Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM VITAMIN D 25-HYDROXY

Facility

$8.00

Service Code	CPT 82306
Hospital Charge Code	900911032
Hospital Revenue Code	301
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$29.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.80
Rate for Payer: Aetna of CA Government/Medicare	$4.80
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.40
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: Intervalley Health Plan Commercial	$29.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: Multiplan Commercial	$6.00

HC SOM VITAMIN D 25-HYDROXY

Facility

$8.00

Service Code	CPT 82306
Hospital Charge Code	900911032
Hospital Revenue Code	301
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.40
Rate for Payer: Cash Price	$8.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.40
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: Multiplan Commercial	$6.00

HC SOM VITAMIN E

Facility

$19.57

Service Code	CPT 84446
Hospital Charge Code	900911174
Hospital Revenue Code	301
Min. Negotiated Rate	$10.76
Max. Negotiated Rate	$15.66
Rate for Payer: Cash Price	$19.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.66
Rate for Payer: Health Smart Auto/Commercial	$11.74
Rate for Payer: LLUH Dept of Risk Management WC	$10.76
Rate for Payer: Multiplan Commercial	$14.68

HC SOM VITAMIN E

Facility

$19.57

Service Code	CPT 84446
Hospital Charge Code	900911174
Hospital Revenue Code	301
Min. Negotiated Rate	$10.76
Max. Negotiated Rate	$15.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.74
Rate for Payer: Aetna of CA Government/Medicare	$11.74
Rate for Payer: Cash Price	$19.57
Rate for Payer: Cash Price	$19.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.66
Rate for Payer: Health Smart Auto/Commercial	$11.74
Rate for Payer: Intervalley Health Plan Commercial	$14.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.74
Rate for Payer: LLUH Dept of Risk Management WC	$10.76
Rate for Payer: Multiplan Commercial	$14.68

HC SOM VITAMIN K

Facility

$45.65

Service Code	CPT 84597
Hospital Charge Code	900911429
Hospital Revenue Code	301
Min. Negotiated Rate	$25.11
Max. Negotiated Rate	$36.52
Rate for Payer: Cash Price	$45.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.52
Rate for Payer: Health Smart Auto/Commercial	$27.39
Rate for Payer: LLUH Dept of Risk Management WC	$25.11
Rate for Payer: Multiplan Commercial	$34.24

HC SOM VITAMIN K

Facility

$45.65

Service Code	CPT 84597
Hospital Charge Code	900911429
Hospital Revenue Code	301
Min. Negotiated Rate	$13.72
Max. Negotiated Rate	$36.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.39
Rate for Payer: Aetna of CA Government/Medicare	$27.39
Rate for Payer: Cash Price	$45.65
Rate for Payer: Cash Price	$45.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.52
Rate for Payer: Health Smart Auto/Commercial	$27.39
Rate for Payer: Intervalley Health Plan Commercial	$13.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.39
Rate for Payer: LLUH Dept of Risk Management WC	$25.11
Rate for Payer: Multiplan Commercial	$34.24

HC SOM VOLATILES BLOOD

Facility

$45.00

Service Code	CPT 80320
Hospital Charge Code	900910583
Hospital Revenue Code	301
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 VOLATILES BLOOD

Facility

$45.00

Service Code	CPT 80320
Hospital Charge Code	900910583
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
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 VOLATILES URINE

Facility

$45.00

Service Code	CPT 80320
Hospital Charge Code	900910584
Hospital Revenue Code	301
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 VOLATILES URINE

Facility

$45.00

Service Code	CPT 80320
Hospital Charge Code	900910584
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.00
Rate for Payer: Health Smart Auto/Commercial	$27.00
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 VONWILLEBRAND AG

Facility

$25.34

Service Code	CPT 85246
Hospital Charge Code	900910112
Hospital Revenue Code	305
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$22.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.20
Rate for Payer: Aetna of CA Government/Medicare	$15.20
Rate for Payer: Cash Price	$25.34
Rate for Payer: Cash Price	$25.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.27
Rate for Payer: Health Smart Auto/Commercial	$15.20
Rate for Payer: Intervalley Health Plan Commercial	$22.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.20
Rate for Payer: LLUH Dept of Risk Management WC	$13.94
Rate for Payer: Multiplan Commercial	$19.00

HC SOM VONWILLEBRAND AG

Facility

$25.34

Service Code	CPT 85246
Hospital Charge Code	900910112
Hospital Revenue Code	305
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$20.27
Rate for Payer: Cash Price	$25.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.27
Rate for Payer: Health Smart Auto/Commercial	$15.20
Rate for Payer: LLUH Dept of Risk Management WC	$13.94
Rate for Payer: Multiplan Commercial	$19.00

HC SOM VON WILLEBRAND FACTOR ACTIVITY

Facility

$74.20

Service Code	CPT 85397
Hospital Charge Code	900912874
Hospital Revenue Code	305
Min. Negotiated Rate	$30.86
Max. Negotiated Rate	$59.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.52
Rate for Payer: Aetna of CA Government/Medicare	$44.52
Rate for Payer: Cash Price	$74.20
Rate for Payer: Cash Price	$74.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$59.36
Rate for Payer: Health Smart Auto/Commercial	$44.52
Rate for Payer: Intervalley Health Plan Commercial	$30.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.52
Rate for Payer: LLUH Dept of Risk Management WC	$40.81
Rate for Payer: Multiplan Commercial	$55.65

HC SOM VON WILLEBRAND FACTOR ACTIVITY

Facility

$74.20

Service Code	CPT 85397
Hospital Charge Code	900912874
Hospital Revenue Code	305
Min. Negotiated Rate	$40.81
Max. Negotiated Rate	$59.36
Rate for Payer: Cash Price	$74.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$59.36
Rate for Payer: Health Smart Auto/Commercial	$44.52
Rate for Payer: LLUH Dept of Risk Management WC	$40.81
Rate for Payer: Multiplan Commercial	$55.65

HC SOM VON WILLEBRAND FACTOR MULTIMER P

Facility

$51.10

Service Code	CPT 85247
Hospital Charge Code	900910113
Hospital Revenue Code	305
Min. Negotiated Rate	$28.11
Max. Negotiated Rate	$40.88
Rate for Payer: Cash Price	$51.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.88
Rate for Payer: Health Smart Auto/Commercial	$30.66
Rate for Payer: LLUH Dept of Risk Management WC	$28.11
Rate for Payer: Multiplan Commercial	$38.33

HC SOM VON WILLEBRAND FACTOR MULTIMER P

Facility

$51.10

Service Code	CPT 85247
Hospital Charge Code	900910113
Hospital Revenue Code	305
Min. Negotiated Rate	$22.94
Max. Negotiated Rate	$40.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.66
Rate for Payer: Aetna of CA Government/Medicare	$30.66
Rate for Payer: Cash Price	$51.10
Rate for Payer: Cash Price	$51.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.88
Rate for Payer: Health Smart Auto/Commercial	$30.66
Rate for Payer: Intervalley Health Plan Commercial	$22.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.66
Rate for Payer: LLUH Dept of Risk Management WC	$28.11
Rate for Payer: Multiplan Commercial	$38.33

HC SOM VORICONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80285
Hospital Charge Code	900912707
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$27.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.27
Rate for Payer: Aetna of CA Government/Medicare	$16.27
Rate for Payer: Cash Price	$27.11
Rate for Payer: Cash Price	$27.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.69
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: Intervalley Health Plan Commercial	$27.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Commercial	$20.33

HC SOM VORICONAZOLE LEVEL

Facility

$27.11

Service Code	CPT 80285
Hospital Charge Code	900912707
Hospital Revenue Code	301
Min. Negotiated Rate	$14.91
Max. Negotiated Rate	$21.69
Rate for Payer: Cash Price	$27.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.69
Rate for Payer: Health Smart Auto/Commercial	$16.27
Rate for Payer: LLUH Dept of Risk Management WC	$14.91
Rate for Payer: Multiplan Commercial	$20.33

HC SOM WESTERN EQUINE ENCEPH AB IGG

Facility

$25.00

Service Code	CPT 86654
Hospital Charge Code	900911337
Hospital Revenue Code	302
Min. Negotiated Rate	$13.19
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	$13.19
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 WESTERN EQUINE ENCEPH AB IGG

Facility

$25.00

Service Code	CPT 86654
Hospital Charge Code	900911337
Hospital Revenue Code	302
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

HC SOM WESTERN EQUINE ENCEPH AB IGM

Facility

$25.00

Service Code	CPT 86654
Hospital Charge Code	900912651
Hospital Revenue Code	302
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

HC SOM WESTERN EQUINE ENCEPH AB IGM

Facility

$25.00

Service Code	CPT 86654
Hospital Charge Code	900912651
Hospital Revenue Code	302
Min. Negotiated Rate	$13.19
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	$13.19
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 WEST NILE VIRUS AB

Facility

$18.39

Service Code	CPT 86788
Hospital Charge Code	900912544
Hospital Revenue Code	302
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$16.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.03
Rate for Payer: Aetna of CA Government/Medicare	$11.03
Rate for Payer: Cash Price	$18.39
Rate for Payer: Cash Price	$18.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.71
Rate for Payer: Health Smart Auto/Commercial	$11.03
Rate for Payer: Intervalley Health Plan Commercial	$16.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.03
Rate for Payer: LLUH Dept of Risk Management WC	$10.11
Rate for Payer: Multiplan Commercial	$13.79

HC SOM WEST NILE VIRUS AB

Facility

$18.39

Service Code	CPT 86788
Hospital Charge Code	900912544
Hospital Revenue Code	302
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$14.71
Rate for Payer: Cash Price	$18.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.71
Rate for Payer: Health Smart Auto/Commercial	$11.03
Rate for Payer: LLUH Dept of Risk Management WC	$10.11
Rate for Payer: Multiplan Commercial	$13.79

HC SOM WEST NILE VIRUS AB IGG CSF

Facility

$15.66

Service Code	CPT 86789
Hospital Charge Code	900912603
Hospital Revenue Code	302
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$15.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.53
Rate for Payer: Health Smart Auto/Commercial	$9.40
Rate for Payer: LLUH Dept of Risk Management WC	$8.61
Rate for Payer: Multiplan Commercial	$11.74

Know your out-of-pocket cost for care.

All Charges