Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC MICRO EXAM/SPERM

Facility

$36.00

Service Code	CPT 89321
Hospital Charge Code	900910155
Hospital Revenue Code	300
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$21.60
Rate for Payer: Aetna of CA Government/Medicare	$21.60
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$21.60
Rate for Payer: LLUH Dept of Risk Management WC	$19.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$27.00

HC MICRO EXAM/SPERM

Facility

$164.00

Service Code	CPT 89321
Hospital Charge Code	900910155
Hospital Revenue Code	300
Min. Negotiated Rate	$90.20
Max. Negotiated Rate	$131.20
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna of CA HMO/PPO	$131.20
Rate for Payer: Health Smart Auto/Commercial	$98.40
Rate for Payer: LLUH Dept of Risk Management WC	$90.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$123.00

HC MICRO EXAM/TRICHOMONAS

Facility

$160.00

Service Code	CPT 87210
Hospital Charge Code	900910156
Hospital Revenue Code	306
Min. Negotiated Rate	$88.00
Max. Negotiated Rate	$128.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna of CA HMO/PPO	$128.00
Rate for Payer: Health Smart Auto/Commercial	$96.00
Rate for Payer: LLUH Dept of Risk Management WC	$88.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$120.00

HC MICRO EXAM/TRICHOMONAS

Facility

$17.00

Service Code	CPT 87210
Hospital Charge Code	900910156
Hospital Revenue Code	306
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$12.75
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: 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 Beech St/Commercial/PHCS	$12.75

HC MICROFIL LARVA

Facility

$200.00

Service Code	CPT 87207
Hospital Charge Code	900911659
Hospital Revenue Code	306
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cigna of CA HMO/PPO	$160.00
Rate for Payer: Health Smart Auto/Commercial	$120.00
Rate for Payer: LLUH Dept of Risk Management WC	$110.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$150.00

HC MICROFIL LARVA

Facility

$22.00

Service Code	CPT 87207
Hospital Charge Code	900911659
Hospital Revenue Code	306
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 MICROGLOBULIN

Facility

$194.00

Service Code	CPT 82232
Hospital Charge Code	900912121
Hospital Revenue Code	301
Min. Negotiated Rate	$106.70
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$87.30
Rate for Payer: Cigna of CA HMO/PPO	$155.20
Rate for Payer: Health Smart Auto/Commercial	$116.40
Rate for Payer: LLUH Dept of Risk Management WC	$106.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$145.50

HC MICROGLOBULIN

Facility

$62.00

Service Code	CPT 82232
Hospital Charge Code	900912121
Hospital Revenue Code	301
Min. Negotiated Rate	$34.10
Max. Negotiated Rate	$46.50
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: Health Smart Auto/Commercial	$37.20
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 Beech St/Commercial/PHCS	$46.50

HC MICROHEMATOCRIT SPUN

Facility

$116.00

Service Code	CPT 85013
Hospital Charge Code	900910790
Hospital Revenue Code	305
Min. Negotiated Rate	$63.80
Max. Negotiated Rate	$92.80
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna of CA HMO/PPO	$92.80
Rate for Payer: Health Smart Auto/Commercial	$69.60
Rate for Payer: LLUH Dept of Risk Management WC	$63.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$87.00

HC MICROHEMATOCRIT SPUN

Facility

$11.00

Service Code	CPT 85013
Hospital Charge Code	900910790
Hospital Revenue Code	305
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$8.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.60
Rate for Payer: Aetna of CA Government/Medicare	$6.60
Rate for Payer: Cash Price	$4.95
Rate for Payer: Health Smart Auto/Commercial	$6.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$6.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.25

HC MONOSPOT (INFECT. MONO TEST)

Facility

$150.00

Service Code	CPT 86308
Hospital Charge Code	900910867
Hospital Revenue Code	302
Min. Negotiated Rate	$82.50
Max. Negotiated Rate	$120.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna of CA HMO/PPO	$120.00
Rate for Payer: Health Smart Auto/Commercial	$90.00
Rate for Payer: LLUH Dept of Risk Management WC	$82.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$112.50

HC MONOSPOT (INFECT. MONO TEST)

Facility

$17.00

Service Code	CPT 86308
Hospital Charge Code	900910867
Hospital Revenue Code	302
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$12.75
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: 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 Beech St/Commercial/PHCS	$12.75

HC MRI BRAIN WO CONTRAST

Facility

$4,236.00

Service Code	CPT 70551
Hospital Charge Code	908801010
Hospital Revenue Code	611
Min. Negotiated Rate	$2,329.80
Max. Negotiated Rate	$3,177.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,541.60
Rate for Payer: Aetna of CA Government/Medicare	$2,541.60
Rate for Payer: Cash Price	$1,906.20
Rate for Payer: Health Smart Auto/Commercial	$2,541.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,541.60
Rate for Payer: LLUH Dept of Risk Management WC	$2,329.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,177.00

HC MRI BRAIN WO CONTRAST

Facility

$9,133.00

Service Code	CPT 70551 TC
Hospital Charge Code	908801010
Hospital Revenue Code	611
Min. Negotiated Rate	$5,023.15
Max. Negotiated Rate	$7,306.40
Rate for Payer: Cash Price	$4,109.85
Rate for Payer: Cigna of CA HMO/PPO	$7,306.40
Rate for Payer: Health Smart Auto/Commercial	$5,479.80
Rate for Payer: LLUH Dept of Risk Management WC	$5,023.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,849.75

HC MRI BRAIN WO CONTRAST

Facility

$9,133.00

Service Code	CPT 70551
Hospital Charge Code	908801010
Hospital Revenue Code	611
Min. Negotiated Rate	$5,023.15
Max. Negotiated Rate	$7,306.40
Rate for Payer: Cash Price	$4,109.85
Rate for Payer: Cigna of CA HMO/PPO	$7,306.40
Rate for Payer: Health Smart Auto/Commercial	$5,479.80
Rate for Payer: LLUH Dept of Risk Management WC	$5,023.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6,849.75

HC MRI BRAIN W WO CONTRAST

Facility

$10,805.00

Service Code	CPT 70553
Hospital Charge Code	908801014
Hospital Revenue Code	611
Min. Negotiated Rate	$5,942.75
Max. Negotiated Rate	$8,644.00
Rate for Payer: Cash Price	$4,862.25
Rate for Payer: Cigna of CA HMO/PPO	$8,644.00
Rate for Payer: Health Smart Auto/Commercial	$6,483.00
Rate for Payer: LLUH Dept of Risk Management WC	$5,942.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8,103.75

HC MRI BRAIN W WO CONTRAST

Facility

$10,805.00

Service Code	CPT 70553 TC
Hospital Charge Code	908801014
Hospital Revenue Code	611
Min. Negotiated Rate	$5,942.75
Max. Negotiated Rate	$8,644.00
Rate for Payer: Cash Price	$4,862.25
Rate for Payer: Cigna of CA HMO/PPO	$8,644.00
Rate for Payer: Health Smart Auto/Commercial	$6,483.00
Rate for Payer: LLUH Dept of Risk Management WC	$5,942.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8,103.75

HC MRI BRAIN W WO CONTRAST

Facility

$5,010.00

Service Code	CPT 70553
Hospital Charge Code	908801014
Hospital Revenue Code	611
Min. Negotiated Rate	$2,755.50
Max. Negotiated Rate	$3,757.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,006.00
Rate for Payer: Aetna of CA Government/Medicare	$3,006.00
Rate for Payer: Cash Price	$2,254.50
Rate for Payer: Health Smart Auto/Commercial	$3,006.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3,006.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,755.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3,757.50

HC MRI LOWER EXTREM JOINT WO CONT

Facility

$6,849.00

Service Code	CPT 73721 TC
Hospital Charge Code	908801441
Hospital Revenue Code	610
Min. Negotiated Rate	$3,766.95
Max. Negotiated Rate	$5,479.20
Rate for Payer: Cash Price	$3,082.05
Rate for Payer: Cigna of CA HMO/PPO	$5,479.20
Rate for Payer: Health Smart Auto/Commercial	$4,109.40
Rate for Payer: LLUH Dept of Risk Management WC	$3,766.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5,136.75

HC MRI LOWER EXTREM JOINT WO CONT

Facility

$6,849.00

Service Code	CPT 73721
Hospital Charge Code	908801441
Hospital Revenue Code	610
Min. Negotiated Rate	$3,766.95
Max. Negotiated Rate	$5,479.20
Rate for Payer: Cash Price	$3,082.05
Rate for Payer: Cigna of CA HMO/PPO	$5,479.20
Rate for Payer: Health Smart Auto/Commercial	$4,109.40
Rate for Payer: LLUH Dept of Risk Management WC	$3,766.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5,136.75

HC MRI LOWER EXTREM JOINT WO CONT

Facility

$3,310.00

Service Code	CPT 73721
Hospital Charge Code	908801441
Hospital Revenue Code	610
Min. Negotiated Rate	$1,820.50
Max. Negotiated Rate	$2,482.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,986.00
Rate for Payer: Aetna of CA Government/Medicare	$1,986.00
Rate for Payer: Cash Price	$1,489.50
Rate for Payer: Health Smart Auto/Commercial	$1,986.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,986.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,820.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,482.50

HC MRSA DNA

Facility

$103.00

Service Code	CPT 87641
Hospital Charge Code	900912328
Hospital Revenue Code	301
Min. Negotiated Rate	$56.65
Max. Negotiated Rate	$77.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$61.80
Rate for Payer: Aetna of CA Government/Medicare	$61.80
Rate for Payer: Cash Price	$46.35
Rate for Payer: Health Smart Auto/Commercial	$61.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$61.80
Rate for Payer: LLUH Dept of Risk Management WC	$56.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$77.25

HC MRSA DNA

Facility

$189.00

Service Code	CPT 87641
Hospital Charge Code	900912328
Hospital Revenue Code	301
Min. Negotiated Rate	$103.95
Max. Negotiated Rate	$151.20
Rate for Payer: Cash Price	$85.05
Rate for Payer: Cigna of CA HMO/PPO	$151.20
Rate for Payer: Health Smart Auto/Commercial	$113.40
Rate for Payer: LLUH Dept of Risk Management WC	$103.95
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$141.75

HC MULTI-PLANAR RECON

Facility

$2,175.00

Service Code	CPT 76376 TC
Hospital Charge Code	909201350
Hospital Revenue Code	359
Min. Negotiated Rate	$1,196.25
Max. Negotiated Rate	$1,631.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,305.00
Rate for Payer: Aetna of CA Government/Medicare	$1,305.00
Rate for Payer: Cash Price	$978.75
Rate for Payer: Health Smart Auto/Commercial	$1,305.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,305.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,196.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,631.25

HC MULTI-PLANAR RECON

Facility

$2,175.00

Service Code	CPT 76376 TC
Hospital Charge Code	909201350
Hospital Revenue Code	359
Min. Negotiated Rate	$1,196.25
Max. Negotiated Rate	$1,740.00
Rate for Payer: Cash Price	$978.75
Rate for Payer: Cigna of CA HMO/PPO	$1,740.00
Rate for Payer: Health Smart Auto/Commercial	$1,305.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,196.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,631.25

Know your out-of-pocket cost for care.

All Charges