Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC IOP PROCESS GROUP

Facility

$325.00

Service Code	CPT G0411
Hospital Charge Code	907804062
Hospital Revenue Code	915
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$260.00
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cigna of CA HMO/PPO	$260.00
Rate for Payer: Health Smart Auto/Commercial	$195.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.75

HC IOP WISDOM GROUP

Facility

$325.00

Service Code	CPT G0411
Hospital Charge Code	907804374
Hospital Revenue Code	915
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$260.00
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cigna of CA HMO/PPO	$260.00
Rate for Payer: Health Smart Auto/Commercial	$195.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.75

HC IOP WISDOM GROUP

Facility

$325.00

Service Code	CPT 90853
Hospital Charge Code	907804374
Hospital Revenue Code	905
Min. Negotiated Rate	$41.00
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$475.00
Rate for Payer: Anthem Blue Cross of CA Commercial/Medicare	$295.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Blue Shield of California Commercial	$349.00
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cigna of CA HMO/PPO	$316.00
Rate for Payer: Health Smart Auto/Commercial	$426.00
Rate for Payer: Heritage Provider Network Commercial	$281.00
Rate for Payer: Heritage Provider Network Senior	$281.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$330.00
Rate for Payer: Intervalley Health Plan Commercial	$520.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$293.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Magellan Commercial	$406.00
Rate for Payer: Managed Health Network (MHN) Commercial	$434.00
Rate for Payer: Managed Health Network (MHN) Medicare	$111.37
Rate for Payer: Mary Free Bed Workers' Compensation	$41.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.75
Rate for Payer: US Behavioral Health Commercial/Medicare	$397.33

HC IOP WISDOM GROUP

Facility

$325.00

Service Code	CPT G0411
Hospital Charge Code	907804374
Hospital Revenue Code	915
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$195.00
Rate for Payer: Aetna of CA Government/Medicare	$195.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$400.00
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Health Smart Auto/Commercial	$195.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$195.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.75

HC IOP WISDOM GROUP

Facility

$325.00

Service Code	CPT 90853
Hospital Charge Code	907804374
Hospital Revenue Code	905
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cigna of CA HMO/PPO	$260.00
Rate for Payer: Health Smart Auto/Commercial	$195.00
Rate for Payer: LLUH Dept of Risk Management WC	$178.75
Rate for Payer: Mary Free Bed Workers' Compensation	$469.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.75

HC IRON BINDING CAPACITY

Facility

$34.00

Service Code	CPT 83550
Hospital Charge Code	900910437
Hospital Revenue Code	301
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 IRON BINDING CAPACITY

Facility

$162.00

Service Code	CPT 83550
Hospital Charge Code	900910437
Hospital Revenue Code	301
Min. Negotiated Rate	$89.10
Max. Negotiated Rate	$129.60
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna of CA HMO/PPO	$129.60
Rate for Payer: Health Smart Auto/Commercial	$97.20
Rate for Payer: LLUH Dept of Risk Management WC	$89.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.50

HC IRON TOTAL

Facility

$130.00

Service Code	CPT 83540
Hospital Charge Code	900910243
Hospital Revenue Code	301
Min. Negotiated Rate	$71.50
Max. Negotiated Rate	$104.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna of CA HMO/PPO	$104.00
Rate for Payer: Health Smart Auto/Commercial	$78.00
Rate for Payer: LLUH Dept of Risk Management WC	$71.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$97.50

HC IRON TOTAL

Facility

$20.00

Service Code	CPT 83540
Hospital Charge Code	900910243
Hospital Revenue Code	301
Min. Negotiated Rate	$11.00
Max. Negotiated Rate	$15.00
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: 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 Beech St/Commercial/PHCS	$15.00

HC JO-1 AUTO AB

Facility

$28.00

Service Code	CPT 86235
Hospital Charge Code	900913526
Hospital Revenue Code	302
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.80
Rate for Payer: Aetna of CA Government/Medicare	$16.80
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Smart Auto/Commercial	$16.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.80
Rate for Payer: LLUH Dept of Risk Management WC	$15.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.00

HC JO-1 AUTO AB

Facility

$162.00

Service Code	CPT 86235
Hospital Charge Code	900913526
Hospital Revenue Code	302
Min. Negotiated Rate	$89.10
Max. Negotiated Rate	$129.60
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna of CA HMO/PPO	$129.60
Rate for Payer: Health Smart Auto/Commercial	$97.20
Rate for Payer: LLUH Dept of Risk Management WC	$89.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$121.50

HC KNEE 1-2 VIEWS

Facility

$795.00

Service Code	CPT 73560
Hospital Charge Code	909001621
Hospital Revenue Code	320
Min. Negotiated Rate	$437.25
Max. Negotiated Rate	$636.00
Rate for Payer: Cash Price	$357.75
Rate for Payer: Cigna of CA HMO/PPO	$636.00
Rate for Payer: Health Smart Auto/Commercial	$477.00
Rate for Payer: LLUH Dept of Risk Management WC	$437.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$596.25

HC KNEE 1-2 VIEWS

Facility

$795.00

Service Code	CPT 73560 TC
Hospital Charge Code	909001621
Hospital Revenue Code	320
Min. Negotiated Rate	$437.25
Max. Negotiated Rate	$636.00
Rate for Payer: Cash Price	$357.75
Rate for Payer: Cigna of CA HMO/PPO	$636.00
Rate for Payer: Health Smart Auto/Commercial	$477.00
Rate for Payer: LLUH Dept of Risk Management WC	$437.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$596.25

HC KNEE 1-2 VIEWS

Facility

$795.00

Service Code	CPT 73560 TC
Hospital Charge Code	909001621
Hospital Revenue Code	320
Min. Negotiated Rate	$437.25
Max. Negotiated Rate	$596.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$477.00
Rate for Payer: Aetna of CA Government/Medicare	$477.00
Rate for Payer: Cash Price	$357.75
Rate for Payer: Health Smart Auto/Commercial	$477.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$477.00
Rate for Payer: LLUH Dept of Risk Management WC	$437.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$596.25

HC KNEE 1-2 VIEWS

Facility

$795.00

Service Code	CPT 73560
Hospital Charge Code	909001621
Hospital Revenue Code	320
Min. Negotiated Rate	$437.25
Max. Negotiated Rate	$596.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$477.00
Rate for Payer: Aetna of CA Government/Medicare	$477.00
Rate for Payer: Cash Price	$357.75
Rate for Payer: Health Smart Auto/Commercial	$477.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$477.00
Rate for Payer: LLUH Dept of Risk Management WC	$437.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$596.25

HC KNEE 3 VIEWS

Facility

$913.00

Service Code	CPT 73562
Hospital Charge Code	909001675
Hospital Revenue Code	320
Min. Negotiated Rate	$502.15
Max. Negotiated Rate	$730.40
Rate for Payer: Health Smart Auto/Commercial	$547.80
Rate for Payer: Cash Price	$410.85
Rate for Payer: Cigna of CA HMO/PPO	$730.40
Rate for Payer: LLUH Dept of Risk Management WC	$502.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$684.75

HC KNEE 3 VIEWS

Facility

$913.00

Service Code	CPT 73562
Hospital Charge Code	909001675
Hospital Revenue Code	320
Min. Negotiated Rate	$502.15
Max. Negotiated Rate	$684.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$547.80
Rate for Payer: Aetna of CA Government/Medicare	$547.80
Rate for Payer: Cash Price	$410.85
Rate for Payer: Health Smart Auto/Commercial	$547.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$547.80
Rate for Payer: LLUH Dept of Risk Management WC	$502.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$684.75

HC KNEE 3 VIEWS

Facility

$913.00

Service Code	CPT 73562 TC
Hospital Charge Code	909001675
Hospital Revenue Code	320
Min. Negotiated Rate	$502.15
Max. Negotiated Rate	$730.40
Rate for Payer: Cash Price	$410.85
Rate for Payer: Cigna of CA HMO/PPO	$730.40
Rate for Payer: Health Smart Auto/Commercial	$547.80
Rate for Payer: LLUH Dept of Risk Management WC	$502.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$684.75

HC KNEE 3 VIEWS

Facility

$913.00

Service Code	CPT 73562 TC
Hospital Charge Code	909001675
Hospital Revenue Code	320
Min. Negotiated Rate	$502.15
Max. Negotiated Rate	$684.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$547.80
Rate for Payer: Aetna of CA Government/Medicare	$547.80
Rate for Payer: Cash Price	$410.85
Rate for Payer: Health Smart Auto/Commercial	$547.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$547.80
Rate for Payer: LLUH Dept of Risk Management WC	$502.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$684.75

HC KNEE COMPLETE 4 VIEWS

Facility

$1,120.00

Service Code	CPT 73564
Hospital Charge Code	909001622
Hospital Revenue Code	320
Min. Negotiated Rate	$616.00
Max. Negotiated Rate	$896.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cigna of CA HMO/PPO	$896.00
Rate for Payer: Health Smart Auto/Commercial	$672.00
Rate for Payer: LLUH Dept of Risk Management WC	$616.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$840.00

HC KNEE COMPLETE 4 VIEWS

Facility

$1,120.00

Service Code	CPT 73564 TC
Hospital Charge Code	909001622
Hospital Revenue Code	320
Min. Negotiated Rate	$616.00
Max. Negotiated Rate	$840.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$672.00
Rate for Payer: Aetna of CA Government/Medicare	$672.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Health Smart Auto/Commercial	$672.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$672.00
Rate for Payer: LLUH Dept of Risk Management WC	$616.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$840.00

HC KNEE COMPLETE 4 VIEWS

Facility

$1,120.00

Service Code	CPT 73564
Hospital Charge Code	909001622
Hospital Revenue Code	320
Min. Negotiated Rate	$616.00
Max. Negotiated Rate	$840.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$672.00
Rate for Payer: Aetna of CA Government/Medicare	$672.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Health Smart Auto/Commercial	$672.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$672.00
Rate for Payer: LLUH Dept of Risk Management WC	$616.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$840.00

HC KNEE COMPLETE 4 VIEWS

Facility

$1,120.00

Service Code	CPT 73564 TC
Hospital Charge Code	909001622
Hospital Revenue Code	320
Min. Negotiated Rate	$616.00
Max. Negotiated Rate	$896.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cigna of CA HMO/PPO	$896.00
Rate for Payer: Health Smart Auto/Commercial	$672.00
Rate for Payer: LLUH Dept of Risk Management WC	$616.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$840.00

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	$16.50
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: Health Smart Auto/Commercial	$13.20
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 Beech St/Commercial/PHCS	$16.50

HC LAB REF ACH RECEPTOR MODULATING ABS

Facility

$22.00

Service Code	CPT 83519 90
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: Cigna of CA 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 Beech St/Commercial/PHCS	$16.50

Know your out-of-pocket cost for care.

All Charges