Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC URINE CHEMISTRY SCREEN

Facility

$87.00

Service Code	CPT 81003
Hospital Charge Code	900910180
Hospital Revenue Code	307
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$69.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.20
Rate for Payer: Aetna of CA Government/Medicare	$52.20
Rate for Payer: Cash Price	$39.15
Rate for Payer: Cash Price	$39.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.60
Rate for Payer: Health Smart Auto/Commercial	$52.20
Rate for Payer: Intervalley Health Plan Commercial	$2.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.20
Rate for Payer: LLUH Dept of Risk Management WC	$47.85
Rate for Payer: Multiplan Commercial	$65.25

HC URINE CHEM SCREEN POC

Facility

$87.00

Service Code	CPT 81003
Hospital Charge Code	900912015
Hospital Revenue Code	306
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$69.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$52.20
Rate for Payer: Aetna of CA Government/Medicare	$52.20
Rate for Payer: Cash Price	$39.15
Rate for Payer: Cash Price	$39.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.60
Rate for Payer: Health Smart Auto/Commercial	$52.20
Rate for Payer: Intervalley Health Plan Commercial	$2.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$52.20
Rate for Payer: LLUH Dept of Risk Management WC	$47.85
Rate for Payer: Multiplan Commercial	$65.25

HC URINE CHEM SCREEN POC

Facility

$87.00

Service Code	CPT 81003
Hospital Charge Code	900912015
Hospital Revenue Code	306
Min. Negotiated Rate	$47.85
Max. Negotiated Rate	$69.60
Rate for Payer: Cash Price	$39.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.60
Rate for Payer: Health Smart Auto/Commercial	$52.20
Rate for Payer: LLUH Dept of Risk Management WC	$47.85
Rate for Payer: Multiplan Commercial	$65.25

HC VALPROIC ACID (DEPAKENE)

Facility

$116.00

Service Code	CPT 80164
Hospital Charge Code	900910927
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$92.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$69.60
Rate for Payer: Aetna of CA Government/Medicare	$69.60
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cash Price	$52.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$92.80
Rate for Payer: Health Smart Auto/Commercial	$69.60
Rate for Payer: Intervalley Health Plan Commercial	$13.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$69.60
Rate for Payer: LLUH Dept of Risk Management WC	$63.80
Rate for Payer: Multiplan Commercial	$87.00

HC VALPROIC ACID (DEPAKENE)

Facility

$218.00

Service Code	CPT 80164
Hospital Charge Code	900910927
Hospital Revenue Code	301
Min. Negotiated Rate	$119.90
Max. Negotiated Rate	$174.40
Rate for Payer: Cash Price	$98.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$174.40
Rate for Payer: Health Smart Auto/Commercial	$130.80
Rate for Payer: LLUH Dept of Risk Management WC	$119.90
Rate for Payer: Multiplan Commercial	$163.50

HC VANCOMYCIN

Facility

$51.00

Service Code	CPT 80202
Hospital Charge Code	900910934
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$40.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$30.60
Rate for Payer: Aetna of CA Government/Medicare	$30.60
Rate for Payer: Cash Price	$22.95
Rate for Payer: Cash Price	$22.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$40.80
Rate for Payer: Health Smart Auto/Commercial	$30.60
Rate for Payer: Intervalley Health Plan Commercial	$13.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$30.60
Rate for Payer: LLUH Dept of Risk Management WC	$28.05
Rate for Payer: Multiplan Commercial	$38.25

HC VANCOMYCIN

Facility

$245.00

Service Code	CPT 80202
Hospital Charge Code	900910934
Hospital Revenue Code	301
Min. Negotiated Rate	$134.75
Max. Negotiated Rate	$196.00
Rate for Payer: Cash Price	$110.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$196.00
Rate for Payer: Health Smart Auto/Commercial	$147.00
Rate for Payer: LLUH Dept of Risk Management WC	$134.75
Rate for Payer: Multiplan Commercial	$183.75

HC VANILMANDELIC ACID

Facility

$40.00

Service Code	CPT 84585
Hospital Charge Code	900910531
Hospital Revenue Code	301
Min. Negotiated Rate	$22.00
Max. Negotiated Rate	$32.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Commercial	$30.00

HC VANILMANDELIC ACID

Facility

$36.00

Service Code	CPT 84585
Hospital Charge Code	900910531
Hospital Revenue Code	301
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$28.80
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: Cash Price	$16.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$28.80
Rate for Payer: Health Smart Auto/Commercial	$21.60
Rate for Payer: Intervalley Health Plan Commercial	$15.50
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 Commercial	$27.00

HC VARICELLA ZOSTER ANTIBODY

Facility

$144.73

Service Code	CPT 86787
Hospital Charge Code	900913671
Hospital Revenue Code	302
Min. Negotiated Rate	$79.60
Max. Negotiated Rate	$115.78
Rate for Payer: Cash Price	$65.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$115.78
Rate for Payer: Health Smart Auto/Commercial	$86.84
Rate for Payer: LLUH Dept of Risk Management WC	$79.60
Rate for Payer: Multiplan Commercial	$108.55

HC VARICELLA ZOSTER ANTIBODY

Facility

$131.58

Service Code	CPT 86787
Hospital Charge Code	900913671
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$105.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$78.95
Rate for Payer: Aetna of CA Government/Medicare	$78.95
Rate for Payer: Cash Price	$59.21
Rate for Payer: Cash Price	$59.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$105.26
Rate for Payer: Health Smart Auto/Commercial	$78.95
Rate for Payer: Intervalley Health Plan Commercial	$12.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$78.95
Rate for Payer: LLUH Dept of Risk Management WC	$72.37
Rate for Payer: Multiplan Commercial	$98.69

HC VITAMIN B12

Facility

$270.00

Service Code	CPT 82607
Hospital Charge Code	900910830
Hospital Revenue Code	301
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$216.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$216.00
Rate for Payer: Health Smart Auto/Commercial	$162.00
Rate for Payer: LLUH Dept of Risk Management WC	$148.50
Rate for Payer: Multiplan Commercial	$202.50

HC VITAMIN B12

Facility

$140.35

Service Code	CPT 82607
Hospital Charge Code	900910830
Hospital Revenue Code	301
Min. Negotiated Rate	$15.08
Max. Negotiated Rate	$112.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$84.21
Rate for Payer: Aetna of CA Government/Medicare	$84.21
Rate for Payer: Cash Price	$63.16
Rate for Payer: Cash Price	$63.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$112.28
Rate for Payer: Health Smart Auto/Commercial	$84.21
Rate for Payer: Intervalley Health Plan Commercial	$15.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$84.21
Rate for Payer: LLUH Dept of Risk Management WC	$77.19
Rate for Payer: Multiplan Commercial	$105.26

HC VITAMIN D TOTAL

Facility

$302.27

Service Code	CPT 82306
Hospital Charge Code	900912240
Hospital Revenue Code	302
Min. Negotiated Rate	$166.25
Max. Negotiated Rate	$241.82
Rate for Payer: Cash Price	$136.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$241.82
Rate for Payer: Health Smart Auto/Commercial	$181.36
Rate for Payer: LLUH Dept of Risk Management WC	$166.25
Rate for Payer: Multiplan Commercial	$226.70

HC VITAMIN D TOTAL

Facility

$272.05

Service Code	CPT 82306
Hospital Charge Code	900912240
Hospital Revenue Code	302
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$217.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$163.23
Rate for Payer: Aetna of CA Government/Medicare	$163.23
Rate for Payer: Cash Price	$122.42
Rate for Payer: Cash Price	$122.42
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$217.64
Rate for Payer: Health Smart Auto/Commercial	$163.23
Rate for Payer: Intervalley Health Plan Commercial	$29.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$163.23
Rate for Payer: LLUH Dept of Risk Management WC	$149.63
Rate for Payer: Multiplan Commercial	$204.04

HC VOIDING CYSTO URETHROGRAM

Facility

$1,155.00

Service Code	CPT 74455
Hospital Charge Code	909001902
Hospital Revenue Code	320
Min. Negotiated Rate	$635.25
Max. Negotiated Rate	$924.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$693.00
Rate for Payer: Aetna of CA Government/Medicare	$693.00
Rate for Payer: Cash Price	$519.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$924.00
Rate for Payer: Health Smart Auto/Commercial	$693.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$693.00
Rate for Payer: LLUH Dept of Risk Management WC	$635.25
Rate for Payer: Multiplan Commercial	$866.25

HC VOIDING CYSTO URETHROGRAM

Facility

$1,155.00

Service Code	CPT 74455
Hospital Charge Code	909001902
Hospital Revenue Code	320
Min. Negotiated Rate	$635.25
Max. Negotiated Rate	$924.00
Rate for Payer: Cash Price	$519.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$924.00
Rate for Payer: Health Smart Auto/Commercial	$693.00
Rate for Payer: LLUH Dept of Risk Management WC	$635.25
Rate for Payer: Multiplan Commercial	$866.25

HC VZV AB

Facility

$206.00

Service Code	CPT 86787
Hospital Charge Code	900913532
Hospital Revenue Code	302
Min. Negotiated Rate	$113.30
Max. Negotiated Rate	$164.80
Rate for Payer: Cash Price	$92.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$164.80
Rate for Payer: Health Smart Auto/Commercial	$123.60
Rate for Payer: LLUH Dept of Risk Management WC	$113.30
Rate for Payer: Multiplan Commercial	$154.50

HC VZV AB

Facility

$74.00

Service Code	CPT 86787
Hospital Charge Code	900913532
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$59.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$44.40
Rate for Payer: Aetna of CA Government/Medicare	$44.40
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cash Price	$33.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$59.20
Rate for Payer: Health Smart Auto/Commercial	$44.40
Rate for Payer: Intervalley Health Plan Commercial	$12.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$44.40
Rate for Payer: LLUH Dept of Risk Management WC	$40.70
Rate for Payer: Multiplan Commercial	$55.50

HC WEAK ACIDIC DRUG CONF & ID

Facility

$624.00

Service Code	CPT 80307
Hospital Charge Code	900910512
Hospital Revenue Code	301
Min. Negotiated Rate	$343.20
Max. Negotiated Rate	$499.20
Rate for Payer: Cash Price	$280.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$499.20
Rate for Payer: Health Smart Auto/Commercial	$374.40
Rate for Payer: LLUH Dept of Risk Management WC	$343.20
Rate for Payer: Multiplan Commercial	$468.00

HC WEAK ACIDIC DRUG CONF & ID

Facility

$518.00

Service Code	CPT 80307
Hospital Charge Code	900910512
Hospital Revenue Code	301
Min. Negotiated Rate	$62.14
Max. Negotiated Rate	$414.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$310.80
Rate for Payer: Aetna of CA Government/Medicare	$310.80
Rate for Payer: Cash Price	$233.10
Rate for Payer: Cash Price	$233.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$414.40
Rate for Payer: Health Smart Auto/Commercial	$310.80
Rate for Payer: Intervalley Health Plan Commercial	$62.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$310.80
Rate for Payer: LLUH Dept of Risk Management WC	$284.90
Rate for Payer: Multiplan Commercial	$388.50

HC WRIST COMPLETE MIN 3 VIEWS

Facility

$1,106.00

Service Code	CPT 73110
Hospital Charge Code	909001210
Hospital Revenue Code	320
Min. Negotiated Rate	$608.30
Max. Negotiated Rate	$884.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$663.60
Rate for Payer: Aetna of CA Government/Medicare	$663.60
Rate for Payer: Cash Price	$497.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$884.80
Rate for Payer: Health Smart Auto/Commercial	$663.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$663.60
Rate for Payer: LLUH Dept of Risk Management WC	$608.30
Rate for Payer: Multiplan Commercial	$829.50

HC WRIST COMPLETE MIN 3 VIEWS

Facility

$1,106.00

Service Code	CPT 73110
Hospital Charge Code	909001210
Hospital Revenue Code	320
Min. Negotiated Rate	$608.30
Max. Negotiated Rate	$884.80
Rate for Payer: Cash Price	$497.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$884.80
Rate for Payer: Health Smart Auto/Commercial	$663.60
Rate for Payer: LLUH Dept of Risk Management WC	$608.30
Rate for Payer: Multiplan Commercial	$829.50

HC WRIST LIMITED

Facility

$919.00

Service Code	CPT 73100
Hospital Charge Code	909001514
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 WRIST LIMITED

Facility

$919.00

Service Code	CPT 73100
Hospital Charge Code	909001514
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

Know your out-of-pocket cost for care.

All Charges