Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC PARASITE SCREEN

Facility

$313.00

Service Code	CPT 87272
Hospital Charge Code	900911729
Hospital Revenue Code	306
Min. Negotiated Rate	$172.15
Max. Negotiated Rate	$250.40
Rate for Payer: Cash Price	$140.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$250.40
Rate for Payer: Health Smart Auto/Commercial	$187.80
Rate for Payer: LLUH Dept of Risk Management WC	$172.15
Rate for Payer: Multiplan Commercial	$234.75

HC PELVIS 1 OR 2 VIEWS

Facility

$919.00

Service Code	CPT 72170
Hospital Charge Code	909001339
Hospital Revenue Code	320
Min. Negotiated Rate	$505.45
Max. Negotiated Rate	$735.20
Rate for Payer: Cash Price	$413.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$735.20
Rate for Payer: Health Smart Auto/Commercial	$551.40
Rate for Payer: LLUH Dept of Risk Management WC	$505.45
Rate for Payer: Multiplan Commercial	$689.25

HC PELVIS 1 OR 2 VIEWS

Facility

$919.00

Service Code	CPT 72170
Hospital Charge Code	909001339
Hospital Revenue Code	320
Min. Negotiated Rate	$505.45
Max. Negotiated Rate	$735.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$551.40
Rate for Payer: Aetna of CA Government/Medicare	$551.40
Rate for Payer: Cash Price	$413.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$735.20
Rate for Payer: Health Smart Auto/Commercial	$551.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$551.40
Rate for Payer: LLUH Dept of Risk Management WC	$505.45
Rate for Payer: Multiplan Commercial	$689.25

HC PELVIS COMPLETE MIN 3 VIEWS

Facility

$1,471.00

Service Code	CPT 72190
Hospital Charge Code	909001342
Hospital Revenue Code	320
Min. Negotiated Rate	$809.05
Max. Negotiated Rate	$1,176.80
Rate for Payer: Cash Price	$661.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,176.80
Rate for Payer: Health Smart Auto/Commercial	$882.60
Rate for Payer: LLUH Dept of Risk Management WC	$809.05
Rate for Payer: Multiplan Commercial	$1,103.25

HC PELVIS COMPLETE MIN 3 VIEWS

Facility

$1,471.00

Service Code	CPT 72190
Hospital Charge Code	909001342
Hospital Revenue Code	320
Min. Negotiated Rate	$809.05
Max. Negotiated Rate	$1,176.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$882.60
Rate for Payer: Aetna of CA Government/Medicare	$882.60
Rate for Payer: Cash Price	$661.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,176.80
Rate for Payer: Health Smart Auto/Commercial	$882.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$882.60
Rate for Payer: LLUH Dept of Risk Management WC	$809.05
Rate for Payer: Multiplan Commercial	$1,103.25

HC PERIOD ACID SCHIFF

Facility

$136.00

Service Code	CPT 88313
Hospital Charge Code	900910051
Hospital Revenue Code	310
Min. Negotiated Rate	$74.80
Max. Negotiated Rate	$108.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$81.60
Rate for Payer: Aetna of CA Government/Medicare	$81.60
Rate for Payer: Cash Price	$61.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$108.80
Rate for Payer: Health Smart Auto/Commercial	$81.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$81.60
Rate for Payer: LLUH Dept of Risk Management WC	$74.80
Rate for Payer: Multiplan Commercial	$102.00

HC PERIOD ACID SCHIFF

Facility

$634.00

Service Code	CPT 88313
Hospital Charge Code	900910051
Hospital Revenue Code	310
Min. Negotiated Rate	$348.70
Max. Negotiated Rate	$507.20
Rate for Payer: Cash Price	$285.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$507.20
Rate for Payer: Health Smart Auto/Commercial	$380.40
Rate for Payer: LLUH Dept of Risk Management WC	$348.70
Rate for Payer: Multiplan Commercial	$475.50

HC PEROXIDASE STAIN

Facility

$383.00

Service Code	CPT 88319
Hospital Charge Code	900910037
Hospital Revenue Code	310
Min. Negotiated Rate	$210.65
Max. Negotiated Rate	$306.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$229.80
Rate for Payer: Aetna of CA Government/Medicare	$229.80
Rate for Payer: Cash Price	$172.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$306.40
Rate for Payer: Health Smart Auto/Commercial	$229.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$229.80
Rate for Payer: LLUH Dept of Risk Management WC	$210.65
Rate for Payer: Multiplan Commercial	$287.25

HC PEROXIDASE STAIN

Facility

$1,056.00

Service Code	CPT 88319
Hospital Charge Code	900910037
Hospital Revenue Code	310
Min. Negotiated Rate	$580.80
Max. Negotiated Rate	$844.80
Rate for Payer: Cash Price	$475.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$844.80
Rate for Payer: Health Smart Auto/Commercial	$633.60
Rate for Payer: LLUH Dept of Risk Management WC	$580.80
Rate for Payer: Multiplan Commercial	$792.00

HC PET TUMOR LIMITED

Facility

$7,638.00

Service Code	CPT 78811
Hospital Charge Code	909301480
Hospital Revenue Code	404
Min. Negotiated Rate	$4,200.90
Max. Negotiated Rate	$6,110.40
Rate for Payer: Cash Price	$3,437.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6,110.40
Rate for Payer: Health Smart Auto/Commercial	$4,582.80
Rate for Payer: LLUH Dept of Risk Management WC	$4,200.90
Rate for Payer: Multiplan Commercial	$5,728.50

HC PET TUMOR LIMITED

Facility

$7,638.00

Service Code	CPT 78811
Hospital Charge Code	909301480
Hospital Revenue Code	404
Min. Negotiated Rate	$4,200.90
Max. Negotiated Rate	$6,110.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4,582.80
Rate for Payer: Aetna of CA Government/Medicare	$4,582.80
Rate for Payer: Cash Price	$3,437.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6,110.40
Rate for Payer: Health Smart Auto/Commercial	$4,582.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4,582.80
Rate for Payer: LLUH Dept of Risk Management WC	$4,200.90
Rate for Payer: Multiplan Commercial	$5,728.50

HC PHARM-CHLORIDE IV SOLUTION

Facility

$24.00

Hospital Charge Code	900912107
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Commercial	$18.00

HC PHARM-CHLORIDE IV SOLUTION

Facility

$20.00

Hospital Charge Code	900912107
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC PHARM-GLUCOSE IV SOLUTION

Facility

$24.00

Service Code	CPT 81099
Hospital Charge Code	900912109
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Commercial	$18.00

HC PHARM-GLUCOSE IV SOLUTION

Facility

$17.00

Service Code	CPT 81099
Hospital Charge Code	900912109
Hospital Revenue Code	301
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$13.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.20
Rate for Payer: Aetna of CA Government/Medicare	$10.20
Rate for Payer: Cash Price	$7.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$13.60
Rate for Payer: Health Smart Auto/Commercial	$10.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.20
Rate for Payer: LLUH Dept of Risk Management WC	$9.35
Rate for Payer: Multiplan Commercial	$12.75

HC PHARM-PHOSPHORUS IV SOLUTION

Facility

$20.00

Hospital Charge Code	900912108
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC PHARM-PHOSPHORUS IV SOLUTION

Facility

$24.00

Hospital Charge Code	900912108
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Commercial	$18.00

HC PHARM-POTASSIUM IV SOLUTION

Facility

$20.00

Hospital Charge Code	900912106
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC PHARM-POTASSIUM IV SOLUTION

Facility

$24.00

Hospital Charge Code	900912106
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Commercial	$18.00

HC PHARM-SODIUM IV SOLUTION

Facility

$24.00

Hospital Charge Code	900912105
Hospital Revenue Code	301
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$19.20
Rate for Payer: Cash Price	$10.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.20
Rate for Payer: Health Smart Auto/Commercial	$14.40
Rate for Payer: LLUH Dept of Risk Management WC	$13.20
Rate for Payer: Multiplan Commercial	$18.00

HC PHARM-SODIUM IV SOLUTION

Facility

$20.00

Hospital Charge Code	900912105
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.00
Rate for Payer: Aetna of CA Government/Medicare	$12.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.00
Rate for Payer: Health Smart Auto/Commercial	$12.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.00
Rate for Payer: LLUH Dept of Risk Management WC	$11.00
Rate for Payer: Multiplan Commercial	$15.00

HC PH BODY FLUID

Facility

$14.00

Service Code	CPT 83986
Hospital Charge Code	900910261
Hospital Revenue Code	301
Min. Negotiated Rate	$3.58
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	$3.58
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 PH BODY FLUID

Facility

$166.00

Service Code	CPT 83986
Hospital Charge Code	900910261
Hospital Revenue Code	301
Min. Negotiated Rate	$91.30
Max. Negotiated Rate	$132.80
Rate for Payer: Cash Price	$74.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$132.80
Rate for Payer: Health Smart Auto/Commercial	$99.60
Rate for Payer: LLUH Dept of Risk Management WC	$91.30
Rate for Payer: Multiplan Commercial	$124.50

HC PHENCYCLIDINE CONF

Facility

$259.00

Service Code	CPT 83992
Hospital Charge Code	900910517
Hospital Revenue Code	301
Min. Negotiated Rate	$142.45
Max. Negotiated Rate	$207.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$155.40
Rate for Payer: Aetna of CA Government/Medicare	$155.40
Rate for Payer: Cash Price	$116.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$207.20
Rate for Payer: Health Smart Auto/Commercial	$155.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$155.40
Rate for Payer: LLUH Dept of Risk Management WC	$142.45
Rate for Payer: Multiplan Commercial	$194.25

HC PHENCYCLIDINE CONF

Facility

$312.00

Service Code	CPT 83992
Hospital Charge Code	900910517
Hospital Revenue Code	301
Min. Negotiated Rate	$171.60
Max. Negotiated Rate	$249.60
Rate for Payer: Cash Price	$140.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$249.60
Rate for Payer: Health Smart Auto/Commercial	$187.20
Rate for Payer: LLUH Dept of Risk Management WC	$171.60
Rate for Payer: Multiplan Commercial	$234.00

Know your out-of-pocket cost for care.

All Charges