Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$16.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.56
Rate for Payer: Aetna of CA Government/Medicare	$7.56
Rate for Payer: Cash Price	$12.60
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: Intervalley Health Plan Commercial	$16.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.56
Rate for Payer: LLUH Dept of Risk Management WC	$6.93
Rate for Payer: Multiplan Commercial	$9.45

HC SOM HALDOL(HALOPERIDOL) LEVEL

Facility

$60.00

Service Code	CPT 80173
Hospital Charge Code	900911401
Hospital Revenue Code	301
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$48.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.00
Rate for Payer: Health Smart Auto/Commercial	$36.00
Rate for Payer: LLUH Dept of Risk Management WC	$33.00
Rate for Payer: Multiplan Commercial	$45.00

HC SOM HALDOL(HALOPERIDOL) LEVEL

Facility

$60.00

Service Code	CPT 80173
Hospital Charge Code	900911401
Hospital Revenue Code	301
Min. Negotiated Rate	$15.78
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.00
Rate for Payer: Aetna of CA Government/Medicare	$36.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.00
Rate for Payer: Health Smart Auto/Commercial	$36.00
Rate for Payer: Intervalley Health Plan Commercial	$15.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.00
Rate for Payer: LLUH Dept of Risk Management WC	$33.00
Rate for Payer: Multiplan Commercial	$45.00

HC SOM HANDLING FEE

Facility

$35.00

Service Code	CPT 99001
Hospital Charge Code	900913932
Hospital Revenue Code	300
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 HANDLING FEE

Facility

$39.00

Service Code	CPT 99001
Hospital Charge Code	900913932
Hospital Revenue Code	300
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$31.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.40
Rate for Payer: Aetna of CA Government/Medicare	$23.40
Rate for Payer: Cash Price	$39.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.20
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Commercial	$29.25

HC SOM HBEL ELECTROPHORESIS SUMMARY INTERP

Facility

$169.02

Service Code	CPT 83020
Hospital Charge Code	900915460
Hospital Revenue Code	300
Min. Negotiated Rate	$92.96
Max. Negotiated Rate	$135.22
Rate for Payer: Cash Price	$169.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$135.22
Rate for Payer: Health Smart Auto/Commercial	$101.41
Rate for Payer: LLUH Dept of Risk Management WC	$92.96
Rate for Payer: Multiplan Commercial	$126.77

HC SOM HBEL ELECTROPHORESIS SUMMARY INTERP

Facility

$169.02

Service Code	CPT 83020
Hospital Charge Code	900915460
Hospital Revenue Code	300
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$135.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$101.41
Rate for Payer: Aetna of CA Government/Medicare	$101.41
Rate for Payer: Cash Price	$169.02
Rate for Payer: Cash Price	$169.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$135.22
Rate for Payer: Health Smart Auto/Commercial	$101.41
Rate for Payer: Intervalley Health Plan Commercial	$12.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$101.41
Rate for Payer: LLUH Dept of Risk Management WC	$92.96
Rate for Payer: Multiplan Commercial	$126.77

HC SOM HBEL VARIANT, A2 AND F QUANTITATION,B

Facility

$12.82

Service Code	CPT 83020
Hospital Charge Code	900915458
Hospital Revenue Code	300
Min. Negotiated Rate	$7.05
Max. Negotiated Rate	$12.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.69
Rate for Payer: Aetna of CA Government/Medicare	$7.69
Rate for Payer: Cash Price	$12.82
Rate for Payer: Cash Price	$12.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.26
Rate for Payer: Health Smart Auto/Commercial	$7.69
Rate for Payer: Intervalley Health Plan Commercial	$12.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.69
Rate for Payer: LLUH Dept of Risk Management WC	$7.05
Rate for Payer: Multiplan Commercial	$9.62

HC SOM HBEL VARIANT, A2 AND F QUANTITATION,B

Facility

$12.82

Service Code	CPT 83020
Hospital Charge Code	900915458
Hospital Revenue Code	300
Min. Negotiated Rate	$7.05
Max. Negotiated Rate	$10.26
Rate for Payer: Cash Price	$12.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.26
Rate for Payer: Health Smart Auto/Commercial	$7.69
Rate for Payer: LLUH Dept of Risk Management WC	$7.05
Rate for Payer: Multiplan Commercial	$9.62

HC SOM HBEL VARIANT B

Facility

$18.00

Service Code	CPT 83021
Hospital Charge Code	900915459
Hospital Revenue Code	300
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$14.40
Rate for Payer: Cash Price	$18.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Commercial	$13.50

HC SOM HBEL VARIANT B

Facility

$18.00

Service Code	CPT 83021
Hospital Charge Code	900915459
Hospital Revenue Code	300
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$18.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Intervalley Health Plan Commercial	$18.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Commercial	$13.50

HC SOM HCG HIGH SENSITIVITY

Facility

$16.77

Service Code	CPT 84702
Hospital Charge Code	900914546
Hospital Revenue Code	301
Min. Negotiated Rate	$9.22
Max. Negotiated Rate	$13.42
Rate for Payer: Cash Price	$16.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.42
Rate for Payer: Health Smart Auto/Commercial	$10.06
Rate for Payer: LLUH Dept of Risk Management WC	$9.22
Rate for Payer: Multiplan Commercial	$12.58

HC SOM HCG HIGH SENSITIVITY

Facility

$16.77

Service Code	CPT 84702
Hospital Charge Code	900914546
Hospital Revenue Code	301
Min. Negotiated Rate	$9.22
Max. Negotiated Rate	$15.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.06
Rate for Payer: Aetna of CA Government/Medicare	$10.06
Rate for Payer: Cash Price	$16.77
Rate for Payer: Cash Price	$16.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.42
Rate for Payer: Health Smart Auto/Commercial	$10.06
Rate for Payer: Intervalley Health Plan Commercial	$15.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.06
Rate for Payer: LLUH Dept of Risk Management WC	$9.22
Rate for Payer: Multiplan Commercial	$12.58

HC SOM HCV GENOTYPING

Facility

$125.55

Service Code	CPT 87902
Hospital Charge Code	900911374
Hospital Revenue Code	301
Min. Negotiated Rate	$69.05
Max. Negotiated Rate	$257.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.33
Rate for Payer: Aetna of CA Government/Medicare	$75.33
Rate for Payer: Cash Price	$125.55
Rate for Payer: Cash Price	$125.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.44
Rate for Payer: Health Smart Auto/Commercial	$75.33
Rate for Payer: Intervalley Health Plan Commercial	$257.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.33
Rate for Payer: LLUH Dept of Risk Management WC	$69.05
Rate for Payer: Multiplan Commercial	$94.16

HC SOM HCV GENOTYPING

Facility

$125.55

Service Code	CPT 87902
Hospital Charge Code	900911374
Hospital Revenue Code	301
Min. Negotiated Rate	$69.05
Max. Negotiated Rate	$100.44
Rate for Payer: Cash Price	$125.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.44
Rate for Payer: Health Smart Auto/Commercial	$75.33
Rate for Payer: LLUH Dept of Risk Management WC	$69.05
Rate for Payer: Multiplan Commercial	$94.16

HC SOM HEMO A INV INTERP

Facility

$553.05

Service Code	CPT 81403
Hospital Charge Code	900914242
Hospital Revenue Code	309
Min. Negotiated Rate	$185.20
Max. Negotiated Rate	$442.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$331.83
Rate for Payer: Aetna of CA Government/Medicare	$331.83
Rate for Payer: Cash Price	$553.05
Rate for Payer: Cash Price	$553.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$442.44
Rate for Payer: Health Smart Auto/Commercial	$331.83
Rate for Payer: Intervalley Health Plan Commercial	$185.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$331.83
Rate for Payer: LLUH Dept of Risk Management WC	$304.18
Rate for Payer: Multiplan Commercial	$414.79

HC SOM HEMO A INV INTERP

Facility

$553.05

Service Code	CPT 81403
Hospital Charge Code	900914242
Hospital Revenue Code	309
Min. Negotiated Rate	$304.18
Max. Negotiated Rate	$442.44
Rate for Payer: Cash Price	$553.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$442.44
Rate for Payer: Health Smart Auto/Commercial	$331.83
Rate for Payer: LLUH Dept of Risk Management WC	$304.18
Rate for Payer: Multiplan Commercial	$414.79

HC SOM HEMOCHROMATOSIS GENE PCR

Facility

$95.84

Service Code	CPT 81256
Hospital Charge Code	900910606
Hospital Revenue Code	301
Min. Negotiated Rate	$52.71
Max. Negotiated Rate	$76.67
Rate for Payer: Cash Price	$95.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.67
Rate for Payer: Health Smart Auto/Commercial	$57.50
Rate for Payer: LLUH Dept of Risk Management WC	$52.71
Rate for Payer: Multiplan Commercial	$71.88

HC SOM HEMOCHROMATOSIS GENE PCR

Facility

$95.84

Service Code	CPT 81256
Hospital Charge Code	900910606
Hospital Revenue Code	301
Min. Negotiated Rate	$52.71
Max. Negotiated Rate	$76.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.50
Rate for Payer: Aetna of CA Government/Medicare	$57.50
Rate for Payer: Cash Price	$95.84
Rate for Payer: Cash Price	$95.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.67
Rate for Payer: Health Smart Auto/Commercial	$57.50
Rate for Payer: Intervalley Health Plan Commercial	$65.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.50
Rate for Payer: LLUH Dept of Risk Management WC	$52.71
Rate for Payer: Multiplan Commercial	$71.88

HC SOM HEMOSIDERIN, URINE

Facility

$125.67

Service Code	CPT 83070
Hospital Charge Code	900910748
Hospital Revenue Code	301
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$100.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.40
Rate for Payer: Aetna of CA Government/Medicare	$75.40
Rate for Payer: Cash Price	$125.67
Rate for Payer: Cash Price	$125.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.54
Rate for Payer: Health Smart Auto/Commercial	$75.40
Rate for Payer: Intervalley Health Plan Commercial	$4.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.40
Rate for Payer: LLUH Dept of Risk Management WC	$69.12
Rate for Payer: Multiplan Commercial	$94.25

HC SOM HEMOSIDERIN, URINE

Facility

$125.67

Service Code	CPT 83070
Hospital Charge Code	900910748
Hospital Revenue Code	301
Min. Negotiated Rate	$69.12
Max. Negotiated Rate	$100.54
Rate for Payer: Cash Price	$125.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.54
Rate for Payer: Health Smart Auto/Commercial	$75.40
Rate for Payer: LLUH Dept of Risk Management WC	$69.12
Rate for Payer: Multiplan Commercial	$94.25

HC SOM HEPARIN-PF4 AB

Facility

$25.00

Service Code	CPT 86022
Hospital Charge Code	900912527
Hospital Revenue Code	305
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

HC SOM HEPARIN-PF4 AB

Facility

$25.00

Service Code	CPT 86022
Hospital Charge Code	900912527
Hospital Revenue Code	305
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Intervalley Health Plan Commercial	$18.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

HC SOM HEPATITIS B DNA (QUANT)

Facility

$79.33

Service Code	CPT 87517
Hospital Charge Code	900911402
Hospital Revenue Code	306
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$63.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$47.60
Rate for Payer: Aetna of CA Government/Medicare	$47.60
Rate for Payer: Cash Price	$79.33
Rate for Payer: Cash Price	$79.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$63.46
Rate for Payer: Health Smart Auto/Commercial	$47.60
Rate for Payer: Intervalley Health Plan Commercial	$42.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$47.60
Rate for Payer: LLUH Dept of Risk Management WC	$43.63
Rate for Payer: Multiplan Commercial	$59.50

HC SOM HEPATITIS B DNA (QUANT)

Facility

$79.33

Service Code	CPT 87517
Hospital Charge Code	900911402
Hospital Revenue Code	306
Min. Negotiated Rate	$43.63
Max. Negotiated Rate	$63.46
Rate for Payer: Cash Price	$79.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$63.46
Rate for Payer: Health Smart Auto/Commercial	$47.60
Rate for Payer: LLUH Dept of Risk Management WC	$43.63
Rate for Payer: Multiplan Commercial	$59.50

Know your out-of-pocket cost for care.

All Charges