Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC ESBL DISK CONFIRMATION

Facility

$210.00

Service Code	CPT 87184
Hospital Charge Code	900912449
Hospital Revenue Code	306
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$168.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$168.00
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: Multiplan Commercial	$157.50

HC ESBL DISK CONFIRMATION

Facility

$46.00

Service Code	CPT 87184
Hospital Charge Code	900912449
Hospital Revenue Code	306
Min. Negotiated Rate	$7.48
Max. Negotiated Rate	$36.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.60
Rate for Payer: Aetna of CA Government/Medicare	$27.60
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cash Price	$20.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$36.80
Rate for Payer: Health Smart Auto/Commercial	$27.60
Rate for Payer: Intervalley Health Plan Commercial	$7.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.60
Rate for Payer: LLUH Dept of Risk Management WC	$25.30
Rate for Payer: Multiplan Commercial	$34.50

HC ESOPHOGRAM

Facility

$1,198.00

Service Code	CPT 74220
Hospital Charge Code	909001802
Hospital Revenue Code	320
Min. Negotiated Rate	$658.90
Max. Negotiated Rate	$958.40
Rate for Payer: Cash Price	$539.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$958.40
Rate for Payer: Health Smart Auto/Commercial	$718.80
Rate for Payer: LLUH Dept of Risk Management WC	$658.90
Rate for Payer: Multiplan Commercial	$898.50

HC ESOPHOGRAM

Facility

$1,198.00

Service Code	CPT 74220
Hospital Charge Code	909001802
Hospital Revenue Code	320
Min. Negotiated Rate	$658.90
Max. Negotiated Rate	$958.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$718.80
Rate for Payer: Aetna of CA Government/Medicare	$718.80
Rate for Payer: Cash Price	$539.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$958.40
Rate for Payer: Health Smart Auto/Commercial	$718.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$718.80
Rate for Payer: LLUH Dept of Risk Management WC	$658.90
Rate for Payer: Multiplan Commercial	$898.50

HC ESTRADIOL

Facility

$252.00

Service Code	CPT 82670
Hospital Charge Code	900912127
Hospital Revenue Code	301
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$201.60
Rate for Payer: Cash Price	$113.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$201.60
Rate for Payer: Health Smart Auto/Commercial	$151.20
Rate for Payer: LLUH Dept of Risk Management WC	$138.60
Rate for Payer: Multiplan Commercial	$189.00

HC ESTRADIOL

Facility

$192.15

Service Code	CPT 82670
Hospital Charge Code	900912127
Hospital Revenue Code	301
Min. Negotiated Rate	$27.94
Max. Negotiated Rate	$153.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$115.29
Rate for Payer: Aetna of CA Government/Medicare	$115.29
Rate for Payer: Cash Price	$86.47
Rate for Payer: Cash Price	$86.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$153.72
Rate for Payer: Health Smart Auto/Commercial	$115.29
Rate for Payer: Intervalley Health Plan Commercial	$27.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$115.29
Rate for Payer: LLUH Dept of Risk Management WC	$105.68
Rate for Payer: Multiplan Commercial	$144.11

HC EVL/TRTMT MH OR SUB USE DISORDER REMOTE 15-29 MIN

Facility

$105.00

Service Code	CPT C7900
Hospital Charge Code	907807900
Hospital Revenue Code	914
Min. Negotiated Rate	$57.75
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$63.00
Rate for Payer: Aetna of CA Government/Medicare	$63.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$84.00
Rate for Payer: Health Smart Auto/Commercial	$63.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$63.00
Rate for Payer: LLUH Dept of Risk Management WC	$57.75
Rate for Payer: Multiplan Commercial	$78.75

HC EVL/TRTMT MH OR SUB USE DISORDER REMOTE 15-29 MIN

Facility

$105.00

Service Code	CPT C7900
Hospital Charge Code	907807900
Hospital Revenue Code	914
Min. Negotiated Rate	$57.75
Max. Negotiated Rate	$84.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$84.00
Rate for Payer: Health Smart Auto/Commercial	$63.00
Rate for Payer: LLUH Dept of Risk Management WC	$57.75
Rate for Payer: Multiplan Commercial	$78.75

HC EVL/TRTMT MH OR SUB USE DISORDER REMOTE 30-60 MIN

Facility

$267.00

Service Code	CPT C7901
Hospital Charge Code	907807901
Hospital Revenue Code	914
Min. Negotiated Rate	$146.85
Max. Negotiated Rate	$213.60
Rate for Payer: Cash Price	$120.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$213.60
Rate for Payer: Health Smart Auto/Commercial	$160.20
Rate for Payer: LLUH Dept of Risk Management WC	$146.85
Rate for Payer: Multiplan Commercial	$200.25

HC EVL/TRTMT MH OR SUB USE DISORDER REMOTE 30-60 MIN

Facility

$267.00

Service Code	CPT C7901
Hospital Charge Code	907807901
Hospital Revenue Code	914
Min. Negotiated Rate	$146.85
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$160.20
Rate for Payer: Aetna of CA Government/Medicare	$160.20
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Cash Price	$120.15
Rate for Payer: Cash Price	$120.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$213.60
Rate for Payer: Health Smart Auto/Commercial	$160.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$160.20
Rate for Payer: LLUH Dept of Risk Management WC	$146.85
Rate for Payer: Multiplan Commercial	$200.25

HC EVL/TRTMT MH OR SUB USE DISORDER REMOTE EA ADD 15 MIN

Facility

$133.00

Service Code	CPT C7902
Hospital Charge Code	907807902
Hospital Revenue Code	914
Min. Negotiated Rate	$73.15
Max. Negotiated Rate	$106.40
Rate for Payer: Cash Price	$59.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$106.40
Rate for Payer: Health Smart Auto/Commercial	$79.80
Rate for Payer: LLUH Dept of Risk Management WC	$73.15
Rate for Payer: Multiplan Commercial	$99.75

HC EVL/TRTMT MH OR SUB USE DISORDER REMOTE EA ADD 15 MIN

Facility

$133.00

Service Code	CPT C7902
Hospital Charge Code	907807902
Hospital Revenue Code	914
Min. Negotiated Rate	$73.15
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$79.80
Rate for Payer: Aetna of CA Government/Medicare	$79.80
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Cash Price	$59.85
Rate for Payer: Cash Price	$59.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$106.40
Rate for Payer: Health Smart Auto/Commercial	$79.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$79.80
Rate for Payer: LLUH Dept of Risk Management WC	$73.15
Rate for Payer: Multiplan Commercial	$99.75

HC FACIAL BONES COMPLETE

Facility

$1,695.00

Service Code	CPT 70150
Hospital Charge Code	909001101
Hospital Revenue Code	320
Min. Negotiated Rate	$932.25
Max. Negotiated Rate	$1,356.00
Rate for Payer: Cash Price	$762.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,356.00
Rate for Payer: Health Smart Auto/Commercial	$1,017.00
Rate for Payer: LLUH Dept of Risk Management WC	$932.25
Rate for Payer: Multiplan Commercial	$1,271.25

HC FACIAL BONES COMPLETE

Facility

$1,695.00

Service Code	CPT 70150
Hospital Charge Code	909001101
Hospital Revenue Code	320
Min. Negotiated Rate	$932.25
Max. Negotiated Rate	$1,356.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,017.00
Rate for Payer: Aetna of CA Government/Medicare	$1,017.00
Rate for Payer: Cash Price	$762.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,356.00
Rate for Payer: Health Smart Auto/Commercial	$1,017.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,017.00
Rate for Payer: LLUH Dept of Risk Management WC	$932.25
Rate for Payer: Multiplan Commercial	$1,271.25

HC FACTOR II (2) ASSAY

Facility

$59.00

Service Code	CPT 85210
Hospital Charge Code	900910075
Hospital Revenue Code	305
Min. Negotiated Rate	$12.98
Max. Negotiated Rate	$47.20
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: Cash Price	$26.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.20
Rate for Payer: Health Smart Auto/Commercial	$35.40
Rate for Payer: Intervalley Health Plan Commercial	$12.98
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 Commercial	$44.25

HC FACTOR II (2) ASSAY

Facility

$527.00

Service Code	CPT 85210
Hospital Charge Code	900910075
Hospital Revenue Code	305
Min. Negotiated Rate	$289.85
Max. Negotiated Rate	$421.60
Rate for Payer: Cash Price	$237.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$421.60
Rate for Payer: Health Smart Auto/Commercial	$316.20
Rate for Payer: LLUH Dept of Risk Management WC	$289.85
Rate for Payer: Multiplan Commercial	$395.25

HC FACTOR IX PTC

Facility

$480.00

Service Code	CPT 85250
Hospital Charge Code	900910029
Hospital Revenue Code	305
Min. Negotiated Rate	$264.00
Max. Negotiated Rate	$384.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$384.00
Rate for Payer: Health Smart Auto/Commercial	$288.00
Rate for Payer: LLUH Dept of Risk Management WC	$264.00
Rate for Payer: Multiplan Commercial	$360.00

HC FACTOR IX PTC

Facility

$168.00

Service Code	CPT 85250
Hospital Charge Code	900910029
Hospital Revenue Code	305
Min. Negotiated Rate	$19.04
Max. Negotiated Rate	$134.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$100.80
Rate for Payer: Aetna of CA Government/Medicare	$100.80
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cash Price	$75.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$134.40
Rate for Payer: Health Smart Auto/Commercial	$100.80
Rate for Payer: Intervalley Health Plan Commercial	$19.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$100.80
Rate for Payer: LLUH Dept of Risk Management WC	$92.40
Rate for Payer: Multiplan Commercial	$126.00

HC FACTOR V, ACG

Facility

$322.00

Service Code	CPT 85220
Hospital Charge Code	900910060
Hospital Revenue Code	305
Min. Negotiated Rate	$177.10
Max. Negotiated Rate	$257.60
Rate for Payer: Cash Price	$144.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$257.60
Rate for Payer: Health Smart Auto/Commercial	$193.20
Rate for Payer: LLUH Dept of Risk Management WC	$177.10
Rate for Payer: Multiplan Commercial	$241.50

HC FACTOR V, ACG

Facility

$154.00

Service Code	CPT 85220
Hospital Charge Code	900910060
Hospital Revenue Code	305
Min. Negotiated Rate	$17.65
Max. Negotiated Rate	$123.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$92.40
Rate for Payer: Aetna of CA Government/Medicare	$92.40
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cash Price	$69.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$123.20
Rate for Payer: Health Smart Auto/Commercial	$92.40
Rate for Payer: Intervalley Health Plan Commercial	$17.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$92.40
Rate for Payer: LLUH Dept of Risk Management WC	$84.70
Rate for Payer: Multiplan Commercial	$115.50

HC FACTOR VIII AHG

Facility

$156.00

Service Code	CPT 85240
Hospital Charge Code	900910028
Hospital Revenue Code	305
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$124.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$93.60
Rate for Payer: Aetna of CA Government/Medicare	$93.60
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cash Price	$70.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$124.80
Rate for Payer: Health Smart Auto/Commercial	$93.60
Rate for Payer: Intervalley Health Plan Commercial	$17.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$93.60
Rate for Payer: LLUH Dept of Risk Management WC	$85.80
Rate for Payer: Multiplan Commercial	$117.00

HC FACTOR VIII AHG

Facility

$364.00

Service Code	CPT 85240
Hospital Charge Code	900910028
Hospital Revenue Code	305
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$291.20
Rate for Payer: Cash Price	$163.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$291.20
Rate for Payer: Health Smart Auto/Commercial	$218.40
Rate for Payer: LLUH Dept of Risk Management WC	$200.20
Rate for Payer: Multiplan Commercial	$273.00

HC FACTOR VII, (PROCONVERTIN)

Facility

$156.00

Service Code	CPT 85230
Hospital Charge Code	900910027
Hospital Revenue Code	305
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$124.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$93.60
Rate for Payer: Aetna of CA Government/Medicare	$93.60
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cash Price	$70.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$124.80
Rate for Payer: Health Smart Auto/Commercial	$93.60
Rate for Payer: Intervalley Health Plan Commercial	$17.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$93.60
Rate for Payer: LLUH Dept of Risk Management WC	$85.80
Rate for Payer: Multiplan Commercial	$117.00

HC FACTOR VII, (PROCONVERTIN)

Facility

$445.00

Service Code	CPT 85230
Hospital Charge Code	900910027
Hospital Revenue Code	305
Min. Negotiated Rate	$244.75
Max. Negotiated Rate	$356.00
Rate for Payer: Cash Price	$200.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$356.00
Rate for Payer: Health Smart Auto/Commercial	$267.00
Rate for Payer: LLUH Dept of Risk Management WC	$244.75
Rate for Payer: Multiplan Commercial	$333.75

HC FACTOR V LEIDEN MUTATION

Facility

$727.00

Service Code	CPT 81241
Hospital Charge Code	900912323
Hospital Revenue Code	310
Min. Negotiated Rate	$399.85
Max. Negotiated Rate	$581.60
Rate for Payer: Cash Price	$327.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$581.60
Rate for Payer: Health Smart Auto/Commercial	$436.20
Rate for Payer: LLUH Dept of Risk Management WC	$399.85
Rate for Payer: Multiplan Commercial	$545.25

Know your out-of-pocket cost for care.

All Charges