Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM ANTI-NEUTROPHIL AB

Facility

$68.00

Service Code	CPT 86021
Hospital Charge Code	900911211
Hospital Revenue Code	302
Min. Negotiated Rate	$15.05
Max. Negotiated Rate	$54.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Intervalley Health Plan Commercial	$15.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Commercial	$51.00

HC SOM ANTI-NEUTROPHIL AB

Facility

$68.00

Service Code	CPT 86021
Hospital Charge Code	900911211
Hospital Revenue Code	302
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$54.40
Rate for Payer: Cash Price	$68.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Commercial	$51.00

HC SOM ANTI-NEUTROPHIL CYTOPLASM ANTI

Facility

$23.15

Service Code	CPT 86255
Hospital Charge Code	900910287
Hospital Revenue Code	302
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$18.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.89
Rate for Payer: Aetna of CA Government/Medicare	$13.89
Rate for Payer: Cash Price	$23.15
Rate for Payer: Cash Price	$23.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.52
Rate for Payer: Health Smart Auto/Commercial	$13.89
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.89
Rate for Payer: LLUH Dept of Risk Management WC	$12.73
Rate for Payer: Multiplan Commercial	$17.36

HC SOM ANTI-NEUTROPHIL CYTOPLASM ANTI

Facility

$23.15

Service Code	CPT 86255
Hospital Charge Code	900910287
Hospital Revenue Code	302
Min. Negotiated Rate	$12.73
Max. Negotiated Rate	$18.52
Rate for Payer: Cash Price	$23.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.52
Rate for Payer: Health Smart Auto/Commercial	$13.89
Rate for Payer: LLUH Dept of Risk Management WC	$12.73
Rate for Payer: Multiplan Commercial	$17.36

HC SOM ANTINUCLEAR AB,HEP-2 SUB,S

Facility

$10.00

Service Code	CPT 86039
Hospital Charge Code	900912903
Hospital Revenue Code	302
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 ANTINUCLEAR AB,HEP-2 SUB,S

Facility

$10.00

Service Code	CPT 86039
Hospital Charge Code	900912903
Hospital Revenue Code	302
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$11.16
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	$11.16
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 ANTINUCLEAR ANTIBODY(MULTI

Facility

$16.00

Service Code	CPT 86039
Hospital Charge Code	900912906
Hospital Revenue Code	302
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$12.80
Rate for Payer: Cash Price	$16.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.80
Rate for Payer: Health Smart Auto/Commercial	$9.60
Rate for Payer: LLUH Dept of Risk Management WC	$8.80
Rate for Payer: Multiplan Commercial	$12.00

HC SOM ANTINUCLEAR ANTIBODY(MULTI

Facility

$16.00

Service Code	CPT 86039
Hospital Charge Code	900912906
Hospital Revenue Code	302
Min. Negotiated Rate	$8.80
Max. Negotiated Rate	$12.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.60
Rate for Payer: Aetna of CA Government/Medicare	$9.60
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.80
Rate for Payer: Health Smart Auto/Commercial	$9.60
Rate for Payer: Intervalley Health Plan Commercial	$11.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.60
Rate for Payer: LLUH Dept of Risk Management WC	$8.80
Rate for Payer: Multiplan Commercial	$12.00

HC SOM ANTI-SMOOTH MUSCLE

Facility

$12.90

Service Code	CPT 86015
Hospital Charge Code	900911176
Hospital Revenue Code	302
Min. Negotiated Rate	$7.09
Max. Negotiated Rate	$12.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.74
Rate for Payer: Aetna of CA Government/Medicare	$7.74
Rate for Payer: Cash Price	$12.90
Rate for Payer: Cash Price	$12.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.32
Rate for Payer: Health Smart Auto/Commercial	$7.74
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.74
Rate for Payer: LLUH Dept of Risk Management WC	$7.09
Rate for Payer: Multiplan Commercial	$9.68

HC SOM ANTI-SMOOTH MUSCLE

Facility

$12.90

Service Code	CPT 86015
Hospital Charge Code	900911176
Hospital Revenue Code	302
Min. Negotiated Rate	$7.09
Max. Negotiated Rate	$10.32
Rate for Payer: Cash Price	$12.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.32
Rate for Payer: Health Smart Auto/Commercial	$7.74
Rate for Payer: LLUH Dept of Risk Management WC	$7.09
Rate for Payer: Multiplan Commercial	$9.68

HC SOM ANTI-STRIATED MUSCLE AB

Facility

$24.00

Service Code	CPT 83520
Hospital Charge Code	900911368
Hospital Revenue Code	302
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
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	$17.27
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 ANTI-STRIATED MUSCLE AB

Facility

$24.00

Service Code	CPT 83520
Hospital Charge Code	900911368
Hospital Revenue Code	302
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 APOLIPOPROTEIN A-1

Facility

$20.00

Service Code	CPT 82172
Hospital Charge Code	900910800
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$21.09
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	$21.09
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 APOLIPOPROTEIN A-1

Facility

$20.00

Service Code	CPT 82172
Hospital Charge Code	900910800
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 APOLIPOPROTEIN B

Facility

$16.77

Service Code	CPT 82172
Hospital Charge Code	900910801
Hospital Revenue Code	301
Min. Negotiated Rate	$9.22
Max. Negotiated Rate	$13.42
Rate for Payer: Cash Price	$16.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.42
Rate for Payer: Health Smart Auto/Commercial	$10.06
Rate for Payer: LLUH Dept of Risk Management WC	$9.22
Rate for Payer: Multiplan Commercial	$12.58

HC SOM APOLIPOPROTEIN B

Facility

$16.77

Service Code	CPT 82172
Hospital Charge Code	900910801
Hospital Revenue Code	301
Min. Negotiated Rate	$9.22
Max. Negotiated Rate	$21.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.06
Rate for Payer: Aetna of CA Government/Medicare	$10.06
Rate for Payer: Cash Price	$16.77
Rate for Payer: Cash Price	$16.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.42
Rate for Payer: Health Smart Auto/Commercial	$10.06
Rate for Payer: Intervalley Health Plan Commercial	$21.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.06
Rate for Payer: LLUH Dept of Risk Management WC	$9.22
Rate for Payer: Multiplan Commercial	$12.58

HC SOM APOLIPOPROTEIN E GENOTYPING

Facility

$203.61

Service Code	CPT 81401
Hospital Charge Code	900914646
Hospital Revenue Code	310
Min. Negotiated Rate	$111.99
Max. Negotiated Rate	$162.89
Rate for Payer: Cash Price	$203.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$162.89
Rate for Payer: Health Smart Auto/Commercial	$122.17
Rate for Payer: LLUH Dept of Risk Management WC	$111.99
Rate for Payer: Multiplan Commercial	$152.71

HC SOM APOLIPOPROTEIN E GENOTYPING

Facility

$203.61

Service Code	CPT 81401
Hospital Charge Code	900914646
Hospital Revenue Code	310
Min. Negotiated Rate	$111.99
Max. Negotiated Rate	$162.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$122.17
Rate for Payer: Aetna of CA Government/Medicare	$122.17
Rate for Payer: Cash Price	$203.61
Rate for Payer: Cash Price	$203.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$162.89
Rate for Payer: Health Smart Auto/Commercial	$122.17
Rate for Payer: Intervalley Health Plan Commercial	$137.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$122.17
Rate for Payer: LLUH Dept of Risk Management WC	$111.99
Rate for Payer: Multiplan Commercial	$152.71

HC SOM ARSENIC BLOOD

Facility

$25.00

Service Code	CPT 82175
Hospital Charge Code	900910563
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

HC SOM ARSENIC BLOOD

Facility

$25.00

Service Code	CPT 82175
Hospital Charge Code	900910563
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Intervalley Health Plan Commercial	$18.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

HC SOM ARSENIC URINE QUANT

Facility

$25.00

Service Code	CPT 82175
Hospital Charge Code	900911289
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Intervalley Health Plan Commercial	$18.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

HC SOM ARSENIC URINE QUANT

Facility

$25.00

Service Code	CPT 82175
Hospital Charge Code	900911289
Hospital Revenue Code	301
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

HC SOM ARYLSULFATASE A, URINE

Facility

$125.00

Service Code	CPT 84311
Hospital Charge Code	900910723
Hospital Revenue Code	301
Min. Negotiated Rate	$68.75
Max. Negotiated Rate	$100.00
Rate for Payer: Cash Price	$125.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.00
Rate for Payer: Health Smart Auto/Commercial	$75.00
Rate for Payer: LLUH Dept of Risk Management WC	$68.75
Rate for Payer: Multiplan Commercial	$93.75

HC SOM ARYLSULFATASE A, URINE

Facility

$125.00

Service Code	CPT 84311
Hospital Charge Code	900910723
Hospital Revenue Code	301
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.00
Rate for Payer: Aetna of CA Government/Medicare	$75.00
Rate for Payer: Cash Price	$125.00
Rate for Payer: Cash Price	$125.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.00
Rate for Payer: Health Smart Auto/Commercial	$75.00
Rate for Payer: Intervalley Health Plan Commercial	$8.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.00
Rate for Payer: LLUH Dept of Risk Management WC	$68.75
Rate for Payer: Multiplan Commercial	$93.75

HC SOM ASPERGILLUS AG BAL

Facility

$20.00

Service Code	CPT 87305
Hospital Charge Code	900915471
Hospital Revenue Code	300
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	$11.98
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

Know your out-of-pocket cost for care.

All Charges