Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM PREGNENOLONE, SERUM

Facility

$25.00

Service Code	CPT 84140
Hospital Charge Code	900915512
Hospital Revenue Code	300
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.67
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	$20.67
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 PRIMIDONE LEVEL

Facility

$26.01

Service Code	CPT 80188
Hospital Charge Code	900911489
Hospital Revenue Code	301
Min. Negotiated Rate	$14.31
Max. Negotiated Rate	$20.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.61
Rate for Payer: Aetna of CA Government/Medicare	$15.61
Rate for Payer: Cash Price	$26.01
Rate for Payer: Cash Price	$26.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.81
Rate for Payer: Health Smart Auto/Commercial	$15.61
Rate for Payer: Intervalley Health Plan Commercial	$16.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.61
Rate for Payer: LLUH Dept of Risk Management WC	$14.31
Rate for Payer: Multiplan Commercial	$19.51

HC SOM PRIMIDONE LEVEL

Facility

$26.01

Service Code	CPT 80188
Hospital Charge Code	900911489
Hospital Revenue Code	301
Min. Negotiated Rate	$14.31
Max. Negotiated Rate	$20.81
Rate for Payer: Cash Price	$26.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.81
Rate for Payer: Health Smart Auto/Commercial	$15.61
Rate for Payer: LLUH Dept of Risk Management WC	$14.31
Rate for Payer: Multiplan Commercial	$19.51

HC SOM PROINSULIN

Facility

$26.69

Service Code	CPT 84206
Hospital Charge Code	900911398
Hospital Revenue Code	301
Min. Negotiated Rate	$14.68
Max. Negotiated Rate	$21.35
Rate for Payer: Cash Price	$26.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.35
Rate for Payer: Health Smart Auto/Commercial	$16.01
Rate for Payer: LLUH Dept of Risk Management WC	$14.68
Rate for Payer: Multiplan Commercial	$20.02

HC SOM PROINSULIN

Facility

$26.69

Service Code	CPT 84206
Hospital Charge Code	900911398
Hospital Revenue Code	301
Min. Negotiated Rate	$14.68
Max. Negotiated Rate	$26.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.01
Rate for Payer: Aetna of CA Government/Medicare	$16.01
Rate for Payer: Cash Price	$26.69
Rate for Payer: Cash Price	$26.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.35
Rate for Payer: Health Smart Auto/Commercial	$16.01
Rate for Payer: Intervalley Health Plan Commercial	$26.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.01
Rate for Payer: LLUH Dept of Risk Management WC	$14.68
Rate for Payer: Multiplan Commercial	$20.02

HC SOM PROSTATE HEALTH INDEX

Facility

$13.28

Service Code	CPT 84153
Hospital Charge Code	900915518
Hospital Revenue Code	300
Min. Negotiated Rate	$7.30
Max. Negotiated Rate	$18.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.97
Rate for Payer: Aetna of CA Government/Medicare	$7.97
Rate for Payer: Cash Price	$13.28
Rate for Payer: Cash Price	$13.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.62
Rate for Payer: Health Smart Auto/Commercial	$7.97
Rate for Payer: Intervalley Health Plan Commercial	$18.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.97
Rate for Payer: LLUH Dept of Risk Management WC	$7.30
Rate for Payer: Multiplan Commercial	$9.96

HC SOM PROSTATE HEALTH INDEX

Facility

$13.28

Service Code	CPT 84153
Hospital Charge Code	900915518
Hospital Revenue Code	300
Min. Negotiated Rate	$7.30
Max. Negotiated Rate	$10.62
Rate for Payer: Cash Price	$13.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.62
Rate for Payer: Health Smart Auto/Commercial	$7.97
Rate for Payer: LLUH Dept of Risk Management WC	$7.30
Rate for Payer: Multiplan Commercial	$9.96

HC SOM PROTEINASE 3 AB

Facility

$19.01

Service Code	CPT 83516
Hospital Charge Code	900912701
Hospital Revenue Code	302
Min. Negotiated Rate	$10.46
Max. Negotiated Rate	$15.21
Rate for Payer: Cash Price	$19.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.21
Rate for Payer: Health Smart Auto/Commercial	$11.41
Rate for Payer: LLUH Dept of Risk Management WC	$10.46
Rate for Payer: Multiplan Commercial	$14.26

HC SOM PROTEINASE 3 AB

Facility

$19.01

Service Code	CPT 83516
Hospital Charge Code	900912701
Hospital Revenue Code	302
Min. Negotiated Rate	$10.46
Max. Negotiated Rate	$15.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.41
Rate for Payer: Aetna of CA Government/Medicare	$11.41
Rate for Payer: Cash Price	$19.01
Rate for Payer: Cash Price	$19.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.21
Rate for Payer: Health Smart Auto/Commercial	$11.41
Rate for Payer: Intervalley Health Plan Commercial	$11.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.41
Rate for Payer: LLUH Dept of Risk Management WC	$10.46
Rate for Payer: Multiplan Commercial	$14.26

HC SOM PROTEIN C AG

Facility

$223.58

Service Code	CPT 85302
Hospital Charge Code	900913801
Hospital Revenue Code	305
Min. Negotiated Rate	$122.97
Max. Negotiated Rate	$178.86
Rate for Payer: Cash Price	$223.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$178.86
Rate for Payer: Health Smart Auto/Commercial	$134.15
Rate for Payer: LLUH Dept of Risk Management WC	$122.97
Rate for Payer: Multiplan Commercial	$167.69

HC SOM PROTEIN C AG

Facility

$223.58

Service Code	CPT 85302
Hospital Charge Code	900913801
Hospital Revenue Code	305
Min. Negotiated Rate	$12.01
Max. Negotiated Rate	$178.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$134.15
Rate for Payer: Aetna of CA Government/Medicare	$134.15
Rate for Payer: Cash Price	$223.58
Rate for Payer: Cash Price	$223.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$178.86
Rate for Payer: Health Smart Auto/Commercial	$134.15
Rate for Payer: Intervalley Health Plan Commercial	$12.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$134.15
Rate for Payer: LLUH Dept of Risk Management WC	$122.97
Rate for Payer: Multiplan Commercial	$167.69

HC SOM PROTEIN ELECT URINE

Facility

$24.88

Service Code	CPT 84166
Hospital Charge Code	900912721
Hospital Revenue Code	301
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$19.90
Rate for Payer: Cash Price	$24.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.90
Rate for Payer: Health Smart Auto/Commercial	$14.93
Rate for Payer: LLUH Dept of Risk Management WC	$13.68
Rate for Payer: Multiplan Commercial	$18.66

HC SOM PROTEIN ELECT URINE

Facility

$24.88

Service Code	CPT 84166
Hospital Charge Code	900912721
Hospital Revenue Code	301
Min. Negotiated Rate	$13.68
Max. Negotiated Rate	$19.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.93
Rate for Payer: Aetna of CA Government/Medicare	$14.93
Rate for Payer: Cash Price	$24.88
Rate for Payer: Cash Price	$24.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.90
Rate for Payer: Health Smart Auto/Commercial	$14.93
Rate for Payer: Intervalley Health Plan Commercial	$17.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.93
Rate for Payer: LLUH Dept of Risk Management WC	$13.68
Rate for Payer: Multiplan Commercial	$18.66

HC SOM PROTEIN S AG

Facility

$50.00

Service Code	CPT 85306
Hospital Charge Code	900913807
Hospital Revenue Code	305
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 PROTEIN S AG

Facility

$50.00

Service Code	CPT 85306
Hospital Charge Code	900913807
Hospital Revenue Code	305
Min. Negotiated Rate	$15.32
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	$15.32
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 PROTEIN S PLASMA

Facility

$28.63

Service Code	CPT 85306
Hospital Charge Code	900911277
Hospital Revenue Code	305
Min. Negotiated Rate	$15.32
Max. Negotiated Rate	$22.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.18
Rate for Payer: Aetna of CA Government/Medicare	$17.18
Rate for Payer: Cash Price	$28.63
Rate for Payer: Cash Price	$28.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.90
Rate for Payer: Health Smart Auto/Commercial	$17.18
Rate for Payer: Intervalley Health Plan Commercial	$15.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.18
Rate for Payer: LLUH Dept of Risk Management WC	$15.75
Rate for Payer: Multiplan Commercial	$21.47

HC SOM PROTEIN S PLASMA

Facility

$28.63

Service Code	CPT 85306
Hospital Charge Code	900911277
Hospital Revenue Code	305
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$22.90
Rate for Payer: Cash Price	$28.63
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.90
Rate for Payer: Health Smart Auto/Commercial	$17.18
Rate for Payer: LLUH Dept of Risk Management WC	$15.75
Rate for Payer: Multiplan Commercial	$21.47

HC SOM PROTEIN, TOTAL, RANDOM, U

Facility

$4.13

Service Code	CPT 84156
Hospital Charge Code	900912892
Hospital Revenue Code	301
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.30
Rate for Payer: Cash Price	$4.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Commercial	$3.10

HC SOM PROTEIN, TOTAL, RANDOM, U

Facility

$4.13

Service Code	CPT 84156
Hospital Charge Code	900912892
Hospital Revenue Code	301
Min. Negotiated Rate	$2.27
Max. Negotiated Rate	$3.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.48
Rate for Payer: Aetna of CA Government/Medicare	$2.48
Rate for Payer: Cash Price	$4.13
Rate for Payer: Cash Price	$4.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.30
Rate for Payer: Health Smart Auto/Commercial	$2.48
Rate for Payer: Intervalley Health Plan Commercial	$3.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.48
Rate for Payer: LLUH Dept of Risk Management WC	$2.27
Rate for Payer: Multiplan Commercial	$3.10

HC SOM PROTEIN TOTAL URINE

Facility

$5.12

Service Code	CPT 84156
Hospital Charge Code	900912826
Hospital Revenue Code	301
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.07
Rate for Payer: Aetna of CA Government/Medicare	$3.07
Rate for Payer: Cash Price	$5.12
Rate for Payer: Cash Price	$5.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Intervalley Health Plan Commercial	$3.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.07
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Commercial	$3.84

HC SOM PROTEIN TOTAL URINE

Facility

$5.12

Service Code	CPT 84156
Hospital Charge Code	900912826
Hospital Revenue Code	301
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.10
Rate for Payer: Cash Price	$5.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Commercial	$3.84

HC SOM PROTOPORPH FR RBC

Facility

$355.71

Service Code	CPT 82542
Hospital Charge Code	900911168
Hospital Revenue Code	301
Min. Negotiated Rate	$24.09
Max. Negotiated Rate	$284.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$213.43
Rate for Payer: Aetna of CA Government/Medicare	$213.43
Rate for Payer: Cash Price	$355.71
Rate for Payer: Cash Price	$355.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$284.57
Rate for Payer: Health Smart Auto/Commercial	$213.43
Rate for Payer: Intervalley Health Plan Commercial	$24.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$213.43
Rate for Payer: LLUH Dept of Risk Management WC	$195.64
Rate for Payer: Multiplan Commercial	$266.78

HC SOM PROTOPORPH FR RBC

Facility

$355.71

Service Code	CPT 82542
Hospital Charge Code	900911168
Hospital Revenue Code	301
Min. Negotiated Rate	$195.64
Max. Negotiated Rate	$284.57
Rate for Payer: Cash Price	$355.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$284.57
Rate for Payer: Health Smart Auto/Commercial	$213.43
Rate for Payer: LLUH Dept of Risk Management WC	$195.64
Rate for Payer: Multiplan Commercial	$266.78

HC SOM PROTRIPTYLINE (VIVACTYL)

Facility

$62.99

Service Code	CPT 80335
Hospital Charge Code	900911246
Hospital Revenue Code	301
Min. Negotiated Rate	$34.64
Max. Negotiated Rate	$50.39
Rate for Payer: Cash Price	$62.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$50.39
Rate for Payer: Health Smart Auto/Commercial	$37.79
Rate for Payer: LLUH Dept of Risk Management WC	$34.64
Rate for Payer: Multiplan Commercial	$47.24

HC SOM PROTRIPTYLINE (VIVACTYL)

Facility

$62.99

Service Code	CPT 80335
Hospital Charge Code	900911246
Hospital Revenue Code	301
Min. Negotiated Rate	$34.64
Max. Negotiated Rate	$50.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.79
Rate for Payer: Aetna of CA Government/Medicare	$37.79
Rate for Payer: Cash Price	$62.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$50.39
Rate for Payer: Health Smart Auto/Commercial	$37.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.79
Rate for Payer: LLUH Dept of Risk Management WC	$34.64
Rate for Payer: Multiplan Commercial	$47.24

Know your out-of-pocket cost for care.

All Charges