Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM TRYPTASE

Facility

$37.70

Service Code	CPT 83520
Hospital Charge Code	900910734
Hospital Revenue Code	302
Min. Negotiated Rate	$20.73
Max. Negotiated Rate	$30.16
Rate for Payer: Cash Price	$37.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.16
Rate for Payer: Health Smart Auto/Commercial	$22.62
Rate for Payer: LLUH Dept of Risk Management WC	$20.73
Rate for Payer: Multiplan Commercial	$28.27

HC SOM TSH SENSITIVE, SERUM

Facility

$24.06

Service Code	CPT 84443
Hospital Charge Code	900913813
Hospital Revenue Code	301
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$19.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.44
Rate for Payer: Aetna of CA Government/Medicare	$14.44
Rate for Payer: Cash Price	$24.06
Rate for Payer: Cash Price	$24.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.25
Rate for Payer: Health Smart Auto/Commercial	$14.44
Rate for Payer: Intervalley Health Plan Commercial	$16.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.44
Rate for Payer: LLUH Dept of Risk Management WC	$13.23
Rate for Payer: Multiplan Commercial	$18.05

HC SOM TSH SENSITIVE, SERUM

Facility

$24.06

Service Code	CPT 84443
Hospital Charge Code	900913813
Hospital Revenue Code	301
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$19.25
Rate for Payer: Cash Price	$24.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.25
Rate for Payer: Health Smart Auto/Commercial	$14.44
Rate for Payer: LLUH Dept of Risk Management WC	$13.23
Rate for Payer: Multiplan Commercial	$18.05

HC SOM UBEMS 81406

Facility

$967.50

Service Code	CPT 81406
Hospital Charge Code	900914886
Hospital Revenue Code	309
Min. Negotiated Rate	$282.88
Max. Negotiated Rate	$774.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$580.50
Rate for Payer: Aetna of CA Government/Medicare	$580.50
Rate for Payer: Cash Price	$967.50
Rate for Payer: Cash Price	$967.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$774.00
Rate for Payer: Health Smart Auto/Commercial	$580.50
Rate for Payer: Intervalley Health Plan Commercial	$282.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$580.50
Rate for Payer: LLUH Dept of Risk Management WC	$532.12
Rate for Payer: Multiplan Commercial	$725.62

HC SOM UBEMS 81406

Facility

$967.50

Service Code	CPT 81406
Hospital Charge Code	900914886
Hospital Revenue Code	309
Min. Negotiated Rate	$532.12
Max. Negotiated Rate	$774.00
Rate for Payer: Cash Price	$967.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$774.00
Rate for Payer: Health Smart Auto/Commercial	$580.50
Rate for Payer: LLUH Dept of Risk Management WC	$532.12
Rate for Payer: Multiplan Commercial	$725.62

HC SOM UNIPARENTAL DISOMY AMP

Facility

$275.48

Service Code	CPT 81402
Hospital Charge Code	900914445
Hospital Revenue Code	309
Min. Negotiated Rate	$151.51
Max. Negotiated Rate	$220.38
Rate for Payer: Cash Price	$275.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$220.38
Rate for Payer: Health Smart Auto/Commercial	$165.29
Rate for Payer: LLUH Dept of Risk Management WC	$151.51
Rate for Payer: Multiplan Commercial	$206.61

HC SOM UNIPARENTAL DISOMY AMP

Facility

$275.48

Service Code	CPT 81402
Hospital Charge Code	900914445
Hospital Revenue Code	309
Min. Negotiated Rate	$150.33
Max. Negotiated Rate	$220.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$165.29
Rate for Payer: Aetna of CA Government/Medicare	$165.29
Rate for Payer: Cash Price	$275.48
Rate for Payer: Cash Price	$275.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$220.38
Rate for Payer: Health Smart Auto/Commercial	$165.29
Rate for Payer: Intervalley Health Plan Commercial	$150.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$165.29
Rate for Payer: LLUH Dept of Risk Management WC	$151.51
Rate for Payer: Multiplan Commercial	$206.61

HC SOM UREAPLASMA PCR

Facility

$37.50

Service Code	CPT 87798
Hospital Charge Code	900912878
Hospital Revenue Code	306
Min. Negotiated Rate	$20.62
Max. Negotiated Rate	$35.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.50
Rate for Payer: Aetna of CA Government/Medicare	$22.50
Rate for Payer: Cash Price	$37.50
Rate for Payer: Cash Price	$37.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.00
Rate for Payer: Health Smart Auto/Commercial	$22.50
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.50
Rate for Payer: LLUH Dept of Risk Management WC	$20.62
Rate for Payer: Multiplan Commercial	$28.12

HC SOM UREAPLASMA PCR

Facility

$37.50

Service Code	CPT 87798
Hospital Charge Code	900912878
Hospital Revenue Code	306
Min. Negotiated Rate	$20.62
Max. Negotiated Rate	$30.00
Rate for Payer: Cash Price	$37.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.00
Rate for Payer: Health Smart Auto/Commercial	$22.50
Rate for Payer: LLUH Dept of Risk Management WC	$20.62
Rate for Payer: Multiplan Commercial	$28.12

HC SOM VARICELLA ZOSTER ANTIBODY

Facility

$14.17

Service Code	CPT 86787
Hospital Charge Code	900912868
Hospital Revenue Code	302
Min. Negotiated Rate	$7.79
Max. Negotiated Rate	$12.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.50
Rate for Payer: Aetna of CA Government/Medicare	$8.50
Rate for Payer: Cash Price	$14.17
Rate for Payer: Cash Price	$14.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.34
Rate for Payer: Health Smart Auto/Commercial	$8.50
Rate for Payer: Intervalley Health Plan Commercial	$12.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.50
Rate for Payer: LLUH Dept of Risk Management WC	$7.79
Rate for Payer: Multiplan Commercial	$10.63

HC SOM VARICELLA ZOSTER ANTIBODY

Facility

$14.17

Service Code	CPT 86787
Hospital Charge Code	900912868
Hospital Revenue Code	302
Min. Negotiated Rate	$7.79
Max. Negotiated Rate	$11.34
Rate for Payer: Cash Price	$14.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.34
Rate for Payer: Health Smart Auto/Commercial	$8.50
Rate for Payer: LLUH Dept of Risk Management WC	$7.79
Rate for Payer: Multiplan Commercial	$10.63

HC SOM VASCULITIS PANEL P3 AB

Facility

$17.50

Service Code	CPT 83516
Hospital Charge Code	900912702
Hospital Revenue Code	301
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.50
Rate for Payer: Aetna of CA Government/Medicare	$10.50
Rate for Payer: Cash Price	$17.50
Rate for Payer: Cash Price	$17.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.00
Rate for Payer: Health Smart Auto/Commercial	$10.50
Rate for Payer: Intervalley Health Plan Commercial	$11.53
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.50
Rate for Payer: LLUH Dept of Risk Management WC	$9.62
Rate for Payer: Multiplan Commercial	$13.12

HC SOM VASCULITIS PANEL P3 AB

Facility

$17.50

Service Code	CPT 83516
Hospital Charge Code	900912702
Hospital Revenue Code	301
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$14.00
Rate for Payer: Cash Price	$17.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.00
Rate for Payer: Health Smart Auto/Commercial	$10.50
Rate for Payer: LLUH Dept of Risk Management WC	$9.62
Rate for Payer: Multiplan Commercial	$13.12

HC SOM VASOACTIVE INTESTINAL PEPTIDE

Facility

$50.00

Service Code	CPT 84586
Hospital Charge Code	900911186
Hospital Revenue Code	301
Min. Negotiated Rate	$27.50
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	$35.33
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 VASOACTIVE INTESTINAL PEPTIDE

Facility

$50.00

Service Code	CPT 84586
Hospital Charge Code	900911186
Hospital Revenue Code	301
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 VDER 87529

Facility

$50.27

Service Code	CPT 87529
Hospital Charge Code	900913965
Hospital Revenue Code	306
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$40.22
Rate for Payer: Cash Price	$50.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.22
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Commercial	$37.70

HC SOM VDER 87529

Facility

$50.27

Service Code	CPT 87529
Hospital Charge Code	900913965
Hospital Revenue Code	306
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$40.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.16
Rate for Payer: Aetna of CA Government/Medicare	$30.16
Rate for Payer: Cash Price	$50.27
Rate for Payer: Cash Price	$50.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.22
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Commercial	$37.70

HC SOM VDER 87798

Facility

$50.27

Service Code	CPT 87798
Hospital Charge Code	900913966
Hospital Revenue Code	306
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$40.22
Rate for Payer: Cash Price	$50.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.22
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Commercial	$37.70

HC SOM VDER 87798

Facility

$50.27

Service Code	CPT 87798
Hospital Charge Code	900913966
Hospital Revenue Code	306
Min. Negotiated Rate	$27.65
Max. Negotiated Rate	$40.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.16
Rate for Payer: Aetna of CA Government/Medicare	$30.16
Rate for Payer: Cash Price	$50.27
Rate for Payer: Cash Price	$50.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.22
Rate for Payer: Health Smart Auto/Commercial	$30.16
Rate for Payer: Intervalley Health Plan Commercial	$35.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.16
Rate for Payer: LLUH Dept of Risk Management WC	$27.65
Rate for Payer: Multiplan Commercial	$37.70

HC SOM VITAMIN A

Facility

$17.90

Service Code	CPT 84590
Hospital Charge Code	900911173
Hospital Revenue Code	301
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$14.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.74
Rate for Payer: Aetna of CA Government/Medicare	$10.74
Rate for Payer: Cash Price	$17.90
Rate for Payer: Cash Price	$17.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: Intervalley Health Plan Commercial	$11.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.85
Rate for Payer: Multiplan Commercial	$13.43

HC SOM VITAMIN A

Facility

$17.90

Service Code	CPT 84590
Hospital Charge Code	900911173
Hospital Revenue Code	301
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$14.32
Rate for Payer: Cash Price	$17.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.85
Rate for Payer: Multiplan Commercial	$13.43

HC SOM VITAMIN B1 (THIAMINE)

Facility

$22.00

Service Code	CPT 84425
Hospital Charge Code	900911048
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$21.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.20
Rate for Payer: Aetna of CA Government/Medicare	$13.20
Rate for Payer: Cash Price	$22.00
Rate for Payer: Cash Price	$22.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Intervalley Health Plan Commercial	$21.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Commercial	$16.50

HC SOM VITAMIN B1 (THIAMINE)

Facility

$22.00

Service Code	CPT 84425
Hospital Charge Code	900911048
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$22.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Commercial	$16.50

HC SOM VITAMIN B6

Facility

$28.25

Service Code	CPT 84207
Hospital Charge Code	900911400
Hospital Revenue Code	301
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$22.60
Rate for Payer: Cash Price	$28.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.60
Rate for Payer: Health Smart Auto/Commercial	$16.95
Rate for Payer: LLUH Dept of Risk Management WC	$15.54
Rate for Payer: Multiplan Commercial	$21.19

HC SOM VITAMIN B6

Facility

$28.25

Service Code	CPT 84207
Hospital Charge Code	900911400
Hospital Revenue Code	301
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$28.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.95
Rate for Payer: Aetna of CA Government/Medicare	$16.95
Rate for Payer: Cash Price	$28.25
Rate for Payer: Cash Price	$28.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$22.60
Rate for Payer: Health Smart Auto/Commercial	$16.95
Rate for Payer: Intervalley Health Plan Commercial	$28.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.95
Rate for Payer: LLUH Dept of Risk Management WC	$15.54
Rate for Payer: Multiplan Commercial	$21.19

Know your out-of-pocket cost for care.

All Charges