Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SODIUM URINE

Facility

$30.00

Service Code	CPT 84300
Hospital Charge Code	900910270
Hospital Revenue Code	301
Min. Negotiated Rate	$5.06
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cash Price	$13.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Intervalley Health Plan Commercial	$5.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

HC SODIUM URINE

Facility

$100.00

Service Code	CPT 84300
Hospital Charge Code	900910270
Hospital Revenue Code	301
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$80.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.00
Rate for Payer: Health Smart Auto/Commercial	$60.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.00
Rate for Payer: Multiplan Commercial	$75.00

HC SOF 60735 MYCOP IGG 86738

Facility

$65.04

Service Code	CPT 86738
Hospital Charge Code	900914877
Hospital Revenue Code	302
Min. Negotiated Rate	$35.77
Max. Negotiated Rate	$52.03
Rate for Payer: Cash Price	$29.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.03
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Commercial	$48.78

HC SOF 60735 MYCOP IGG 86738

Facility

$65.04

Service Code	CPT 86738
Hospital Charge Code	900914877
Hospital Revenue Code	302
Min. Negotiated Rate	$13.24
Max. Negotiated Rate	$52.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.02
Rate for Payer: Aetna of CA Government/Medicare	$39.02
Rate for Payer: Cash Price	$29.27
Rate for Payer: Cash Price	$29.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.03
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: Intervalley Health Plan Commercial	$13.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Commercial	$48.78

HC SOF 60735 MYCOP IGM 86738

Facility

$65.04

Service Code	CPT 86738
Hospital Charge Code	900914878
Hospital Revenue Code	302
Min. Negotiated Rate	$13.24
Max. Negotiated Rate	$52.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.02
Rate for Payer: Aetna of CA Government/Medicare	$39.02
Rate for Payer: Cash Price	$29.27
Rate for Payer: Cash Price	$29.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.03
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: Intervalley Health Plan Commercial	$13.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Commercial	$48.78

HC SOF 60735 MYCOP IGM 86738

Facility

$65.04

Service Code	CPT 86738
Hospital Charge Code	900914878
Hospital Revenue Code	302
Min. Negotiated Rate	$35.77
Max. Negotiated Rate	$52.03
Rate for Payer: Cash Price	$29.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.03
Rate for Payer: Health Smart Auto/Commercial	$39.02
Rate for Payer: LLUH Dept of Risk Management WC	$35.77
Rate for Payer: Multiplan Commercial	$48.78

HC SOF ADENOVIRUS DNA QUANT PCR

Facility

$349.00

Service Code	CPT 87799
Hospital Charge Code	900912932
Hospital Revenue Code	306
Min. Negotiated Rate	$191.95
Max. Negotiated Rate	$279.20
Rate for Payer: Cash Price	$157.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$279.20
Rate for Payer: Health Smart Auto/Commercial	$209.40
Rate for Payer: LLUH Dept of Risk Management WC	$191.95
Rate for Payer: Multiplan Commercial	$261.75

HC SOF ADENOVIRUS DNA QUANT PCR

Facility

$349.00

Service Code	CPT 87799
Hospital Charge Code	900912932
Hospital Revenue Code	306
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$279.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$209.40
Rate for Payer: Aetna of CA Government/Medicare	$209.40
Rate for Payer: Cash Price	$157.05
Rate for Payer: Cash Price	$157.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$279.20
Rate for Payer: Health Smart Auto/Commercial	$209.40
Rate for Payer: Intervalley Health Plan Commercial	$42.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$209.40
Rate for Payer: LLUH Dept of Risk Management WC	$191.95
Rate for Payer: Multiplan Commercial	$261.75

HC SOGDX 230 GCH1 81479

Facility

$925.00

Service Code	CPT 81479
Hospital Charge Code	900914803
Hospital Revenue Code	309
Min. Negotiated Rate	$508.75
Max. Negotiated Rate	$740.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$555.00
Rate for Payer: Aetna of CA Government/Medicare	$555.00
Rate for Payer: Cash Price	$416.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$740.00
Rate for Payer: Health Smart Auto/Commercial	$555.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$555.00
Rate for Payer: LLUH Dept of Risk Management WC	$508.75
Rate for Payer: Multiplan Commercial	$693.75

HC SOGDX 230 GCH1 81479

Facility

$925.00

Service Code	CPT 81479
Hospital Charge Code	900914803
Hospital Revenue Code	309
Min. Negotiated Rate	$508.75
Max. Negotiated Rate	$740.00
Rate for Payer: Cash Price	$416.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$740.00
Rate for Payer: Health Smart Auto/Commercial	$555.00
Rate for Payer: LLUH Dept of Risk Management WC	$508.75
Rate for Payer: Multiplan Commercial	$693.75

HC SOGDX 317 SIX1 81479

Facility

$675.00

Service Code	CPT 81479
Hospital Charge Code	900914808
Hospital Revenue Code	309
Min. Negotiated Rate	$371.25
Max. Negotiated Rate	$540.00
Rate for Payer: Cash Price	$303.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$540.00
Rate for Payer: Health Smart Auto/Commercial	$405.00
Rate for Payer: LLUH Dept of Risk Management WC	$371.25
Rate for Payer: Multiplan Commercial	$506.25

HC SOGDX 317 SIX1 81479

Facility

$675.00

Service Code	CPT 81479
Hospital Charge Code	900914808
Hospital Revenue Code	309
Min. Negotiated Rate	$371.25
Max. Negotiated Rate	$540.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$405.00
Rate for Payer: Aetna of CA Government/Medicare	$405.00
Rate for Payer: Cash Price	$303.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$540.00
Rate for Payer: Health Smart Auto/Commercial	$405.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$405.00
Rate for Payer: LLUH Dept of Risk Management WC	$371.25
Rate for Payer: Multiplan Commercial	$506.25

HC SOGDX 559 TP53 GENE 81405

Facility

$1,395.00

Service Code	CPT 81405
Hospital Charge Code	900914849
Hospital Revenue Code	309
Min. Negotiated Rate	$767.25
Max. Negotiated Rate	$1,116.00
Rate for Payer: Cash Price	$627.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,116.00
Rate for Payer: Health Smart Auto/Commercial	$837.00
Rate for Payer: LLUH Dept of Risk Management WC	$767.25
Rate for Payer: Multiplan Commercial	$1,046.25

HC SOGDX 559 TP53 GENE 81405

Facility

$1,395.00

Service Code	CPT 81405
Hospital Charge Code	900914849
Hospital Revenue Code	309
Min. Negotiated Rate	$301.35
Max. Negotiated Rate	$1,116.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$837.00
Rate for Payer: Aetna of CA Government/Medicare	$837.00
Rate for Payer: Cash Price	$627.75
Rate for Payer: Cash Price	$627.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,116.00
Rate for Payer: Health Smart Auto/Commercial	$837.00
Rate for Payer: Intervalley Health Plan Commercial	$301.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$837.00
Rate for Payer: LLUH Dept of Risk Management WC	$767.25
Rate for Payer: Multiplan Commercial	$1,046.25

HC SOLUBLE FIBRIN

Facility

$85.00

Service Code	CPT 85366
Hospital Charge Code	900910118
Hospital Revenue Code	305
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$80.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.00
Rate for Payer: Aetna of CA Government/Medicare	$51.00
Rate for Payer: Cash Price	$38.25
Rate for Payer: Cash Price	$38.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.00
Rate for Payer: Health Smart Auto/Commercial	$51.00
Rate for Payer: Intervalley Health Plan Commercial	$80.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.00
Rate for Payer: LLUH Dept of Risk Management WC	$46.75
Rate for Payer: Multiplan Commercial	$63.75

HC SOLUBLE FIBRIN

Facility

$121.00

Service Code	CPT 85366
Hospital Charge Code	900910118
Hospital Revenue Code	305
Min. Negotiated Rate	$66.55
Max. Negotiated Rate	$96.80
Rate for Payer: Cash Price	$54.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$96.80
Rate for Payer: Health Smart Auto/Commercial	$72.60
Rate for Payer: LLUH Dept of Risk Management WC	$66.55
Rate for Payer: Multiplan Commercial	$90.75

HC SOM 11-DEOXYCORTISOL (COMPOUNDS)

Facility

$120.00

Service Code	CPT 82633
Hospital Charge Code	900911027
Hospital Revenue Code	301
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$96.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$96.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: Multiplan Commercial	$90.00

HC SOM 11-DEOXYCORTISOL (COMPOUNDS)

Facility

$120.00

Service Code	CPT 82633
Hospital Charge Code	900911027
Hospital Revenue Code	301
Min. Negotiated Rate	$30.98
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$96.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Intervalley Health Plan Commercial	$30.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: Multiplan Commercial	$90.00

HC SOM 17-OH-PROGESTERONE

Facility

$17.55

Service Code	CPT 83498
Hospital Charge Code	900911017
Hospital Revenue Code	301
Min. Negotiated Rate	$9.65
Max. Negotiated Rate	$27.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.53
Rate for Payer: Aetna of CA Government/Medicare	$10.53
Rate for Payer: Cash Price	$17.55
Rate for Payer: Cash Price	$17.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.04
Rate for Payer: Health Smart Auto/Commercial	$10.53
Rate for Payer: Intervalley Health Plan Commercial	$27.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.53
Rate for Payer: LLUH Dept of Risk Management WC	$9.65
Rate for Payer: Multiplan Commercial	$13.16

HC SOM 17-OH-PROGESTERONE

Facility

$17.55

Service Code	CPT 83498
Hospital Charge Code	900911017
Hospital Revenue Code	301
Min. Negotiated Rate	$9.65
Max. Negotiated Rate	$14.04
Rate for Payer: Cash Price	$17.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.04
Rate for Payer: Health Smart Auto/Commercial	$10.53
Rate for Payer: LLUH Dept of Risk Management WC	$9.65
Rate for Payer: Multiplan Commercial	$13.16

HC SOM 18-OH CORTICOSTERONE

Facility

$169.00

Service Code	CPT 82542
Hospital Charge Code	900910709
Hospital Revenue Code	301
Min. Negotiated Rate	$92.95
Max. Negotiated Rate	$135.20
Rate for Payer: Cash Price	$169.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$135.20
Rate for Payer: Health Smart Auto/Commercial	$101.40
Rate for Payer: LLUH Dept of Risk Management WC	$92.95
Rate for Payer: Multiplan Commercial	$126.75

HC SOM 18-OH CORTICOSTERONE

Facility

$169.00

Service Code	CPT 82542
Hospital Charge Code	900910709
Hospital Revenue Code	301
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$135.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$101.40
Rate for Payer: Aetna of CA Government/Medicare	$101.40
Rate for Payer: Cash Price	$169.00
Rate for Payer: Cash Price	$169.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$135.20
Rate for Payer: Health Smart Auto/Commercial	$101.40
Rate for Payer: Intervalley Health Plan Commercial	$24.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$101.40
Rate for Payer: LLUH Dept of Risk Management WC	$92.95
Rate for Payer: Multiplan Commercial	$126.75

HC SOM 199PC 86301

Facility

$29.81

Service Code	CPT 86301
Hospital Charge Code	900914879
Hospital Revenue Code	301
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$23.85
Rate for Payer: Cash Price	$29.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.85
Rate for Payer: Health Smart Auto/Commercial	$17.89
Rate for Payer: LLUH Dept of Risk Management WC	$16.40
Rate for Payer: Multiplan Commercial	$22.36

HC SOM 199PC 86301

Facility

$29.81

Service Code	CPT 86301
Hospital Charge Code	900914879
Hospital Revenue Code	301
Min. Negotiated Rate	$16.40
Max. Negotiated Rate	$23.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.89
Rate for Payer: Aetna of CA Government/Medicare	$17.89
Rate for Payer: Cash Price	$29.81
Rate for Payer: Cash Price	$29.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$23.85
Rate for Payer: Health Smart Auto/Commercial	$17.89
Rate for Payer: Intervalley Health Plan Commercial	$20.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.89
Rate for Payer: LLUH Dept of Risk Management WC	$16.40
Rate for Payer: Multiplan Commercial	$22.36

HC SOM 2 DAYS TURNAROUND 6800

Facility

$27.00

Service Code	CPT U0005
Hospital Charge Code	900915350
Hospital Revenue Code	306
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.20
Rate for Payer: Aetna of CA Government/Medicare	$16.20
Rate for Payer: Cash Price	$27.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.60
Rate for Payer: Health Smart Auto/Commercial	$16.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.20
Rate for Payer: LLUH Dept of Risk Management WC	$14.85
Rate for Payer: Multiplan Commercial	$20.25

Know your out-of-pocket cost for care.

All Charges