Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM INSULIN-LIKE GROWTH FACTOR I

Facility

$62.50

Service Code	CPT 84305
Hospital Charge Code	900911132
Hospital Revenue Code	301
Min. Negotiated Rate	$21.26
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.50
Rate for Payer: Aetna of CA Government/Medicare	$37.50
Rate for Payer: Cash Price	$62.50
Rate for Payer: Cash Price	$62.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$50.00
Rate for Payer: Health Smart Auto/Commercial	$37.50
Rate for Payer: Intervalley Health Plan Commercial	$21.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.50
Rate for Payer: LLUH Dept of Risk Management WC	$34.38
Rate for Payer: Multiplan Commercial	$46.88

HC SOM INTRINSIC FACTOR BLOCKING AB

Facility

$25.00

Service Code	CPT 86340
Hospital Charge Code	900911094
Hospital Revenue Code	302
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	$15.08
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 INTRINSIC FACTOR BLOCKING AB

Facility

$25.00

Service Code	CPT 86340
Hospital Charge Code	900911094
Hospital Revenue Code	302
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 IRON LIVER TISSUE

Facility

$9.28

Service Code	CPT 83540
Hospital Charge Code	900914805
Hospital Revenue Code	301
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$7.42
Rate for Payer: Cash Price	$9.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.42
Rate for Payer: Health Smart Auto/Commercial	$5.57
Rate for Payer: LLUH Dept of Risk Management WC	$5.10
Rate for Payer: Multiplan Commercial	$6.96

HC SOM IRON LIVER TISSUE

Facility

$9.28

Service Code	CPT 83540
Hospital Charge Code	900914805
Hospital Revenue Code	301
Min. Negotiated Rate	$5.10
Max. Negotiated Rate	$7.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.57
Rate for Payer: Aetna of CA Government/Medicare	$5.57
Rate for Payer: Cash Price	$9.28
Rate for Payer: Cash Price	$9.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.42
Rate for Payer: Health Smart Auto/Commercial	$5.57
Rate for Payer: Intervalley Health Plan Commercial	$6.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.57
Rate for Payer: LLUH Dept of Risk Management WC	$5.10
Rate for Payer: Multiplan Commercial	$6.96

HC SOM ITRACONAZOLE LEVEL

Facility

$40.00

Service Code	CPT 80189
Hospital Charge Code	900911379
Hospital Revenue Code	301
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$32.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Commercial	$30.00

HC SOM ITRACONAZOLE LEVEL

Facility

$40.00

Service Code	CPT 80189
Hospital Charge Code	900911379
Hospital Revenue Code	301
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.00
Rate for Payer: Aetna of CA Government/Medicare	$24.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: Intervalley Health Plan Commercial	$27.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Commercial	$30.00

HC SOM JAK 2 V617F MUTATION

Facility

$101.66

Service Code	CPT 81270
Hospital Charge Code	900912994
Hospital Revenue Code	309
Min. Negotiated Rate	$55.91
Max. Negotiated Rate	$81.33
Rate for Payer: Cash Price	$101.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$81.33
Rate for Payer: Health Smart Auto/Commercial	$61.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.91
Rate for Payer: Multiplan Commercial	$76.25

HC SOM JAK 2 V617F MUTATION

Facility

$101.66

Service Code	CPT 81270
Hospital Charge Code	900912994
Hospital Revenue Code	309
Min. Negotiated Rate	$55.91
Max. Negotiated Rate	$91.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$61.00
Rate for Payer: Aetna of CA Government/Medicare	$61.00
Rate for Payer: Cash Price	$101.66
Rate for Payer: Cash Price	$101.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$81.33
Rate for Payer: Health Smart Auto/Commercial	$61.00
Rate for Payer: Intervalley Health Plan Commercial	$91.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$61.00
Rate for Payer: LLUH Dept of Risk Management WC	$55.91
Rate for Payer: Multiplan Commercial	$76.25

HC SOM JC VIRUS BY PCR

Facility

$65.00

Service Code	CPT 87798
Hospital Charge Code	900912607
Hospital Revenue Code	306
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$52.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.00
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Commercial	$48.75

HC SOM JC VIRUS BY PCR

Facility

$65.00

Service Code	CPT 87798
Hospital Charge Code	900912607
Hospital Revenue Code	306
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.00
Rate for Payer: Aetna of CA Government/Medicare	$39.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.00
Rate for Payer: Health Smart Auto/Commercial	$39.00
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.00
Rate for Payer: LLUH Dept of Risk Management WC	$35.75
Rate for Payer: Multiplan Commercial	$48.75

HC SOM KAPPA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521
Hospital Charge Code	900910385
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$12.60
Rate for Payer: Cash Price	$15.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.60
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Commercial	$11.81

HC SOM KAPPA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521
Hospital Charge Code	900910385
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$17.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.45
Rate for Payer: Aetna of CA Government/Medicare	$9.45
Rate for Payer: Cash Price	$15.75
Rate for Payer: Cash Price	$15.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.60
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: Intervalley Health Plan Commercial	$17.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Commercial	$11.81

HC SOM KPNRP 87798

Facility

$157.95

Service Code	CPT 87798
Hospital Charge Code	900915274
Hospital Revenue Code	301
Min. Negotiated Rate	$86.87
Max. Negotiated Rate	$126.36
Rate for Payer: Cash Price	$157.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$126.36
Rate for Payer: Health Smart Auto/Commercial	$94.77
Rate for Payer: LLUH Dept of Risk Management WC	$86.87
Rate for Payer: Multiplan Commercial	$118.46

HC SOM KPNRP 87798

Facility

$157.95

Service Code	CPT 87798
Hospital Charge Code	900915274
Hospital Revenue Code	301
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$126.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$94.77
Rate for Payer: Aetna of CA Government/Medicare	$94.77
Rate for Payer: Cash Price	$157.95
Rate for Payer: Cash Price	$157.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$126.36
Rate for Payer: Health Smart Auto/Commercial	$94.77
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$94.77
Rate for Payer: LLUH Dept of Risk Management WC	$86.87
Rate for Payer: Multiplan Commercial	$118.46

HC SOM LAMBDA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521
Hospital Charge Code	900910386
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$17.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.45
Rate for Payer: Aetna of CA Government/Medicare	$9.45
Rate for Payer: Cash Price	$15.75
Rate for Payer: Cash Price	$15.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.60
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: Intervalley Health Plan Commercial	$17.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Commercial	$11.81

HC SOM LAMBDA LIGHT CHAINS

Facility

$15.75

Service Code	CPT 83521
Hospital Charge Code	900910386
Hospital Revenue Code	301
Min. Negotiated Rate	$8.66
Max. Negotiated Rate	$12.60
Rate for Payer: Cash Price	$15.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.60
Rate for Payer: Health Smart Auto/Commercial	$9.45
Rate for Payer: LLUH Dept of Risk Management WC	$8.66
Rate for Payer: Multiplan Commercial	$11.81

HC SOM LAMICTAL (LAMOTRIGINE)

Facility

$14.32

Service Code	CPT 80175
Hospital Charge Code	900910411
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$11.46
Rate for Payer: Cash Price	$14.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.46
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Commercial	$10.74

HC SOM LAMICTAL (LAMOTRIGINE)

Facility

$14.32

Service Code	CPT 80175
Hospital Charge Code	900910411
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$13.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.59
Rate for Payer: Aetna of CA Government/Medicare	$8.59
Rate for Payer: Cash Price	$14.32
Rate for Payer: Cash Price	$14.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.46
Rate for Payer: Health Smart Auto/Commercial	$8.59
Rate for Payer: Intervalley Health Plan Commercial	$13.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.59
Rate for Payer: LLUH Dept of Risk Management WC	$7.88
Rate for Payer: Multiplan Commercial	$10.74

HC SOM LASIX

Facility

$119.28

Service Code	CPT 80299
Hospital Charge Code	900911247
Hospital Revenue Code	301
Min. Negotiated Rate	$65.60
Max. Negotiated Rate	$95.42
Rate for Payer: Cash Price	$119.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$95.42
Rate for Payer: Health Smart Auto/Commercial	$71.57
Rate for Payer: LLUH Dept of Risk Management WC	$65.60
Rate for Payer: Multiplan Commercial	$89.46

HC SOM LASIX

Facility

$119.28

Service Code	CPT 80299
Hospital Charge Code	900911247
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$95.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$71.57
Rate for Payer: Aetna of CA Government/Medicare	$71.57
Rate for Payer: Cash Price	$119.28
Rate for Payer: Cash Price	$119.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$95.42
Rate for Payer: Health Smart Auto/Commercial	$71.57
Rate for Payer: Intervalley Health Plan Commercial	$18.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$71.57
Rate for Payer: LLUH Dept of Risk Management WC	$65.60
Rate for Payer: Multiplan Commercial	$89.46

HC SOM LD ACTIVITY TOTAL

Facility

$11.23

Service Code	CPT 83615
Hospital Charge Code	900912823
Hospital Revenue Code	301
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$11.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Commercial	$8.42

HC SOM LD ACTIVITY TOTAL

Facility

$11.23

Service Code	CPT 83615
Hospital Charge Code	900912823
Hospital Revenue Code	301
Min. Negotiated Rate	$6.04
Max. Negotiated Rate	$8.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.74
Rate for Payer: Aetna of CA Government/Medicare	$6.74
Rate for Payer: Cash Price	$11.23
Rate for Payer: Cash Price	$11.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: Intervalley Health Plan Commercial	$6.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Commercial	$8.42

HC SOM LD ISOENZYMES

Facility

$11.22

Service Code	CPT 83625
Hospital Charge Code	900910804
Hospital Revenue Code	301
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$11.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.73
Rate for Payer: LLUH Dept of Risk Management WC	$6.17
Rate for Payer: Multiplan Commercial	$8.41

HC SOM LD ISOENZYMES

Facility

$11.22

Service Code	CPT 83625
Hospital Charge Code	900910804
Hospital Revenue Code	301
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$12.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.73
Rate for Payer: Aetna of CA Government/Medicare	$6.73
Rate for Payer: Cash Price	$11.22
Rate for Payer: Cash Price	$11.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.73
Rate for Payer: Intervalley Health Plan Commercial	$12.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.73
Rate for Payer: LLUH Dept of Risk Management WC	$6.17
Rate for Payer: Multiplan Commercial	$8.41

Know your out-of-pocket cost for care.

All Charges