Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

HC SOM AMITRIPTYLINE LEVEL

Facility

$234.83

Service Code	CPT 80335
Hospital Charge Code	900912504
Hospital Revenue Code	301
Min. Negotiated Rate	$129.16
Max. Negotiated Rate	$187.86
Rate for Payer: Cash Price	$234.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$187.86
Rate for Payer: Health Smart Auto/Commercial	$140.90
Rate for Payer: LLUH Dept of Risk Management WC	$129.16
Rate for Payer: Multiplan Commercial	$176.12

HC SOM AMITRIPTYLINE LEVEL

Facility

$234.83

Service Code	CPT 80335
Hospital Charge Code	900912504
Hospital Revenue Code	301
Min. Negotiated Rate	$129.16
Max. Negotiated Rate	$187.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$140.90
Rate for Payer: Aetna of CA Government/Medicare	$140.90
Rate for Payer: Cash Price	$234.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$187.86
Rate for Payer: Health Smart Auto/Commercial	$140.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$140.90
Rate for Payer: LLUH Dept of Risk Management WC	$129.16
Rate for Payer: Multiplan Commercial	$176.12

HC SOM AMOBARBITAL

Facility

$285.90

Service Code	CPT 80345
Hospital Charge Code	900910550
Hospital Revenue Code	301
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$228.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$171.54
Rate for Payer: Aetna of CA Government/Medicare	$171.54
Rate for Payer: Cash Price	$285.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$228.72
Rate for Payer: Health Smart Auto/Commercial	$171.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$171.54
Rate for Payer: LLUH Dept of Risk Management WC	$157.25
Rate for Payer: Multiplan Commercial	$214.43

HC SOM AMOBARBITAL

Facility

$285.90

Service Code	CPT 80345
Hospital Charge Code	900910550
Hospital Revenue Code	301
Min. Negotiated Rate	$157.25
Max. Negotiated Rate	$228.72
Rate for Payer: Cash Price	$285.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$228.72
Rate for Payer: Health Smart Auto/Commercial	$171.54
Rate for Payer: LLUH Dept of Risk Management WC	$157.25
Rate for Payer: Multiplan Commercial	$214.43

HC SOM AMOXAPINE

Facility

$65.46

Service Code	CPT 80335
Hospital Charge Code	900911071
Hospital Revenue Code	301
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$52.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.28
Rate for Payer: Aetna of CA Government/Medicare	$39.28
Rate for Payer: Cash Price	$65.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.37
Rate for Payer: Health Smart Auto/Commercial	$39.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.28
Rate for Payer: LLUH Dept of Risk Management WC	$36.00
Rate for Payer: Multiplan Commercial	$49.09

HC SOM AMOXAPINE

Facility

$65.46

Service Code	CPT 80335
Hospital Charge Code	900911071
Hospital Revenue Code	301
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$52.37
Rate for Payer: Cash Price	$65.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.37
Rate for Payer: Health Smart Auto/Commercial	$39.28
Rate for Payer: LLUH Dept of Risk Management WC	$36.00
Rate for Payer: Multiplan Commercial	$49.09

HC SOM AMPHETAMINE QUANT

Facility

$20.78

Service Code	CPT 80325
Hospital Charge Code	900910720
Hospital Revenue Code	301
Min. Negotiated Rate	$11.43
Max. Negotiated Rate	$16.62
Rate for Payer: Cash Price	$20.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.62
Rate for Payer: Health Smart Auto/Commercial	$12.47
Rate for Payer: LLUH Dept of Risk Management WC	$11.43
Rate for Payer: Multiplan Commercial	$15.59

HC SOM AMPHETAMINE QUANT

Facility

$20.78

Service Code	CPT 80325
Hospital Charge Code	900910720
Hospital Revenue Code	301
Min. Negotiated Rate	$11.43
Max. Negotiated Rate	$16.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.47
Rate for Payer: Aetna of CA Government/Medicare	$12.47
Rate for Payer: Cash Price	$20.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.62
Rate for Payer: Health Smart Auto/Commercial	$12.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.47
Rate for Payer: LLUH Dept of Risk Management WC	$11.43
Rate for Payer: Multiplan Commercial	$15.59

HC SOM AMYLASE BF

Facility

$10.00

Service Code	CPT 82150
Hospital Charge Code	900914004
Hospital Revenue Code	301
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Cash Price	$10.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.00
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Commercial	$7.50

HC SOM AMYLASE BF

Facility

$10.00

Service Code	CPT 82150
Hospital Charge Code	900914004
Hospital Revenue Code	301
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.00
Rate for Payer: Aetna of CA Government/Medicare	$6.00
Rate for Payer: Cash Price	$10.00
Rate for Payer: Cash Price	$10.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.00
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Intervalley Health Plan Commercial	$6.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Commercial	$7.50

HC SOM ANDROSTENEDIONE

Facility

$24.00

Service Code	CPT 82157
Hospital Charge Code	900911011
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$24.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Commercial	$18.00

HC SOM ANDROSTENEDIONE

Facility

$24.00

Service Code	CPT 82157
Hospital Charge Code	900911011
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$29.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.40
Rate for Payer: Aetna of CA Government/Medicare	$14.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: Intervalley Health Plan Commercial	$29.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Commercial	$18.00

HC SOM ANGIOTENSIN 1 CONVERTING ENZYM

Facility

$12.00

Service Code	CPT 82164
Hospital Charge Code	900911119
Hospital Revenue Code	301
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.60
Rate for Payer: Cash Price	$12.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Commercial	$9.00

HC SOM ANGIOTENSIN 1 CONVERTING ENZYM

Facility

$12.00

Service Code	CPT 82164
Hospital Charge Code	900911119
Hospital Revenue Code	301
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$14.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.60
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Intervalley Health Plan Commercial	$14.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: Multiplan Commercial	$9.00

HC SOM ANGIOTENSIN CONVERT ENZ CS

Facility

$68.50

Service Code	CPT 82164
Hospital Charge Code	900913826
Hospital Revenue Code	301
Min. Negotiated Rate	$14.60
Max. Negotiated Rate	$54.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$41.10
Rate for Payer: Aetna of CA Government/Medicare	$41.10
Rate for Payer: Cash Price	$68.50
Rate for Payer: Cash Price	$68.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.80
Rate for Payer: Health Smart Auto/Commercial	$41.10
Rate for Payer: Intervalley Health Plan Commercial	$14.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$41.10
Rate for Payer: LLUH Dept of Risk Management WC	$37.67
Rate for Payer: Multiplan Commercial	$51.38

HC SOM ANGIOTENSIN CONVERT ENZ CS

Facility

$68.50

Service Code	CPT 82164
Hospital Charge Code	900913826
Hospital Revenue Code	301
Min. Negotiated Rate	$37.67
Max. Negotiated Rate	$54.80
Rate for Payer: Cash Price	$68.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.80
Rate for Payer: Health Smart Auto/Commercial	$41.10
Rate for Payer: LLUH Dept of Risk Management WC	$37.67
Rate for Payer: Multiplan Commercial	$51.38

HC SOM ANTI-DIURETIC HORMONE

Facility

$80.00

Service Code	CPT 84588
Hospital Charge Code	900911035
Hospital Revenue Code	301
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$64.00
Rate for Payer: Health Smart Auto/Commercial	$48.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.00
Rate for Payer: Multiplan Commercial	$60.00

HC SOM ANTI-DIURETIC HORMONE

Facility

$80.00

Service Code	CPT 84588
Hospital Charge Code	900911035
Hospital Revenue Code	301
Min. Negotiated Rate	$33.94
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.00
Rate for Payer: Aetna of CA Government/Medicare	$48.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$64.00
Rate for Payer: Health Smart Auto/Commercial	$48.00
Rate for Payer: Intervalley Health Plan Commercial	$33.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.00
Rate for Payer: Multiplan Commercial	$60.00

HC SOM ANTI-GBM TITER AB

Facility

$26.00

Service Code	CPT 83516
Hospital Charge Code	900911188
Hospital Revenue Code	301
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$20.80
Rate for Payer: Cash Price	$26.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.80
Rate for Payer: Health Smart Auto/Commercial	$15.60
Rate for Payer: LLUH Dept of Risk Management WC	$14.30
Rate for Payer: Multiplan Commercial	$19.50

HC SOM ANTI-GBM TITER AB

Facility

$26.00

Service Code	CPT 83516
Hospital Charge Code	900911188
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$20.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.60
Rate for Payer: Aetna of CA Government/Medicare	$15.60
Rate for Payer: Cash Price	$26.00
Rate for Payer: Cash Price	$26.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.80
Rate for Payer: Health Smart Auto/Commercial	$15.60
Rate for Payer: Intervalley Health Plan Commercial	$11.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.60
Rate for Payer: LLUH Dept of Risk Management WC	$14.30
Rate for Payer: Multiplan Commercial	$19.50

HC SOM ANTI-LIVERKIDNEY MICROSOMAL AB

Facility

$21.76

Service Code	CPT 86376
Hospital Charge Code	900911453
Hospital Revenue Code	302
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$17.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.06
Rate for Payer: Aetna of CA Government/Medicare	$13.06
Rate for Payer: Cash Price	$21.76
Rate for Payer: Cash Price	$21.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.41
Rate for Payer: Health Smart Auto/Commercial	$13.06
Rate for Payer: Intervalley Health Plan Commercial	$14.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.06
Rate for Payer: LLUH Dept of Risk Management WC	$11.97
Rate for Payer: Multiplan Commercial	$16.32

HC SOM ANTI-LIVERKIDNEY MICROSOMAL AB

Facility

$21.76

Service Code	CPT 86376
Hospital Charge Code	900911453
Hospital Revenue Code	302
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$17.41
Rate for Payer: Cash Price	$21.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.41
Rate for Payer: Health Smart Auto/Commercial	$13.06
Rate for Payer: LLUH Dept of Risk Management WC	$11.97
Rate for Payer: Multiplan Commercial	$16.32

HC SOM ANTIMULLERIAN HORMONE, S

Facility

$55.00

Service Code	CPT 83520
Hospital Charge Code	900912908
Hospital Revenue Code	302
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.00
Rate for Payer: Aetna of CA Government/Medicare	$33.00
Rate for Payer: Cash Price	$55.00
Rate for Payer: Cash Price	$55.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Intervalley Health Plan Commercial	$17.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Commercial	$41.25

HC SOM ANTIMULLERIAN HORMONE, S

Facility

$55.00

Service Code	CPT 83520
Hospital Charge Code	900912908
Hospital Revenue Code	302
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$44.00
Rate for Payer: Cash Price	$55.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Commercial	$41.25

Know your out-of-pocket cost for care.

All Charges