Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC METHOTREXATE

Facility

$120.00

Service Code	CPT 80204
Hospital Charge Code	900910937
Hospital Revenue Code	301
Min. Negotiated Rate	$38.57
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$96.00
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Intervalley Health Plan Commercial	$38.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: Multiplan Commercial	$90.00

HC METHOTREXATE

Facility

$223.00

Service Code	CPT 80204
Hospital Charge Code	900910937
Hospital Revenue Code	301
Min. Negotiated Rate	$122.65
Max. Negotiated Rate	$178.40
Rate for Payer: Cash Price	$100.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$178.40
Rate for Payer: Health Smart Auto/Commercial	$133.80
Rate for Payer: LLUH Dept of Risk Management WC	$122.65
Rate for Payer: Multiplan Commercial	$167.25

HC MFN DRUG ADD-ON, PER DOSE

Facility

$300.00

Service Code	CPT M1145
Hospital Charge Code	901700053
Hospital Revenue Code	636
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$180.00
Rate for Payer: Aetna of CA Government/Medicare	$180.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$240.00
Rate for Payer: Health Smart Auto/Commercial	$180.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$180.00
Rate for Payer: LLUH Dept of Risk Management WC	$165.00
Rate for Payer: Multiplan Commercial	$225.00

HC MFN DRUG ADD-ON, PER DOSE

Facility

$300.00

Service Code	CPT M1145
Hospital Charge Code	901700053
Hospital Revenue Code	636
Min. Negotiated Rate	$165.00
Max. Negotiated Rate	$240.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$240.00
Rate for Payer: Health Smart Auto/Commercial	$180.00
Rate for Payer: LLUH Dept of Risk Management WC	$165.00
Rate for Payer: Multiplan Commercial	$225.00

HC MICROALBUMIN

Facility

$215.00

Service Code	CPT 82043
Hospital Charge Code	900912131
Hospital Revenue Code	301
Min. Negotiated Rate	$118.25
Max. Negotiated Rate	$172.00
Rate for Payer: Cash Price	$96.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$172.00
Rate for Payer: Health Smart Auto/Commercial	$129.00
Rate for Payer: LLUH Dept of Risk Management WC	$118.25
Rate for Payer: Multiplan Commercial	$161.25

HC MICROALBUMIN

Facility

$62.00

Service Code	CPT 82043
Hospital Charge Code	900912131
Hospital Revenue Code	301
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$49.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$37.20
Rate for Payer: Aetna of CA Government/Medicare	$37.20
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cash Price	$27.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$49.60
Rate for Payer: Health Smart Auto/Commercial	$37.20
Rate for Payer: Intervalley Health Plan Commercial	$5.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$37.20
Rate for Payer: LLUH Dept of Risk Management WC	$34.10
Rate for Payer: Multiplan Commercial	$46.50

HC MICRO EXAM/CRYSTALS

Facility

$31.00

Service Code	CPT 89060
Hospital Charge Code	900910153
Hospital Revenue Code	300
Min. Negotiated Rate	$7.33
Max. Negotiated Rate	$24.80
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: Cash Price	$13.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.80
Rate for Payer: Health Smart Auto/Commercial	$18.60
Rate for Payer: Intervalley Health Plan Commercial	$7.33
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 Commercial	$23.25

HC MICRO EXAM/CRYSTALS

Facility

$190.00

Service Code	CPT 89060
Hospital Charge Code	900910153
Hospital Revenue Code	300
Min. Negotiated Rate	$104.50
Max. Negotiated Rate	$152.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$152.00
Rate for Payer: Health Smart Auto/Commercial	$114.00
Rate for Payer: LLUH Dept of Risk Management WC	$104.50
Rate for Payer: Multiplan Commercial	$142.50

HC MICRO EXAM/SPERM

Facility

$161.00

Service Code	CPT 89321
Hospital Charge Code	900910155
Hospital Revenue Code	300
Min. Negotiated Rate	$88.55
Max. Negotiated Rate	$128.80
Rate for Payer: Cash Price	$72.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$128.80
Rate for Payer: Health Smart Auto/Commercial	$96.60
Rate for Payer: LLUH Dept of Risk Management WC	$88.55
Rate for Payer: Multiplan Commercial	$120.75

HC MICRO EXAM/SPERM

Facility

$82.00

Service Code	CPT 89321
Hospital Charge Code	900910155
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$65.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.20
Rate for Payer: Aetna of CA Government/Medicare	$49.20
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cash Price	$36.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$65.60
Rate for Payer: Health Smart Auto/Commercial	$49.20
Rate for Payer: Intervalley Health Plan Commercial	$12.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.20
Rate for Payer: LLUH Dept of Risk Management WC	$45.10
Rate for Payer: Multiplan Commercial	$61.50

HC MICRO EXAM/TRICHOMONAS

Facility

$40.00

Service Code	CPT 87210
Hospital Charge Code	900910156
Hospital Revenue Code	306
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$32.00
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	$5.82
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 MICRO EXAM/TRICHOMONAS

Facility

$156.00

Service Code	CPT 87210
Hospital Charge Code	900910156
Hospital Revenue Code	306
Min. Negotiated Rate	$85.80
Max. Negotiated Rate	$124.80
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: LLUH Dept of Risk Management WC	$85.80
Rate for Payer: Multiplan Commercial	$117.00

HC MICROFIL LARVA

Facility

$196.00

Service Code	CPT 87207
Hospital Charge Code	900911659
Hospital Revenue Code	306
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$156.80
Rate for Payer: Cash Price	$88.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$156.80
Rate for Payer: Health Smart Auto/Commercial	$117.60
Rate for Payer: LLUH Dept of Risk Management WC	$107.80
Rate for Payer: Multiplan Commercial	$147.00

HC MICROFIL LARVA

Facility

$27.00

Service Code	CPT 87207
Hospital Charge Code	900911659
Hospital Revenue Code	306
Min. Negotiated Rate	$5.99
Max. Negotiated Rate	$21.60
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: Cash Price	$12.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$21.60
Rate for Payer: Health Smart Auto/Commercial	$16.20
Rate for Payer: Intervalley Health Plan Commercial	$5.99
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 Commercial	$20.25

HC MICROGLOBULIN

Facility

$144.00

Service Code	CPT 82232
Hospital Charge Code	900912121
Hospital Revenue Code	301
Min. Negotiated Rate	$16.18
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$86.40
Rate for Payer: Aetna of CA Government/Medicare	$86.40
Rate for Payer: Cash Price	$64.80
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: Intervalley Health Plan Commercial	$16.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$86.40
Rate for Payer: LLUH Dept of Risk Management WC	$79.20
Rate for Payer: Multiplan Commercial	$108.00

HC MICROGLOBULIN

Facility

$178.00

Service Code	CPT 82232
Hospital Charge Code	900912121
Hospital Revenue Code	301
Min. Negotiated Rate	$97.90
Max. Negotiated Rate	$142.40
Rate for Payer: Cash Price	$80.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$142.40
Rate for Payer: Health Smart Auto/Commercial	$106.80
Rate for Payer: LLUH Dept of Risk Management WC	$97.90
Rate for Payer: Multiplan Commercial	$133.50

HC MICROHEMATOCRIT SPUN

Facility

$10.00

Service Code	CPT 85013
Hospital Charge Code	900910790
Hospital Revenue Code	305
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.00
Rate for Payer: Aetna of CA Government/Medicare	$6.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cash Price	$4.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.00
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Intervalley Health Plan Commercial	$7.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Commercial	$7.50

HC MICROHEMATOCRIT SPUN

Facility

$110.00

Service Code	CPT 85013
Hospital Charge Code	900910790
Hospital Revenue Code	305
Min. Negotiated Rate	$60.50
Max. Negotiated Rate	$88.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.00
Rate for Payer: Health Smart Auto/Commercial	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$60.50
Rate for Payer: Multiplan Commercial	$82.50

HC MONOSPOT (INFECT. MONO TEST)

Facility

$54.00

Service Code	CPT 86308
Hospital Charge Code	900910867
Hospital Revenue Code	302
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$32.40
Rate for Payer: Aetna of CA Government/Medicare	$32.40
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$43.20
Rate for Payer: Health Smart Auto/Commercial	$32.40
Rate for Payer: Intervalley Health Plan Commercial	$5.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$32.40
Rate for Payer: LLUH Dept of Risk Management WC	$29.70
Rate for Payer: Multiplan Commercial	$40.50

HC MONOSPOT (INFECT. MONO TEST)

Facility

$198.00

Service Code	CPT 86308
Hospital Charge Code	900910867
Hospital Revenue Code	302
Min. Negotiated Rate	$108.90
Max. Negotiated Rate	$158.40
Rate for Payer: Cash Price	$89.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$158.40
Rate for Payer: Health Smart Auto/Commercial	$118.80
Rate for Payer: LLUH Dept of Risk Management WC	$108.90
Rate for Payer: Multiplan Commercial	$148.50

HC MRI BRAIN WO CONTRAST

Facility

$5,126.00

Service Code	CPT 70551
Hospital Charge Code	908801010
Hospital Revenue Code	611
Min. Negotiated Rate	$2,819.30
Max. Negotiated Rate	$4,100.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,075.60
Rate for Payer: Aetna of CA Government/Medicare	$3,075.60
Rate for Payer: Cash Price	$2,306.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,100.80
Rate for Payer: Health Smart Auto/Commercial	$3,075.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3,075.60
Rate for Payer: LLUH Dept of Risk Management WC	$2,819.30
Rate for Payer: Multiplan Commercial	$3,844.50

HC MRI BRAIN WO CONTRAST

Facility

$11,051.00

Service Code	CPT 70551
Hospital Charge Code	908801010
Hospital Revenue Code	611
Min. Negotiated Rate	$6,078.05
Max. Negotiated Rate	$8,840.80
Rate for Payer: Cash Price	$4,972.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8,840.80
Rate for Payer: Health Smart Auto/Commercial	$6,630.60
Rate for Payer: LLUH Dept of Risk Management WC	$6,078.05
Rate for Payer: Multiplan Commercial	$8,288.25

HC MRI BRAIN W WO CONTRAST

Facility

$6,338.00

Service Code	CPT 70553
Hospital Charge Code	908801014
Hospital Revenue Code	611
Min. Negotiated Rate	$3,485.90
Max. Negotiated Rate	$5,070.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,802.80
Rate for Payer: Aetna of CA Government/Medicare	$3,802.80
Rate for Payer: Cash Price	$2,852.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5,070.40
Rate for Payer: Health Smart Auto/Commercial	$3,802.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3,802.80
Rate for Payer: LLUH Dept of Risk Management WC	$3,485.90
Rate for Payer: Multiplan Commercial	$4,753.50

HC MRI BRAIN W WO CONTRAST

Facility

$13,075.00

Service Code	CPT 70553
Hospital Charge Code	908801014
Hospital Revenue Code	611
Min. Negotiated Rate	$7,191.25
Max. Negotiated Rate	$10,460.00
Rate for Payer: Cash Price	$5,883.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10,460.00
Rate for Payer: Health Smart Auto/Commercial	$7,845.00
Rate for Payer: LLUH Dept of Risk Management WC	$7,191.25
Rate for Payer: Multiplan Commercial	$9,806.25

HC MRI LOWER EXTREM JOINT WO CONT

Facility

$8,287.00

Service Code	CPT 73721
Hospital Charge Code	908801441
Hospital Revenue Code	610
Min. Negotiated Rate	$4,557.85
Max. Negotiated Rate	$6,629.60
Rate for Payer: Cash Price	$3,729.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6,629.60
Rate for Payer: Health Smart Auto/Commercial	$4,972.20
Rate for Payer: LLUH Dept of Risk Management WC	$4,557.85
Rate for Payer: Multiplan Commercial	$6,215.25

Know your out-of-pocket cost for care.

All Charges