Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION [3584]

Facility

$7.19

Service Code	CPT J1630
Hospital Charge Code	1720105
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$5.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$1.15
Rate for Payer: Aetna of CA Government/Medicare	$4.31
Rate for Payer: Aetna of CA Government/Medicare	$0.64
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cash Price	$3.24
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Health Smart Auto/Commercial	$4.31
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: LLUH Dept of Risk Management WC	$3.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.80

HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION [3584]

Facility

$7.19

Service Code	CPT J1630
Hospital Charge Code	1720105
Hospital Revenue Code	636
Min. Negotiated Rate	$3.95
Max. Negotiated Rate	$5.75
Rate for Payer: Cash Price	$3.24
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cash Price	$0.86
Rate for Payer: Cigna of CA HMO/PPO	$5.75
Rate for Payer: Cigna of CA HMO/PPO	$1.54
Rate for Payer: Cigna of CA HMO/PPO	$0.85
Rate for Payer: Health Smart Auto/Commercial	$1.15
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: Health Smart Auto/Commercial	$4.31
Rate for Payer: LLUH Dept of Risk Management WC	$1.06
Rate for Payer: LLUH Dept of Risk Management WC	$3.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.39

HC 5-HIAA BY HPLC

Facility

$49.00

Service Code	CPT 83497
Hospital Charge Code	900910535
Hospital Revenue Code	301
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$36.75
Rate for Payer: Health Smart Auto/Commercial	$29.40
Rate for Payer: Cash Price	$22.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.40
Rate for Payer: Aetna of CA Government/Medicare	$29.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.75

HC 5-HIAA BY HPLC

Facility

$130.00

Service Code	CPT 83497
Hospital Charge Code	900910535
Hospital Revenue Code	301
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$104.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna of CA HMO/PPO	$104.00
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$97.50

HC ABDOMEN KUB SUPINE

Facility

$539.00

Service Code	CPT 74018
Hospital Charge Code	909001702
Hospital Revenue Code	320
Min. Negotiated Rate	$296.45
Max. Negotiated Rate	$431.20
Rate for Payer: Cash Price	$242.55
Rate for Payer: Cigna of CA HMO/PPO	$431.20
Rate for Payer: Health Smart Auto/Commercial	$323.40
Rate for Payer: LLUH Dept of Risk Management WC	$296.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$404.25

HC ABDOMEN KUB SUPINE

Facility

$539.00

Service Code	CPT 74018
Hospital Charge Code	909001702
Hospital Revenue Code	320
Min. Negotiated Rate	$296.45
Max. Negotiated Rate	$404.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$323.40
Rate for Payer: Aetna of CA Government/Medicare	$323.40
Rate for Payer: Cash Price	$242.55
Rate for Payer: Health Smart Auto/Commercial	$323.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$323.40
Rate for Payer: LLUH Dept of Risk Management WC	$296.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$404.25

HC ABDOMEN KUB SUPINE

Facility

$539.00

Service Code	CPT 74018 TC
Hospital Charge Code	909001702
Hospital Revenue Code	320
Min. Negotiated Rate	$296.45
Max. Negotiated Rate	$431.20
Rate for Payer: Cash Price	$242.55
Rate for Payer: Cigna of CA HMO/PPO	$431.20
Rate for Payer: Health Smart Auto/Commercial	$323.40
Rate for Payer: LLUH Dept of Risk Management WC	$296.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$404.25

HC ABDOMEN KUB SUPINE

Facility

$539.00

Service Code	CPT 74018 TC
Hospital Charge Code	909001702
Hospital Revenue Code	320
Min. Negotiated Rate	$296.45
Max. Negotiated Rate	$404.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$323.40
Rate for Payer: Aetna of CA Government/Medicare	$323.40
Rate for Payer: Cash Price	$242.55
Rate for Payer: Health Smart Auto/Commercial	$323.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$323.40
Rate for Payer: LLUH Dept of Risk Management WC	$296.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$404.25

HC ABDOMEN THREE OR MORE VIEWS

Facility

$842.00

Service Code	CPT 74021
Hospital Charge Code	909074021
Hospital Revenue Code	320
Min. Negotiated Rate	$463.10
Max. Negotiated Rate	$673.60
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna of CA HMO/PPO	$673.60
Rate for Payer: Health Smart Auto/Commercial	$505.20
Rate for Payer: LLUH Dept of Risk Management WC	$463.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$631.50

HC ABDOMEN THREE OR MORE VIEWS

Facility

$842.00

Service Code	CPT 74021 TC
Hospital Charge Code	909074021
Hospital Revenue Code	320
Min. Negotiated Rate	$463.10
Max. Negotiated Rate	$673.60
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna of CA HMO/PPO	$673.60
Rate for Payer: Health Smart Auto/Commercial	$505.20
Rate for Payer: LLUH Dept of Risk Management WC	$463.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$631.50

HC ABDOMEN THREE OR MORE VIEWS

Facility

$842.00

Service Code	CPT 74021 TC
Hospital Charge Code	909074021
Hospital Revenue Code	320
Min. Negotiated Rate	$463.10
Max. Negotiated Rate	$631.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$505.20
Rate for Payer: Aetna of CA Government/Medicare	$505.20
Rate for Payer: Cash Price	$378.90
Rate for Payer: Health Smart Auto/Commercial	$505.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$505.20
Rate for Payer: LLUH Dept of Risk Management WC	$463.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$631.50

HC ABDOMEN THREE OR MORE VIEWS

Facility

$842.00

Service Code	CPT 74021
Hospital Charge Code	909074021
Hospital Revenue Code	320
Min. Negotiated Rate	$463.10
Max. Negotiated Rate	$631.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$505.20
Rate for Payer: Aetna of CA Government/Medicare	$505.20
Rate for Payer: Cash Price	$378.90
Rate for Payer: Health Smart Auto/Commercial	$505.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$505.20
Rate for Payer: LLUH Dept of Risk Management WC	$463.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$631.50

HC ABDOMEN TWO VIEWS

Facility

$674.00

Service Code	CPT 74019 TC
Hospital Charge Code	909074019
Hospital Revenue Code	320
Min. Negotiated Rate	$370.70
Max. Negotiated Rate	$539.20
Rate for Payer: Cash Price	$303.30
Rate for Payer: Cigna of CA HMO/PPO	$539.20
Rate for Payer: Health Smart Auto/Commercial	$404.40
Rate for Payer: LLUH Dept of Risk Management WC	$370.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$505.50

HC ABDOMEN TWO VIEWS

Facility

$674.00

Service Code	CPT 74019 TC
Hospital Charge Code	909074019
Hospital Revenue Code	320
Min. Negotiated Rate	$370.70
Max. Negotiated Rate	$505.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$404.40
Rate for Payer: Aetna of CA Government/Medicare	$404.40
Rate for Payer: Cash Price	$303.30
Rate for Payer: Health Smart Auto/Commercial	$404.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$404.40
Rate for Payer: LLUH Dept of Risk Management WC	$370.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$505.50

HC ABDOMEN TWO VIEWS

Facility

$674.00

Service Code	CPT 74019
Hospital Charge Code	909074019
Hospital Revenue Code	320
Min. Negotiated Rate	$370.70
Max. Negotiated Rate	$505.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$404.40
Rate for Payer: Aetna of CA Government/Medicare	$404.40
Rate for Payer: Cash Price	$303.30
Rate for Payer: Health Smart Auto/Commercial	$404.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$404.40
Rate for Payer: LLUH Dept of Risk Management WC	$370.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$505.50

HC ABDOMEN TWO VIEWS

Facility

$674.00

Service Code	CPT 74019
Hospital Charge Code	909074019
Hospital Revenue Code	320
Min. Negotiated Rate	$370.70
Max. Negotiated Rate	$539.20
Rate for Payer: Cash Price	$303.30
Rate for Payer: Cigna of CA HMO/PPO	$539.20
Rate for Payer: Health Smart Auto/Commercial	$404.40
Rate for Payer: LLUH Dept of Risk Management WC	$370.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$505.50

HC ACETAMINOPHEN (TYLENOL)

Facility

$59.00

Service Code	CPT G0480
Hospital Charge Code	900911302
Hospital Revenue Code	301
Min. Negotiated Rate	$32.45
Max. Negotiated Rate	$44.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.40
Rate for Payer: Aetna of CA Government/Medicare	$35.40
Rate for Payer: Cash Price	$26.55
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.40
Rate for Payer: LLUH Dept of Risk Management WC	$32.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.25

HC ACETAMINOPHEN (TYLENOL)

Facility

$415.00

Service Code	CPT G0480
Hospital Charge Code	900911302
Hospital Revenue Code	301
Min. Negotiated Rate	$228.25
Max. Negotiated Rate	$332.00
Rate for Payer: Cash Price	$186.75
Rate for Payer: Cigna of CA HMO/PPO	$332.00
Rate for Payer: Health Smart Auto/Commercial	$249.00
Rate for Payer: LLUH Dept of Risk Management WC	$228.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$311.25

HC ACETAMINOPHEN (TYLENOL)

Facility

$415.00

Service Code	CPT 80143
Hospital Charge Code	900911302
Hospital Revenue Code	301
Min. Negotiated Rate	$228.25
Max. Negotiated Rate	$332.00
Rate for Payer: Cash Price	$186.75
Rate for Payer: Cigna of CA HMO/PPO	$332.00
Rate for Payer: Health Smart Auto/Commercial	$249.00
Rate for Payer: LLUH Dept of Risk Management WC	$228.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$311.25

HC ACETAMINOPHEN (TYLENOL)

Facility

$59.00

Service Code	CPT 80143
Hospital Charge Code	900911302
Hospital Revenue Code	301
Min. Negotiated Rate	$32.45
Max. Negotiated Rate	$44.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.40
Rate for Payer: Aetna of CA Government/Medicare	$35.40
Rate for Payer: Cash Price	$26.55
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.40
Rate for Payer: LLUH Dept of Risk Management WC	$32.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$44.25

HC ACETOACETATE, SEMIQUANTITATIVE

Facility

$221.00

Service Code	CPT 82010
Hospital Charge Code	900910466
Hospital Revenue Code	301
Min. Negotiated Rate	$121.55
Max. Negotiated Rate	$176.80
Rate for Payer: Cash Price	$99.45
Rate for Payer: Cigna of CA HMO/PPO	$176.80
Rate for Payer: Health Smart Auto/Commercial	$132.60
Rate for Payer: LLUH Dept of Risk Management WC	$121.55
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$165.75

HC ACETOACETATE, SEMIQUANTITATIVE

Facility

$31.00

Service Code	CPT 82010
Hospital Charge Code	900910466
Hospital Revenue Code	301
Min. Negotiated Rate	$17.05
Max. Negotiated Rate	$23.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.60
Rate for Payer: Aetna of CA Government/Medicare	$18.60
Rate for Payer: Cash Price	$13.95
Rate for Payer: Health Smart Auto/Commercial	$18.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.60
Rate for Payer: LLUH Dept of Risk Management WC	$17.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.25

HC ACID FAST CONCENTRATION

Facility

$143.00

Service Code	CPT 87015
Hospital Charge Code	900911551
Hospital Revenue Code	306
Min. Negotiated Rate	$78.65
Max. Negotiated Rate	$114.40
Rate for Payer: Cash Price	$64.35
Rate for Payer: Cigna of CA HMO/PPO	$114.40
Rate for Payer: Health Smart Auto/Commercial	$85.80
Rate for Payer: LLUH Dept of Risk Management WC	$78.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$107.25

HC ACID FAST CONCENTRATION

Facility

$26.00

Service Code	CPT 87015
Hospital Charge Code	900911551
Hospital Revenue Code	306
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$19.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.60
Rate for Payer: Aetna of CA Government/Medicare	$15.60
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Smart Auto/Commercial	$15.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.60
Rate for Payer: LLUH Dept of Risk Management WC	$14.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.50

HC ACID HEMOGLOBIN CONFIRMATION

Facility

$68.00

Service Code	CPT 83020
Hospital Charge Code	900913569
Hospital Revenue Code	302
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$54.40
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$51.00

Know your out-of-pocket cost for care.

All Charges