Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM LEAD BLOOD

Facility

$9.10

Service Code	CPT 83655
Hospital Charge Code	900911201
Hospital Revenue Code	301
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$7.28
Rate for Payer: Cash Price	$9.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.28
Rate for Payer: Health Smart Auto/Commercial	$5.46
Rate for Payer: LLUH Dept of Risk Management WC	$5.00
Rate for Payer: Multiplan Commercial	$6.83

HC SOM LEAD BLOOD

Facility

$9.10

Service Code	CPT 83655
Hospital Charge Code	900911201
Hospital Revenue Code	301
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$12.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.46
Rate for Payer: Aetna of CA Government/Medicare	$5.46
Rate for Payer: Cash Price	$9.10
Rate for Payer: Cash Price	$9.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.28
Rate for Payer: Health Smart Auto/Commercial	$5.46
Rate for Payer: Intervalley Health Plan Commercial	$12.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.46
Rate for Payer: LLUH Dept of Risk Management WC	$5.00
Rate for Payer: Multiplan Commercial	$6.83

HC SOM LEAD URINE

Facility

$174.80

Service Code	CPT 83655
Hospital Charge Code	900911141
Hospital Revenue Code	301
Min. Negotiated Rate	$12.11
Max. Negotiated Rate	$139.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$104.88
Rate for Payer: Aetna of CA Government/Medicare	$104.88
Rate for Payer: Cash Price	$174.80
Rate for Payer: Cash Price	$174.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$139.84
Rate for Payer: Health Smart Auto/Commercial	$104.88
Rate for Payer: Intervalley Health Plan Commercial	$12.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$104.88
Rate for Payer: LLUH Dept of Risk Management WC	$96.14
Rate for Payer: Multiplan Commercial	$131.10

HC SOM LEAD URINE

Facility

$174.80

Service Code	CPT 83655
Hospital Charge Code	900911141
Hospital Revenue Code	301
Min. Negotiated Rate	$96.14
Max. Negotiated Rate	$139.84
Rate for Payer: Cash Price	$174.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$139.84
Rate for Payer: Health Smart Auto/Commercial	$104.88
Rate for Payer: LLUH Dept of Risk Management WC	$96.14
Rate for Payer: Multiplan Commercial	$131.10

HC SOM LEFLUNOMIDE METABOLITE

Facility

$150.00

Service Code	CPT 80193
Hospital Charge Code	900913937
Hospital Revenue Code	301
Min. Negotiated Rate	$38.57
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	$38.57
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 LEFLUNOMIDE METABOLITE

Facility

$150.00

Service Code	CPT 80193
Hospital Charge Code	900913937
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 LEGIONELLA AB

Facility

$14.90

Service Code	CPT 86713
Hospital Charge Code	900912567
Hospital Revenue Code	302
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.94
Rate for Payer: Aetna of CA Government/Medicare	$8.94
Rate for Payer: Cash Price	$14.90
Rate for Payer: Cash Price	$14.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.92
Rate for Payer: Health Smart Auto/Commercial	$8.94
Rate for Payer: Intervalley Health Plan Commercial	$15.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.94
Rate for Payer: LLUH Dept of Risk Management WC	$8.20
Rate for Payer: Multiplan Commercial	$11.18

HC SOM LEGIONELLA AB

Facility

$14.90

Service Code	CPT 86713
Hospital Charge Code	900912567
Hospital Revenue Code	302
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$11.92
Rate for Payer: Cash Price	$14.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.92
Rate for Payer: Health Smart Auto/Commercial	$8.94
Rate for Payer: LLUH Dept of Risk Management WC	$8.20
Rate for Payer: Multiplan Commercial	$11.18

HC SOM LEGIONELLA AG URINE

Facility

$16.07

Service Code	CPT 87899
Hospital Charge Code	900911293
Hospital Revenue Code	301
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$12.86
Rate for Payer: Cash Price	$16.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.86
Rate for Payer: Health Smart Auto/Commercial	$9.64
Rate for Payer: LLUH Dept of Risk Management WC	$8.84
Rate for Payer: Multiplan Commercial	$12.05

HC SOM LEGIONELLA AG URINE

Facility

$16.07

Service Code	CPT 87899
Hospital Charge Code	900911293
Hospital Revenue Code	301
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$16.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.64
Rate for Payer: Aetna of CA Government/Medicare	$9.64
Rate for Payer: Cash Price	$16.07
Rate for Payer: Cash Price	$16.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.86
Rate for Payer: Health Smart Auto/Commercial	$9.64
Rate for Payer: Intervalley Health Plan Commercial	$16.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.64
Rate for Payer: LLUH Dept of Risk Management WC	$8.84
Rate for Payer: Multiplan Commercial	$12.05

HC SOM LEGIONELLA PCR

Facility

$50.00

Service Code	CPT 87801
Hospital Charge Code	900915470
Hospital Revenue Code	300
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Commercial	$37.50

HC SOM LEGIONELLA PCR

Facility

$50.00

Service Code	CPT 87801
Hospital Charge Code	900915470
Hospital Revenue Code	300
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Intervalley Health Plan Commercial	$70.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Commercial	$37.50

HC SOM LEPTOSPIRA IGM

Facility

$50.00

Service Code	CPT 86720
Hospital Charge Code	900911765
Hospital Revenue Code	302
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$40.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Commercial	$37.50

HC SOM LEPTOSPIRA IGM

Facility

$50.00

Service Code	CPT 86720
Hospital Charge Code	900911765
Hospital Revenue Code	302
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Intervalley Health Plan Commercial	$16.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Commercial	$37.50

HC SOM LEVETIRACETAM LEVEL

Facility

$14.50

Service Code	CPT 80177
Hospital Charge Code	900912530
Hospital Revenue Code	301
Min. Negotiated Rate	$7.97
Max. Negotiated Rate	$11.60
Rate for Payer: Cash Price	$14.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.60
Rate for Payer: Health Smart Auto/Commercial	$8.70
Rate for Payer: LLUH Dept of Risk Management WC	$7.97
Rate for Payer: Multiplan Commercial	$10.88

HC SOM LEVETIRACETAM LEVEL

Facility

$14.50

Service Code	CPT 80177
Hospital Charge Code	900912530
Hospital Revenue Code	301
Min. Negotiated Rate	$7.97
Max. Negotiated Rate	$13.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.70
Rate for Payer: Aetna of CA Government/Medicare	$8.70
Rate for Payer: Cash Price	$14.50
Rate for Payer: Cash Price	$14.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.60
Rate for Payer: Health Smart Auto/Commercial	$8.70
Rate for Payer: Intervalley Health Plan Commercial	$13.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.70
Rate for Payer: LLUH Dept of Risk Management WC	$7.97
Rate for Payer: Multiplan Commercial	$10.88

HC SOM LIPASE BF

Facility

$25.00

Service Code	CPT 83690
Hospital Charge Code	900913938
Hospital Revenue Code	301
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 LIPASE BF

Facility

$17.00

Service Code	CPT 83690
Hospital Charge Code	900913938
Hospital Revenue Code	301
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$13.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.20
Rate for Payer: Aetna of CA Government/Medicare	$10.20
Rate for Payer: Cash Price	$17.00
Rate for Payer: Cash Price	$17.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.60
Rate for Payer: Health Smart Auto/Commercial	$10.20
Rate for Payer: Intervalley Health Plan Commercial	$6.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.20
Rate for Payer: LLUH Dept of Risk Management WC	$9.35
Rate for Payer: Multiplan Commercial	$12.75

HC SOM LIPASE RANDOM URINE

Facility

$67.10

Service Code	CPT 83690
Hospital Charge Code	900912532
Hospital Revenue Code	301
Min. Negotiated Rate	$36.91
Max. Negotiated Rate	$53.68
Rate for Payer: Cash Price	$67.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.68
Rate for Payer: Health Smart Auto/Commercial	$40.26
Rate for Payer: LLUH Dept of Risk Management WC	$36.91
Rate for Payer: Multiplan Commercial	$50.33

HC SOM LIPASE RANDOM URINE

Facility

$67.10

Service Code	CPT 83690
Hospital Charge Code	900912532
Hospital Revenue Code	301
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$53.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.26
Rate for Payer: Aetna of CA Government/Medicare	$40.26
Rate for Payer: Cash Price	$67.10
Rate for Payer: Cash Price	$67.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$53.68
Rate for Payer: Health Smart Auto/Commercial	$40.26
Rate for Payer: Intervalley Health Plan Commercial	$6.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.26
Rate for Payer: LLUH Dept of Risk Management WC	$36.91
Rate for Payer: Multiplan Commercial	$50.33

HC SOM LIPOPROTEIN A

Facility

$14.65

Service Code	CPT 83695
Hospital Charge Code	900910756
Hospital Revenue Code	301
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$11.72
Rate for Payer: Cash Price	$14.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.72
Rate for Payer: Health Smart Auto/Commercial	$8.79
Rate for Payer: LLUH Dept of Risk Management WC	$8.06
Rate for Payer: Multiplan Commercial	$10.99

HC SOM LIPOPROTEIN A

Facility

$14.65

Service Code	CPT 83695
Hospital Charge Code	900910756
Hospital Revenue Code	301
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$14.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.79
Rate for Payer: Aetna of CA Government/Medicare	$8.79
Rate for Payer: Cash Price	$14.65
Rate for Payer: Cash Price	$14.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.72
Rate for Payer: Health Smart Auto/Commercial	$8.79
Rate for Payer: Intervalley Health Plan Commercial	$14.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.79
Rate for Payer: LLUH Dept of Risk Management WC	$8.06
Rate for Payer: Multiplan Commercial	$10.99

HC SOM LYME DISEASE AB IGG

Facility

$15.00

Service Code	CPT 86617
Hospital Charge Code	900912569
Hospital Revenue Code	302
Min. Negotiated Rate	$8.25
Max. Negotiated Rate	$15.49
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	$15.49
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 LYME DISEASE AB IGG

Facility

$15.00

Service Code	CPT 86617
Hospital Charge Code	900912569
Hospital Revenue Code	302
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 LYME DISEASE AB IGM

Facility

$15.00

Service Code	CPT 86617
Hospital Charge Code	900912696
Hospital Revenue Code	302
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

Know your out-of-pocket cost for care.

All Charges