Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC CT MAXILLOFAC W CONT

Facility

$5,098.00

Service Code	CPT 70487 TC
Hospital Charge Code	909201907
Hospital Revenue Code	351
Min. Negotiated Rate	$2,803.90
Max. Negotiated Rate	$4,078.40
Rate for Payer: Cash Price	$2,294.10
Rate for Payer: Cigna of CA HMO/PPO	$4,078.40
Rate for Payer: Health Smart Auto/Commercial	$3,058.80
Rate for Payer: LLUH Dept of Risk Management WC	$2,803.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,823.50

HC CT MAXILLOFAC W CONT

Facility

$2,862.00

Service Code	CPT 70487
Hospital Charge Code	909201907
Hospital Revenue Code	351
Min. Negotiated Rate	$1,574.10
Max. Negotiated Rate	$2,146.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,717.20
Rate for Payer: Aetna of CA Government/Medicare	$1,717.20
Rate for Payer: Cash Price	$1,287.90
Rate for Payer: Health Smart Auto/Commercial	$1,717.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,717.20
Rate for Payer: LLUH Dept of Risk Management WC	$1,574.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,146.50

HC CT MAXILLOFAC W CONT

Facility

$5,098.00

Service Code	CPT 70487
Hospital Charge Code	909201907
Hospital Revenue Code	351
Min. Negotiated Rate	$2,803.90
Max. Negotiated Rate	$4,078.40
Rate for Payer: Health Smart Auto/Commercial	$3,058.80
Rate for Payer: Cash Price	$2,294.10
Rate for Payer: Cigna of CA HMO/PPO	$4,078.40
Rate for Payer: LLUH Dept of Risk Management WC	$2,803.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,823.50

HC CT MAXILLOFAC W/O CO

Facility

$4,451.00

Service Code	CPT 70486 TC
Hospital Charge Code	909201906
Hospital Revenue Code	351
Min. Negotiated Rate	$2,448.05
Max. Negotiated Rate	$3,560.80
Rate for Payer: Cash Price	$2,002.95
Rate for Payer: Cigna of CA HMO/PPO	$3,560.80
Rate for Payer: Health Smart Auto/Commercial	$2,670.60
Rate for Payer: LLUH Dept of Risk Management WC	$2,448.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,338.25

HC CT MAXILLOFAC W/O CO

Facility

$2,499.00

Service Code	CPT 70486
Hospital Charge Code	909201906
Hospital Revenue Code	351
Min. Negotiated Rate	$1,374.45
Max. Negotiated Rate	$1,874.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,499.40
Rate for Payer: Aetna of CA Government/Medicare	$1,499.40
Rate for Payer: Cash Price	$1,124.55
Rate for Payer: Health Smart Auto/Commercial	$1,499.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,499.40
Rate for Payer: LLUH Dept of Risk Management WC	$1,374.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,874.25

HC CT MAXILLOFAC W/O CO

Facility

$4,451.00

Service Code	CPT 70486
Hospital Charge Code	909201906
Hospital Revenue Code	351
Min. Negotiated Rate	$2,448.05
Max. Negotiated Rate	$3,560.80
Rate for Payer: Cash Price	$2,002.95
Rate for Payer: Cigna of CA HMO/PPO	$3,560.80
Rate for Payer: Health Smart Auto/Commercial	$2,670.60
Rate for Payer: LLUH Dept of Risk Management WC	$2,448.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,338.25

HC CT SOFT TIS NCK W CONTR

Facility

$5,744.00

Service Code	CPT 70491
Hospital Charge Code	909201910
Hospital Revenue Code	351
Min. Negotiated Rate	$3,159.20
Max. Negotiated Rate	$4,595.20
Rate for Payer: Cash Price	$2,584.80
Rate for Payer: Cigna of CA HMO/PPO	$4,595.20
Rate for Payer: Health Smart Auto/Commercial	$3,446.40
Rate for Payer: LLUH Dept of Risk Management WC	$3,159.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,308.00

HC CT SOFT TIS NCK W CONTR

Facility

$3,224.00

Service Code	CPT 70491
Hospital Charge Code	909201910
Hospital Revenue Code	351
Min. Negotiated Rate	$1,773.20
Max. Negotiated Rate	$2,418.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,934.40
Rate for Payer: Aetna of CA Government/Medicare	$1,934.40
Rate for Payer: Cash Price	$1,450.80
Rate for Payer: Health Smart Auto/Commercial	$1,934.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,934.40
Rate for Payer: LLUH Dept of Risk Management WC	$1,773.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,418.00

HC CT SOFT TIS NCK W CONTR

Facility

$5,744.00

Service Code	CPT 70491 TC
Hospital Charge Code	909201910
Hospital Revenue Code	351
Min. Negotiated Rate	$3,159.20
Max. Negotiated Rate	$4,595.20
Rate for Payer: Cash Price	$2,584.80
Rate for Payer: Cigna of CA HMO/PPO	$4,595.20
Rate for Payer: Health Smart Auto/Commercial	$3,446.40
Rate for Payer: LLUH Dept of Risk Management WC	$3,159.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,308.00

HC CT SOFT TIS NCK WO CONTR

Facility

$2,862.00

Service Code	CPT 70490
Hospital Charge Code	909201909
Hospital Revenue Code	351
Min. Negotiated Rate	$1,574.10
Max. Negotiated Rate	$2,146.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,717.20
Rate for Payer: Aetna of CA Government/Medicare	$1,717.20
Rate for Payer: Cash Price	$1,287.90
Rate for Payer: Health Smart Auto/Commercial	$1,717.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,717.20
Rate for Payer: LLUH Dept of Risk Management WC	$1,574.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,146.50

HC CT SOFT TIS NCK WO CONTR

Facility

$5,098.00

Service Code	CPT 70490 TC
Hospital Charge Code	909201909
Hospital Revenue Code	351
Min. Negotiated Rate	$2,803.90
Max. Negotiated Rate	$4,078.40
Rate for Payer: Cash Price	$2,294.10
Rate for Payer: Cigna of CA HMO/PPO	$4,078.40
Rate for Payer: Health Smart Auto/Commercial	$3,058.80
Rate for Payer: LLUH Dept of Risk Management WC	$2,803.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,823.50

HC CT SOFT TIS NCK WO CONTR

Facility

$5,098.00

Service Code	CPT 70490
Hospital Charge Code	909201909
Hospital Revenue Code	351
Min. Negotiated Rate	$2,803.90
Max. Negotiated Rate	$4,078.40
Rate for Payer: Cash Price	$2,294.10
Rate for Payer: Cigna of CA HMO/PPO	$4,078.40
Rate for Payer: Health Smart Auto/Commercial	$3,058.80
Rate for Payer: LLUH Dept of Risk Management WC	$2,803.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,823.50

HC CT SOFT TISSUE NECK W/WO CNTRST

Facility

$5,834.00

Service Code	CPT 70492 TC
Hospital Charge Code	909201911
Hospital Revenue Code	351
Min. Negotiated Rate	$3,208.70
Max. Negotiated Rate	$4,667.20
Rate for Payer: Cash Price	$2,625.30
Rate for Payer: Cigna of CA HMO/PPO	$4,667.20
Rate for Payer: Health Smart Auto/Commercial	$3,500.40
Rate for Payer: LLUH Dept of Risk Management WC	$3,208.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,375.50

HC CT SOFT TISSUE NECK W/WO CNTRST

Facility

$5,834.00

Service Code	CPT 70492
Hospital Charge Code	909201911
Hospital Revenue Code	351
Min. Negotiated Rate	$3,208.70
Max. Negotiated Rate	$4,667.20
Rate for Payer: Cash Price	$2,625.30
Rate for Payer: Cigna of CA HMO/PPO	$4,667.20
Rate for Payer: Health Smart Auto/Commercial	$3,500.40
Rate for Payer: LLUH Dept of Risk Management WC	$3,208.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,375.50

HC CT SOFT TISSUE NECK W/WO CNTRST

Facility

$3,842.00

Service Code	CPT 70492
Hospital Charge Code	909201911
Hospital Revenue Code	351
Min. Negotiated Rate	$2,113.10
Max. Negotiated Rate	$2,881.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,305.20
Rate for Payer: Aetna of CA Government/Medicare	$2,305.20
Rate for Payer: Cash Price	$1,728.90
Rate for Payer: Health Smart Auto/Commercial	$2,305.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,305.20
Rate for Payer: LLUH Dept of Risk Management WC	$2,113.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,881.50

HC CT TSPINE W W/O CONTRAST

Facility

$6,019.00

Service Code	CPT 72130
Hospital Charge Code	909201966
Hospital Revenue Code	352
Min. Negotiated Rate	$3,310.45
Max. Negotiated Rate	$4,815.20
Rate for Payer: Cash Price	$2,708.55
Rate for Payer: Cigna of CA HMO/PPO	$4,815.20
Rate for Payer: Health Smart Auto/Commercial	$3,611.40
Rate for Payer: LLUH Dept of Risk Management WC	$3,310.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,514.25

HC CT TSPINE W W/O CONTRAST

Facility

$3,534.00

Service Code	CPT 72130
Hospital Charge Code	909201966
Hospital Revenue Code	352
Min. Negotiated Rate	$1,943.70
Max. Negotiated Rate	$2,650.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,120.40
Rate for Payer: Aetna of CA Government/Medicare	$2,120.40
Rate for Payer: Cash Price	$1,590.30
Rate for Payer: Health Smart Auto/Commercial	$2,120.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,120.40
Rate for Payer: LLUH Dept of Risk Management WC	$1,943.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,650.50

HC CT TSPINE W W/O CONTRAST

Facility

$6,019.00

Service Code	CPT 72130 TC
Hospital Charge Code	909201966
Hospital Revenue Code	352
Min. Negotiated Rate	$3,310.45
Max. Negotiated Rate	$4,815.20
Rate for Payer: Cash Price	$2,708.55
Rate for Payer: Cigna of CA HMO/PPO	$4,815.20
Rate for Payer: Health Smart Auto/Commercial	$3,611.40
Rate for Payer: LLUH Dept of Risk Management WC	$3,310.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,514.25

HC CULTURE AEROBIC ID

Facility

$204.00

Service Code	CPT 87077
Hospital Charge Code	900911554
Hospital Revenue Code	306
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$163.20
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna of CA HMO/PPO	$163.20
Rate for Payer: Health Smart Auto/Commercial	$122.40
Rate for Payer: LLUH Dept of Risk Management WC	$112.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$153.00

HC CULTURE AEROBIC ID

Facility

$27.00

Service Code	CPT 87077
Hospital Charge Code	900911554
Hospital Revenue Code	306
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$20.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.20
Rate for Payer: Aetna of CA Government/Medicare	$16.20
Rate for Payer: Cash Price	$12.15
Rate for Payer: Health Smart Auto/Commercial	$16.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.20
Rate for Payer: LLUH Dept of Risk Management WC	$14.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.25

HC CULTURE ANAEROBIC

Facility

$31.00

Service Code	CPT 87075
Hospital Charge Code	900911501
Hospital Revenue Code	306
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 CULTURE ANAEROBIC

Facility

$355.00

Service Code	CPT 87075
Hospital Charge Code	900911501
Hospital Revenue Code	306
Min. Negotiated Rate	$195.25
Max. Negotiated Rate	$284.00
Rate for Payer: Cash Price	$159.75
Rate for Payer: Cigna of CA HMO/PPO	$284.00
Rate for Payer: Health Smart Auto/Commercial	$213.00
Rate for Payer: LLUH Dept of Risk Management WC	$195.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$266.25

HC CULTURE ANAEROBIC IDS RAPID

Facility

$31.00

Service Code	CPT 87076
Hospital Charge Code	900911553
Hospital Revenue Code	306
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 CULTURE ANAEROBIC IDS RAPID

Facility

$204.00

Service Code	CPT 87076
Hospital Charge Code	900911553
Hospital Revenue Code	306
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$163.20
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna of CA HMO/PPO	$163.20
Rate for Payer: Health Smart Auto/Commercial	$122.40
Rate for Payer: LLUH Dept of Risk Management WC	$112.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$153.00

HC CULTURE BACTERIAL AG H INFLU

Facility

$13.00

Service Code	CPT 87147
Hospital Charge Code	900911711
Hospital Revenue Code	306
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$9.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.80
Rate for Payer: Aetna of CA Government/Medicare	$7.80
Rate for Payer: Cash Price	$5.85
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.75

Know your out-of-pocket cost for care.

All Charges