Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM MILK PROCESSED IGE

Facility

$4.75

Service Code	CPT 86003
Hospital Charge Code	900914157
Hospital Revenue Code	302
Min. Negotiated Rate	$2.61
Max. Negotiated Rate	$3.80
Rate for Payer: Cash Price	$2.14
Rate for Payer: Cigna of CA HMO/PPO	$3.80
Rate for Payer: Health Smart Auto/Commercial	$2.85
Rate for Payer: LLUH Dept of Risk Management WC	$2.61
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.56

HC SOM MIRA VISTA HC HISTOPLASMA AG

Facility

$140.00

Service Code	CPT 87385
Hospital Charge Code	900913883
Hospital Revenue Code	306
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$112.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna of CA HMO/PPO	$112.00
Rate for Payer: Health Smart Auto/Commercial	$84.00
Rate for Payer: LLUH Dept of Risk Management WC	$77.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$105.00

HC SOM MIRA VISTA HC HISTOPLASMA AG

Facility

$140.00

Service Code	CPT 87385 90
Hospital Charge Code	900913883
Hospital Revenue Code	306
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$112.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna of CA HMO/PPO	$112.00
Rate for Payer: Health Smart Auto/Commercial	$84.00
Rate for Payer: LLUH Dept of Risk Management WC	$77.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$105.00

HC SOM MIRA VISTA HC HISTOPLASMA AG

Facility

$140.00

Service Code	CPT 87385 90
Hospital Charge Code	900913883
Hospital Revenue Code	306
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$84.00
Rate for Payer: Aetna of CA Government/Medicare	$84.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Health Smart Auto/Commercial	$84.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$84.00
Rate for Payer: LLUH Dept of Risk Management WC	$77.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$105.00

HC SOM MIRA VISTA HC HISTOPLASMA AG

Facility

$140.00

Service Code	CPT 87385
Hospital Charge Code	900913883
Hospital Revenue Code	306
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$84.00
Rate for Payer: Aetna of CA Government/Medicare	$84.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Health Smart Auto/Commercial	$84.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$84.00
Rate for Payer: LLUH Dept of Risk Management WC	$77.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$105.00

HC SOM MITOCHONDRIAL ANTIBO

Facility

$10.82

Service Code	CPT 86381
Hospital Charge Code	900911178
Hospital Revenue Code	302
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$8.66
Rate for Payer: Cash Price	$4.87
Rate for Payer: Cigna of CA HMO/PPO	$8.66
Rate for Payer: Health Smart Auto/Commercial	$6.49
Rate for Payer: LLUH Dept of Risk Management WC	$5.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.12

HC SOM MITOCHONDRIAL ANTIBO

Facility

$10.82

Service Code	CPT 86381
Hospital Charge Code	900911178
Hospital Revenue Code	302
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$8.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.49
Rate for Payer: Aetna of CA Government/Medicare	$6.49
Rate for Payer: Cash Price	$4.87
Rate for Payer: Health Smart Auto/Commercial	$6.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.49
Rate for Payer: LLUH Dept of Risk Management WC	$5.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.12

HC SOM MITOCHONDRIAL ANTIBO

Facility

$10.82

Service Code	CPT 86381 90
Hospital Charge Code	900911178
Hospital Revenue Code	302
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$8.66
Rate for Payer: Cash Price	$4.87
Rate for Payer: Cigna of CA HMO/PPO	$8.66
Rate for Payer: Health Smart Auto/Commercial	$6.49
Rate for Payer: LLUH Dept of Risk Management WC	$5.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.12

HC SOM MITOCHONDRIAL ANTIBO

Facility

$10.82

Service Code	CPT 86381 90
Hospital Charge Code	900911178
Hospital Revenue Code	302
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$8.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.49
Rate for Payer: Aetna of CA Government/Medicare	$6.49
Rate for Payer: Cash Price	$4.87
Rate for Payer: Health Smart Auto/Commercial	$6.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.49
Rate for Payer: LLUH Dept of Risk Management WC	$5.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.12

HC SOM MMRV 86735

Facility

$100.43

Service Code	CPT 86735 90
Hospital Charge Code	900914957
Hospital Revenue Code	302
Min. Negotiated Rate	$55.24
Max. Negotiated Rate	$80.34
Rate for Payer: Health Smart Auto/Commercial	$60.26
Rate for Payer: Cash Price	$45.19
Rate for Payer: Cigna of CA HMO/PPO	$80.34
Rate for Payer: LLUH Dept of Risk Management WC	$55.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.32

HC SOM MMRV 86735

Facility

$100.43

Service Code	CPT 86735
Hospital Charge Code	900914957
Hospital Revenue Code	302
Min. Negotiated Rate	$55.24
Max. Negotiated Rate	$75.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.26
Rate for Payer: Aetna of CA Government/Medicare	$60.26
Rate for Payer: Cash Price	$45.19
Rate for Payer: Health Smart Auto/Commercial	$60.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.26
Rate for Payer: LLUH Dept of Risk Management WC	$55.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.32

HC SOM MMRV 86735

Facility

$100.43

Service Code	CPT 86735
Hospital Charge Code	900914957
Hospital Revenue Code	302
Min. Negotiated Rate	$55.24
Max. Negotiated Rate	$80.34
Rate for Payer: Cash Price	$45.19
Rate for Payer: Cigna of CA HMO/PPO	$80.34
Rate for Payer: Health Smart Auto/Commercial	$60.26
Rate for Payer: LLUH Dept of Risk Management WC	$55.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.32

HC SOM MMRV 86735

Facility

$100.43

Service Code	CPT 86735 90
Hospital Charge Code	900914957
Hospital Revenue Code	302
Min. Negotiated Rate	$55.24
Max. Negotiated Rate	$75.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.26
Rate for Payer: Aetna of CA Government/Medicare	$60.26
Rate for Payer: Cash Price	$45.19
Rate for Payer: Health Smart Auto/Commercial	$60.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.26
Rate for Payer: LLUH Dept of Risk Management WC	$55.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$75.32

HC SOM MMRV 86762

Facility

$70.05

Service Code	CPT 86762 90
Hospital Charge Code	900914958
Hospital Revenue Code	302
Min. Negotiated Rate	$38.53
Max. Negotiated Rate	$56.04
Rate for Payer: Cash Price	$31.52
Rate for Payer: Cigna of CA HMO/PPO	$56.04
Rate for Payer: Health Smart Auto/Commercial	$42.03
Rate for Payer: LLUH Dept of Risk Management WC	$38.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.54

HC SOM MMRV 86762

Facility

$70.05

Service Code	CPT 86762 90
Hospital Charge Code	900914958
Hospital Revenue Code	302
Min. Negotiated Rate	$38.53
Max. Negotiated Rate	$52.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.03
Rate for Payer: Aetna of CA Government/Medicare	$42.03
Rate for Payer: Cash Price	$31.52
Rate for Payer: Health Smart Auto/Commercial	$42.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.03
Rate for Payer: LLUH Dept of Risk Management WC	$38.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.54

HC SOM MMRV 86762

Facility

$70.05

Service Code	CPT 86762
Hospital Charge Code	900914958
Hospital Revenue Code	302
Min. Negotiated Rate	$38.53
Max. Negotiated Rate	$56.04
Rate for Payer: Cash Price	$31.52
Rate for Payer: Cigna of CA HMO/PPO	$56.04
Rate for Payer: Health Smart Auto/Commercial	$42.03
Rate for Payer: LLUH Dept of Risk Management WC	$38.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.54

HC SOM MMRV 86762

Facility

$70.05

Service Code	CPT 86762
Hospital Charge Code	900914958
Hospital Revenue Code	302
Min. Negotiated Rate	$38.53
Max. Negotiated Rate	$52.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.03
Rate for Payer: Aetna of CA Government/Medicare	$42.03
Rate for Payer: Cash Price	$31.52
Rate for Payer: Health Smart Auto/Commercial	$42.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.03
Rate for Payer: LLUH Dept of Risk Management WC	$38.53
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$52.54

HC SOM MMRV 86765

Facility

$17.90

Service Code	CPT 86765 90
Hospital Charge Code	900914956
Hospital Revenue Code	302
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$14.32
Rate for Payer: Cash Price	$8.06
Rate for Payer: Cigna of CA HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.42

HC SOM MMRV 86765

Facility

$17.90

Service Code	CPT 86765
Hospital Charge Code	900914956
Hospital Revenue Code	302
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$14.32
Rate for Payer: Cash Price	$8.06
Rate for Payer: Cigna of CA HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.42

HC SOM MMRV 86765

Facility

$17.90

Service Code	CPT 86765
Hospital Charge Code	900914956
Hospital Revenue Code	302
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$13.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.74
Rate for Payer: Aetna of CA Government/Medicare	$10.74
Rate for Payer: Cash Price	$8.06
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.42

HC SOM MMRV 86765

Facility

$17.90

Service Code	CPT 86765 90
Hospital Charge Code	900914956
Hospital Revenue Code	302
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$13.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.74
Rate for Payer: Aetna of CA Government/Medicare	$10.74
Rate for Payer: Cash Price	$8.06
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.42

HC SOM MMRV 86787

Facility

$29.73

Service Code	CPT 86787 90
Hospital Charge Code	900914959
Hospital Revenue Code	302
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$22.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.84
Rate for Payer: Aetna of CA Government/Medicare	$17.84
Rate for Payer: Cash Price	$13.38
Rate for Payer: Health Smart Auto/Commercial	$17.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.84
Rate for Payer: LLUH Dept of Risk Management WC	$16.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.30

HC SOM MMRV 86787

Facility

$29.73

Service Code	CPT 86787
Hospital Charge Code	900914959
Hospital Revenue Code	302
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$22.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.84
Rate for Payer: Aetna of CA Government/Medicare	$17.84
Rate for Payer: Cash Price	$13.38
Rate for Payer: Health Smart Auto/Commercial	$17.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.84
Rate for Payer: LLUH Dept of Risk Management WC	$16.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.30

HC SOM MMRV 86787

Facility

$29.73

Service Code	CPT 86787 90
Hospital Charge Code	900914959
Hospital Revenue Code	302
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$23.78
Rate for Payer: Cash Price	$13.38
Rate for Payer: Cigna of CA HMO/PPO	$23.78
Rate for Payer: Health Smart Auto/Commercial	$17.84
Rate for Payer: LLUH Dept of Risk Management WC	$16.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.30

HC SOM MMRV 86787

Facility

$29.73

Service Code	CPT 86787
Hospital Charge Code	900914959
Hospital Revenue Code	302
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$23.78
Rate for Payer: Cash Price	$13.38
Rate for Payer: Cigna of CA HMO/PPO	$23.78
Rate for Payer: Health Smart Auto/Commercial	$17.84
Rate for Payer: LLUH Dept of Risk Management WC	$16.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.30

Know your out-of-pocket cost for care.

All Charges