Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM FACTOR VIII INHIB PROF INTERP

Facility

$75.00

Service Code	CPT 85390
Hospital Charge Code	900915510
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 VIII INHIB PROF INTERP

Facility

$75.00

Service Code	CPT 85390
Hospital Charge Code	900915510
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 VIII INH. SCREEN

Facility

$125.00

Service Code	CPT 85335
Hospital Charge Code	900912803
Hospital Revenue Code	305
Min. Negotiated Rate	$12.87
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	$12.87
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 FACTOR VIII INH. SCREEN

Facility

$125.00

Service Code	CPT 85335
Hospital Charge Code	900912803
Hospital Revenue Code	305
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 FANBF 86038

Facility

$75.00

Service Code	CPT 86038
Hospital Charge Code	900914925
Hospital Revenue Code	301
Min. Negotiated Rate	$12.09
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	$12.09
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 FANBF 86038

Facility

$75.00

Service Code	CPT 86038
Hospital Charge Code	900914925
Hospital Revenue Code	301
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 FAP KNOWN MUT EXTRACT

Facility

$318.21

Service Code	CPT 81202
Hospital Charge Code	900914620
Hospital Revenue Code	309
Min. Negotiated Rate	$175.02
Max. Negotiated Rate	$280.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$190.93
Rate for Payer: Aetna of CA Government/Medicare	$190.93
Rate for Payer: Cash Price	$318.21
Rate for Payer: Cash Price	$318.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$254.57
Rate for Payer: Health Smart Auto/Commercial	$190.93
Rate for Payer: Intervalley Health Plan Commercial	$280.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$190.93
Rate for Payer: LLUH Dept of Risk Management WC	$175.02
Rate for Payer: Multiplan Commercial	$238.66

HC SOM FAP KNOWN MUT EXTRACT

Facility

$318.21

Service Code	CPT 81202
Hospital Charge Code	900914620
Hospital Revenue Code	309
Min. Negotiated Rate	$175.02
Max. Negotiated Rate	$254.57
Rate for Payer: Cash Price	$318.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$254.57
Rate for Payer: Health Smart Auto/Commercial	$190.93
Rate for Payer: LLUH Dept of Risk Management WC	$175.02
Rate for Payer: Multiplan Commercial	$238.66

HC SOM FAT FECAL QUANT

Facility

$28.02

Service Code	CPT 82710
Hospital Charge Code	900911139
Hospital Revenue Code	301
Min. Negotiated Rate	$15.41
Max. Negotiated Rate	$22.42
Rate for Payer: Cash Price	$28.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.42
Rate for Payer: Health Smart Auto/Commercial	$16.81
Rate for Payer: LLUH Dept of Risk Management WC	$15.41
Rate for Payer: Multiplan Commercial	$21.02

HC SOM FAT FECAL QUANT

Facility

$28.02

Service Code	CPT 82710
Hospital Charge Code	900911139
Hospital Revenue Code	301
Min. Negotiated Rate	$15.41
Max. Negotiated Rate	$22.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.81
Rate for Payer: Aetna of CA Government/Medicare	$16.81
Rate for Payer: Cash Price	$28.02
Rate for Payer: Cash Price	$28.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.42
Rate for Payer: Health Smart Auto/Commercial	$16.81
Rate for Payer: Intervalley Health Plan Commercial	$16.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.81
Rate for Payer: LLUH Dept of Risk Management WC	$15.41
Rate for Payer: Multiplan Commercial	$21.02

HC SOM FATTY ACIDS FREE

Facility

$200.00

Service Code	CPT 82725
Hospital Charge Code	900910286
Hospital Revenue Code	301
Min. Negotiated Rate	$18.77
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$120.00
Rate for Payer: Aetna of CA Government/Medicare	$120.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: Intervalley Health Plan Commercial	$18.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Commercial	$150.00

HC SOM FATTY ACIDS FREE

Facility

$200.00

Service Code	CPT 82725
Hospital Charge Code	900910286
Hospital Revenue Code	301
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Commercial	$150.00

HC SOM FATTY ACIDS PEROXISOMAL

Facility

$150.00

Service Code	CPT 82726
Hospital Charge Code	900911471
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 FATTY ACIDS PEROXISOMAL

Facility

$150.00

Service Code	CPT 82726
Hospital Charge Code	900911471
Hospital Revenue Code	301
Min. Negotiated Rate	$19.75
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	$19.75
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 FBP1 88273

Facility

$84.86

Service Code	CPT 88273
Hospital Charge Code	900914874
Hospital Revenue Code	309
Min. Negotiated Rate	$34.81
Max. Negotiated Rate	$67.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.92
Rate for Payer: Aetna of CA Government/Medicare	$50.92
Rate for Payer: Cash Price	$84.86
Rate for Payer: Cash Price	$84.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.89
Rate for Payer: Health Smart Auto/Commercial	$50.92
Rate for Payer: Intervalley Health Plan Commercial	$34.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.92
Rate for Payer: LLUH Dept of Risk Management WC	$46.67
Rate for Payer: Multiplan Commercial	$63.65

HC SOM FBP1 88273

Facility

$84.86

Service Code	CPT 88273
Hospital Charge Code	900914874
Hospital Revenue Code	309
Min. Negotiated Rate	$46.67
Max. Negotiated Rate	$67.89
Rate for Payer: Cash Price	$84.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$67.89
Rate for Payer: Health Smart Auto/Commercial	$50.92
Rate for Payer: LLUH Dept of Risk Management WC	$46.67
Rate for Payer: Multiplan Commercial	$63.65

HC SOM FBP1 88291

Facility

$71.15

Service Code	CPT 88291
Hospital Charge Code	900914873
Hospital Revenue Code	309
Min. Negotiated Rate	$39.13
Max. Negotiated Rate	$56.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.69
Rate for Payer: Aetna of CA Government/Medicare	$42.69
Rate for Payer: Cash Price	$71.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.92
Rate for Payer: Health Smart Auto/Commercial	$42.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.69
Rate for Payer: LLUH Dept of Risk Management WC	$39.13
Rate for Payer: Multiplan Commercial	$53.36

HC SOM FBP1 88291

Facility

$71.15

Service Code	CPT 88291
Hospital Charge Code	900914873
Hospital Revenue Code	309
Min. Negotiated Rate	$39.13
Max. Negotiated Rate	$56.92
Rate for Payer: Cash Price	$71.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.92
Rate for Payer: Health Smart Auto/Commercial	$42.69
Rate for Payer: LLUH Dept of Risk Management WC	$39.13
Rate for Payer: Multiplan Commercial	$53.36

HC SOM FCFQN 86171

Facility

$67.00

Service Code	CPT 86171
Hospital Charge Code	900914248
Hospital Revenue Code	302
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$53.60
Rate for Payer: Cash Price	$67.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.60
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Commercial	$50.25

HC SOM FCFQN 86171

Facility

$67.00

Service Code	CPT 86171
Hospital Charge Code	900914248
Hospital Revenue Code	302
Min. Negotiated Rate	$10.01
Max. Negotiated Rate	$53.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.20
Rate for Payer: Aetna of CA Government/Medicare	$40.20
Rate for Payer: Cash Price	$67.00
Rate for Payer: Cash Price	$67.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.60
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: Intervalley Health Plan Commercial	$10.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Commercial	$50.25

HC SOM FDSAC 82657

Facility

$168.92

Service Code	CPT 82657
Hospital Charge Code	900914885
Hospital Revenue Code	301
Min. Negotiated Rate	$22.17
Max. Negotiated Rate	$135.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$101.35
Rate for Payer: Aetna of CA Government/Medicare	$101.35
Rate for Payer: Cash Price	$168.92
Rate for Payer: Cash Price	$168.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$135.14
Rate for Payer: Health Smart Auto/Commercial	$101.35
Rate for Payer: Intervalley Health Plan Commercial	$22.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$101.35
Rate for Payer: LLUH Dept of Risk Management WC	$92.91
Rate for Payer: Multiplan Commercial	$126.69

HC SOM FDSAC 82657

Facility

$168.92

Service Code	CPT 82657
Hospital Charge Code	900914885
Hospital Revenue Code	301
Min. Negotiated Rate	$92.91
Max. Negotiated Rate	$135.14
Rate for Payer: Cash Price	$168.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$135.14
Rate for Payer: Health Smart Auto/Commercial	$101.35
Rate for Payer: LLUH Dept of Risk Management WC	$92.91
Rate for Payer: Multiplan Commercial	$126.69

HC SOM FEAGR 86682

Facility

$52.57

Service Code	CPT 86682
Hospital Charge Code	900914927
Hospital Revenue Code	302
Min. Negotiated Rate	$28.91
Max. Negotiated Rate	$42.06
Rate for Payer: Cash Price	$52.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.06
Rate for Payer: Health Smart Auto/Commercial	$31.54
Rate for Payer: LLUH Dept of Risk Management WC	$28.91
Rate for Payer: Multiplan Commercial	$39.43

HC SOM FEAGR 86682

Facility

$52.57

Service Code	CPT 86682
Hospital Charge Code	900914927
Hospital Revenue Code	302
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$42.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.54
Rate for Payer: Aetna of CA Government/Medicare	$31.54
Rate for Payer: Cash Price	$52.57
Rate for Payer: Cash Price	$52.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.06
Rate for Payer: Health Smart Auto/Commercial	$31.54
Rate for Payer: Intervalley Health Plan Commercial	$13.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.54
Rate for Payer: LLUH Dept of Risk Management WC	$28.91
Rate for Payer: Multiplan Commercial	$39.43

HC SOM FELBAMATE S

Facility

$21.17

Service Code	CPT 80167
Hospital Charge Code	900914198
Hospital Revenue Code	301
Min. Negotiated Rate	$11.64
Max. Negotiated Rate	$16.94
Rate for Payer: Cash Price	$21.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.94
Rate for Payer: Health Smart Auto/Commercial	$12.70
Rate for Payer: LLUH Dept of Risk Management WC	$11.64
Rate for Payer: Multiplan Commercial	$15.88

Know your out-of-pocket cost for care.

All Charges