50
Rate for Payer: Aetna of CA Government/Medicare	$76.50
Rate for Payer: Cash Price	$57.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$102.00
Rate for Payer: Health Smart Auto/Commercial	$76.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$76.50
Rate for Payer: LLUH Dept of Risk Management WC	$70.12
Rate for Payer: Multiplan Commercial	$95.62

HC SOP CELIAC PLUS 81382

Facility

$276.25

Service Code	CPT 81382
Hospital Charge Code	900914907
Hospital Revenue Code	309
Min. Negotiated Rate	$123.68
Max. Negotiated Rate	$221.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$165.75
Rate for Payer: Aetna of CA Government/Medicare	$165.75
Rate for Payer: Cash Price	$124.31
Rate for Payer: Cash Price	$124.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$221.00
Rate for Payer: Health Smart Auto/Commercial	$165.75
Rate for Payer: Intervalley Health Plan Commercial	$123.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$165.75
Rate for Payer: LLUH Dept of Risk Management WC	$151.94
Rate for Payer: Multiplan Commercial	$207.19

HC SOP CELIAC PLUS 81382

Facility

$276.25

Service Code	CPT 81382
Hospital Charge Code	900914907
Hospital Revenue Code	309
Min. Negotiated Rate	$151.94
Max. Negotiated Rate	$221.00
Rate for Payer: Cash Price	$124.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$221.00
Rate for Payer: Health Smart Auto/Commercial	$165.75
Rate for Payer: LLUH Dept of Risk Management WC	$151.94
Rate for Payer: Multiplan Commercial	$207.19

HC SOP CELIAC PLUS 82784

Facility

$21.26

Service Code	CPT 82784
Hospital Charge Code	900914909
Hospital Revenue Code	309
Min. Negotiated Rate	$11.69
Max. Negotiated Rate	$17.01
Rate for Payer: Cash Price	$9.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.01
Rate for Payer: Health Smart Auto/Commercial	$12.76
Rate for Payer: LLUH Dept of Risk Management WC	$11.69
Rate for Payer: Multiplan Commercial	$15.95

HC SOP CELIAC PLUS 82784

Facility

$21.26

Service Code	CPT 82784
Hospital Charge Code	900914909
Hospital Revenue Code	309
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$17.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.76
Rate for Payer: Aetna of CA Government/Medicare	$12.76
Rate for Payer: Cash Price	$9.57
Rate for Payer: Cash Price	$9.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.01
Rate for Payer: Health Smart Auto/Commercial	$12.76
Rate for Payer: Intervalley Health Plan Commercial	$9.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.76
Rate for Payer: LLUH Dept of Risk Management WC	$11.69
Rate for Payer: Multiplan Commercial	$15.95

HC SOP CELIAC PLUS 83520

Facility

$32.58

Service Code	CPT 83520
Hospital Charge Code	900914908
Hospital Revenue Code	309
Min. Negotiated Rate	$17.92
Max. Negotiated Rate	$26.06
Rate for Payer: Cash Price	$14.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.06
Rate for Payer: Health Smart Auto/Commercial	$19.55
Rate for Payer: LLUH Dept of Risk Management WC	$17.92
Rate for Payer: Multiplan Commercial	$24.43

HC SOP CELIAC PLUS 83520

Facility

$32.58

Service Code	CPT 83520
Hospital Charge Code	900914908
Hospital Revenue Code	309
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$26.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.55
Rate for Payer: Aetna of CA Government/Medicare	$19.55
Rate for Payer: Cash Price	$14.66
Rate for Payer: Cash Price	$14.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.06
Rate for Payer: Health Smart Auto/Commercial	$19.55
Rate for Payer: Intervalley Health Plan Commercial	$17.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.55
Rate for Payer: LLUH Dept of Risk Management WC	$17.92
Rate for Payer: Multiplan Commercial	$24.43

Know your out-of-pocket cost for care.

All Charges