Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM ENTEROVIRUS PCR CSF

Facility

$39.23

Service Code	CPT 87498
Hospital Charge Code	900910771
Hospital Revenue Code	301
Min. Negotiated Rate	$21.58
Max. Negotiated Rate	$31.38
Rate for Payer: Cash Price	$39.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.38
Rate for Payer: Health Smart Auto/Commercial	$23.54
Rate for Payer: LLUH Dept of Risk Management WC	$21.58
Rate for Payer: Multiplan Commercial	$29.42

HC SOM ERYTHROPOIETIN

Facility

$15.68

Service Code	CPT 82668
Hospital Charge Code	900911227
Hospital Revenue Code	301
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$18.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.41
Rate for Payer: Aetna of CA Government/Medicare	$9.41
Rate for Payer: Cash Price	$15.68
Rate for Payer: Cash Price	$15.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.54
Rate for Payer: Health Smart Auto/Commercial	$9.41
Rate for Payer: Intervalley Health Plan Commercial	$18.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.41
Rate for Payer: LLUH Dept of Risk Management WC	$8.62
Rate for Payer: Multiplan Commercial	$11.76

HC SOM ERYTHROPOIETIN

Facility

$15.68

Service Code	CPT 82668
Hospital Charge Code	900911227
Hospital Revenue Code	301
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$12.54
Rate for Payer: Cash Price	$15.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.54
Rate for Payer: Health Smart Auto/Commercial	$9.41
Rate for Payer: LLUH Dept of Risk Management WC	$8.62
Rate for Payer: Multiplan Commercial	$11.76

HC SOM ESTRADIOL

Facility

$23.80

Service Code	CPT 82671
Hospital Charge Code	900911014
Hospital Revenue Code	301
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$19.04
Rate for Payer: Cash Price	$23.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.04
Rate for Payer: Health Smart Auto/Commercial	$14.28
Rate for Payer: LLUH Dept of Risk Management WC	$13.09
Rate for Payer: Multiplan Commercial	$17.85

HC SOM ESTRADIOL

Facility

$23.80

Service Code	CPT 82671
Hospital Charge Code	900911014
Hospital Revenue Code	301
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$32.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.28
Rate for Payer: Aetna of CA Government/Medicare	$14.28
Rate for Payer: Cash Price	$23.80
Rate for Payer: Cash Price	$23.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.04
Rate for Payer: Health Smart Auto/Commercial	$14.28
Rate for Payer: Intervalley Health Plan Commercial	$32.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.28
Rate for Payer: LLUH Dept of Risk Management WC	$13.09
Rate for Payer: Multiplan Commercial	$17.85

HC SOM ESTRIOL

Facility

$202.56

Service Code	CPT 82677
Hospital Charge Code	900911036
Hospital Revenue Code	301
Min. Negotiated Rate	$111.41
Max. Negotiated Rate	$162.05
Rate for Payer: Cash Price	$202.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$162.05
Rate for Payer: Health Smart Auto/Commercial	$121.54
Rate for Payer: LLUH Dept of Risk Management WC	$111.41
Rate for Payer: Multiplan Commercial	$151.92

HC SOM ESTRIOL

Facility

$202.56

Service Code	CPT 82677
Hospital Charge Code	900911036
Hospital Revenue Code	301
Min. Negotiated Rate	$24.18
Max. Negotiated Rate	$162.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$121.54
Rate for Payer: Aetna of CA Government/Medicare	$121.54
Rate for Payer: Cash Price	$202.56
Rate for Payer: Cash Price	$202.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$162.05
Rate for Payer: Health Smart Auto/Commercial	$121.54
Rate for Payer: Intervalley Health Plan Commercial	$24.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$121.54
Rate for Payer: LLUH Dept of Risk Management WC	$111.41
Rate for Payer: Multiplan Commercial	$151.92

HC SOM ESTRONE

Facility

$20.00

Service Code	CPT 82679
Hospital Charge Code	900911482
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$24.95
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	$24.95
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 ESTRONE

Facility

$20.00

Service Code	CPT 82679
Hospital Charge Code	900911482
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 ETHANOL, U

Facility

$49.90

Service Code	CPT 80320
Hospital Charge Code	900912919
Hospital Revenue Code	301
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$39.92
Rate for Payer: Cash Price	$49.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.92
Rate for Payer: Health Smart Auto/Commercial	$29.94
Rate for Payer: LLUH Dept of Risk Management WC	$27.45
Rate for Payer: Multiplan Commercial	$37.42

HC SOM ETHANOL, U

Facility

$49.90

Service Code	CPT 80320
Hospital Charge Code	900912919
Hospital Revenue Code	301
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$39.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.94
Rate for Payer: Aetna of CA Government/Medicare	$29.94
Rate for Payer: Cash Price	$49.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$39.92
Rate for Payer: Health Smart Auto/Commercial	$29.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.94
Rate for Payer: LLUH Dept of Risk Management WC	$27.45
Rate for Payer: Multiplan Commercial	$37.42

HC SOM ETHCHLORVINYL (PLACIDYL)

Facility

$45.00

Service Code	CPT 80307
Hospital Charge Code	900910427
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$62.14
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	$62.14
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 ETHCHLORVINYL (PLACIDYL)

Facility

$45.00

Service Code	CPT 80307
Hospital Charge Code	900910427
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 ETHOSUXIMIDE (ZARONTIN)

Facility

$35.00

Service Code	CPT 80168
Hospital Charge Code	900910338
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 ETHOSUXIMIDE (ZARONTIN)

Facility

$35.00

Service Code	CPT 80168
Hospital Charge Code	900910338
Hospital Revenue Code	301
Min. Negotiated Rate	$16.34
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	$16.34
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 EVEROLIMUS B

Facility

$41.42

Service Code	CPT 80169
Hospital Charge Code	900913810
Hospital Revenue Code	301
Min. Negotiated Rate	$22.78
Max. Negotiated Rate	$33.14
Rate for Payer: Cash Price	$41.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.14
Rate for Payer: Health Smart Auto/Commercial	$24.85
Rate for Payer: LLUH Dept of Risk Management WC	$22.78
Rate for Payer: Multiplan Commercial	$31.07

HC SOM EVEROLIMUS B

Facility

$41.42

Service Code	CPT 80169
Hospital Charge Code	900913810
Hospital Revenue Code	301
Min. Negotiated Rate	$13.73
Max. Negotiated Rate	$33.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.85
Rate for Payer: Aetna of CA Government/Medicare	$24.85
Rate for Payer: Cash Price	$41.42
Rate for Payer: Cash Price	$41.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$33.14
Rate for Payer: Health Smart Auto/Commercial	$24.85
Rate for Payer: Intervalley Health Plan Commercial	$13.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.85
Rate for Payer: LLUH Dept of Risk Management WC	$22.78
Rate for Payer: Multiplan Commercial	$31.07

HC SOM FACTOR IX BETHESDA UNITS

Facility

$110.00

Service Code	CPT 85335
Hospital Charge Code	900915517
Hospital Revenue Code	300
Min. Negotiated Rate	$60.50
Max. Negotiated Rate	$88.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.00
Rate for Payer: Health Smart Auto/Commercial	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$60.50
Rate for Payer: Multiplan Commercial	$82.50

HC SOM FACTOR IX BETHESDA UNITS

Facility

$110.00

Service Code	CPT 85335
Hospital Charge Code	900915517
Hospital Revenue Code	300
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$66.00
Rate for Payer: Aetna of CA Government/Medicare	$66.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.00
Rate for Payer: Health Smart Auto/Commercial	$66.00
Rate for Payer: Intervalley Health Plan Commercial	$12.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$60.50
Rate for Payer: Multiplan Commercial	$82.50

HC SOM FACTOR IX INHIB PROF INTERP

Facility

$75.00

Service Code	CPT 85390
Hospital Charge Code	900915516
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 FACTOR IX INHIB PROF INTERP

Facility

$75.00

Service Code	CPT 85390
Hospital Charge Code	900915516
Hospital Revenue Code	300
Min. Negotiated Rate	$15.48
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	$15.48
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 FACTOR IX INH. SCREEN

Facility

$55.00

Service Code	CPT 85335
Hospital Charge Code	900915515
Hospital Revenue Code	300
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

HC SOM FACTOR IX INH. SCREEN

Facility

$55.00

Service Code	CPT 85335
Hospital Charge Code	900915515
Hospital Revenue Code	300
Min. Negotiated Rate	$12.87
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	$12.87
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 FACTOR VIII BETHESDA UNITS

Facility

$110.00

Service Code	CPT 85335
Hospital Charge Code	900915511
Hospital Revenue Code	300
Min. Negotiated Rate	$60.50
Max. Negotiated Rate	$88.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.00
Rate for Payer: Health Smart Auto/Commercial	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$60.50
Rate for Payer: Multiplan Commercial	$82.50

HC SOM FACTOR VIII BETHESDA UNITS

Facility

$110.00

Service Code	CPT 85335
Hospital Charge Code	900915511
Hospital Revenue Code	300
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$66.00
Rate for Payer: Aetna of CA Government/Medicare	$66.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Cash Price	$110.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.00
Rate for Payer: Health Smart Auto/Commercial	$66.00
Rate for Payer: Intervalley Health Plan Commercial	$12.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$60.50
Rate for Payer: Multiplan Commercial	$82.50

Know your out-of-pocket cost for care.

All Charges