Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM ALK PHOS TOTAL (SO)

Facility

$5.73

Service Code	CPT 84075
Hospital Charge Code	900912824
Hospital Revenue Code	301
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$5.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.44
Rate for Payer: Aetna of CA Government/Medicare	$3.44
Rate for Payer: Cash Price	$5.73
Rate for Payer: Cash Price	$5.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.58
Rate for Payer: Health Smart Auto/Commercial	$3.44
Rate for Payer: Intervalley Health Plan Commercial	$5.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.44
Rate for Payer: LLUH Dept of Risk Management WC	$3.15
Rate for Payer: Multiplan Commercial	$4.30

HC SOM ALK PHOS TOTAL (SO)

Facility

$5.73

Service Code	CPT 84075
Hospital Charge Code	900912824
Hospital Revenue Code	301
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$4.58
Rate for Payer: Cash Price	$5.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.58
Rate for Payer: Health Smart Auto/Commercial	$3.44
Rate for Payer: LLUH Dept of Risk Management WC	$3.15
Rate for Payer: Multiplan Commercial	$4.30

HC SOM ALPHA-1-ANTITRYPSIN PHENO A1AT

Facility

$12.77

Service Code	CPT 82103
Hospital Charge Code	900912818
Hospital Revenue Code	301
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$10.22
Rate for Payer: Cash Price	$12.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.22
Rate for Payer: Health Smart Auto/Commercial	$7.66
Rate for Payer: LLUH Dept of Risk Management WC	$7.02
Rate for Payer: Multiplan Commercial	$9.58

HC SOM ALPHA-1-ANTITRYPSIN PHENO A1AT

Facility

$12.77

Service Code	CPT 82103
Hospital Charge Code	900912818
Hospital Revenue Code	301
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$13.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.66
Rate for Payer: Aetna of CA Government/Medicare	$7.66
Rate for Payer: Cash Price	$12.77
Rate for Payer: Cash Price	$12.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.22
Rate for Payer: Health Smart Auto/Commercial	$7.66
Rate for Payer: Intervalley Health Plan Commercial	$13.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.66
Rate for Payer: LLUH Dept of Risk Management WC	$7.02
Rate for Payer: Multiplan Commercial	$9.58

HC SOM ALPHA 1-ANTITRYPSIN PHENOTYPE

Facility

$12.77

Service Code	CPT 82104
Hospital Charge Code	900911068
Hospital Revenue Code	301
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$10.22
Rate for Payer: Cash Price	$12.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.22
Rate for Payer: Health Smart Auto/Commercial	$7.66
Rate for Payer: LLUH Dept of Risk Management WC	$7.02
Rate for Payer: Multiplan Commercial	$9.58

HC SOM ALPHA 1-ANTITRYPSIN PHENOTYPE

Facility

$12.77

Service Code	CPT 82104
Hospital Charge Code	900911068
Hospital Revenue Code	301
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$14.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.66
Rate for Payer: Aetna of CA Government/Medicare	$7.66
Rate for Payer: Cash Price	$12.77
Rate for Payer: Cash Price	$12.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.22
Rate for Payer: Health Smart Auto/Commercial	$7.66
Rate for Payer: Intervalley Health Plan Commercial	$14.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.66
Rate for Payer: LLUH Dept of Risk Management WC	$7.02
Rate for Payer: Multiplan Commercial	$9.58

HC SOM ALPHA-1-ANTITRYPSIN, STOOL

Facility

$20.00

Service Code	CPT 82103
Hospital Charge Code	900910858
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Intervalley Health Plan Commercial	$13.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC SOM ALPHA-1-ANTITRYPSIN, STOOL

Facility

$20.00

Service Code	CPT 82103
Hospital Charge Code	900910858
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC SOM ALPHA-2-MACROGLOBULIN

Facility

$30.00

Service Code	CPT 83883
Hospital Charge Code	900911487
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$30.00
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: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

HC SOM ALPHA-2-MACROGLOBULIN

Facility

$30.00

Service Code	CPT 83883
Hospital Charge Code	900911487
Hospital Revenue Code	301
Min. Negotiated Rate	$13.60
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	$30.00
Rate for Payer: Cash Price	$30.00
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	$13.60
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 SOM ALPHA-FETOPROTEIN, AMNIOTIC FL

Facility

$35.00

Service Code	CPT 82106
Hospital Charge Code	900910946
Hospital Revenue Code	301
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.00
Rate for Payer: Aetna of CA Government/Medicare	$21.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.00
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: Intervalley Health Plan Commercial	$17.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Commercial	$26.25

HC SOM ALPHA-FETOPROTEIN, AMNIOTIC FL

Facility

$35.00

Service Code	CPT 82106
Hospital Charge Code	900910946
Hospital Revenue Code	301
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$28.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.00
Rate for Payer: Health Smart Auto/Commercial	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Commercial	$26.25

HC SOM ALPHA FETOPROTEIN CSF

Facility

$15.00

Service Code	CPT 86316
Hospital Charge Code	900910585
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Commercial	$11.25

HC SOM ALPHA FETOPROTEIN CSF

Facility

$15.00

Service Code	CPT 86316
Hospital Charge Code	900910585
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$20.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Intervalley Health Plan Commercial	$20.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Commercial	$11.25

HC SOM ALPHA GALACTOSIDASE

Facility

$250.00

Service Code	CPT 82657
Hospital Charge Code	900910718
Hospital Revenue Code	301
Min. Negotiated Rate	$137.50
Max. Negotiated Rate	$200.00
Rate for Payer: Cash Price	$250.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$200.00
Rate for Payer: Health Smart Auto/Commercial	$150.00
Rate for Payer: LLUH Dept of Risk Management WC	$137.50
Rate for Payer: Multiplan Commercial	$187.50

HC SOM ALPHA GALACTOSIDASE

Facility

$250.00

Service Code	CPT 82657
Hospital Charge Code	900910718
Hospital Revenue Code	301
Min. Negotiated Rate	$22.17
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$150.00
Rate for Payer: Aetna of CA Government/Medicare	$150.00
Rate for Payer: Cash Price	$250.00
Rate for Payer: Cash Price	$250.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$200.00
Rate for Payer: Health Smart Auto/Commercial	$150.00
Rate for Payer: Intervalley Health Plan Commercial	$22.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$150.00
Rate for Payer: LLUH Dept of Risk Management WC	$137.50
Rate for Payer: Multiplan Commercial	$187.50

HC SOM ALUMINUM

Facility

$19.99

Service Code	CPT 82108
Hospital Charge Code	900911262
Hospital Revenue Code	301
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$25.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.99
Rate for Payer: Aetna of CA Government/Medicare	$11.99
Rate for Payer: Cash Price	$19.99
Rate for Payer: Cash Price	$19.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.99
Rate for Payer: Health Smart Auto/Commercial	$11.99
Rate for Payer: Intervalley Health Plan Commercial	$25.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.99
Rate for Payer: LLUH Dept of Risk Management WC	$10.99
Rate for Payer: Multiplan Commercial	$14.99

HC SOM ALUMINUM

Facility

$19.99

Service Code	CPT 82108
Hospital Charge Code	900911262
Hospital Revenue Code	301
Min. Negotiated Rate	$10.99
Max. Negotiated Rate	$15.99
Rate for Payer: Cash Price	$19.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.99
Rate for Payer: Health Smart Auto/Commercial	$11.99
Rate for Payer: LLUH Dept of Risk Management WC	$10.99
Rate for Payer: Multiplan Commercial	$14.99

HC SOM AMEBIASIS AB TITER

Facility

$30.00

Service Code	CPT 86753
Hospital Charge Code	900911754
Hospital Revenue Code	302
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$30.00
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: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

HC SOM AMEBIASIS AB TITER

Facility

$30.00

Service Code	CPT 86753
Hospital Charge Code	900911754
Hospital Revenue Code	302
Min. Negotiated Rate	$12.39
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	$30.00
Rate for Payer: Cash Price	$30.00
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	$12.39
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 SOM AMINO ACID QUANT UR RANDOM

Facility

$100.00

Service Code	CPT 82139
Hospital Charge Code	900911210
Hospital Revenue Code	301
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$80.00
Rate for Payer: Cash Price	$100.00
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 SOM AMINO ACID QUANT UR RANDOM

Facility

$100.00

Service Code	CPT 82139
Hospital Charge Code	900911210
Hospital Revenue Code	301
Min. Negotiated Rate	$16.87
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.00
Rate for Payer: Aetna of CA Government/Medicare	$60.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cash Price	$100.00
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: Intervalley Health Plan Commercial	$16.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.00
Rate for Payer: Multiplan Commercial	$75.00

HC SOM AMINO ACIDS PLASMA

Facility

$75.00

Service Code	CPT 82139
Hospital Charge Code	900910486
Hospital Revenue Code	301
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$60.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Commercial	$56.25

HC SOM AMINO ACIDS PLASMA

Facility

$75.00

Service Code	CPT 82139
Hospital Charge Code	900910486
Hospital Revenue Code	301
Min. Negotiated Rate	$16.87
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$45.00
Rate for Payer: Aetna of CA Government/Medicare	$45.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$60.00
Rate for Payer: Health Smart Auto/Commercial	$45.00
Rate for Payer: Intervalley Health Plan Commercial	$16.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$45.00
Rate for Payer: LLUH Dept of Risk Management WC	$41.25
Rate for Payer: Multiplan Commercial	$56.25

HC SOM AMIODARONE

Facility

$30.00

Service Code	CPT 80151
Hospital Charge Code	900911286
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
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	$30.00
Rate for Payer: Cash Price	$30.00
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	$18.64
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

Know your out-of-pocket cost for care.

All Charges