Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM NICOTINE

Facility

$20.35

Service Code	CPT 80323
Hospital Charge Code	900910769
Hospital Revenue Code	301
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$16.28
Rate for Payer: Cash Price	$20.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.28
Rate for Payer: Health Smart Auto/Commercial	$12.21
Rate for Payer: LLUH Dept of Risk Management WC	$11.19
Rate for Payer: Multiplan Commercial	$15.26

HC SOM NICOTINE

Facility

$20.35

Service Code	CPT 80323
Hospital Charge Code	900910769
Hospital Revenue Code	301
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$16.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.21
Rate for Payer: Aetna of CA Government/Medicare	$12.21
Rate for Payer: Cash Price	$20.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.28
Rate for Payer: Health Smart Auto/Commercial	$12.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.21
Rate for Payer: LLUH Dept of Risk Management WC	$11.19
Rate for Payer: Multiplan Commercial	$15.26

HC SOM NITROGEN STOOL

Facility

$422.40

Service Code	CPT 84999
Hospital Charge Code	900911229
Hospital Revenue Code	301
Min. Negotiated Rate	$232.32
Max. Negotiated Rate	$337.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$253.44
Rate for Payer: Aetna of CA Government/Medicare	$253.44
Rate for Payer: Cash Price	$422.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$337.92
Rate for Payer: Health Smart Auto/Commercial	$253.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$253.44
Rate for Payer: LLUH Dept of Risk Management WC	$232.32
Rate for Payer: Multiplan Commercial	$316.80

HC SOM NITROGEN STOOL

Facility

$422.40

Service Code	CPT 84999
Hospital Charge Code	900911229
Hospital Revenue Code	301
Min. Negotiated Rate	$232.32
Max. Negotiated Rate	$337.92
Rate for Payer: Cash Price	$422.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$337.92
Rate for Payer: Health Smart Auto/Commercial	$253.44
Rate for Payer: LLUH Dept of Risk Management WC	$232.32
Rate for Payer: Multiplan Commercial	$316.80

HC SOM NMHIN 83789

Facility

$162.45

Service Code	CPT 83789
Hospital Charge Code	900914806
Hospital Revenue Code	301
Min. Negotiated Rate	$24.11
Max. Negotiated Rate	$129.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$97.47
Rate for Payer: Aetna of CA Government/Medicare	$97.47
Rate for Payer: Cash Price	$162.45
Rate for Payer: Cash Price	$162.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$129.96
Rate for Payer: Health Smart Auto/Commercial	$97.47
Rate for Payer: Intervalley Health Plan Commercial	$24.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$97.47
Rate for Payer: LLUH Dept of Risk Management WC	$89.35
Rate for Payer: Multiplan Commercial	$121.84

HC SOM NMHIN 83789

Facility

$162.45

Service Code	CPT 83789
Hospital Charge Code	900914806
Hospital Revenue Code	301
Min. Negotiated Rate	$89.35
Max. Negotiated Rate	$129.96
Rate for Payer: Cash Price	$162.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$129.96
Rate for Payer: Health Smart Auto/Commercial	$97.47
Rate for Payer: LLUH Dept of Risk Management WC	$89.35
Rate for Payer: Multiplan Commercial	$121.84

HC SOM NMO/AQP4 FACS

Facility

$227.49

Service Code	CPT 86053
Hospital Charge Code	900915463
Hospital Revenue Code	300
Min. Negotiated Rate	$37.73
Max. Negotiated Rate	$181.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$136.49
Rate for Payer: Aetna of CA Government/Medicare	$136.49
Rate for Payer: Cash Price	$227.49
Rate for Payer: Cash Price	$227.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$181.99
Rate for Payer: Health Smart Auto/Commercial	$136.49
Rate for Payer: Intervalley Health Plan Commercial	$37.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$136.49
Rate for Payer: LLUH Dept of Risk Management WC	$125.12
Rate for Payer: Multiplan Commercial	$170.62

HC SOM NMO/AQP4 FACS

Facility

$227.49

Service Code	CPT 86053
Hospital Charge Code	900915463
Hospital Revenue Code	300
Min. Negotiated Rate	$125.12
Max. Negotiated Rate	$181.99
Rate for Payer: Cash Price	$227.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$181.99
Rate for Payer: Health Smart Auto/Commercial	$136.49
Rate for Payer: LLUH Dept of Risk Management WC	$125.12
Rate for Payer: Multiplan Commercial	$170.62

HC SOM NMO/AQP4 FACS TITER

Facility

$75.00

Service Code	CPT 86053
Hospital Charge Code	900915464
Hospital Revenue Code	300
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

HC SOM NMO/AQP4 FACS TITER

Facility

$75.00

Service Code	CPT 86053
Hospital Charge Code	900915464
Hospital Revenue Code	300
Min. Negotiated Rate	$37.73
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	$37.73
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 SOMN NC05 CSF P-5-P 82491

Facility

$185.00

Service Code	CPT 82542
Hospital Charge Code	900914867
Hospital Revenue Code	301
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$148.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$111.00
Rate for Payer: Aetna of CA Government/Medicare	$111.00
Rate for Payer: Cash Price	$83.25
Rate for Payer: Cash Price	$83.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$148.00
Rate for Payer: Health Smart Auto/Commercial	$111.00
Rate for Payer: Intervalley Health Plan Commercial	$24.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$111.00
Rate for Payer: LLUH Dept of Risk Management WC	$101.75
Rate for Payer: Multiplan Commercial	$138.75

HC SOMN NC05 CSF P-5-P 82491

Facility

$185.00

Service Code	CPT 82542
Hospital Charge Code	900914867
Hospital Revenue Code	301
Min. Negotiated Rate	$101.75
Max. Negotiated Rate	$148.00
Rate for Payer: Cash Price	$83.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$148.00
Rate for Payer: Health Smart Auto/Commercial	$111.00
Rate for Payer: LLUH Dept of Risk Management WC	$101.75
Rate for Payer: Multiplan Commercial	$138.75

HC SOM NORCLOZAPINE LEVEL

Facility

$15.80

Service Code	CPT 80159
Hospital Charge Code	900912685
Hospital Revenue Code	301
Min. Negotiated Rate	$8.69
Max. Negotiated Rate	$12.64
Rate for Payer: Cash Price	$15.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.64
Rate for Payer: Health Smart Auto/Commercial	$9.48
Rate for Payer: LLUH Dept of Risk Management WC	$8.69
Rate for Payer: Multiplan Commercial	$11.85

HC SOM NORCLOZAPINE LEVEL

Facility

$15.80

Service Code	CPT 80159
Hospital Charge Code	900912685
Hospital Revenue Code	301
Min. Negotiated Rate	$8.69
Max. Negotiated Rate	$20.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.48
Rate for Payer: Aetna of CA Government/Medicare	$9.48
Rate for Payer: Cash Price	$15.80
Rate for Payer: Cash Price	$15.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.64
Rate for Payer: Health Smart Auto/Commercial	$9.48
Rate for Payer: Intervalley Health Plan Commercial	$20.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.48
Rate for Payer: LLUH Dept of Risk Management WC	$8.69
Rate for Payer: Multiplan Commercial	$11.85

HC SOM NORDOXEPIN LEVEL

Facility

$35.00

Service Code	CPT 80335
Hospital Charge Code	900912562
Hospital Revenue Code	301
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.00
Rate for Payer: Aetna of CA Government/Medicare	$21.00
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.00
Rate for Payer: LLUH Dept of Risk Management WC	$19.25
Rate for Payer: Multiplan Commercial	$26.25

HC SOM NORDOXEPIN LEVEL

Facility

$35.00

Service Code	CPT 80335
Hospital Charge Code	900912562
Hospital Revenue Code	301
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 NOROVIRUS AG

Facility

$126.00

Service Code	CPT 87449
Hospital Charge Code	900914127
Hospital Revenue Code	306
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$100.80
Rate for Payer: Cash Price	$126.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.80
Rate for Payer: Health Smart Auto/Commercial	$75.60
Rate for Payer: LLUH Dept of Risk Management WC	$69.30
Rate for Payer: Multiplan Commercial	$94.50

HC SOM NOROVIRUS AG

Facility

$126.00

Service Code	CPT 87449
Hospital Charge Code	900914127
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$75.60
Rate for Payer: Aetna of CA Government/Medicare	$75.60
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$100.80
Rate for Payer: Health Smart Auto/Commercial	$75.60
Rate for Payer: Intervalley Health Plan Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$75.60
Rate for Payer: LLUH Dept of Risk Management WC	$69.30
Rate for Payer: Multiplan Commercial	$94.50

HC SOM NOROVIRUS RNA

Facility

$245.52

Service Code	CPT 87798
Hospital Charge Code	900913809
Hospital Revenue Code	309
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$196.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$147.31
Rate for Payer: Aetna of CA Government/Medicare	$147.31
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cash Price	$245.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$196.42
Rate for Payer: Health Smart Auto/Commercial	$147.31
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$147.31
Rate for Payer: LLUH Dept of Risk Management WC	$135.04
Rate for Payer: Multiplan Commercial	$184.14

HC SOM NOROVIRUS RNA

Facility

$245.52

Service Code	CPT 87798
Hospital Charge Code	900913809
Hospital Revenue Code	309
Min. Negotiated Rate	$135.04
Max. Negotiated Rate	$196.42
Rate for Payer: Cash Price	$245.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$196.42
Rate for Payer: Health Smart Auto/Commercial	$147.31
Rate for Payer: LLUH Dept of Risk Management WC	$135.04
Rate for Payer: Multiplan Commercial	$184.14

HC SOM N-TELOPEPTIDE URINE

Facility

$19.23

Service Code	CPT 82523
Hospital Charge Code	900911412
Hospital Revenue Code	301
Min. Negotiated Rate	$10.58
Max. Negotiated Rate	$18.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.54
Rate for Payer: Aetna of CA Government/Medicare	$11.54
Rate for Payer: Cash Price	$19.23
Rate for Payer: Cash Price	$19.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.38
Rate for Payer: Health Smart Auto/Commercial	$11.54
Rate for Payer: Intervalley Health Plan Commercial	$18.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.54
Rate for Payer: LLUH Dept of Risk Management WC	$10.58
Rate for Payer: Multiplan Commercial	$14.42

HC SOM N-TELOPEPTIDE URINE

Facility

$19.23

Service Code	CPT 82523
Hospital Charge Code	900911412
Hospital Revenue Code	301
Min. Negotiated Rate	$10.58
Max. Negotiated Rate	$15.38
Rate for Payer: Cash Price	$19.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.38
Rate for Payer: Health Smart Auto/Commercial	$11.54
Rate for Payer: LLUH Dept of Risk Management WC	$10.58
Rate for Payer: Multiplan Commercial	$14.42

HC SOM NUCLEOPHOSMIN MUTAT ANAL

Facility

$350.00

Service Code	CPT 81310
Hospital Charge Code	900914001
Hospital Revenue Code	309
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Commercial	$262.50

HC SOM NUCLEOPHOSMIN MUTAT ANAL

Facility

$350.00

Service Code	CPT 81310
Hospital Charge Code	900914001
Hospital Revenue Code	309
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$280.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$210.00
Rate for Payer: Aetna of CA Government/Medicare	$210.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Cash Price	$350.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$280.00
Rate for Payer: Health Smart Auto/Commercial	$210.00
Rate for Payer: Intervalley Health Plan Commercial	$246.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$210.00
Rate for Payer: LLUH Dept of Risk Management WC	$192.50
Rate for Payer: Multiplan Commercial	$262.50

HC SOM OLANZAPINE

Facility

$93.80

Service Code	CPT 80299
Hospital Charge Code	900910772
Hospital Revenue Code	301
Min. Negotiated Rate	$51.59
Max. Negotiated Rate	$75.04
Rate for Payer: Cash Price	$93.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$75.04
Rate for Payer: Health Smart Auto/Commercial	$56.28
Rate for Payer: LLUH Dept of Risk Management WC	$51.59
Rate for Payer: Multiplan Commercial	$70.35

Know your out-of-pocket cost for care.

All Charges