Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC FACTOR V LEIDEN MUTATION

Facility

$386.00

Service Code	CPT 81241
Hospital Charge Code	900912323
Hospital Revenue Code	310
Min. Negotiated Rate	$73.37
Max. Negotiated Rate	$308.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$231.60
Rate for Payer: Aetna of CA Government/Medicare	$231.60
Rate for Payer: Cash Price	$173.70
Rate for Payer: Cash Price	$173.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$308.80
Rate for Payer: Health Smart Auto/Commercial	$231.60
Rate for Payer: Intervalley Health Plan Commercial	$73.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$231.60
Rate for Payer: LLUH Dept of Risk Management WC	$212.30
Rate for Payer: Multiplan Commercial	$289.50

HC FACTOR V LEIDEN MUTATN B INDI

Facility

$431.00

Service Code	CPT 81241
Hospital Charge Code	900913619
Hospital Revenue Code	301
Min. Negotiated Rate	$237.05
Max. Negotiated Rate	$344.80
Rate for Payer: Cash Price	$193.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$344.80
Rate for Payer: Health Smart Auto/Commercial	$258.60
Rate for Payer: LLUH Dept of Risk Management WC	$237.05
Rate for Payer: Multiplan Commercial	$323.25

HC FACTOR V LEIDEN MUTATN B INDI

Facility

$431.00

Service Code	CPT 81241
Hospital Charge Code	900913619
Hospital Revenue Code	301
Min. Negotiated Rate	$73.37
Max. Negotiated Rate	$344.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$258.60
Rate for Payer: Aetna of CA Government/Medicare	$258.60
Rate for Payer: Cash Price	$193.95
Rate for Payer: Cash Price	$193.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$344.80
Rate for Payer: Health Smart Auto/Commercial	$258.60
Rate for Payer: Intervalley Health Plan Commercial	$73.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$258.60
Rate for Payer: LLUH Dept of Risk Management WC	$237.05
Rate for Payer: Multiplan Commercial	$323.25

HC FACTOR XII HAGEMANN

Facility

$512.00

Service Code	CPT 85280
Hospital Charge Code	900910062
Hospital Revenue Code	305
Min. Negotiated Rate	$281.60
Max. Negotiated Rate	$409.60
Rate for Payer: Cash Price	$230.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$409.60
Rate for Payer: Health Smart Auto/Commercial	$307.20
Rate for Payer: LLUH Dept of Risk Management WC	$281.60
Rate for Payer: Multiplan Commercial	$384.00

HC FACTOR XII HAGEMANN

Facility

$70.00

Service Code	CPT 85280
Hospital Charge Code	900910062
Hospital Revenue Code	305
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.00
Rate for Payer: Aetna of CA Government/Medicare	$42.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cash Price	$31.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.00
Rate for Payer: Health Smart Auto/Commercial	$42.00
Rate for Payer: Intervalley Health Plan Commercial	$19.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.00
Rate for Payer: LLUH Dept of Risk Management WC	$38.50
Rate for Payer: Multiplan Commercial	$52.50

HC FACTOR XIII SCREEN

Facility

$151.00

Service Code	CPT 85291
Hospital Charge Code	900910023
Hospital Revenue Code	305
Min. Negotiated Rate	$83.05
Max. Negotiated Rate	$120.80
Rate for Payer: Cash Price	$67.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$120.80
Rate for Payer: Health Smart Auto/Commercial	$90.60
Rate for Payer: LLUH Dept of Risk Management WC	$83.05
Rate for Payer: Multiplan Commercial	$113.25

HC FACTOR XIII SCREEN

Facility

$44.00

Service Code	CPT 85291
Hospital Charge Code	900910023
Hospital Revenue Code	305
Min. Negotiated Rate	$9.11
Max. Negotiated Rate	$35.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$26.40
Rate for Payer: Aetna of CA Government/Medicare	$26.40
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cash Price	$19.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$35.20
Rate for Payer: Health Smart Auto/Commercial	$26.40
Rate for Payer: Intervalley Health Plan Commercial	$9.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$26.40
Rate for Payer: LLUH Dept of Risk Management WC	$24.20
Rate for Payer: Multiplan Commercial	$33.00

HC FACTOR XI PTA

Facility

$461.00

Service Code	CPT 85270
Hospital Charge Code	900910061
Hospital Revenue Code	305
Min. Negotiated Rate	$253.55
Max. Negotiated Rate	$368.80
Rate for Payer: Cash Price	$207.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$368.80
Rate for Payer: Health Smart Auto/Commercial	$276.60
Rate for Payer: LLUH Dept of Risk Management WC	$253.55
Rate for Payer: Multiplan Commercial	$345.75

HC FACTOR XI PTA

Facility

$156.00

Service Code	CPT 85270
Hospital Charge Code	900910061
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 X STUART-PROWER

Facility

$517.00

Service Code	CPT 85260
Hospital Charge Code	900910076
Hospital Revenue Code	305
Min. Negotiated Rate	$284.35
Max. Negotiated Rate	$413.60
Rate for Payer: Cash Price	$232.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$413.60
Rate for Payer: Health Smart Auto/Commercial	$310.20
Rate for Payer: LLUH Dept of Risk Management WC	$284.35
Rate for Payer: Multiplan Commercial	$387.75

HC FACTOR X STUART-PROWER

Facility

$78.00

Service Code	CPT 85260
Hospital Charge Code	900910076
Hospital Revenue Code	305
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$62.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$46.80
Rate for Payer: Aetna of CA Government/Medicare	$46.80
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$62.40
Rate for Payer: Health Smart Auto/Commercial	$46.80
Rate for Payer: Intervalley Health Plan Commercial	$17.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$46.80
Rate for Payer: LLUH Dept of Risk Management WC	$42.90
Rate for Payer: Multiplan Commercial	$58.50

HC FAMILY THERAPY WITH PATIENT

Facility

$553.00

Service Code	CPT 90847
Hospital Charge Code	907804050
Hospital Revenue Code	912
Min. Negotiated Rate	$304.15
Max. Negotiated Rate	$703.72
Rate for Payer: Cash Price	$248.85
Rate for Payer: Cash Price	$248.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$442.40
Rate for Payer: Health Smart Auto/Commercial	$331.80
Rate for Payer: LLUH Dept of Risk Management WC	$304.15
Rate for Payer: Mary Free Bed Workers' Compensation	$703.72
Rate for Payer: Multiplan Commercial	$414.75

HC FAMILY THERAPY WITH PATIENT

Facility

$553.00

Service Code	CPT 90847
Hospital Charge Code	907804050
Hospital Revenue Code	912
Min. Negotiated Rate	$120.20
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$769.00
Rate for Payer: Aetna of CA Government/Medicare	$176.80
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$600.00
Rate for Payer: Blue Shield of California Commercial	$569.00
Rate for Payer: Cash Price	$248.85
Rate for Payer: Cash Price	$248.85
Rate for Payer: Cash Price	$248.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$594.00
Rate for Payer: Health Smart Auto/Commercial	$616.00
Rate for Payer: Intervalley Health Plan Commercial	$720.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$588.00
Rate for Payer: LLUH Dept of Risk Management WC	$304.15
Rate for Payer: Magellan Commercial	$825.00
Rate for Payer: Managed Health Network (MHN) Commercial	$716.00
Rate for Payer: Mary Free Bed Workers' Compensation	$120.20
Rate for Payer: Multiplan Commercial	$414.75
Rate for Payer: US Behavioral Health Commercial/Medicare	$516.13

HC FA STAIN ADENOVIRUS

Facility

$332.00

Service Code	CPT 87260
Hospital Charge Code	900911780
Hospital Revenue Code	306
Min. Negotiated Rate	$182.60
Max. Negotiated Rate	$265.60
Rate for Payer: Cash Price	$149.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$265.60
Rate for Payer: Health Smart Auto/Commercial	$199.20
Rate for Payer: LLUH Dept of Risk Management WC	$182.60
Rate for Payer: Multiplan Commercial	$249.00

HC FA STAIN ADENOVIRUS

Facility

$38.00

Service Code	CPT 87260
Hospital Charge Code	900911780
Hospital Revenue Code	306
Min. Negotiated Rate	$14.43
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.80
Rate for Payer: Aetna of CA Government/Medicare	$22.80
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cash Price	$17.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.40
Rate for Payer: Health Smart Auto/Commercial	$22.80
Rate for Payer: Intervalley Health Plan Commercial	$14.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.80
Rate for Payer: LLUH Dept of Risk Management WC	$20.90
Rate for Payer: Multiplan Commercial	$28.50

HC FA STAIN BORDETELLA

Facility

$332.00

Service Code	CPT 87265
Hospital Charge Code	900911732
Hospital Revenue Code	306
Min. Negotiated Rate	$182.60
Max. Negotiated Rate	$265.60
Rate for Payer: Cash Price	$149.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$265.60
Rate for Payer: Health Smart Auto/Commercial	$199.20
Rate for Payer: LLUH Dept of Risk Management WC	$182.60
Rate for Payer: Multiplan Commercial	$249.00

HC FA STAIN BORDETELLA

Facility

$38.00

Service Code	CPT 87265
Hospital Charge Code	900911732
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.80
Rate for Payer: Aetna of CA Government/Medicare	$22.80
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cash Price	$17.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.40
Rate for Payer: Health Smart Auto/Commercial	$22.80
Rate for Payer: Intervalley Health Plan Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.80
Rate for Payer: LLUH Dept of Risk Management WC	$20.90
Rate for Payer: Multiplan Commercial	$28.50

HC FA STAIN CHLAMYDIA

Facility

$38.00

Service Code	CPT 87270
Hospital Charge Code	900911730
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.80
Rate for Payer: Aetna of CA Government/Medicare	$22.80
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cash Price	$17.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.40
Rate for Payer: Health Smart Auto/Commercial	$22.80
Rate for Payer: Intervalley Health Plan Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.80
Rate for Payer: LLUH Dept of Risk Management WC	$20.90
Rate for Payer: Multiplan Commercial	$28.50

HC FA STAIN CHLAMYDIA

Facility

$332.00

Service Code	CPT 87270
Hospital Charge Code	900911730
Hospital Revenue Code	306
Min. Negotiated Rate	$182.60
Max. Negotiated Rate	$265.60
Rate for Payer: Cash Price	$149.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$265.60
Rate for Payer: Health Smart Auto/Commercial	$199.20
Rate for Payer: LLUH Dept of Risk Management WC	$182.60
Rate for Payer: Multiplan Commercial	$249.00

HC FA STAIN CMV

Facility

$38.00

Service Code	CPT 87271
Hospital Charge Code	900911784
Hospital Revenue Code	306
Min. Negotiated Rate	$13.42
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.80
Rate for Payer: Aetna of CA Government/Medicare	$22.80
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cash Price	$17.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.40
Rate for Payer: Health Smart Auto/Commercial	$22.80
Rate for Payer: Intervalley Health Plan Commercial	$13.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.80
Rate for Payer: LLUH Dept of Risk Management WC	$20.90
Rate for Payer: Multiplan Commercial	$28.50

HC FA STAIN CMV

Facility

$332.00

Service Code	CPT 87271
Hospital Charge Code	900911784
Hospital Revenue Code	306
Min. Negotiated Rate	$182.60
Max. Negotiated Rate	$265.60
Rate for Payer: Cash Price	$149.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$265.60
Rate for Payer: Health Smart Auto/Commercial	$199.20
Rate for Payer: LLUH Dept of Risk Management WC	$182.60
Rate for Payer: Multiplan Commercial	$249.00

HC FA STAIN HERPES SIMPLEX VIRUS TYPE 1

Facility

$38.00

Service Code	CPT 87274
Hospital Charge Code	900911734
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.80
Rate for Payer: Aetna of CA Government/Medicare	$22.80
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cash Price	$17.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.40
Rate for Payer: Health Smart Auto/Commercial	$22.80
Rate for Payer: Intervalley Health Plan Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.80
Rate for Payer: LLUH Dept of Risk Management WC	$20.90
Rate for Payer: Multiplan Commercial	$28.50

HC FA STAIN HERPES SIMPLEX VIRUS TYPE 1

Facility

$332.00

Service Code	CPT 87274
Hospital Charge Code	900911734
Hospital Revenue Code	306
Min. Negotiated Rate	$182.60
Max. Negotiated Rate	$265.60
Rate for Payer: Cash Price	$149.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$265.60
Rate for Payer: Health Smart Auto/Commercial	$199.20
Rate for Payer: LLUH Dept of Risk Management WC	$182.60
Rate for Payer: Multiplan Commercial	$249.00

HC FA STAIN HERPES SIMPLEX VIRUS TYPE 2

Facility

$332.00

Service Code	CPT 87273
Hospital Charge Code	900911731
Hospital Revenue Code	306
Min. Negotiated Rate	$182.60
Max. Negotiated Rate	$265.60
Rate for Payer: Cash Price	$149.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$265.60
Rate for Payer: Health Smart Auto/Commercial	$199.20
Rate for Payer: LLUH Dept of Risk Management WC	$182.60
Rate for Payer: Multiplan Commercial	$249.00

HC FA STAIN HERPES SIMPLEX VIRUS TYPE 2

Facility

$38.00

Service Code	CPT 87273
Hospital Charge Code	900911731
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$30.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.80
Rate for Payer: Aetna of CA Government/Medicare	$22.80
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cash Price	$17.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.40
Rate for Payer: Health Smart Auto/Commercial	$22.80
Rate for Payer: Intervalley Health Plan Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.80
Rate for Payer: LLUH Dept of Risk Management WC	$20.90
Rate for Payer: Multiplan Commercial	$28.50

Know your out-of-pocket cost for care.

All Charges