Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC OT TASK GROUP

Facility

$325.00

Service Code	CPT 90853
Hospital Charge Code	907804025
Hospital Revenue Code	431
Min. Negotiated Rate	$41.00
Max. Negotiated Rate	$243.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.76
Rate for Payer: Aetna of CA Government/Medicare	$55.76
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: Mary Free Bed Workers' Compensation	$41.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$243.75

HC OT TASK GROUP

Facility

$325.00

Service Code	CPT 90853
Hospital Charge Code	907804025
Hospital Revenue Code	431
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 OT TASK GROUP

Facility

$325.00

Service Code	CPT 90853
Hospital Charge Code	907804025
Hospital Revenue Code	912
Min. Negotiated Rate	$41.00
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	$55.76
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	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
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: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$463.00
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	$178.75
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	$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	$498.68

HC OT TASK GROUP

Facility

$325.00

Service Code	CPT G0177
Hospital Charge Code	907804025
Hospital Revenue Code	942
Min. Negotiated Rate	$178.75
Max. Negotiated Rate	$243.75
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: 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 OT TASK GROUP

Facility

$325.00

Service Code	CPT G0177
Hospital Charge Code	907804025
Hospital Revenue Code	942
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 OVA & PARASITES, PRESERVED

Facility

$204.00

Service Code	CPT 87177
Hospital Charge Code	900911726
Hospital Revenue Code	306
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$163.20
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna of CA HMO/PPO	$163.20
Rate for Payer: Health Smart Auto/Commercial	$122.40
Rate for Payer: LLUH Dept of Risk Management WC	$112.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$153.00

HC OVA & PARASITES, PRESERVED

Facility

$54.00

Service Code	CPT 87177
Hospital Charge Code	900911726
Hospital Revenue Code	306
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$40.50
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: Health Smart Auto/Commercial	$32.40
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 Beech St/Commercial/PHCS	$40.50

HC PARASITE SCREEN

Facility

$46.00

Service Code	CPT 87272
Hospital Charge Code	900911729
Hospital Revenue Code	306
Min. Negotiated Rate	$25.30
Max. Negotiated Rate	$34.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.60
Rate for Payer: Aetna of CA Government/Medicare	$27.60
Rate for Payer: Cash Price	$20.70
Rate for Payer: Health Smart Auto/Commercial	$27.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.60
Rate for Payer: LLUH Dept of Risk Management WC	$25.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$34.50

HC PARASITE SCREEN

Facility

$320.00

Service Code	CPT 87272
Hospital Charge Code	900911729
Hospital Revenue Code	306
Min. Negotiated Rate	$176.00
Max. Negotiated Rate	$256.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cigna of CA HMO/PPO	$256.00
Rate for Payer: Health Smart Auto/Commercial	$192.00
Rate for Payer: LLUH Dept of Risk Management WC	$176.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$240.00

HC PELVIS 1 OR 2 VIEWS

Facility

$827.00

Service Code	CPT 72170
Hospital Charge Code	909001339
Hospital Revenue Code	320
Min. Negotiated Rate	$454.85
Max. Negotiated Rate	$620.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$496.20
Rate for Payer: Aetna of CA Government/Medicare	$496.20
Rate for Payer: Cash Price	$372.15
Rate for Payer: Health Smart Auto/Commercial	$496.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$496.20
Rate for Payer: LLUH Dept of Risk Management WC	$454.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$620.25

HC PELVIS 1 OR 2 VIEWS

Facility

$827.00

Service Code	CPT 72170
Hospital Charge Code	909001339
Hospital Revenue Code	320
Min. Negotiated Rate	$454.85
Max. Negotiated Rate	$661.60
Rate for Payer: Cash Price	$372.15
Rate for Payer: Cigna of CA HMO/PPO	$661.60
Rate for Payer: Health Smart Auto/Commercial	$496.20
Rate for Payer: LLUH Dept of Risk Management WC	$454.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$620.25

HC PELVIS 1 OR 2 VIEWS

Facility

$827.00

Service Code	CPT 72170 TC
Hospital Charge Code	909001339
Hospital Revenue Code	320
Min. Negotiated Rate	$454.85
Max. Negotiated Rate	$661.60
Rate for Payer: Cash Price	$372.15
Rate for Payer: Cigna of CA HMO/PPO	$661.60
Rate for Payer: Health Smart Auto/Commercial	$496.20
Rate for Payer: LLUH Dept of Risk Management WC	$454.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$620.25

HC PELVIS 1 OR 2 VIEWS

Facility

$827.00

Service Code	CPT 72170 TC
Hospital Charge Code	909001339
Hospital Revenue Code	320
Min. Negotiated Rate	$454.85
Max. Negotiated Rate	$620.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$496.20
Rate for Payer: Aetna of CA Government/Medicare	$496.20
Rate for Payer: Cash Price	$372.15
Rate for Payer: Health Smart Auto/Commercial	$496.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$496.20
Rate for Payer: LLUH Dept of Risk Management WC	$454.85
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$620.25

HC PELVIS COMPLETE MIN 3 VIEWS

Facility

$1,325.00

Service Code	CPT 72190 TC
Hospital Charge Code	909001342
Hospital Revenue Code	320
Min. Negotiated Rate	$728.75
Max. Negotiated Rate	$993.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$795.00
Rate for Payer: Aetna of CA Government/Medicare	$795.00
Rate for Payer: Cash Price	$596.25
Rate for Payer: Health Smart Auto/Commercial	$795.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$795.00
Rate for Payer: LLUH Dept of Risk Management WC	$728.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$993.75

HC PELVIS COMPLETE MIN 3 VIEWS

Facility

$1,325.00

Service Code	CPT 72190 TC
Hospital Charge Code	909001342
Hospital Revenue Code	320
Min. Negotiated Rate	$728.75
Max. Negotiated Rate	$1,060.00
Rate for Payer: Cash Price	$596.25
Rate for Payer: Cigna of CA HMO/PPO	$1,060.00
Rate for Payer: Health Smart Auto/Commercial	$795.00
Rate for Payer: LLUH Dept of Risk Management WC	$728.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$993.75

HC PELVIS COMPLETE MIN 3 VIEWS

Facility

$1,325.00

Service Code	CPT 72190
Hospital Charge Code	909001342
Hospital Revenue Code	320
Min. Negotiated Rate	$728.75
Max. Negotiated Rate	$993.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$795.00
Rate for Payer: Aetna of CA Government/Medicare	$795.00
Rate for Payer: Cash Price	$596.25
Rate for Payer: Health Smart Auto/Commercial	$795.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$795.00
Rate for Payer: LLUH Dept of Risk Management WC	$728.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$993.75

HC PELVIS COMPLETE MIN 3 VIEWS

Facility

$1,325.00

Service Code	CPT 72190
Hospital Charge Code	909001342
Hospital Revenue Code	320
Min. Negotiated Rate	$728.75
Max. Negotiated Rate	$1,060.00
Rate for Payer: Cash Price	$596.25
Rate for Payer: Cigna of CA HMO/PPO	$1,060.00
Rate for Payer: Health Smart Auto/Commercial	$795.00
Rate for Payer: LLUH Dept of Risk Management WC	$728.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$993.75

HC PERIOD ACID SCHIFF

Facility

$551.00

Service Code	CPT 88313 90
Hospital Charge Code	900910051
Hospital Revenue Code	310
Min. Negotiated Rate	$303.05
Max. Negotiated Rate	$440.80
Rate for Payer: Cash Price	$247.95
Rate for Payer: Cigna of CA HMO/PPO	$440.80
Rate for Payer: Health Smart Auto/Commercial	$330.60
Rate for Payer: LLUH Dept of Risk Management WC	$303.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$413.25

HC PERIOD ACID SCHIFF

Facility

$551.00

Service Code	CPT 88313
Hospital Charge Code	900910051
Hospital Revenue Code	310
Min. Negotiated Rate	$303.05
Max. Negotiated Rate	$440.80
Rate for Payer: Cash Price	$247.95
Rate for Payer: Cigna of CA HMO/PPO	$440.80
Rate for Payer: Health Smart Auto/Commercial	$330.60
Rate for Payer: LLUH Dept of Risk Management WC	$303.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$413.25

HC PERIOD ACID SCHIFF

Facility

$118.00

Service Code	CPT 88313
Hospital Charge Code	900910051
Hospital Revenue Code	310
Min. Negotiated Rate	$64.90
Max. Negotiated Rate	$88.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$70.80
Rate for Payer: Aetna of CA Government/Medicare	$70.80
Rate for Payer: Cash Price	$53.10
Rate for Payer: Health Smart Auto/Commercial	$70.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$70.80
Rate for Payer: LLUH Dept of Risk Management WC	$64.90
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$88.50

HC PEROXIDASE STAIN

Facility

$1,080.00

Service Code	CPT 88319 TC
Hospital Charge Code	900910037
Hospital Revenue Code	310
Min. Negotiated Rate	$594.00
Max. Negotiated Rate	$864.00
Rate for Payer: Cash Price	$486.00
Rate for Payer: Cigna of CA HMO/PPO	$864.00
Rate for Payer: Health Smart Auto/Commercial	$648.00
Rate for Payer: LLUH Dept of Risk Management WC	$594.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$810.00

HC PEROXIDASE STAIN

Facility

$392.00

Service Code	CPT 88319
Hospital Charge Code	900910037
Hospital Revenue Code	310
Min. Negotiated Rate	$215.60
Max. Negotiated Rate	$294.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$235.20
Rate for Payer: Aetna of CA Government/Medicare	$235.20
Rate for Payer: Cash Price	$176.40
Rate for Payer: Health Smart Auto/Commercial	$235.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$235.20
Rate for Payer: LLUH Dept of Risk Management WC	$215.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$294.00

HC PEROXIDASE STAIN

Facility

$1,080.00

Service Code	CPT 88319
Hospital Charge Code	900910037
Hospital Revenue Code	310
Min. Negotiated Rate	$594.00
Max. Negotiated Rate	$864.00
Rate for Payer: Cash Price	$486.00
Rate for Payer: Cigna of CA HMO/PPO	$864.00
Rate for Payer: Health Smart Auto/Commercial	$648.00
Rate for Payer: LLUH Dept of Risk Management WC	$594.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$810.00

HC PET TUMOR LIMITED

Facility

$9,459.00

Service Code	CPT 78811
Hospital Charge Code	909301480
Hospital Revenue Code	404
Min. Negotiated Rate	$5,202.45
Max. Negotiated Rate	$7,094.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5,675.40
Rate for Payer: Aetna of CA Government/Medicare	$5,675.40
Rate for Payer: Cash Price	$4,256.55
Rate for Payer: Health Smart Auto/Commercial	$5,675.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5,675.40
Rate for Payer: LLUH Dept of Risk Management WC	$5,202.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,094.25

HC PET TUMOR LIMITED

Facility

$9,459.00

Service Code	CPT 78811 TC
Hospital Charge Code	909301480
Hospital Revenue Code	409
Min. Negotiated Rate	$5,202.45
Max. Negotiated Rate	$7,094.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5,675.40
Rate for Payer: Aetna of CA Government/Medicare	$5,675.40
Rate for Payer: Cash Price	$4,256.55
Rate for Payer: Health Smart Auto/Commercial	$5,675.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5,675.40
Rate for Payer: LLUH Dept of Risk Management WC	$5,202.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7,094.25

Know your out-of-pocket cost for care.

All Charges