Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM FNTSM 82492B

Facility

$175.00

Service Code	CPT 82542
Hospital Charge Code	900914869
Hospital Revenue Code	301
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.00
Rate for Payer: Aetna of CA Government/Medicare	$105.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Cash Price	$175.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.00
Rate for Payer: Health Smart Auto/Commercial	$105.00
Rate for Payer: Intervalley Health Plan Commercial	$24.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.00
Rate for Payer: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Commercial	$131.25

HC SOM FOLATE, RBC

Facility

$52.50

Service Code	CPT 82747
Hospital Charge Code	900913862
Hospital Revenue Code	301
Min. Negotiated Rate	$28.88
Max. Negotiated Rate	$42.00
Rate for Payer: Cash Price	$52.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.00
Rate for Payer: Health Smart Auto/Commercial	$31.50
Rate for Payer: LLUH Dept of Risk Management WC	$28.88
Rate for Payer: Multiplan Commercial	$39.38

HC SOM FOLATE, RBC

Facility

$52.50

Service Code	CPT 82747
Hospital Charge Code	900913862
Hospital Revenue Code	301
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.50
Rate for Payer: Aetna of CA Government/Medicare	$31.50
Rate for Payer: Cash Price	$52.50
Rate for Payer: Cash Price	$52.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.00
Rate for Payer: Health Smart Auto/Commercial	$31.50
Rate for Payer: Intervalley Health Plan Commercial	$17.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.50
Rate for Payer: LLUH Dept of Risk Management WC	$28.88
Rate for Payer: Multiplan Commercial	$39.38

HC SOM FPSAP 84153

Facility

$89.50

Service Code	CPT 84153
Hospital Charge Code	900914765
Hospital Revenue Code	301
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$71.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.70
Rate for Payer: Aetna of CA Government/Medicare	$53.70
Rate for Payer: Cash Price	$89.50
Rate for Payer: Cash Price	$89.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.60
Rate for Payer: Health Smart Auto/Commercial	$53.70
Rate for Payer: Intervalley Health Plan Commercial	$18.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.70
Rate for Payer: LLUH Dept of Risk Management WC	$49.23
Rate for Payer: Multiplan Commercial	$67.12

HC SOM FPSAP 84153

Facility

$89.50

Service Code	CPT 84153
Hospital Charge Code	900914765
Hospital Revenue Code	301
Min. Negotiated Rate	$49.23
Max. Negotiated Rate	$71.60
Rate for Payer: Cash Price	$89.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.60
Rate for Payer: Health Smart Auto/Commercial	$53.70
Rate for Payer: LLUH Dept of Risk Management WC	$49.23
Rate for Payer: Multiplan Commercial	$67.12

HC SOM FQUET 82491

Facility

$66.16

Service Code	CPT 82542
Hospital Charge Code	900914892
Hospital Revenue Code	301
Min. Negotiated Rate	$36.39
Max. Negotiated Rate	$52.93
Rate for Payer: Cash Price	$66.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.93
Rate for Payer: Health Smart Auto/Commercial	$39.70
Rate for Payer: LLUH Dept of Risk Management WC	$36.39
Rate for Payer: Multiplan Commercial	$49.62

HC SOM FQUET 82491

Facility

$66.16

Service Code	CPT 82542
Hospital Charge Code	900914892
Hospital Revenue Code	301
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$52.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.70
Rate for Payer: Aetna of CA Government/Medicare	$39.70
Rate for Payer: Cash Price	$66.16
Rate for Payer: Cash Price	$66.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.93
Rate for Payer: Health Smart Auto/Commercial	$39.70
Rate for Payer: Intervalley Health Plan Commercial	$24.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.70
Rate for Payer: LLUH Dept of Risk Management WC	$36.39
Rate for Payer: Multiplan Commercial	$49.62

HC SOM FRAGILE X MOLECULAR ANALYSIS

Facility

$450.00

Service Code	CPT 81243
Hospital Charge Code	900912503
Hospital Revenue Code	301
Min. Negotiated Rate	$247.50
Max. Negotiated Rate	$360.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$360.00
Rate for Payer: Health Smart Auto/Commercial	$270.00
Rate for Payer: LLUH Dept of Risk Management WC	$247.50
Rate for Payer: Multiplan Commercial	$337.50

HC SOM FRAGILE X MOLECULAR ANALYSIS

Facility

$450.00

Service Code	CPT 81243
Hospital Charge Code	900912503
Hospital Revenue Code	301
Min. Negotiated Rate	$57.04
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$270.00
Rate for Payer: Aetna of CA Government/Medicare	$270.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$360.00
Rate for Payer: Health Smart Auto/Commercial	$270.00
Rate for Payer: Intervalley Health Plan Commercial	$57.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$270.00
Rate for Payer: LLUH Dept of Risk Management WC	$247.50
Rate for Payer: Multiplan Commercial	$337.50

HC SOM FRANSICELLA AB

Facility

$47.50

Service Code	CPT 86000
Hospital Charge Code	900911647
Hospital Revenue Code	302
Min. Negotiated Rate	$26.12
Max. Negotiated Rate	$38.00
Rate for Payer: Cash Price	$47.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.00
Rate for Payer: Health Smart Auto/Commercial	$28.50
Rate for Payer: LLUH Dept of Risk Management WC	$26.12
Rate for Payer: Multiplan Commercial	$35.62

HC SOM FRANSICELLA AB

Facility

$47.50

Service Code	CPT 86000
Hospital Charge Code	900911647
Hospital Revenue Code	302
Min. Negotiated Rate	$6.98
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.50
Rate for Payer: Aetna of CA Government/Medicare	$28.50
Rate for Payer: Cash Price	$47.50
Rate for Payer: Cash Price	$47.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.00
Rate for Payer: Health Smart Auto/Commercial	$28.50
Rate for Payer: Intervalley Health Plan Commercial	$6.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.50
Rate for Payer: LLUH Dept of Risk Management WC	$26.12
Rate for Payer: Multiplan Commercial	$35.62

HC SOM FREE FATTY ACIDS

Facility

$32.00

Service Code	CPT 82725
Hospital Charge Code	900914522
Hospital Revenue Code	301
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$25.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.20
Rate for Payer: Aetna of CA Government/Medicare	$19.20
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.60
Rate for Payer: Health Smart Auto/Commercial	$19.20
Rate for Payer: Intervalley Health Plan Commercial	$18.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.20
Rate for Payer: LLUH Dept of Risk Management WC	$17.60
Rate for Payer: Multiplan Commercial	$24.00

HC SOM FREE FATTY ACIDS

Facility

$32.00

Service Code	CPT 82725
Hospital Charge Code	900914522
Hospital Revenue Code	301
Min. Negotiated Rate	$17.60
Max. Negotiated Rate	$25.60
Rate for Payer: Cash Price	$32.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.60
Rate for Payer: Health Smart Auto/Commercial	$19.20
Rate for Payer: LLUH Dept of Risk Management WC	$17.60
Rate for Payer: Multiplan Commercial	$24.00

HC SOM FR TYR IDX BIND CAP

Facility

$9.27

Service Code	CPT 84479
Hospital Charge Code	900912805
Hospital Revenue Code	301
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$7.42
Rate for Payer: Cash Price	$9.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.42
Rate for Payer: Health Smart Auto/Commercial	$5.56
Rate for Payer: LLUH Dept of Risk Management WC	$5.10
Rate for Payer: Multiplan Commercial	$6.95

HC SOM FR TYR IDX BIND CAP

Facility

$9.27

Service Code	CPT 84479
Hospital Charge Code	900912805
Hospital Revenue Code	301
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$7.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.56
Rate for Payer: Aetna of CA Government/Medicare	$5.56
Rate for Payer: Cash Price	$9.27
Rate for Payer: Cash Price	$9.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.42
Rate for Payer: Health Smart Auto/Commercial	$5.56
Rate for Payer: Intervalley Health Plan Commercial	$6.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.56
Rate for Payer: LLUH Dept of Risk Management WC	$5.10
Rate for Payer: Multiplan Commercial	$6.95

HC SOM FRUCTOSAMINE

Facility

$16.04

Service Code	CPT 82985
Hospital Charge Code	900913929
Hospital Revenue Code	301
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$12.83
Rate for Payer: Cash Price	$16.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.83
Rate for Payer: Health Smart Auto/Commercial	$9.62
Rate for Payer: LLUH Dept of Risk Management WC	$8.82
Rate for Payer: Multiplan Commercial	$12.03

HC SOM FRUCTOSAMINE

Facility

$16.04

Service Code	CPT 82985
Hospital Charge Code	900913929
Hospital Revenue Code	301
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$16.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.62
Rate for Payer: Aetna of CA Government/Medicare	$9.62
Rate for Payer: Cash Price	$16.04
Rate for Payer: Cash Price	$16.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.83
Rate for Payer: Health Smart Auto/Commercial	$9.62
Rate for Payer: Intervalley Health Plan Commercial	$16.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.62
Rate for Payer: LLUH Dept of Risk Management WC	$8.82
Rate for Payer: Multiplan Commercial	$12.03

HC SOM FUNGITELL ASSAY

Facility

$130.00

Service Code	CPT 87449
Hospital Charge Code	900912985
Hospital Revenue Code	306
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$104.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$104.00
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Commercial	$97.50

HC SOM FUNGITELL ASSAY

Facility

$130.00

Service Code	CPT 87449
Hospital Charge Code	900912985
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$104.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$78.00
Rate for Payer: Aetna of CA Government/Medicare	$78.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$104.00
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: Intervalley Health Plan Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Commercial	$97.50

HC SOM GABAPENTIN (NEURONTIN)

Facility

$19.00

Service Code	CPT 80171
Hospital Charge Code	900910415
Hospital Revenue Code	301
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$21.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.40
Rate for Payer: Aetna of CA Government/Medicare	$11.40
Rate for Payer: Cash Price	$19.00
Rate for Payer: Cash Price	$19.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.20
Rate for Payer: Health Smart Auto/Commercial	$11.40
Rate for Payer: Intervalley Health Plan Commercial	$21.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.40
Rate for Payer: LLUH Dept of Risk Management WC	$10.45
Rate for Payer: Multiplan Commercial	$14.25

HC SOM GABAPENTIN (NEURONTIN)

Facility

$19.00

Service Code	CPT 80171
Hospital Charge Code	900910415
Hospital Revenue Code	301
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$15.20
Rate for Payer: Cash Price	$19.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.20
Rate for Payer: Health Smart Auto/Commercial	$11.40
Rate for Payer: LLUH Dept of Risk Management WC	$10.45
Rate for Payer: Multiplan Commercial	$14.25

HC SOM GAD 65 ANTIBODIES

Facility

$18.08

Service Code	CPT 86341
Hospital Charge Code	900912683
Hospital Revenue Code	302
Min. Negotiated Rate	$9.94
Max. Negotiated Rate	$23.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.85
Rate for Payer: Aetna of CA Government/Medicare	$10.85
Rate for Payer: Cash Price	$18.08
Rate for Payer: Cash Price	$18.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.46
Rate for Payer: Health Smart Auto/Commercial	$10.85
Rate for Payer: Intervalley Health Plan Commercial	$23.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.94
Rate for Payer: Multiplan Commercial	$13.56

HC SOM GAD 65 ANTIBODIES

Facility

$18.08

Service Code	CPT 86341
Hospital Charge Code	900912683
Hospital Revenue Code	302
Min. Negotiated Rate	$9.94
Max. Negotiated Rate	$14.46
Rate for Payer: Cash Price	$18.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.46
Rate for Payer: Health Smart Auto/Commercial	$10.85
Rate for Payer: LLUH Dept of Risk Management WC	$9.94
Rate for Payer: Multiplan Commercial	$13.56

HC SOM GAL-1-PO4 URIDYL TR

Facility

$75.00

Service Code	CPT 82775
Hospital Charge Code	900911057
Hospital Revenue Code	301
Min. Negotiated Rate	$21.07
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	$21.07
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 GAL-1-PO4 URIDYL TR

Facility

$75.00

Service Code	CPT 82775
Hospital Charge Code	900911057
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

Know your out-of-pocket cost for care.

All Charges