Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC ESOPHOGRAM

Facility

$1,198.00

Service Code	CPT 74220 TC
Hospital Charge Code	909001802
Hospital Revenue Code	320
Min. Negotiated Rate	$658.90
Max. Negotiated Rate	$898.50
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: 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 Beech St/Commercial/PHCS	$898.50

HC ESOPHOGRAM

Facility

$1,198.00

Service Code	CPT 74220 TC
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: Cigna of CA 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 Beech St/Commercial/PHCS	$898.50

HC ESTRADIOL

Facility

$88.00

Service Code	CPT 82670
Hospital Charge Code	900912127
Hospital Revenue Code	301
Min. Negotiated Rate	$48.40
Max. Negotiated Rate	$66.00
Rate for Payer: Health Smart Auto/Commercial	$52.80
Rate for Payer: Cash Price	$39.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.80
Rate for Payer: Aetna of CA Government/Medicare	$52.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.80
Rate for Payer: LLUH Dept of Risk Management WC	$48.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$66.00

HC ESTRADIOL

Facility

$332.00

Service Code	CPT 82670
Hospital Charge Code	900912127
Hospital Revenue Code	301
Min. Negotiated Rate	$182.60
Max. Negotiated Rate	$265.60
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$249.00

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

Facility

$87.00

Service Code	CPT C7900
Hospital Charge Code	907807900
Hospital Revenue Code	914
Min. Negotiated Rate	$47.85
Max. Negotiated Rate	$69.60
Rate for Payer: Cash Price	$39.15
Rate for Payer: Cigna of CA HMO/PPO	$69.60
Rate for Payer: Health Smart Auto/Commercial	$52.20
Rate for Payer: LLUH Dept of Risk Management WC	$47.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.25

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

Facility

$87.00

Service Code	CPT C7900
Hospital Charge Code	907807900
Hospital Revenue Code	914
Min. Negotiated Rate	$47.85
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.20
Rate for Payer: Aetna of CA Government/Medicare	$52.20
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Cash Price	$39.15
Rate for Payer: Cash Price	$39.15
Rate for Payer: Health Smart Auto/Commercial	$52.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.20
Rate for Payer: LLUH Dept of Risk Management WC	$47.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$65.25

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

Facility

$222.00

Service Code	CPT C7901
Hospital Charge Code	907807901
Hospital Revenue Code	914
Min. Negotiated Rate	$122.10
Max. Negotiated Rate	$177.60
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna of CA HMO/PPO	$177.60
Rate for Payer: Health Smart Auto/Commercial	$133.20
Rate for Payer: LLUH Dept of Risk Management WC	$122.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$166.50

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

Facility

$222.00

Service Code	CPT C7901
Hospital Charge Code	907807901
Hospital Revenue Code	914
Min. Negotiated Rate	$122.10
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$133.20
Rate for Payer: Aetna of CA Government/Medicare	$133.20
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cash Price	$99.90
Rate for Payer: Health Smart Auto/Commercial	$133.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$133.20
Rate for Payer: LLUH Dept of Risk Management WC	$122.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$166.50

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

Facility

$111.00

Service Code	CPT C7902
Hospital Charge Code	907807902
Hospital Revenue Code	914
Min. Negotiated Rate	$61.05
Max. Negotiated Rate	$88.80
Rate for Payer: Cash Price	$49.95
Rate for Payer: Cigna of CA HMO/PPO	$88.80
Rate for Payer: Health Smart Auto/Commercial	$66.60
Rate for Payer: LLUH Dept of Risk Management WC	$61.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$83.25

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

Facility

$111.00

Service Code	CPT C7902
Hospital Charge Code	907807902
Hospital Revenue Code	914
Min. Negotiated Rate	$61.05
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$66.60
Rate for Payer: Aetna of CA Government/Medicare	$66.60
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Cash Price	$49.95
Rate for Payer: Cash Price	$49.95
Rate for Payer: Health Smart Auto/Commercial	$66.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$66.60
Rate for Payer: LLUH Dept of Risk Management WC	$61.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$83.25

HC FACIAL BONES COMPLETE

Facility

$1,527.00

Service Code	CPT 70150
Hospital Charge Code	909001101
Hospital Revenue Code	320
Min. Negotiated Rate	$839.85
Max. Negotiated Rate	$1,145.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$916.20
Rate for Payer: Aetna of CA Government/Medicare	$916.20
Rate for Payer: Cash Price	$687.15
Rate for Payer: Health Smart Auto/Commercial	$916.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$916.20
Rate for Payer: LLUH Dept of Risk Management WC	$839.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,145.25

HC FACIAL BONES COMPLETE

Facility

$1,527.00

Service Code	CPT 70150 TC
Hospital Charge Code	909001101
Hospital Revenue Code	320
Min. Negotiated Rate	$839.85
Max. Negotiated Rate	$1,145.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$916.20
Rate for Payer: Aetna of CA Government/Medicare	$916.20
Rate for Payer: Cash Price	$687.15
Rate for Payer: Health Smart Auto/Commercial	$916.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$916.20
Rate for Payer: LLUH Dept of Risk Management WC	$839.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,145.25

HC FACIAL BONES COMPLETE

Facility

$1,527.00

Service Code	CPT 70150
Hospital Charge Code	909001101
Hospital Revenue Code	320
Min. Negotiated Rate	$839.85
Max. Negotiated Rate	$1,221.60
Rate for Payer: Cash Price	$687.15
Rate for Payer: Cigna of CA HMO/PPO	$1,221.60
Rate for Payer: Health Smart Auto/Commercial	$916.20
Rate for Payer: LLUH Dept of Risk Management WC	$839.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,145.25

HC FACIAL BONES COMPLETE

Facility

$1,527.00

Service Code	CPT 70150 TC
Hospital Charge Code	909001101
Hospital Revenue Code	320
Min. Negotiated Rate	$839.85
Max. Negotiated Rate	$1,221.60
Rate for Payer: Cash Price	$687.15
Rate for Payer: Cigna of CA HMO/PPO	$1,221.60
Rate for Payer: Health Smart Auto/Commercial	$916.20
Rate for Payer: LLUH Dept of Risk Management WC	$839.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,145.25

HC FACTOR II (2) ASSAY

Facility

$1,090.00

Service Code	CPT 85210
Hospital Charge Code	900910075
Hospital Revenue Code	305
Min. Negotiated Rate	$599.50
Max. Negotiated Rate	$872.00
Rate for Payer: Cash Price	$490.50
Rate for Payer: Cigna of CA HMO/PPO	$872.00
Rate for Payer: Health Smart Auto/Commercial	$654.00
Rate for Payer: LLUH Dept of Risk Management WC	$599.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$817.50

HC FACTOR II (2) ASSAY

Facility

$49.00

Service Code	CPT 85210
Hospital Charge Code	900910075
Hospital Revenue Code	305
Min. Negotiated Rate	$26.95
Max. Negotiated Rate	$36.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$29.40
Rate for Payer: Aetna of CA Government/Medicare	$29.40
Rate for Payer: Cash Price	$22.05
Rate for Payer: Health Smart Auto/Commercial	$29.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$29.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.75

HC FACTOR IX PTC

Facility

$505.00

Service Code	CPT 85250
Hospital Charge Code	900910029
Hospital Revenue Code	305
Min. Negotiated Rate	$277.75
Max. Negotiated Rate	$404.00
Rate for Payer: Cash Price	$227.25
Rate for Payer: Cigna of CA HMO/PPO	$404.00
Rate for Payer: Health Smart Auto/Commercial	$303.00
Rate for Payer: LLUH Dept of Risk Management WC	$277.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$378.75

HC FACTOR IX PTC

Facility

$73.00

Service Code	CPT 85250
Hospital Charge Code	900910029
Hospital Revenue Code	305
Min. Negotiated Rate	$40.15
Max. Negotiated Rate	$54.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$43.80
Rate for Payer: Aetna of CA Government/Medicare	$43.80
Rate for Payer: Cash Price	$32.85
Rate for Payer: Health Smart Auto/Commercial	$43.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$43.80
Rate for Payer: LLUH Dept of Risk Management WC	$40.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$54.75

HC FACTOR V, ACG

Facility

$523.00

Service Code	CPT 85220
Hospital Charge Code	900910060
Hospital Revenue Code	305
Min. Negotiated Rate	$287.65
Max. Negotiated Rate	$418.40
Rate for Payer: Cash Price	$235.35
Rate for Payer: Cigna of CA HMO/PPO	$418.40
Rate for Payer: Health Smart Auto/Commercial	$313.80
Rate for Payer: LLUH Dept of Risk Management WC	$287.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$392.25

HC FACTOR V, ACG

Facility

$67.00

Service Code	CPT 85220
Hospital Charge Code	900910060
Hospital Revenue Code	305
Min. Negotiated Rate	$36.85
Max. Negotiated Rate	$50.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.20
Rate for Payer: Aetna of CA Government/Medicare	$40.20
Rate for Payer: Cash Price	$30.15
Rate for Payer: Health Smart Auto/Commercial	$40.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.20
Rate for Payer: LLUH Dept of Risk Management WC	$36.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$50.25

HC FACTOR VIII AHG

Facility

$68.00

Service Code	CPT 85240
Hospital Charge Code	900910028
Hospital Revenue Code	305
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC FACTOR VIII AHG

Facility

$468.00

Service Code	CPT 85240
Hospital Charge Code	900910028
Hospital Revenue Code	305
Min. Negotiated Rate	$257.40
Max. Negotiated Rate	$374.40
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cigna of CA HMO/PPO	$374.40
Rate for Payer: Health Smart Auto/Commercial	$280.80
Rate for Payer: LLUH Dept of Risk Management WC	$257.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$351.00

HC FACTOR VII, (PROCONVERTIN)

Facility

$468.00

Service Code	CPT 85230
Hospital Charge Code	900910027
Hospital Revenue Code	305
Min. Negotiated Rate	$257.40
Max. Negotiated Rate	$374.40
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cigna of CA HMO/PPO	$374.40
Rate for Payer: Health Smart Auto/Commercial	$280.80
Rate for Payer: LLUH Dept of Risk Management WC	$257.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$351.00

HC FACTOR VII, (PROCONVERTIN)

Facility

$68.00

Service Code	CPT 85230
Hospital Charge Code	900910027
Hospital Revenue Code	305
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC FACTOR V LEIDEN MUTATION

Facility

$632.00

Service Code	CPT 81241
Hospital Charge Code	900912323
Hospital Revenue Code	310
Min. Negotiated Rate	$347.60
Max. Negotiated Rate	$505.60
Rate for Payer: Cash Price	$284.40
Rate for Payer: Cigna of CA HMO/PPO	$505.60
Rate for Payer: Health Smart Auto/Commercial	$379.20
Rate for Payer: LLUH Dept of Risk Management WC	$347.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$474.00

Know your out-of-pocket cost for care.

All Charges