Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM OLANZAPINE

Facility

$93.80

Service Code	CPT 80299
Hospital Charge Code	900910772
Hospital Revenue Code	301
Min. Negotiated Rate	$18.64
Max. Negotiated Rate	$75.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$56.28
Rate for Payer: Aetna of CA Government/Medicare	$56.28
Rate for Payer: Cash Price	$93.80
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: Intervalley Health Plan Commercial	$18.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$56.28
Rate for Payer: LLUH Dept of Risk Management WC	$51.59
Rate for Payer: Multiplan Commercial	$70.35

HC SOM OLIGOCLONAL BANDS CSF

Facility

$22.86

Service Code	CPT 83916
Hospital Charge Code	900911235
Hospital Revenue Code	301
Min. Negotiated Rate	$12.57
Max. Negotiated Rate	$27.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.72
Rate for Payer: Aetna of CA Government/Medicare	$13.72
Rate for Payer: Cash Price	$22.86
Rate for Payer: Cash Price	$22.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.29
Rate for Payer: Health Smart Auto/Commercial	$13.72
Rate for Payer: Intervalley Health Plan Commercial	$27.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.72
Rate for Payer: LLUH Dept of Risk Management WC	$12.57
Rate for Payer: Multiplan Commercial	$17.14

HC SOM OLIGOCLONAL BANDS CSF

Facility

$22.86

Service Code	CPT 83916
Hospital Charge Code	900911235
Hospital Revenue Code	301
Min. Negotiated Rate	$12.57
Max. Negotiated Rate	$18.29
Rate for Payer: Cash Price	$22.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.29
Rate for Payer: Health Smart Auto/Commercial	$13.72
Rate for Payer: LLUH Dept of Risk Management WC	$12.57
Rate for Payer: Multiplan Commercial	$17.14

HC SOM OLIGOCLONAL BANDS SERUM

Facility

$22.86

Service Code	CPT 83916
Hospital Charge Code	900912657
Hospital Revenue Code	301
Min. Negotiated Rate	$12.57
Max. Negotiated Rate	$18.29
Rate for Payer: Cash Price	$22.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.29
Rate for Payer: Health Smart Auto/Commercial	$13.72
Rate for Payer: LLUH Dept of Risk Management WC	$12.57
Rate for Payer: Multiplan Commercial	$17.14

HC SOM OLIGOCLONAL BANDS SERUM

Facility

$22.86

Service Code	CPT 83916
Hospital Charge Code	900912657
Hospital Revenue Code	301
Min. Negotiated Rate	$12.57
Max. Negotiated Rate	$27.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.72
Rate for Payer: Aetna of CA Government/Medicare	$13.72
Rate for Payer: Cash Price	$22.86
Rate for Payer: Cash Price	$22.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.29
Rate for Payer: Health Smart Auto/Commercial	$13.72
Rate for Payer: Intervalley Health Plan Commercial	$27.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.72
Rate for Payer: LLUH Dept of Risk Management WC	$12.57
Rate for Payer: Multiplan Commercial	$17.14

HC SOM ORGANIC ACID SCREEN

Facility

$40.00

Service Code	CPT 83919
Hospital Charge Code	900911179
Hospital Revenue Code	301
Min. Negotiated Rate	$16.45
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	$16.45
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 ORGANIC ACID SCREEN

Facility

$40.00

Service Code	CPT 83919
Hospital Charge Code	900911179
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 ORG REFER FOR ID, AEROBIC

Facility

$17.20

Service Code	CPT 87077
Hospital Charge Code	900912887
Hospital Revenue Code	306
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$13.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.32
Rate for Payer: Aetna of CA Government/Medicare	$10.32
Rate for Payer: Cash Price	$17.20
Rate for Payer: Cash Price	$17.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.76
Rate for Payer: Health Smart Auto/Commercial	$10.32
Rate for Payer: Intervalley Health Plan Commercial	$8.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.32
Rate for Payer: LLUH Dept of Risk Management WC	$9.46
Rate for Payer: Multiplan Commercial	$12.90

HC SOM ORG REFER FOR ID, AEROBIC

Facility

$17.20

Service Code	CPT 87077
Hospital Charge Code	900912887
Hospital Revenue Code	306
Min. Negotiated Rate	$9.46
Max. Negotiated Rate	$13.76
Rate for Payer: Cash Price	$17.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.76
Rate for Payer: Health Smart Auto/Commercial	$10.32
Rate for Payer: LLUH Dept of Risk Management WC	$9.46
Rate for Payer: Multiplan Commercial	$12.90

HC SOM ORG REFER FOR ID, ANAEROB

Facility

$23.74

Service Code	CPT 87076
Hospital Charge Code	900912889
Hospital Revenue Code	306
Min. Negotiated Rate	$13.06
Max. Negotiated Rate	$18.99
Rate for Payer: Cash Price	$23.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.99
Rate for Payer: Health Smart Auto/Commercial	$14.24
Rate for Payer: LLUH Dept of Risk Management WC	$13.06
Rate for Payer: Multiplan Commercial	$17.80

HC SOM ORG REFER FOR ID, ANAEROB

Facility

$23.74

Service Code	CPT 87076
Hospital Charge Code	900912889
Hospital Revenue Code	306
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$18.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.24
Rate for Payer: Aetna of CA Government/Medicare	$14.24
Rate for Payer: Cash Price	$23.74
Rate for Payer: Cash Price	$23.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.99
Rate for Payer: Health Smart Auto/Commercial	$14.24
Rate for Payer: Intervalley Health Plan Commercial	$8.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.24
Rate for Payer: LLUH Dept of Risk Management WC	$13.06
Rate for Payer: Multiplan Commercial	$17.80

HC SOM OSTEOCALCIN

Facility

$41.00

Service Code	CPT 83937
Hospital Charge Code	900911399
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$32.80
Rate for Payer: Cash Price	$41.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.80
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Commercial	$30.75

HC SOM OSTEOCALCIN

Facility

$41.00

Service Code	CPT 83937
Hospital Charge Code	900911399
Hospital Revenue Code	301
Min. Negotiated Rate	$22.55
Max. Negotiated Rate	$32.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.60
Rate for Payer: Aetna of CA Government/Medicare	$24.60
Rate for Payer: Cash Price	$41.00
Rate for Payer: Cash Price	$41.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.80
Rate for Payer: Health Smart Auto/Commercial	$24.60
Rate for Payer: Intervalley Health Plan Commercial	$29.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.60
Rate for Payer: LLUH Dept of Risk Management WC	$22.55
Rate for Payer: Multiplan Commercial	$30.75

HC SOM OXALATE

Facility

$20.00

Service Code	CPT 83945
Hospital Charge Code	900911124
Hospital Revenue Code	301
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 OXALATE

Facility

$20.00

Service Code	CPT 83945
Hospital Charge Code	900911124
Hospital Revenue Code	301
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	$14.45
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 OXALATE PLASMA

Facility

$68.00

Service Code	CPT 83945
Hospital Charge Code	900910579
Hospital Revenue Code	301
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$54.40
Rate for Payer: Cash Price	$68.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Commercial	$51.00

HC SOM OXALATE PLASMA

Facility

$68.00

Service Code	CPT 83945
Hospital Charge Code	900910579
Hospital Revenue Code	301
Min. Negotiated Rate	$14.45
Max. Negotiated Rate	$54.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Intervalley Health Plan Commercial	$14.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Commercial	$51.00

HC SOM OXCARBAZEPINE LEVEL

Facility

$20.00

Service Code	CPT 80183
Hospital Charge Code	900912537
Hospital Revenue Code	301
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 OXCARBAZEPINE LEVEL

Facility

$20.00

Service Code	CPT 80183
Hospital Charge Code	900912537
Hospital Revenue Code	301
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	$13.25
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 PANCREATIC ELASTASE/STOOL

Facility

$80.00

Service Code	CPT 82653
Hospital Charge Code	900912993
Hospital Revenue Code	301
Min. Negotiated Rate	$22.97
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.00
Rate for Payer: Aetna of CA Government/Medicare	$48.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$64.00
Rate for Payer: Health Smart Auto/Commercial	$48.00
Rate for Payer: Intervalley Health Plan Commercial	$22.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.00
Rate for Payer: Multiplan Commercial	$60.00

HC SOM PANCREATIC ELASTASE/STOOL

Facility

$80.00

Service Code	CPT 82653
Hospital Charge Code	900912993
Hospital Revenue Code	301
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$64.00
Rate for Payer: Health Smart Auto/Commercial	$48.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.00
Rate for Payer: Multiplan Commercial	$60.00

HC SOM PANCREATIC POLYPEPTIDE

Facility

$555.29

Service Code	CPT 83519
Hospital Charge Code	900911326
Hospital Revenue Code	301
Min. Negotiated Rate	$305.41
Max. Negotiated Rate	$444.23
Rate for Payer: Cash Price	$555.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$444.23
Rate for Payer: Health Smart Auto/Commercial	$333.17
Rate for Payer: LLUH Dept of Risk Management WC	$305.41
Rate for Payer: Multiplan Commercial	$416.47

HC SOM PANCREATIC POLYPEPTIDE

Facility

$555.29

Service Code	CPT 83519
Hospital Charge Code	900911326
Hospital Revenue Code	301
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$444.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$333.17
Rate for Payer: Aetna of CA Government/Medicare	$333.17
Rate for Payer: Cash Price	$555.29
Rate for Payer: Cash Price	$555.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$444.23
Rate for Payer: Health Smart Auto/Commercial	$333.17
Rate for Payer: Intervalley Health Plan Commercial	$18.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$333.17
Rate for Payer: LLUH Dept of Risk Management WC	$305.41
Rate for Payer: Multiplan Commercial	$416.47

HC SOM PARIETAL CELL AB

Facility

$25.00

Service Code	CPT 83516
Hospital Charge Code	900911267
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
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	$11.53
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 PARIETAL CELL AB

Facility

$25.00

Service Code	CPT 83516
Hospital Charge Code	900911267
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

Know your out-of-pocket cost for care.

All Charges