Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC CT ABDOMEN WO CONTR

Facility

$4,791.00

Service Code	CPT 74150
Hospital Charge Code	909201927
Hospital Revenue Code	352
Min. Negotiated Rate	$2,635.05
Max. Negotiated Rate	$3,832.80
Rate for Payer: Cash Price	$2,155.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3,832.80
Rate for Payer: Health Smart Auto/Commercial	$2,874.60
Rate for Payer: LLUH Dept of Risk Management WC	$2,635.05
Rate for Payer: Multiplan Commercial	$3,593.25

HC CT ABDOMEN WO CONTR

Facility

$2,665.00

Service Code	CPT 74150
Hospital Charge Code	909201927
Hospital Revenue Code	352
Min. Negotiated Rate	$1,465.75
Max. Negotiated Rate	$2,132.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,599.00
Rate for Payer: Aetna of CA Government/Medicare	$1,599.00
Rate for Payer: Cash Price	$1,199.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,132.00
Rate for Payer: Health Smart Auto/Commercial	$1,599.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,599.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,465.75
Rate for Payer: Multiplan Commercial	$1,998.75

HC CT ABDOMEN W/WO CONT

Facility

$3,505.00

Service Code	CPT 74170
Hospital Charge Code	909201929
Hospital Revenue Code	352
Min. Negotiated Rate	$1,927.75
Max. Negotiated Rate	$2,804.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,103.00
Rate for Payer: Aetna of CA Government/Medicare	$2,103.00
Rate for Payer: Cash Price	$1,577.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,804.00
Rate for Payer: Health Smart Auto/Commercial	$2,103.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,103.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,927.75
Rate for Payer: Multiplan Commercial	$2,628.75

HC CT ABDOMEN W/WO CONT

Facility

$6,243.00

Service Code	CPT 74170
Hospital Charge Code	909201929
Hospital Revenue Code	352
Min. Negotiated Rate	$3,433.65
Max. Negotiated Rate	$4,994.40
Rate for Payer: Cash Price	$2,809.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,994.40
Rate for Payer: Health Smart Auto/Commercial	$3,745.80
Rate for Payer: LLUH Dept of Risk Management WC	$3,433.65
Rate for Payer: Multiplan Commercial	$4,682.25

HC CT ADDITIONAL SCAN

Facility

$149.00

Service Code	CPT 76499
Hospital Charge Code	906901215
Hospital Revenue Code	359
Min. Negotiated Rate	$81.95
Max. Negotiated Rate	$119.20
Rate for Payer: Cash Price	$67.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$119.20
Rate for Payer: Health Smart Auto/Commercial	$89.40
Rate for Payer: LLUH Dept of Risk Management WC	$81.95
Rate for Payer: Multiplan Commercial	$111.75

HC CT ADDITIONAL SCAN

Facility

$149.00

Service Code	CPT 76499
Hospital Charge Code	906901215
Hospital Revenue Code	359
Min. Negotiated Rate	$81.95
Max. Negotiated Rate	$119.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$89.40
Rate for Payer: Aetna of CA Government/Medicare	$89.40
Rate for Payer: Cash Price	$67.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$119.20
Rate for Payer: Health Smart Auto/Commercial	$89.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$89.40
Rate for Payer: LLUH Dept of Risk Management WC	$81.95
Rate for Payer: Multiplan Commercial	$111.75

HC CT BONE PELVIS W CONTRAST

Facility

$2,761.00

Service Code	CPT 72193
Hospital Charge Code	909201931
Hospital Revenue Code	352
Min. Negotiated Rate	$1,518.55
Max. Negotiated Rate	$2,208.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,656.60
Rate for Payer: Aetna of CA Government/Medicare	$1,656.60
Rate for Payer: Cash Price	$1,242.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,208.80
Rate for Payer: Health Smart Auto/Commercial	$1,656.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,656.60
Rate for Payer: LLUH Dept of Risk Management WC	$1,518.55
Rate for Payer: Multiplan Commercial	$2,070.75

HC CT BONE PELVIS W CONTRAST

Facility

$4,918.00

Service Code	CPT 72193
Hospital Charge Code	909201931
Hospital Revenue Code	352
Min. Negotiated Rate	$2,704.90
Max. Negotiated Rate	$3,934.40
Rate for Payer: Cash Price	$2,213.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3,934.40
Rate for Payer: Health Smart Auto/Commercial	$2,950.80
Rate for Payer: LLUH Dept of Risk Management WC	$2,704.90
Rate for Payer: Multiplan Commercial	$3,688.50

HC CT BONE PELVIS W/O CONTRAST

Facility

$4,525.00

Service Code	CPT 72192
Hospital Charge Code	909201930
Hospital Revenue Code	352
Min. Negotiated Rate	$2,488.75
Max. Negotiated Rate	$3,620.00
Rate for Payer: Cash Price	$2,036.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3,620.00
Rate for Payer: Health Smart Auto/Commercial	$2,715.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,488.75
Rate for Payer: Multiplan Commercial	$3,393.75

HC CT BONE PELVIS W/O CONTRAST

Facility

$2,541.00

Service Code	CPT 72192
Hospital Charge Code	909201930
Hospital Revenue Code	352
Min. Negotiated Rate	$1,397.55
Max. Negotiated Rate	$2,032.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,524.60
Rate for Payer: Aetna of CA Government/Medicare	$1,524.60
Rate for Payer: Cash Price	$1,143.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,032.80
Rate for Payer: Health Smart Auto/Commercial	$1,524.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,524.60
Rate for Payer: LLUH Dept of Risk Management WC	$1,397.55
Rate for Payer: Multiplan Commercial	$1,905.75

HC CT BONE PELVIS W/WO CONTRAST

Facility

$5,375.00

Service Code	CPT 72194
Hospital Charge Code	909201932
Hospital Revenue Code	352
Min. Negotiated Rate	$2,956.25
Max. Negotiated Rate	$4,300.00
Rate for Payer: Cash Price	$2,418.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,300.00
Rate for Payer: Health Smart Auto/Commercial	$3,225.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,956.25
Rate for Payer: Multiplan Commercial	$4,031.25

HC CT BONE PELVIS W/WO CONTRAST

Facility

$3,018.00

Service Code	CPT 72194
Hospital Charge Code	909201932
Hospital Revenue Code	352
Min. Negotiated Rate	$1,659.90
Max. Negotiated Rate	$2,414.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,810.80
Rate for Payer: Aetna of CA Government/Medicare	$1,810.80
Rate for Payer: Cash Price	$1,358.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,414.40
Rate for Payer: Health Smart Auto/Commercial	$1,810.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,810.80
Rate for Payer: LLUH Dept of Risk Management WC	$1,659.90
Rate for Payer: Multiplan Commercial	$2,263.50

HC CT CHEST W CONTRAST

Facility

$4,918.00

Service Code	CPT 71260
Hospital Charge Code	909201913
Hospital Revenue Code	352
Min. Negotiated Rate	$2,704.90
Max. Negotiated Rate	$3,934.40
Rate for Payer: Cash Price	$2,213.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3,934.40
Rate for Payer: Health Smart Auto/Commercial	$2,950.80
Rate for Payer: LLUH Dept of Risk Management WC	$2,704.90
Rate for Payer: Multiplan Commercial	$3,688.50

HC CT CHEST W CONTRAST

Facility

$2,761.00

Service Code	CPT 71260
Hospital Charge Code	909201913
Hospital Revenue Code	352
Min. Negotiated Rate	$1,518.55
Max. Negotiated Rate	$2,208.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,656.60
Rate for Payer: Aetna of CA Government/Medicare	$1,656.60
Rate for Payer: Cash Price	$1,242.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,208.80
Rate for Payer: Health Smart Auto/Commercial	$1,656.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,656.60
Rate for Payer: LLUH Dept of Risk Management WC	$1,518.55
Rate for Payer: Multiplan Commercial	$2,070.75

HC CT CHEST W/O CONTRAST

Facility

$4,005.00

Service Code	CPT 71250
Hospital Charge Code	909201912
Hospital Revenue Code	352
Min. Negotiated Rate	$2,202.75
Max. Negotiated Rate	$3,204.00
Rate for Payer: Cash Price	$1,802.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3,204.00
Rate for Payer: Health Smart Auto/Commercial	$2,403.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,202.75
Rate for Payer: Multiplan Commercial	$3,003.75

HC CT CHEST W/O CONTRAST

Facility

$2,248.00

Service Code	CPT 71250
Hospital Charge Code	909201912
Hospital Revenue Code	352
Min. Negotiated Rate	$1,236.40
Max. Negotiated Rate	$1,798.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,348.80
Rate for Payer: Aetna of CA Government/Medicare	$1,348.80
Rate for Payer: Cash Price	$1,011.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,798.40
Rate for Payer: Health Smart Auto/Commercial	$1,348.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,348.80
Rate for Payer: LLUH Dept of Risk Management WC	$1,236.40
Rate for Payer: Multiplan Commercial	$1,686.00

HC CT CHEST W WO CONTRA

Facility

$5,833.00

Service Code	CPT 71270
Hospital Charge Code	909201914
Hospital Revenue Code	352
Min. Negotiated Rate	$3,208.15
Max. Negotiated Rate	$4,666.40
Rate for Payer: Cash Price	$2,624.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,666.40
Rate for Payer: Health Smart Auto/Commercial	$3,499.80
Rate for Payer: LLUH Dept of Risk Management WC	$3,208.15
Rate for Payer: Multiplan Commercial	$4,374.75

HC CT CHEST W WO CONTRA

Facility

$3,274.00

Service Code	CPT 71270
Hospital Charge Code	909201914
Hospital Revenue Code	352
Min. Negotiated Rate	$1,800.70
Max. Negotiated Rate	$2,619.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,964.40
Rate for Payer: Aetna of CA Government/Medicare	$1,964.40
Rate for Payer: Cash Price	$1,473.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,619.20
Rate for Payer: Health Smart Auto/Commercial	$1,964.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,964.40
Rate for Payer: LLUH Dept of Risk Management WC	$1,800.70
Rate for Payer: Multiplan Commercial	$2,455.50

HC CT CSPINE WO CONTRAST

Facility

$4,780.00

Service Code	CPT 72125
Hospital Charge Code	909201915
Hospital Revenue Code	352
Min. Negotiated Rate	$2,629.00
Max. Negotiated Rate	$3,824.00
Rate for Payer: Cash Price	$2,151.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3,824.00
Rate for Payer: Health Smart Auto/Commercial	$2,868.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,629.00
Rate for Payer: Multiplan Commercial	$3,585.00

HC CT CSPINE WO CONTRAST

Facility

$2,684.00

Service Code	CPT 72125
Hospital Charge Code	909201915
Hospital Revenue Code	352
Min. Negotiated Rate	$1,476.20
Max. Negotiated Rate	$2,147.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,610.40
Rate for Payer: Aetna of CA Government/Medicare	$1,610.40
Rate for Payer: Cash Price	$1,207.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,147.20
Rate for Payer: Health Smart Auto/Commercial	$1,610.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,610.40
Rate for Payer: LLUH Dept of Risk Management WC	$1,476.20
Rate for Payer: Multiplan Commercial	$2,013.00

HC CT C SPINE W/WO CONTRAST

Facility

$5,403.00

Service Code	CPT 72127
Hospital Charge Code	909201967
Hospital Revenue Code	352
Min. Negotiated Rate	$2,971.65
Max. Negotiated Rate	$4,322.40
Rate for Payer: Cash Price	$2,431.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,322.40
Rate for Payer: Health Smart Auto/Commercial	$3,241.80
Rate for Payer: LLUH Dept of Risk Management WC	$2,971.65
Rate for Payer: Multiplan Commercial	$4,052.25

HC CT C SPINE W/WO CONTRAST

Facility

$3,018.00

Service Code	CPT 72127
Hospital Charge Code	909201967
Hospital Revenue Code	352
Min. Negotiated Rate	$1,659.90
Max. Negotiated Rate	$2,414.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,810.80
Rate for Payer: Aetna of CA Government/Medicare	$1,810.80
Rate for Payer: Cash Price	$1,358.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,414.40
Rate for Payer: Health Smart Auto/Commercial	$1,810.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,810.80
Rate for Payer: LLUH Dept of Risk Management WC	$1,659.90
Rate for Payer: Multiplan Commercial	$2,263.50

HC CT HEAD NO CONTRAST

Facility

$2,656.00

Service Code	CPT 70450
Hospital Charge Code	909201901
Hospital Revenue Code	351
Min. Negotiated Rate	$1,460.80
Max. Negotiated Rate	$2,124.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,593.60
Rate for Payer: Aetna of CA Government/Medicare	$1,593.60
Rate for Payer: Cash Price	$1,195.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2,124.80
Rate for Payer: Health Smart Auto/Commercial	$1,593.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,593.60
Rate for Payer: LLUH Dept of Risk Management WC	$1,460.80
Rate for Payer: Multiplan Commercial	$1,992.00

HC CT HEAD NO CONTRAST

Facility

$4,522.00

Service Code	CPT 70450
Hospital Charge Code	909201901
Hospital Revenue Code	351
Min. Negotiated Rate	$2,487.10
Max. Negotiated Rate	$3,617.60
Rate for Payer: Cash Price	$2,034.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3,617.60
Rate for Payer: Health Smart Auto/Commercial	$2,713.20
Rate for Payer: LLUH Dept of Risk Management WC	$2,487.10
Rate for Payer: Multiplan Commercial	$3,391.50

HC CT HEAD W CONTRAST

Facility

$5,277.00

Service Code	CPT 70460
Hospital Charge Code	909201900
Hospital Revenue Code	351
Min. Negotiated Rate	$2,902.35
Max. Negotiated Rate	$4,221.60
Rate for Payer: Cash Price	$2,374.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,221.60
Rate for Payer: Health Smart Auto/Commercial	$3,166.20
Rate for Payer: LLUH Dept of Risk Management WC	$2,902.35
Rate for Payer: Multiplan Commercial	$3,957.75

Know your out-of-pocket cost for care.

All Charges