Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM RIBOSOMAL P AB

Facility

$30.00

Service Code	CPT 83516
Hospital Charge Code	900911367
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Intervalley Health Plan Commercial	$11.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

HC SOM RISPERIDONE

Facility

$85.96

Service Code	CPT 80342
Hospital Charge Code	900910787
Hospital Revenue Code	301
Min. Negotiated Rate	$47.28
Max. Negotiated Rate	$68.77
Rate for Payer: Cash Price	$85.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.77
Rate for Payer: Health Smart Auto/Commercial	$51.58
Rate for Payer: LLUH Dept of Risk Management WC	$47.28
Rate for Payer: Multiplan Commercial	$64.47

HC SOM RISPERIDONE

Facility

$85.96

Service Code	CPT 80342
Hospital Charge Code	900910787
Hospital Revenue Code	301
Min. Negotiated Rate	$47.28
Max. Negotiated Rate	$68.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.58
Rate for Payer: Aetna of CA Government/Medicare	$51.58
Rate for Payer: Cash Price	$85.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.77
Rate for Payer: Health Smart Auto/Commercial	$51.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.58
Rate for Payer: LLUH Dept of Risk Management WC	$47.28
Rate for Payer: Multiplan Commercial	$64.47

HC SOM RISTOCETIN-WILLEBRAND FACTOR

Facility

$40.00

Service Code	CPT 85245
Hospital Charge Code	900911282
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	$22.94
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 RISTOCETIN-WILLEBRAND FACTOR

Facility

$40.00

Service Code	CPT 85245
Hospital Charge Code	900911282
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 SACCHAROMY CEREVI AB, IGA

Facility

$18.54

Service Code	CPT 86671
Hospital Charge Code	900913806
Hospital Revenue Code	302
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$14.83
Rate for Payer: Cash Price	$18.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.83
Rate for Payer: Health Smart Auto/Commercial	$11.12
Rate for Payer: LLUH Dept of Risk Management WC	$10.20
Rate for Payer: Multiplan Commercial	$13.90

HC SOM SACCHAROMY CEREVI AB, IGA

Facility

$169.30

Service Code	CPT 86671
Hospital Charge Code	900913805
Hospital Revenue Code	302
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$135.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$101.58
Rate for Payer: Aetna of CA Government/Medicare	$101.58
Rate for Payer: Cash Price	$169.30
Rate for Payer: Cash Price	$169.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$135.44
Rate for Payer: Health Smart Auto/Commercial	$101.58
Rate for Payer: Intervalley Health Plan Commercial	$12.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$101.58
Rate for Payer: LLUH Dept of Risk Management WC	$93.11
Rate for Payer: Multiplan Commercial	$126.97

HC SOM SACCHAROMY CEREVI AB, IGA

Facility

$169.30

Service Code	CPT 86671
Hospital Charge Code	900913805
Hospital Revenue Code	302
Min. Negotiated Rate	$93.11
Max. Negotiated Rate	$135.44
Rate for Payer: Cash Price	$169.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$135.44
Rate for Payer: Health Smart Auto/Commercial	$101.58
Rate for Payer: LLUH Dept of Risk Management WC	$93.11
Rate for Payer: Multiplan Commercial	$126.97

HC SOM SACCHAROMY CEREVI AB, IGA

Facility

$18.54

Service Code	CPT 86671
Hospital Charge Code	900913806
Hospital Revenue Code	302
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$14.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.12
Rate for Payer: Aetna of CA Government/Medicare	$11.12
Rate for Payer: Cash Price	$18.54
Rate for Payer: Cash Price	$18.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.83
Rate for Payer: Health Smart Auto/Commercial	$11.12
Rate for Payer: Intervalley Health Plan Commercial	$12.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.12
Rate for Payer: LLUH Dept of Risk Management WC	$10.20
Rate for Payer: Multiplan Commercial	$13.90

HC SOM SCHISTOSOMIASIS AB IGG

Facility

$45.00

Service Code	CPT 86682
Hospital Charge Code	900911335
Hospital Revenue Code	302
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Intervalley Health Plan Commercial	$13.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Commercial	$33.75

HC SOM SCHISTOSOMIASIS AB IGG

Facility

$45.00

Service Code	CPT 86682
Hospital Charge Code	900911335
Hospital Revenue Code	302
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$36.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Commercial	$33.75

HC SOM SEBV EBNA

Facility

$9.48

Service Code	CPT 86664
Hospital Charge Code	900915457
Hospital Revenue Code	300
Min. Negotiated Rate	$5.21
Max. Negotiated Rate	$7.58
Rate for Payer: Cash Price	$9.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.58
Rate for Payer: Health Smart Auto/Commercial	$5.69
Rate for Payer: LLUH Dept of Risk Management WC	$5.21
Rate for Payer: Multiplan Commercial	$7.11

HC SOM SEBV EBNA

Facility

$9.48

Service Code	CPT 86664
Hospital Charge Code	900915457
Hospital Revenue Code	300
Min. Negotiated Rate	$5.21
Max. Negotiated Rate	$15.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.69
Rate for Payer: Aetna of CA Government/Medicare	$5.69
Rate for Payer: Cash Price	$9.48
Rate for Payer: Cash Price	$9.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.58
Rate for Payer: Health Smart Auto/Commercial	$5.69
Rate for Payer: Intervalley Health Plan Commercial	$15.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.69
Rate for Payer: LLUH Dept of Risk Management WC	$5.21
Rate for Payer: Multiplan Commercial	$7.11

HC SOM SEBV IGG

Facility

$11.26

Service Code	CPT 86665
Hospital Charge Code	900915456
Hospital Revenue Code	300
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$9.01
Rate for Payer: Cash Price	$11.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.01
Rate for Payer: Health Smart Auto/Commercial	$6.76
Rate for Payer: LLUH Dept of Risk Management WC	$6.19
Rate for Payer: Multiplan Commercial	$8.45

HC SOM SEBV IGG

Facility

$11.26

Service Code	CPT 86665
Hospital Charge Code	900915456
Hospital Revenue Code	300
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$18.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.76
Rate for Payer: Aetna of CA Government/Medicare	$6.76
Rate for Payer: Cash Price	$11.26
Rate for Payer: Cash Price	$11.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.01
Rate for Payer: Health Smart Auto/Commercial	$6.76
Rate for Payer: Intervalley Health Plan Commercial	$18.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.76
Rate for Payer: LLUH Dept of Risk Management WC	$6.19
Rate for Payer: Multiplan Commercial	$8.45

HC SOM SEBV IGM

Facility

$11.26

Service Code	CPT 86665
Hospital Charge Code	900915455
Hospital Revenue Code	300
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$18.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.76
Rate for Payer: Aetna of CA Government/Medicare	$6.76
Rate for Payer: Cash Price	$11.26
Rate for Payer: Cash Price	$11.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.01
Rate for Payer: Health Smart Auto/Commercial	$6.76
Rate for Payer: Intervalley Health Plan Commercial	$18.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.76
Rate for Payer: LLUH Dept of Risk Management WC	$6.19
Rate for Payer: Multiplan Commercial	$8.45

HC SOM SEBV IGM

Facility

$11.26

Service Code	CPT 86665
Hospital Charge Code	900915455
Hospital Revenue Code	300
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$9.01
Rate for Payer: Cash Price	$11.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.01
Rate for Payer: Health Smart Auto/Commercial	$6.76
Rate for Payer: LLUH Dept of Risk Management WC	$6.19
Rate for Payer: Multiplan Commercial	$8.45

HC SOM SECOBARBITAL

Facility

$264.70

Service Code	CPT 80345
Hospital Charge Code	900910552
Hospital Revenue Code	301
Min. Negotiated Rate	$145.59
Max. Negotiated Rate	$211.76
Rate for Payer: Cash Price	$264.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$211.76
Rate for Payer: Health Smart Auto/Commercial	$158.82
Rate for Payer: LLUH Dept of Risk Management WC	$145.59
Rate for Payer: Multiplan Commercial	$198.53

HC SOM SECOBARBITAL

Facility

$264.70

Service Code	CPT 80345
Hospital Charge Code	900910552
Hospital Revenue Code	301
Min. Negotiated Rate	$145.59
Max. Negotiated Rate	$211.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$158.82
Rate for Payer: Aetna of CA Government/Medicare	$158.82
Rate for Payer: Cash Price	$264.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$211.76
Rate for Payer: Health Smart Auto/Commercial	$158.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$158.82
Rate for Payer: LLUH Dept of Risk Management WC	$145.59
Rate for Payer: Multiplan Commercial	$198.53

HC SOM SELENIUM URINE

Facility

$25.62

Service Code	CPT 84255
Hospital Charge Code	900911019
Hospital Revenue Code	301
Min. Negotiated Rate	$14.09
Max. Negotiated Rate	$25.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.37
Rate for Payer: Aetna of CA Government/Medicare	$15.37
Rate for Payer: Cash Price	$25.62
Rate for Payer: Cash Price	$25.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.50
Rate for Payer: Health Smart Auto/Commercial	$15.37
Rate for Payer: Intervalley Health Plan Commercial	$25.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.37
Rate for Payer: LLUH Dept of Risk Management WC	$14.09
Rate for Payer: Multiplan Commercial	$19.21

HC SOM SELENIUM URINE

Facility

$25.62

Service Code	CPT 84255
Hospital Charge Code	900911019
Hospital Revenue Code	301
Min. Negotiated Rate	$14.09
Max. Negotiated Rate	$20.50
Rate for Payer: Cash Price	$25.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.50
Rate for Payer: Health Smart Auto/Commercial	$15.37
Rate for Payer: LLUH Dept of Risk Management WC	$14.09
Rate for Payer: Multiplan Commercial	$19.21

HC SOM SEROTONIN BLOOD

Facility

$30.00

Service Code	CPT 84260
Hospital Charge Code	900911033
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$24.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

HC SOM SEROTONIN BLOOD

Facility

$30.00

Service Code	CPT 84260
Hospital Charge Code	900911033
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$30.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.00
Rate for Payer: Aetna of CA Government/Medicare	$18.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.00
Rate for Payer: Health Smart Auto/Commercial	$18.00
Rate for Payer: Intervalley Health Plan Commercial	$30.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.00
Rate for Payer: LLUH Dept of Risk Management WC	$16.50
Rate for Payer: Multiplan Commercial	$22.50

HC SOM SEX HORMN BINDNG GLOBU SER

Facility

$13.00

Service Code	CPT 84270
Hospital Charge Code	900913804
Hospital Revenue Code	301
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$13.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

HC SOM SEX HORMN BINDNG GLOBU SER

Facility

$13.00

Service Code	CPT 84270
Hospital Charge Code	900913804
Hospital Revenue Code	301
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$21.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.80
Rate for Payer: Aetna of CA Government/Medicare	$7.80
Rate for Payer: Cash Price	$13.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: Intervalley Health Plan Commercial	$21.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

Know your out-of-pocket cost for care.

All Charges