Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM DIHYDROTESTERONE

Facility

$41.00

Service Code	CPT 82642
Hospital Charge Code	900911013
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$32.80
Rate for Payer: Cash Price	$41.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.80
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Commercial	$30.75

HC SOM DILANTIN FREE

Facility

$20.00

Service Code	CPT 80186
Hospital Charge Code	900911414
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	$13.76
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 DILANTIN FREE

Facility

$20.00

Service Code	CPT 80186
Hospital Charge Code	900911414
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 DILANTIN LV FREE PHENY TOT

Facility

$20.00

Service Code	CPT 80185
Hospital Charge Code	900912809
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	$13.25
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 DILANTIN LV FREE PHENY TOT

Facility

$20.00

Service Code	CPT 80185
Hospital Charge Code	900912809
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 DIPHTHERIA ANTITOXOID (ELISA)

Facility

$35.00

Service Code	CPT 86317
Hospital Charge Code	900911755
Hospital Revenue Code	302
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 DIPHTHERIA ANTITOXOID (ELISA)

Facility

$35.00

Service Code	CPT 86317
Hospital Charge Code	900911755
Hospital Revenue Code	302
Min. Negotiated Rate	$14.99
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	$14.99
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 DNA AND RNA EXTRACT AND HOLD

Facility

$75.00

Service Code	CPT 81401
Hospital Charge Code	900915521
Hospital Revenue Code	300
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 DNA AND RNA EXTRACT AND HOLD

Facility

$75.00

Service Code	CPT 81401
Hospital Charge Code	900915521
Hospital Revenue Code	300
Min. Negotiated Rate	$41.25
Max. Negotiated Rate	$137.00
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	$137.00
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 DNA EXTRACTION

Facility

$203.61

Service Code	CPT 81401
Hospital Charge Code	900910721
Hospital Revenue Code	301
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 DNA EXTRACTION

Facility

$203.61

Service Code	CPT 81401
Hospital Charge Code	900910721
Hospital Revenue Code	301
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 DRUG SCREEN PRESCRIPTION/OTC U

Facility

$47.95

Service Code	CPT 80307
Hospital Charge Code	900912877
Hospital Revenue Code	301
Min. Negotiated Rate	$26.37
Max. Negotiated Rate	$38.36
Rate for Payer: Cash Price	$47.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.36
Rate for Payer: Health Smart Auto/Commercial	$28.77
Rate for Payer: LLUH Dept of Risk Management WC	$26.37
Rate for Payer: Multiplan Commercial	$35.96

HC SOM DRUG SCREEN PRESCRIPTION/OTC U

Facility

$47.95

Service Code	CPT 80307
Hospital Charge Code	900912877
Hospital Revenue Code	301
Min. Negotiated Rate	$26.37
Max. Negotiated Rate	$62.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.77
Rate for Payer: Aetna of CA Government/Medicare	$28.77
Rate for Payer: Cash Price	$47.95
Rate for Payer: Cash Price	$47.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.36
Rate for Payer: Health Smart Auto/Commercial	$28.77
Rate for Payer: Intervalley Health Plan Commercial	$62.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.77
Rate for Payer: LLUH Dept of Risk Management WC	$26.37
Rate for Payer: Multiplan Commercial	$35.96

HC SOM DRUG SCRN MECONIUM AMPHETAMINE

Facility

$50.00

Service Code	CPT 80307
Hospital Charge Code	900911008
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$62.14
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	$62.14
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 DRUG SCRN MECONIUM AMPHETAMINE

Facility

$50.00

Service Code	CPT 80307
Hospital Charge Code	900911008
Hospital Revenue Code	301
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 EBV PCR QUANT

Facility

$50.27

Service Code	CPT 87798
Hospital Charge Code	900911395
Hospital Revenue Code	301
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$40.22
Rate for Payer: Cash Price	$50.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.22
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Commercial	$37.70

HC SOM EBV PCR QUANT

Facility

$50.27

Service Code	CPT 87798
Hospital Charge Code	900911395
Hospital Revenue Code	301
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$40.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.16
Rate for Payer: Aetna of CA Government/Medicare	$30.16
Rate for Payer: Cash Price	$50.27
Rate for Payer: Cash Price	$50.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.22
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Commercial	$37.70

HC SOM ECHINOCOCCUS AB

Facility

$30.00

Service Code	CPT 86682
Hospital Charge Code	900911392
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 ECHINOCOCCUS AB

Facility

$30.00

Service Code	CPT 86682
Hospital Charge Code	900911392
Hospital Revenue Code	302
Min. Negotiated Rate	$13.01
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	$13.01
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 EHRLICHOSIS

Facility

$35.00

Service Code	CPT 86666
Hospital Charge Code	900911388
Hospital Revenue Code	302
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 EHRLICHOSIS

Facility

$35.00

Service Code	CPT 86666
Hospital Charge Code	900911388
Hospital Revenue Code	302
Min. Negotiated Rate	$10.18
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	$10.18
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 ELECTROPHORES,PROTEN,RANDM

Facility

$20.05

Service Code	CPT 84166
Hospital Charge Code	900912891
Hospital Revenue Code	301
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$16.04
Rate for Payer: Cash Price	$20.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.04
Rate for Payer: Health Smart Auto/Commercial	$12.03
Rate for Payer: LLUH Dept of Risk Management WC	$11.03
Rate for Payer: Multiplan Commercial	$15.04

HC SOM ELECTROPHORES,PROTEN,RANDM

Facility

$20.05

Service Code	CPT 84166
Hospital Charge Code	900912891
Hospital Revenue Code	301
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$17.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.03
Rate for Payer: Aetna of CA Government/Medicare	$12.03
Rate for Payer: Cash Price	$20.05
Rate for Payer: Cash Price	$20.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.04
Rate for Payer: Health Smart Auto/Commercial	$12.03
Rate for Payer: Intervalley Health Plan Commercial	$17.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.03
Rate for Payer: LLUH Dept of Risk Management WC	$11.03
Rate for Payer: Multiplan Commercial	$15.04

HC SOM ENC DPPX AB CBA

Facility

$38.07

Service Code	CPT 86255
Hospital Charge Code	900915478
Hospital Revenue Code	300
Min. Negotiated Rate	$20.94
Max. Negotiated Rate	$30.46
Rate for Payer: Cash Price	$38.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.46
Rate for Payer: Health Smart Auto/Commercial	$22.84
Rate for Payer: LLUH Dept of Risk Management WC	$20.94
Rate for Payer: Multiplan Commercial	$28.55

HC SOM ENC DPPX AB CBA

Facility

$38.07

Service Code	CPT 86255
Hospital Charge Code	900915478
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$30.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.84
Rate for Payer: Aetna of CA Government/Medicare	$22.84
Rate for Payer: Cash Price	$38.07
Rate for Payer: Cash Price	$38.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.46
Rate for Payer: Health Smart Auto/Commercial	$22.84
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.84
Rate for Payer: LLUH Dept of Risk Management WC	$20.94
Rate for Payer: Multiplan Commercial	$28.55

Know your out-of-pocket cost for care.

All Charges