Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC TESTOSTERONE TOTAL

Facility

$120.00

Service Code	CPT 84403
Hospital Charge Code	900912134
Hospital Revenue Code	301
Min. Negotiated Rate	$25.81
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	$25.81
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 TEST URINE VOLUME

Facility

$102.00

Service Code	CPT 81050
Hospital Charge Code	900910797
Hospital Revenue Code	301
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$81.60
Rate for Payer: Cash Price	$45.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$81.60
Rate for Payer: Health Smart Auto/Commercial	$61.20
Rate for Payer: LLUH Dept of Risk Management WC	$56.10
Rate for Payer: Multiplan Commercial	$76.50

HC TEST URINE VOLUME

Facility

$26.00

Service Code	CPT 81050
Hospital Charge Code	900910797
Hospital Revenue Code	301
Min. Negotiated Rate	$3.64
Max. Negotiated Rate	$20.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.60
Rate for Payer: Aetna of CA Government/Medicare	$15.60
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cash Price	$11.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.80
Rate for Payer: Health Smart Auto/Commercial	$15.60
Rate for Payer: Intervalley Health Plan Commercial	$3.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.60
Rate for Payer: LLUH Dept of Risk Management WC	$14.30
Rate for Payer: Multiplan Commercial	$19.50

HC TETRACYCLINE E TEST

Facility

$105.00

Service Code	CPT 87181
Hospital Charge Code	900912444
Hospital Revenue Code	306
Min. Negotiated Rate	$57.75
Max. Negotiated Rate	$84.00
Rate for Payer: Cash Price	$47.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$84.00
Rate for Payer: Health Smart Auto/Commercial	$63.00
Rate for Payer: LLUH Dept of Risk Management WC	$57.75
Rate for Payer: Multiplan Commercial	$78.75

HC TETRACYCLINE E TEST

Facility

$18.00

Service Code	CPT 87181
Hospital Charge Code	900912444
Hospital Revenue Code	306
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cash Price	$8.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Intervalley Health Plan Commercial	$4.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: Multiplan Commercial	$13.50

HC THEOPHYLLINE

Facility

$120.00

Service Code	CPT 80198
Hospital Charge Code	900910457
Hospital Revenue Code	301
Min. Negotiated Rate	$14.14
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	$14.14
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 THEOPHYLLINE

Facility

$200.00

Service Code	CPT 80198
Hospital Charge Code	900910457
Hospital Revenue Code	301
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$160.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$150.00

HC THIOCYANATE SERUM

Facility

$509.00

Service Code	CPT 84430
Hospital Charge Code	900910463
Hospital Revenue Code	301
Min. Negotiated Rate	$279.95
Max. Negotiated Rate	$407.20
Rate for Payer: Cash Price	$229.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$407.20
Rate for Payer: Health Smart Auto/Commercial	$305.40
Rate for Payer: LLUH Dept of Risk Management WC	$279.95
Rate for Payer: Multiplan Commercial	$381.75

HC THIOCYANATE SERUM

Facility

$50.00

Service Code	CPT 84430
Hospital Charge Code	900910463
Hospital Revenue Code	301
Min. Negotiated Rate	$11.63
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.00
Rate for Payer: Aetna of CA Government/Medicare	$30.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.00
Rate for Payer: Health Smart Auto/Commercial	$30.00
Rate for Payer: Intervalley Health Plan Commercial	$11.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.00
Rate for Payer: LLUH Dept of Risk Management WC	$27.50
Rate for Payer: Multiplan Commercial	$37.50

HC THORACIC SPINE 2VIEWS

Facility

$1,133.00

Service Code	CPT 72070
Hospital Charge Code	909001311
Hospital Revenue Code	320
Min. Negotiated Rate	$623.15
Max. Negotiated Rate	$906.40
Rate for Payer: Cash Price	$509.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$906.40
Rate for Payer: Health Smart Auto/Commercial	$679.80
Rate for Payer: LLUH Dept of Risk Management WC	$623.15
Rate for Payer: Multiplan Commercial	$849.75

HC THORACIC SPINE 2VIEWS

Facility

$1,133.00

Service Code	CPT 72070
Hospital Charge Code	909001311
Hospital Revenue Code	320
Min. Negotiated Rate	$623.15
Max. Negotiated Rate	$906.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$679.80
Rate for Payer: Aetna of CA Government/Medicare	$679.80
Rate for Payer: Cash Price	$509.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$906.40
Rate for Payer: Health Smart Auto/Commercial	$679.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$679.80
Rate for Payer: LLUH Dept of Risk Management WC	$623.15
Rate for Payer: Multiplan Commercial	$849.75

HC THORACIC SPINE 3VIEWS

Facility

$1,241.00

Service Code	CPT 72072
Hospital Charge Code	909001310
Hospital Revenue Code	320
Min. Negotiated Rate	$682.55
Max. Negotiated Rate	$992.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$744.60
Rate for Payer: Aetna of CA Government/Medicare	$744.60
Rate for Payer: Cash Price	$558.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$992.80
Rate for Payer: Health Smart Auto/Commercial	$744.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$744.60
Rate for Payer: LLUH Dept of Risk Management WC	$682.55
Rate for Payer: Multiplan Commercial	$930.75

HC THORACIC SPINE 3VIEWS

Facility

$1,241.00

Service Code	CPT 72072
Hospital Charge Code	909001310
Hospital Revenue Code	320
Min. Negotiated Rate	$682.55
Max. Negotiated Rate	$992.80
Rate for Payer: Cash Price	$558.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$992.80
Rate for Payer: Health Smart Auto/Commercial	$744.60
Rate for Payer: LLUH Dept of Risk Management WC	$682.55
Rate for Payer: Multiplan Commercial	$930.75

HC THROMBIN TIME

Facility

$32.00

Service Code	CPT 85670
Hospital Charge Code	900910021
Hospital Revenue Code	305
Min. Negotiated Rate	$5.77
Max. Negotiated Rate	$25.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.20
Rate for Payer: Aetna of CA Government/Medicare	$19.20
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cash Price	$14.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$25.60
Rate for Payer: Health Smart Auto/Commercial	$19.20
Rate for Payer: Intervalley Health Plan Commercial	$5.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.20
Rate for Payer: LLUH Dept of Risk Management WC	$17.60
Rate for Payer: Multiplan Commercial	$24.00

HC THROMBIN TIME

Facility

$173.00

Service Code	CPT 85670
Hospital Charge Code	900910021
Hospital Revenue Code	305
Min. Negotiated Rate	$95.15
Max. Negotiated Rate	$138.40
Rate for Payer: Cash Price	$77.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$138.40
Rate for Payer: Health Smart Auto/Commercial	$103.80
Rate for Payer: LLUH Dept of Risk Management WC	$95.15
Rate for Payer: Multiplan Commercial	$129.75

HC THROMBOELASTOGRAPH

Facility

$70.00

Service Code	CPT 85396
Hospital Charge Code	900912024
Hospital Revenue Code	305
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$42.00
Rate for Payer: Aetna of CA Government/Medicare	$42.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.00
Rate for Payer: Health Smart Auto/Commercial	$42.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$42.00
Rate for Payer: LLUH Dept of Risk Management WC	$38.50
Rate for Payer: Multiplan Commercial	$52.50

HC THROMBOELASTOGRAPH

Facility

$533.00

Service Code	CPT 85396
Hospital Charge Code	900912024
Hospital Revenue Code	305
Min. Negotiated Rate	$293.15
Max. Negotiated Rate	$426.40
Rate for Payer: Cash Price	$239.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$426.40
Rate for Payer: Health Smart Auto/Commercial	$319.80
Rate for Payer: LLUH Dept of Risk Management WC	$293.15
Rate for Payer: Multiplan Commercial	$399.75

HC THYROID HORMONE T3

Facility

$120.00

Service Code	CPT 84480
Hospital Charge Code	900910827
Hospital Revenue Code	301
Min. Negotiated Rate	$14.18
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	$14.18
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 THYROID HORMONE T3

Facility

$288.00

Service Code	CPT 84480
Hospital Charge Code	900910827
Hospital Revenue Code	301
Min. Negotiated Rate	$158.40
Max. Negotiated Rate	$230.40
Rate for Payer: Cash Price	$129.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$230.40
Rate for Payer: Health Smart Auto/Commercial	$172.80
Rate for Payer: LLUH Dept of Risk Management WC	$158.40
Rate for Payer: Multiplan Commercial	$216.00

HC THYROXIN T4

Facility

$60.00

Service Code	CPT 84436
Hospital Charge Code	900910835
Hospital Revenue Code	301
Min. Negotiated Rate	$6.87
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$36.00
Rate for Payer: Aetna of CA Government/Medicare	$36.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$48.00
Rate for Payer: Health Smart Auto/Commercial	$36.00
Rate for Payer: Intervalley Health Plan Commercial	$6.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$36.00
Rate for Payer: LLUH Dept of Risk Management WC	$33.00
Rate for Payer: Multiplan Commercial	$45.00

HC THYROXIN T4

Facility

$153.00

Service Code	CPT 84436
Hospital Charge Code	900910835
Hospital Revenue Code	301
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$122.40
Rate for Payer: Cash Price	$68.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$122.40
Rate for Payer: Health Smart Auto/Commercial	$91.80
Rate for Payer: LLUH Dept of Risk Management WC	$84.15
Rate for Payer: Multiplan Commercial	$114.75

HC TIBIA FIBULA

Facility

$1,013.00

Service Code	CPT 73590
Hospital Charge Code	909001638
Hospital Revenue Code	320
Min. Negotiated Rate	$557.15
Max. Negotiated Rate	$810.40
Rate for Payer: Cash Price	$455.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$810.40
Rate for Payer: Health Smart Auto/Commercial	$607.80
Rate for Payer: LLUH Dept of Risk Management WC	$557.15
Rate for Payer: Multiplan Commercial	$759.75

HC TIBIA FIBULA

Facility

$1,013.00

Service Code	CPT 73590
Hospital Charge Code	909001638
Hospital Revenue Code	320
Min. Negotiated Rate	$557.15
Max. Negotiated Rate	$810.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$607.80
Rate for Payer: Aetna of CA Government/Medicare	$607.80
Rate for Payer: Cash Price	$455.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$810.40
Rate for Payer: Health Smart Auto/Commercial	$607.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$607.80
Rate for Payer: LLUH Dept of Risk Management WC	$557.15
Rate for Payer: Multiplan Commercial	$759.75

HC TISS CUL NEO BONE MARROW BLD

Facility

$746.00

Service Code	CPT 88237
Hospital Charge Code	900918003
Hospital Revenue Code	310
Min. Negotiated Rate	$410.30
Max. Negotiated Rate	$596.80
Rate for Payer: Cash Price	$335.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$596.80
Rate for Payer: Health Smart Auto/Commercial	$447.60
Rate for Payer: LLUH Dept of Risk Management WC	$410.30
Rate for Payer: Multiplan Commercial	$559.50

HC TISS CUL NEO BONE MARROW BLD

Facility

$648.00

Service Code	CPT 88237
Hospital Charge Code	900918003
Hospital Revenue Code	310
Min. Negotiated Rate	$143.75
Max. Negotiated Rate	$518.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$388.80
Rate for Payer: Aetna of CA Government/Medicare	$388.80
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cash Price	$291.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$518.40
Rate for Payer: Health Smart Auto/Commercial	$388.80
Rate for Payer: Intervalley Health Plan Commercial	$143.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$388.80
Rate for Payer: LLUH Dept of Risk Management WC	$356.40
Rate for Payer: Multiplan Commercial	$486.00

Know your out-of-pocket cost for care.

All Charges