Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM GALACTOSE 1 PHOSPHATE ERYTHRO

Facility

$175.00

Service Code	CPT 84378
Hospital Charge Code	900910746
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
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	$11.53
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 GALACTOSE 1 PHOSPHATE ERYTHRO

Facility

$175.00

Service Code	CPT 84378
Hospital Charge Code	900910746
Hospital Revenue Code	301
Min. Negotiated Rate	$96.25
Max. Negotiated Rate	$140.00
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: LLUH Dept of Risk Management WC	$96.25
Rate for Payer: Multiplan Commercial	$131.25

HC SOM GANGLIOSIDE AB IGG ASIALO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900911440
Hospital Revenue Code	302
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	$11.53
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 GANGLIOSIDE AB IGG ASIALO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900911440
Hospital Revenue Code	302
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 GANGLIOSIDE AB IGG DISIALO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900912816
Hospital Revenue Code	302
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	$11.53
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 GANGLIOSIDE AB IGG DISIALO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900912816
Hospital Revenue Code	302
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 GANGLIOSIDE AB IGG MONO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900911442
Hospital Revenue Code	302
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	$11.53
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 GANGLIOSIDE AB IGG MONO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900911442
Hospital Revenue Code	302
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 GANGLIOSIDE AB IGM ASIALO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900911441
Hospital Revenue Code	302
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 GANGLIOSIDE AB IGM ASIALO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900911441
Hospital Revenue Code	302
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	$11.53
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 GANGLIOSIDE AB IGM DISIALO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900912817
Hospital Revenue Code	302
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 GANGLIOSIDE AB IGM DISIALO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900912817
Hospital Revenue Code	302
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	$11.53
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 GANGLIOSIDE AB IGM MONO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900912815
Hospital Revenue Code	302
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 GANGLIOSIDE AB IGM MONO

Facility

$20.00

Service Code	CPT 83516
Hospital Charge Code	900912815
Hospital Revenue Code	302
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	$11.53
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 GASTRIN

Facility

$15.00

Service Code	CPT 82941
Hospital Charge Code	900911200
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$17.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.00
Rate for Payer: Aetna of CA Government/Medicare	$9.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: Intervalley Health Plan Commercial	$17.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Commercial	$11.25

HC SOM GASTRIN

Facility

$15.00

Service Code	CPT 82941
Hospital Charge Code	900911200
Hospital Revenue Code	301
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$12.00
Rate for Payer: Cash Price	$15.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.00
Rate for Payer: Health Smart Auto/Commercial	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$8.25
Rate for Payer: Multiplan Commercial	$11.25

HC SOM GIARDIA LAMBIA AG

Facility

$23.00

Service Code	CPT 87329
Hospital Charge Code	900911396
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$18.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.80
Rate for Payer: Aetna of CA Government/Medicare	$13.80
Rate for Payer: Cash Price	$23.00
Rate for Payer: Cash Price	$23.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.40
Rate for Payer: Health Smart Auto/Commercial	$13.80
Rate for Payer: Intervalley Health Plan Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.80
Rate for Payer: LLUH Dept of Risk Management WC	$12.65
Rate for Payer: Multiplan Commercial	$17.25

HC SOM GIARDIA LAMBIA AG

Facility

$23.00

Service Code	CPT 87329
Hospital Charge Code	900911396
Hospital Revenue Code	306
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$18.40
Rate for Payer: Cash Price	$23.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.40
Rate for Payer: Health Smart Auto/Commercial	$13.80
Rate for Payer: LLUH Dept of Risk Management WC	$12.65
Rate for Payer: Multiplan Commercial	$17.25

HC SOM GLUCAGON

Facility

$38.00

Service Code	CPT 82943
Hospital Charge Code	900911016
Hospital Revenue Code	301
Min. Negotiated Rate	$14.29
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	$14.29
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 GLUCAGON

Facility

$38.00

Service Code	CPT 82943
Hospital Charge Code	900911016
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 GLUCOSE-6-PD SCR

Facility

$22.64

Service Code	CPT 82955
Hospital Charge Code	900911305
Hospital Revenue Code	301
Min. Negotiated Rate	$9.70
Max. Negotiated Rate	$18.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.58
Rate for Payer: Aetna of CA Government/Medicare	$13.58
Rate for Payer: Cash Price	$22.64
Rate for Payer: Cash Price	$22.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.11
Rate for Payer: Health Smart Auto/Commercial	$13.58
Rate for Payer: Intervalley Health Plan Commercial	$9.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.58
Rate for Payer: LLUH Dept of Risk Management WC	$12.45
Rate for Payer: Multiplan Commercial	$16.98

HC SOM GLUCOSE-6-PD SCR

Facility

$22.64

Service Code	CPT 82955
Hospital Charge Code	900911305
Hospital Revenue Code	301
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$18.11
Rate for Payer: Cash Price	$22.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.11
Rate for Payer: Health Smart Auto/Commercial	$13.58
Rate for Payer: LLUH Dept of Risk Management WC	$12.45
Rate for Payer: Multiplan Commercial	$16.98

HC SOM GLUTAMIC ACID DECARBOXYLASE AB

Facility

$27.60

Service Code	CPT 86341
Hospital Charge Code	900911121
Hospital Revenue Code	301
Min. Negotiated Rate	$15.18
Max. Negotiated Rate	$22.08
Rate for Payer: Cash Price	$27.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.08
Rate for Payer: Health Smart Auto/Commercial	$16.56
Rate for Payer: LLUH Dept of Risk Management WC	$15.18
Rate for Payer: Multiplan Commercial	$20.70

HC SOM GLUTAMIC ACID DECARBOXYLASE AB

Facility

$27.60

Service Code	CPT 86341
Hospital Charge Code	900911121
Hospital Revenue Code	301
Min. Negotiated Rate	$15.18
Max. Negotiated Rate	$23.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.56
Rate for Payer: Aetna of CA Government/Medicare	$16.56
Rate for Payer: Cash Price	$27.60
Rate for Payer: Cash Price	$27.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.08
Rate for Payer: Health Smart Auto/Commercial	$16.56
Rate for Payer: Intervalley Health Plan Commercial	$23.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.56
Rate for Payer: LLUH Dept of Risk Management WC	$15.18
Rate for Payer: Multiplan Commercial	$20.70

HC SOM GROWTH HORMONE

Facility

$12.60

Service Code	CPT 83003
Hospital Charge Code	900911488
Hospital Revenue Code	301
Min. Negotiated Rate	$6.93
Max. Negotiated Rate	$10.08
Rate for Payer: Cash Price	$12.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.08
Rate for Payer: Health Smart Auto/Commercial	$7.56
Rate for Payer: LLUH Dept of Risk Management WC	$6.93
Rate for Payer: Multiplan Commercial	$9.45

Know your out-of-pocket cost for care.

All Charges