Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC FACTOR V LEIDEN MUTATION

Facility

$168.00

Service Code	CPT 81241
Hospital Charge Code	900912323
Hospital Revenue Code	310
Min. Negotiated Rate	$92.40
Max. Negotiated Rate	$126.00
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: Health Smart Auto/Commercial	$100.80
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 Beech St/Commercial/PHCS	$126.00

HC FACTOR XII HAGEMANN

Facility

$74.00

Service Code	CPT 85280
Hospital Charge Code	900910062
Hospital Revenue Code	305
Min. Negotiated Rate	$40.70
Max. Negotiated Rate	$55.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.40
Rate for Payer: Aetna of CA Government/Medicare	$44.40
Rate for Payer: Cash Price	$33.30
Rate for Payer: Health Smart Auto/Commercial	$44.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.40
Rate for Payer: LLUH Dept of Risk Management WC	$40.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$55.50

HC FACTOR XII HAGEMANN

Facility

$1,090.00

Service Code	CPT 85280
Hospital Charge Code	900910062
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 XIII SCREEN

Facility

$34.00

Service Code	CPT 85291
Hospital Charge Code	900910023
Hospital Revenue Code	305
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$25.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$20.40
Rate for Payer: Aetna of CA Government/Medicare	$20.40
Rate for Payer: Cash Price	$15.30
Rate for Payer: Health Smart Auto/Commercial	$20.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$20.40
Rate for Payer: LLUH Dept of Risk Management WC	$18.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$25.50

HC FACTOR XIII SCREEN

Facility

$343.00

Service Code	CPT 85291
Hospital Charge Code	900910023
Hospital Revenue Code	305
Min. Negotiated Rate	$188.65
Max. Negotiated Rate	$274.40
Rate for Payer: Cash Price	$154.35
Rate for Payer: Cigna of CA HMO/PPO	$274.40
Rate for Payer: Health Smart Auto/Commercial	$205.80
Rate for Payer: LLUH Dept of Risk Management WC	$188.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$257.25

HC FACTOR XI PTA

Facility

$68.00

Service Code	CPT 85270
Hospital Charge Code	900910061
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 XI PTA

Facility

$485.00

Service Code	CPT 85270
Hospital Charge Code	900910061
Hospital Revenue Code	305
Min. Negotiated Rate	$266.75
Max. Negotiated Rate	$388.00
Rate for Payer: Cash Price	$218.25
Rate for Payer: Cigna of CA HMO/PPO	$388.00
Rate for Payer: Health Smart Auto/Commercial	$291.00
Rate for Payer: LLUH Dept of Risk Management WC	$266.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$363.75

HC FACTOR X STUART-PROWER

Facility

$1,090.00

Service Code	CPT 85260
Hospital Charge Code	900910076
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 X STUART-PROWER

Facility

$68.00

Service Code	CPT 85260
Hospital Charge Code	900910076
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 FAMILY THERAPY WITH PATIENT

Facility

$460.00

Service Code	CPT 90847
Hospital Charge Code	907804050
Hospital Revenue Code	916
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$345.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$176.80
Rate for Payer: Aetna of CA Government/Medicare	$176.80
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Health Smart Auto/Commercial	$276.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$276.00
Rate for Payer: LLUH Dept of Risk Management WC	$253.00
Rate for Payer: Mary Free Bed Workers' Compensation	$110.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$345.00

HC FAMILY THERAPY WITH PATIENT

Facility

$460.00

Service Code	CPT 90847
Hospital Charge Code	907804050
Hospital Revenue Code	916
Min. Negotiated Rate	$253.00
Max. Negotiated Rate	$368.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna of CA HMO/PPO	$368.00
Rate for Payer: Health Smart Auto/Commercial	$276.00
Rate for Payer: LLUH Dept of Risk Management WC	$253.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$345.00

HC FAMILY THERAPY WITH PATIENT

Facility

$460.00

Service Code	CPT 90847
Hospital Charge Code	907804050
Hospital Revenue Code	912
Min. Negotiated Rate	$253.00
Max. Negotiated Rate	$644.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna of CA HMO/PPO	$368.00
Rate for Payer: Health Smart Auto/Commercial	$276.00
Rate for Payer: LLUH Dept of Risk Management WC	$253.00
Rate for Payer: Mary Free Bed Workers' Compensation	$644.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$345.00

HC FAMILY THERAPY WITH PATIENT

Facility

$460.00

Service Code	CPT 90847
Hospital Charge Code	907804050
Hospital Revenue Code	912
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$725.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$725.00
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	$207.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna of CA HMO/PPO	$594.00
Rate for Payer: Health Smart Auto/Commercial	$616.00
Rate for Payer: Heritage Provider Network Commercial	$472.00
Rate for Payer: Heritage Provider Network Senior	$472.00
Rate for Payer: Intervalley Health Plan Commercial	$720.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$522.00
Rate for Payer: LLUH Dept of Risk Management WC	$253.00
Rate for Payer: Magellan Commercial	$637.00
Rate for Payer: Managed Health Network (MHN) Commercial	$682.00
Rate for Payer: Managed Health Network (MHN) Medicare	$199.21
Rate for Payer: Mary Free Bed Workers' Compensation	$110.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$345.00
Rate for Payer: US Behavioral Health Commercial/Medicare	$498.68

HC FA STAIN ADENOVIRUS

Facility

$339.00

Service Code	CPT 87260
Hospital Charge Code	900911780
Hospital Revenue Code	306
Min. Negotiated Rate	$186.45
Max. Negotiated Rate	$271.20
Rate for Payer: Cash Price	$152.55
Rate for Payer: Cigna of CA HMO/PPO	$271.20
Rate for Payer: Health Smart Auto/Commercial	$203.40
Rate for Payer: LLUH Dept of Risk Management WC	$186.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$254.25

HC FA STAIN ADENOVIRUS

Facility

$39.00

Service Code	CPT 87260
Hospital Charge Code	900911780
Hospital Revenue Code	306
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$29.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.40
Rate for Payer: Aetna of CA Government/Medicare	$23.40
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.25

HC FA STAIN BORDETELLA

Facility

$339.00

Service Code	CPT 87265
Hospital Charge Code	900911732
Hospital Revenue Code	306
Min. Negotiated Rate	$186.45
Max. Negotiated Rate	$271.20
Rate for Payer: Cash Price	$152.55
Rate for Payer: Cigna of CA HMO/PPO	$271.20
Rate for Payer: Health Smart Auto/Commercial	$203.40
Rate for Payer: LLUH Dept of Risk Management WC	$186.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$254.25

HC FA STAIN BORDETELLA

Facility

$39.00

Service Code	CPT 87265
Hospital Charge Code	900911732
Hospital Revenue Code	306
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$29.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.40
Rate for Payer: Aetna of CA Government/Medicare	$23.40
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.25

HC FA STAIN CHLAMYDIA

Facility

$39.00

Service Code	CPT 87270
Hospital Charge Code	900911730
Hospital Revenue Code	306
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$29.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.40
Rate for Payer: Aetna of CA Government/Medicare	$23.40
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.25

HC FA STAIN CHLAMYDIA

Facility

$339.00

Service Code	CPT 87270
Hospital Charge Code	900911730
Hospital Revenue Code	306
Min. Negotiated Rate	$186.45
Max. Negotiated Rate	$271.20
Rate for Payer: Cash Price	$152.55
Rate for Payer: Cigna of CA HMO/PPO	$271.20
Rate for Payer: Health Smart Auto/Commercial	$203.40
Rate for Payer: LLUH Dept of Risk Management WC	$186.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$254.25

HC FA STAIN CMV

Facility

$339.00

Service Code	CPT 87271
Hospital Charge Code	900911784
Hospital Revenue Code	306
Min. Negotiated Rate	$186.45
Max. Negotiated Rate	$271.20
Rate for Payer: Cash Price	$152.55
Rate for Payer: Cigna of CA HMO/PPO	$271.20
Rate for Payer: Health Smart Auto/Commercial	$203.40
Rate for Payer: LLUH Dept of Risk Management WC	$186.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$254.25

HC FA STAIN CMV

Facility

$39.00

Service Code	CPT 87271
Hospital Charge Code	900911784
Hospital Revenue Code	306
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$29.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.40
Rate for Payer: Aetna of CA Government/Medicare	$23.40
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.25

HC FA STAIN HERPES SIMPLEX VIRUS TYPE 1

Facility

$39.00

Service Code	CPT 87274
Hospital Charge Code	900911734
Hospital Revenue Code	306
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$29.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.40
Rate for Payer: Aetna of CA Government/Medicare	$23.40
Rate for Payer: Cash Price	$17.55
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.25

HC FA STAIN HERPES SIMPLEX VIRUS TYPE 1

Facility

$339.00

Service Code	CPT 87274
Hospital Charge Code	900911734
Hospital Revenue Code	306
Min. Negotiated Rate	$186.45
Max. Negotiated Rate	$271.20
Rate for Payer: Cash Price	$152.55
Rate for Payer: Cigna of CA HMO/PPO	$271.20
Rate for Payer: Health Smart Auto/Commercial	$203.40
Rate for Payer: LLUH Dept of Risk Management WC	$186.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$254.25

HC FA STAIN HERPES SIMPLEX VIRUS TYPE 2

Facility

$39.00

Service Code	CPT 87273
Hospital Charge Code	900911731
Hospital Revenue Code	306
Min. Negotiated Rate	$21.45
Max. Negotiated Rate	$29.25
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: Cash Price	$17.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.40
Rate for Payer: Aetna of CA Government/Medicare	$23.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$29.25

HC FA STAIN HERPES SIMPLEX VIRUS TYPE 2

Facility

$339.00

Service Code	CPT 87273
Hospital Charge Code	900911731
Hospital Revenue Code	306
Min. Negotiated Rate	$186.45
Max. Negotiated Rate	$271.20
Rate for Payer: Cash Price	$152.55
Rate for Payer: Cigna of CA HMO/PPO	$271.20
Rate for Payer: Health Smart Auto/Commercial	$203.40
Rate for Payer: LLUH Dept of Risk Management WC	$186.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$254.25

Know your out-of-pocket cost for care.

All Charges