Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM COMPLEMENT C-2

Facility

$50.00

Service Code	CPT 86161
Hospital Charge Code	900911110
Hospital Revenue Code	302
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Intervalley Health Plan Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Commercial	$37.50

HC SOM COMPLEMENT C-2

Facility

$50.00

Service Code	CPT 86161
Hospital Charge Code	900911110
Hospital Revenue Code	302
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Commercial	$37.50

HC SOM COMPLEMENT C-5

Facility

$45.00

Service Code	CPT 86160
Hospital Charge Code	900911042
Hospital Revenue Code	302
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Intervalley Health Plan Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Commercial	$33.75

HC SOM COMPLEMENT C-5

Facility

$45.00

Service Code	CPT 86160
Hospital Charge Code	900911042
Hospital Revenue Code	302
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Commercial	$33.75

HC SOM CONF HC DRUG ABUSE SUR 12, U

Facility

$150.00

Service Code	CPT 80307
Hospital Charge Code	900912913
Hospital Revenue Code	301
Min. Negotiated Rate	$62.14
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$90.00
Rate for Payer: Aetna of CA Government/Medicare	$90.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: Intervalley Health Plan Commercial	$62.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Commercial	$112.50

HC SOM CONF HC DRUG ABUSE SUR 12, U

Facility

$150.00

Service Code	CPT 80307
Hospital Charge Code	900912913
Hospital Revenue Code	301
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$120.00
Rate for Payer: Cash Price	$150.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Commercial	$112.50

HC SOM COPPER LIVER TISSUE

Facility

$65.00

Service Code	CPT 82525
Hospital Charge Code	900911029
Hospital Revenue Code	301
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.00
Rate for Payer: Aetna of CA Government/Medicare	$39.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.00
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: Intervalley Health Plan Commercial	$12.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Commercial	$48.75

HC SOM COPPER LIVER TISSUE

Facility

$65.00

Service Code	CPT 82525
Hospital Charge Code	900911029
Hospital Revenue Code	301
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$52.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.00
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Commercial	$48.75

HC SOM COPPER SERUM

Facility

$14.32

Service Code	CPT 82525
Hospital Charge Code	900911099
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$12.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.59
Rate for Payer: Aetna of CA Government/Medicare	$8.59
Rate for Payer: Cash Price	$14.32
Rate for Payer: Cash Price	$14.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.46
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: Intervalley Health Plan Commercial	$12.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Commercial	$10.74

HC SOM COPPER SERUM

Facility

$14.32

Service Code	CPT 82525
Hospital Charge Code	900911099
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$11.46
Rate for Payer: Cash Price	$14.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.46
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Commercial	$10.74

HC SOM COPPER URINE

Facility

$45.00

Service Code	CPT 82525
Hospital Charge Code	900911134
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Commercial	$33.75

HC SOM COPPER URINE

Facility

$45.00

Service Code	CPT 82525
Hospital Charge Code	900911134
Hospital Revenue Code	301
Min. Negotiated Rate	$12.41
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Intervalley Health Plan Commercial	$12.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Commercial	$33.75

HC SOM CORTISOL FREE RANDOM UR

Facility

$25.00

Service Code	CPT 82530
Hospital Charge Code	900912608
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 CORTISOL FREE RANDOM UR

Facility

$25.00

Service Code	CPT 82530
Hospital Charge Code	900912608
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	$16.71
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 CORTISOL FREE SERUM

Facility

$38.00

Service Code	CPT 82530
Hospital Charge Code	900910672
Hospital Revenue Code	301
Min. Negotiated Rate	$16.71
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.80
Rate for Payer: Aetna of CA Government/Medicare	$22.80
Rate for Payer: Cash Price	$38.00
Rate for Payer: Cash Price	$38.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.40
Rate for Payer: Health Smart Auto/Commercial	$22.80
Rate for Payer: Intervalley Health Plan Commercial	$16.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.80
Rate for Payer: LLUH Dept of Risk Management WC	$20.90
Rate for Payer: Multiplan Commercial	$28.50

HC SOM CORTISOL FREE SERUM

Facility

$38.00

Service Code	CPT 82530
Hospital Charge Code	900910672
Hospital Revenue Code	301
Min. Negotiated Rate	$20.90
Max. Negotiated Rate	$30.40
Rate for Payer: Cash Price	$38.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.40
Rate for Payer: Health Smart Auto/Commercial	$22.80
Rate for Payer: LLUH Dept of Risk Management WC	$20.90
Rate for Payer: Multiplan Commercial	$28.50

HC SOM CORTISOL FREE UR

Facility

$25.00

Service Code	CPT 82530
Hospital Charge Code	900914673
Hospital Revenue Code	300
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	$16.71
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 CORTISOL FREE UR

Facility

$25.00

Service Code	CPT 82530
Hospital Charge Code	900914673
Hospital Revenue Code	300
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 CORTISOL FREE URINE

Facility

$25.00

Service Code	CPT 82530
Hospital Charge Code	900911026
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	$16.71
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 CORTISOL FREE URINE

Facility

$25.00

Service Code	CPT 82530
Hospital Charge Code	900911026
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 COUMADIN LEVEL

Facility

$109.00

Service Code	CPT 80375
Hospital Charge Code	900911161
Hospital Revenue Code	301
Min. Negotiated Rate	$59.95
Max. Negotiated Rate	$87.20
Rate for Payer: Cash Price	$109.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$87.20
Rate for Payer: Health Smart Auto/Commercial	$65.40
Rate for Payer: LLUH Dept of Risk Management WC	$59.95
Rate for Payer: Multiplan Commercial	$81.75

HC SOM COUMADIN LEVEL

Facility

$109.00

Service Code	CPT 80375
Hospital Charge Code	900911161
Hospital Revenue Code	301
Min. Negotiated Rate	$59.95
Max. Negotiated Rate	$87.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$65.40
Rate for Payer: Aetna of CA Government/Medicare	$65.40
Rate for Payer: Cash Price	$109.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$87.20
Rate for Payer: Health Smart Auto/Commercial	$65.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$65.40
Rate for Payer: LLUH Dept of Risk Management WC	$59.95
Rate for Payer: Multiplan Commercial	$81.75

HC SOM COXIELLA BURNETTI AB PANEL

Facility

$10.02

Service Code	CPT 86638
Hospital Charge Code	900911769
Hospital Revenue Code	302
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$12.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.01
Rate for Payer: Aetna of CA Government/Medicare	$6.01
Rate for Payer: Cash Price	$10.02
Rate for Payer: Cash Price	$10.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.02
Rate for Payer: Health Smart Auto/Commercial	$6.01
Rate for Payer: Intervalley Health Plan Commercial	$12.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.01
Rate for Payer: LLUH Dept of Risk Management WC	$5.51
Rate for Payer: Multiplan Commercial	$7.51

HC SOM COXIELLA BURNETTI AB PANEL

Facility

$10.02

Service Code	CPT 86638
Hospital Charge Code	900911769
Hospital Revenue Code	302
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$8.02
Rate for Payer: Cash Price	$10.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.02
Rate for Payer: Health Smart Auto/Commercial	$6.01
Rate for Payer: LLUH Dept of Risk Management WC	$5.51
Rate for Payer: Multiplan Commercial	$7.51

HC SOM C-PEPTIDE

Facility

$12.00

Service Code	CPT 84681
Hospital Charge Code	900911116
Hospital Revenue Code	301
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$20.81
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	$20.81
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

Know your out-of-pocket cost for care.

All Charges