Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC IRON TOTAL

Facility

$44.00

Service Code	CPT 83540
Hospital Charge Code	900910243
Hospital Revenue Code	301
Min. Negotiated Rate	$6.47
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	$6.47
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 IRON TOTAL

Facility

$144.00

Service Code	CPT 83540
Hospital Charge Code	900910243
Hospital Revenue Code	301
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$115.20
Rate for Payer: Cash Price	$64.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$115.20
Rate for Payer: Health Smart Auto/Commercial	$86.40
Rate for Payer: LLUH Dept of Risk Management WC	$79.20
Rate for Payer: Multiplan Commercial	$108.00

HC JO-1 AUTO AB

Facility

$44.00

Service Code	CPT 86235
Hospital Charge Code	900913526
Hospital Revenue Code	302
Min. Negotiated Rate	$17.93
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	$17.93
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 JO-1 AUTO AB

Facility

$171.00

Service Code	CPT 86235
Hospital Charge Code	900913526
Hospital Revenue Code	302
Min. Negotiated Rate	$94.05
Max. Negotiated Rate	$136.80
Rate for Payer: Cash Price	$76.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$136.80
Rate for Payer: Health Smart Auto/Commercial	$102.60
Rate for Payer: LLUH Dept of Risk Management WC	$94.05
Rate for Payer: Multiplan Commercial	$128.25

HC KNEE 1-2 VIEWS

Facility

$882.00

Service Code	CPT 73560
Hospital Charge Code	909001621
Hospital Revenue Code	320
Min. Negotiated Rate	$485.10
Max. Negotiated Rate	$705.60
Rate for Payer: Cash Price	$396.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$705.60
Rate for Payer: Health Smart Auto/Commercial	$529.20
Rate for Payer: LLUH Dept of Risk Management WC	$485.10
Rate for Payer: Multiplan Commercial	$661.50

HC KNEE 1-2 VIEWS

Facility

$882.00

Service Code	CPT 73560
Hospital Charge Code	909001621
Hospital Revenue Code	320
Min. Negotiated Rate	$485.10
Max. Negotiated Rate	$705.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$529.20
Rate for Payer: Aetna of CA Government/Medicare	$529.20
Rate for Payer: Cash Price	$396.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$705.60
Rate for Payer: Health Smart Auto/Commercial	$529.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$529.20
Rate for Payer: LLUH Dept of Risk Management WC	$485.10
Rate for Payer: Multiplan Commercial	$661.50

HC KNEE 3 VIEWS

Facility

$1,013.00

Service Code	CPT 73562
Hospital Charge Code	909001675
Hospital Revenue Code	320
Min. Negotiated Rate	$557.15
Max. Negotiated Rate	$810.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$607.80
Rate for Payer: Aetna of CA Government/Medicare	$607.80
Rate for Payer: Cash Price	$455.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$810.40
Rate for Payer: Health Smart Auto/Commercial	$607.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$607.80
Rate for Payer: LLUH Dept of Risk Management WC	$557.15
Rate for Payer: Multiplan Commercial	$759.75

HC KNEE 3 VIEWS

Facility

$1,013.00

Service Code	CPT 73562
Hospital Charge Code	909001675
Hospital Revenue Code	320
Min. Negotiated Rate	$557.15
Max. Negotiated Rate	$810.40
Rate for Payer: Cash Price	$455.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$810.40
Rate for Payer: Health Smart Auto/Commercial	$607.80
Rate for Payer: LLUH Dept of Risk Management WC	$557.15
Rate for Payer: Multiplan Commercial	$759.75

HC KNEE COMPLETE 4 VIEWS

Facility

$1,244.00

Service Code	CPT 73564
Hospital Charge Code	909001622
Hospital Revenue Code	320
Min. Negotiated Rate	$684.20
Max. Negotiated Rate	$995.20
Rate for Payer: Cash Price	$559.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$995.20
Rate for Payer: Health Smart Auto/Commercial	$746.40
Rate for Payer: LLUH Dept of Risk Management WC	$684.20
Rate for Payer: Multiplan Commercial	$933.00

HC KNEE COMPLETE 4 VIEWS

Facility

$1,244.00

Service Code	CPT 73564
Hospital Charge Code	909001622
Hospital Revenue Code	320
Min. Negotiated Rate	$684.20
Max. Negotiated Rate	$995.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$746.40
Rate for Payer: Aetna of CA Government/Medicare	$746.40
Rate for Payer: Cash Price	$559.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$995.20
Rate for Payer: Health Smart Auto/Commercial	$746.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$746.40
Rate for Payer: LLUH Dept of Risk Management WC	$684.20
Rate for Payer: Multiplan Commercial	$933.00

HC LAB REF ACANTHAMEOBA CULTURE

Facility

$11.00

Service Code	CPT 87081
Hospital Charge Code	900911538
Hospital Revenue Code	306
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.60
Rate for Payer: Aetna of CA Government/Medicare	$6.60
Rate for Payer: Cash Price	$4.95
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.80
Rate for Payer: Health Smart Auto/Commercial	$6.60
Rate for Payer: Intervalley Health Plan Commercial	$6.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$6.05
Rate for Payer: Multiplan Commercial	$8.25

HC LAB REF ACANTHAMEOBA CULTURE

Facility

$11.00

Service Code	CPT 87081
Hospital Charge Code	900911538
Hospital Revenue Code	306
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.80
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.80
Rate for Payer: Health Smart Auto/Commercial	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$6.05
Rate for Payer: Multiplan Commercial	$8.25

HC LAB REF ACH RECEPTOR MODULATING ABS

Facility

$22.00

Service Code	CPT 83519
Hospital Charge Code	900912584
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$18.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.20
Rate for Payer: Aetna of CA Government/Medicare	$13.20
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: Intervalley Health Plan Commercial	$18.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Commercial	$16.50

HC LAB REF ACH RECEPTOR MODULATING ABS

Facility

$22.00

Service Code	CPT 83519
Hospital Charge Code	900912584
Hospital Revenue Code	301
Min. Negotiated Rate	$12.10
Max. Negotiated Rate	$17.60
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.60
Rate for Payer: Health Smart Auto/Commercial	$13.20
Rate for Payer: LLUH Dept of Risk Management WC	$12.10
Rate for Payer: Multiplan Commercial	$16.50

HC LAB REF ACOMPARATIVE GENE HYBRIDIZATIO

Facility

$1,025.00

Service Code	CPT 81228
Hospital Charge Code	900912780
Hospital Revenue Code	309
Min. Negotiated Rate	$563.75
Max. Negotiated Rate	$900.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$615.00
Rate for Payer: Aetna of CA Government/Medicare	$615.00
Rate for Payer: Cash Price	$461.25
Rate for Payer: Cash Price	$461.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$820.00
Rate for Payer: Health Smart Auto/Commercial	$615.00
Rate for Payer: Intervalley Health Plan Commercial	$900.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$615.00
Rate for Payer: LLUH Dept of Risk Management WC	$563.75
Rate for Payer: Multiplan Commercial	$768.75

HC LAB REF ACOMPARATIVE GENE HYBRIDIZATIO

Facility

$1,025.00

Service Code	CPT 81228
Hospital Charge Code	900912780
Hospital Revenue Code	309
Min. Negotiated Rate	$563.75
Max. Negotiated Rate	$820.00
Rate for Payer: Cash Price	$461.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$820.00
Rate for Payer: Health Smart Auto/Commercial	$615.00
Rate for Payer: LLUH Dept of Risk Management WC	$563.75
Rate for Payer: Multiplan Commercial	$768.75

HC LAB REF ADDITION KARYOTYPE

Facility

$40.00

Service Code	CPT 88280
Hospital Charge Code	900910745
Hospital Revenue Code	310
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$33.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.00
Rate for Payer: Aetna of CA Government/Medicare	$24.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: Intervalley Health Plan Commercial	$33.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Commercial	$30.00

HC LAB REF ADDITION KARYOTYPE

Facility

$40.00

Service Code	CPT 88280
Hospital Charge Code	900910745
Hospital Revenue Code	310
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$32.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Commercial	$30.00

HC LAB REF ADENOVIRUS AB TITER (CF)

Facility

$101.00

Service Code	CPT 86603
Hospital Charge Code	900911759
Hospital Revenue Code	302
Min. Negotiated Rate	$55.55
Max. Negotiated Rate	$80.80
Rate for Payer: Cash Price	$45.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.80
Rate for Payer: Health Smart Auto/Commercial	$60.60
Rate for Payer: LLUH Dept of Risk Management WC	$55.55
Rate for Payer: Multiplan Commercial	$75.75

HC LAB REF ADENOVIRUS AB TITER (CF)

Facility

$101.00

Service Code	CPT 86603
Hospital Charge Code	900911759
Hospital Revenue Code	302
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$80.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.60
Rate for Payer: Aetna of CA Government/Medicare	$60.60
Rate for Payer: Cash Price	$45.45
Rate for Payer: Cash Price	$45.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.80
Rate for Payer: Health Smart Auto/Commercial	$60.60
Rate for Payer: Intervalley Health Plan Commercial	$12.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.60
Rate for Payer: LLUH Dept of Risk Management WC	$55.55
Rate for Payer: Multiplan Commercial	$75.75

HC LAB REF AEROBIC ROUTINE MIC PANEL

Facility

$14.00

Service Code	CPT 87186
Hospital Charge Code	900911299
Hospital Revenue Code	300
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.20
Rate for Payer: Cash Price	$6.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.20
Rate for Payer: Health Smart Auto/Commercial	$8.40
Rate for Payer: LLUH Dept of Risk Management WC	$7.70
Rate for Payer: Multiplan Commercial	$10.50

HC LAB REF AEROBIC ROUTINE MIC PANEL

Facility

$14.00

Service Code	CPT 87186
Hospital Charge Code	900911299
Hospital Revenue Code	300
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.40
Rate for Payer: Aetna of CA Government/Medicare	$8.40
Rate for Payer: Cash Price	$6.30
Rate for Payer: Cash Price	$6.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.20
Rate for Payer: Health Smart Auto/Commercial	$8.40
Rate for Payer: Intervalley Health Plan Commercial	$8.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.40
Rate for Payer: LLUH Dept of Risk Management WC	$7.70
Rate for Payer: Multiplan Commercial	$10.50

HC LAB REF ALBUMIN CHARGE - SO

Facility

$8.00

Service Code	CPT 82040
Hospital Charge Code	900910549
Hospital Revenue Code	301
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.40
Rate for Payer: Cash Price	$3.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.40
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: Multiplan Commercial	$6.00

HC LAB REF ALBUMIN CHARGE - SO

Facility

$8.00

Service Code	CPT 82040
Hospital Charge Code	900910549
Hospital Revenue Code	301
Min. Negotiated Rate	$4.40
Max. Negotiated Rate	$6.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.80
Rate for Payer: Aetna of CA Government/Medicare	$4.80
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.40
Rate for Payer: Health Smart Auto/Commercial	$4.80
Rate for Payer: Intervalley Health Plan Commercial	$4.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.80
Rate for Payer: LLUH Dept of Risk Management WC	$4.40
Rate for Payer: Multiplan Commercial	$6.00

HC LAB REF ALCOHOL METHYL

Facility

$79.00

Service Code	CPT 80320
Hospital Charge Code	900910716
Hospital Revenue Code	301
Min. Negotiated Rate	$43.45
Max. Negotiated Rate	$63.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$47.40
Rate for Payer: Aetna of CA Government/Medicare	$47.40
Rate for Payer: Cash Price	$35.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$63.20
Rate for Payer: Health Smart Auto/Commercial	$47.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$47.40
Rate for Payer: LLUH Dept of Risk Management WC	$43.45
Rate for Payer: Multiplan Commercial	$59.25

Know your out-of-pocket cost for care.

All Charges