Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC XRAY HIP W/PELVIS BI 3-4 VIEWS

Facility

$1,303.00

Service Code	CPT 73522
Hospital Charge Code	909073522
Hospital Revenue Code	320
Min. Negotiated Rate	$716.65
Max. Negotiated Rate	$1,042.40
Rate for Payer: Cash Price	$586.35
Rate for Payer: Cigna of CA HMO/PPO	$1,042.40
Rate for Payer: Health Smart Auto/Commercial	$781.80
Rate for Payer: LLUH Dept of Risk Management WC	$716.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$977.25

HC XRAY HIP W/PELVIS BI 3-4 VIEWS

Facility

$1,303.00

Service Code	CPT 73522 TC
Hospital Charge Code	909073522
Hospital Revenue Code	320
Min. Negotiated Rate	$716.65
Max. Negotiated Rate	$977.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$781.80
Rate for Payer: Aetna of CA Government/Medicare	$781.80
Rate for Payer: Cash Price	$586.35
Rate for Payer: Health Smart Auto/Commercial	$781.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$781.80
Rate for Payer: LLUH Dept of Risk Management WC	$716.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$977.25

HC XRAY HIP W/PELVIS BI 3-4 VIEWS

Facility

$1,303.00

Service Code	CPT 73522
Hospital Charge Code	909073522
Hospital Revenue Code	320
Min. Negotiated Rate	$716.65
Max. Negotiated Rate	$977.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$781.80
Rate for Payer: Aetna of CA Government/Medicare	$781.80
Rate for Payer: Cash Price	$586.35
Rate for Payer: Health Smart Auto/Commercial	$781.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$781.80
Rate for Payer: LLUH Dept of Risk Management WC	$716.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$977.25

HC XRAY HIP W/PELVIS BI 5/GT VIEWS

Facility

$1,368.00

Service Code	CPT 73523
Hospital Charge Code	909073523
Hospital Revenue Code	320
Min. Negotiated Rate	$752.40
Max. Negotiated Rate	$1,026.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$820.80
Rate for Payer: Aetna of CA Government/Medicare	$820.80
Rate for Payer: Cash Price	$615.60
Rate for Payer: Health Smart Auto/Commercial	$820.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$820.80
Rate for Payer: LLUH Dept of Risk Management WC	$752.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,026.00

HC XRAY HIP W/PELVIS BI 5/GT VIEWS

Facility

$1,368.00

Service Code	CPT 73523 TC
Hospital Charge Code	909073523
Hospital Revenue Code	320
Min. Negotiated Rate	$752.40
Max. Negotiated Rate	$1,094.40
Rate for Payer: Cash Price	$615.60
Rate for Payer: Cigna of CA HMO/PPO	$1,094.40
Rate for Payer: Health Smart Auto/Commercial	$820.80
Rate for Payer: LLUH Dept of Risk Management WC	$752.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,026.00

HC XRAY HIP W/PELVIS BI 5/GT VIEWS

Facility

$1,368.00

Service Code	CPT 73523 TC
Hospital Charge Code	909073523
Hospital Revenue Code	320
Min. Negotiated Rate	$752.40
Max. Negotiated Rate	$1,026.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$820.80
Rate for Payer: Aetna of CA Government/Medicare	$820.80
Rate for Payer: Cash Price	$615.60
Rate for Payer: Health Smart Auto/Commercial	$820.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$820.80
Rate for Payer: LLUH Dept of Risk Management WC	$752.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,026.00

HC XRAY HIP W/PELVIS BI 5/GT VIEWS

Facility

$1,368.00

Service Code	CPT 73523
Hospital Charge Code	909073523
Hospital Revenue Code	320
Min. Negotiated Rate	$752.40
Max. Negotiated Rate	$1,094.40
Rate for Payer: Cash Price	$615.60
Rate for Payer: Cigna of CA HMO/PPO	$1,094.40
Rate for Payer: Health Smart Auto/Commercial	$820.80
Rate for Payer: LLUH Dept of Risk Management WC	$752.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,026.00

HC XRAY HIP W/PELVIS UNI 1 VIEW

Facility

$717.00

Service Code	CPT 73501 TC
Hospital Charge Code	909073501
Hospital Revenue Code	320
Min. Negotiated Rate	$394.35
Max. Negotiated Rate	$537.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$430.20
Rate for Payer: Aetna of CA Government/Medicare	$430.20
Rate for Payer: Cash Price	$322.65
Rate for Payer: Health Smart Auto/Commercial	$430.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$430.20
Rate for Payer: LLUH Dept of Risk Management WC	$394.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$537.75

HC XRAY HIP W/PELVIS UNI 1 VIEW

Facility

$717.00

Service Code	CPT 73501 TC
Hospital Charge Code	909073501
Hospital Revenue Code	320
Min. Negotiated Rate	$394.35
Max. Negotiated Rate	$573.60
Rate for Payer: Cash Price	$322.65
Rate for Payer: Cigna of CA HMO/PPO	$573.60
Rate for Payer: Health Smart Auto/Commercial	$430.20
Rate for Payer: LLUH Dept of Risk Management WC	$394.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$537.75

HC XRAY HIP W/PELVIS UNI 1 VIEW

Facility

$717.00

Service Code	CPT 73501
Hospital Charge Code	909073501
Hospital Revenue Code	320
Min. Negotiated Rate	$394.35
Max. Negotiated Rate	$573.60
Rate for Payer: Cash Price	$322.65
Rate for Payer: Cigna of CA HMO/PPO	$573.60
Rate for Payer: Health Smart Auto/Commercial	$430.20
Rate for Payer: LLUH Dept of Risk Management WC	$394.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$537.75

HC XRAY HIP W/PELVIS UNI 1 VIEW

Facility

$717.00

Service Code	CPT 73501
Hospital Charge Code	909073501
Hospital Revenue Code	320
Min. Negotiated Rate	$394.35
Max. Negotiated Rate	$537.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$430.20
Rate for Payer: Aetna of CA Government/Medicare	$430.20
Rate for Payer: Cash Price	$322.65
Rate for Payer: Health Smart Auto/Commercial	$430.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$430.20
Rate for Payer: LLUH Dept of Risk Management WC	$394.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$537.75

HC XRAY HIP W/PELVIS UNI 2-3 VIEW

Facility

$996.00

Service Code	CPT 73502
Hospital Charge Code	909073502
Hospital Revenue Code	320
Min. Negotiated Rate	$547.80
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$597.60
Rate for Payer: Aetna of CA Government/Medicare	$597.60
Rate for Payer: Cash Price	$448.20
Rate for Payer: Health Smart Auto/Commercial	$597.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$597.60
Rate for Payer: LLUH Dept of Risk Management WC	$547.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$747.00

HC XRAY HIP W/PELVIS UNI 2-3 VIEW

Facility

$996.00

Service Code	CPT 73502 TC
Hospital Charge Code	909073502
Hospital Revenue Code	320
Min. Negotiated Rate	$547.80
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$597.60
Rate for Payer: Aetna of CA Government/Medicare	$597.60
Rate for Payer: Cash Price	$448.20
Rate for Payer: Health Smart Auto/Commercial	$597.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$597.60
Rate for Payer: LLUH Dept of Risk Management WC	$547.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$747.00

HC XRAY HIP W/PELVIS UNI 2-3 VIEW

Facility

$996.00

Service Code	CPT 73502 TC
Hospital Charge Code	909073502
Hospital Revenue Code	320
Min. Negotiated Rate	$547.80
Max. Negotiated Rate	$796.80
Rate for Payer: Cash Price	$448.20
Rate for Payer: Cigna of CA HMO/PPO	$796.80
Rate for Payer: Health Smart Auto/Commercial	$597.60
Rate for Payer: LLUH Dept of Risk Management WC	$547.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$747.00

HC XRAY HIP W/PELVIS UNI 2-3 VIEW

Facility

$996.00

Service Code	CPT 73502
Hospital Charge Code	909073502
Hospital Revenue Code	320
Min. Negotiated Rate	$547.80
Max. Negotiated Rate	$796.80
Rate for Payer: Cash Price	$448.20
Rate for Payer: Cigna of CA HMO/PPO	$796.80
Rate for Payer: Health Smart Auto/Commercial	$597.60
Rate for Payer: LLUH Dept of Risk Management WC	$547.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$747.00

HC XRAY HIP W/PELVIS UNI 4 GT VIEWS

Facility

$1,230.00

Service Code	CPT 73503
Hospital Charge Code	909073503
Hospital Revenue Code	320
Min. Negotiated Rate	$676.50
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$738.00
Rate for Payer: Aetna of CA Government/Medicare	$738.00
Rate for Payer: Cash Price	$553.50
Rate for Payer: Health Smart Auto/Commercial	$738.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$738.00
Rate for Payer: LLUH Dept of Risk Management WC	$676.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$922.50

HC XRAY HIP W/PELVIS UNI 4 GT VIEWS

Facility

$1,230.00

Service Code	CPT 73503 TC
Hospital Charge Code	909073503
Hospital Revenue Code	320
Min. Negotiated Rate	$676.50
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$738.00
Rate for Payer: Aetna of CA Government/Medicare	$738.00
Rate for Payer: Cash Price	$553.50
Rate for Payer: Health Smart Auto/Commercial	$738.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$738.00
Rate for Payer: LLUH Dept of Risk Management WC	$676.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$922.50

HC XRAY HIP W/PELVIS UNI 4 GT VIEWS

Facility

$1,230.00

Service Code	CPT 73503
Hospital Charge Code	909073503
Hospital Revenue Code	320
Min. Negotiated Rate	$676.50
Max. Negotiated Rate	$984.00
Rate for Payer: Cash Price	$553.50
Rate for Payer: Cigna of CA HMO/PPO	$984.00
Rate for Payer: Health Smart Auto/Commercial	$738.00
Rate for Payer: LLUH Dept of Risk Management WC	$676.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$922.50

HC XRAY HIP W/PELVIS UNI 4 GT VIEWS

Facility

$1,230.00

Service Code	CPT 73503 TC
Hospital Charge Code	909073503
Hospital Revenue Code	320
Min. Negotiated Rate	$676.50
Max. Negotiated Rate	$984.00
Rate for Payer: Cash Price	$553.50
Rate for Payer: Cigna of CA HMO/PPO	$984.00
Rate for Payer: Health Smart Auto/Commercial	$738.00
Rate for Payer: LLUH Dept of Risk Management WC	$676.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$922.50

HC XYLOSE TOLERANCE BLD

Facility

$45.00

Service Code	CPT 84620
Hospital Charge Code	900910321
Hospital Revenue Code	301
Min. Negotiated Rate	$24.75
Max. Negotiated Rate	$33.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$27.00
Rate for Payer: Aetna of CA Government/Medicare	$27.00
Rate for Payer: Cash Price	$20.25
Rate for Payer: Health Smart Auto/Commercial	$27.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$27.00
Rate for Payer: LLUH Dept of Risk Management WC	$24.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$33.75

HC XYLOSE TOLERANCE BLD

Facility

$212.00

Service Code	CPT 84620
Hospital Charge Code	900910321
Hospital Revenue Code	301
Min. Negotiated Rate	$116.60
Max. Negotiated Rate	$169.60
Rate for Payer: Health Smart Auto/Commercial	$127.20
Rate for Payer: Cash Price	$95.40
Rate for Payer: Cigna of CA HMO/PPO	$169.60
Rate for Payer: LLUH Dept of Risk Management WC	$116.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$159.00

HEMIN 350 MG INTRAVENOUS POWDER FOR SOLUTION [218818]

Facility

$12,167.51

Service Code	CPT J1640
Hospital Charge Code	ERX218818
Hospital Revenue Code	636
Min. Negotiated Rate	$6,692.13
Max. Negotiated Rate	$9,734.01
Rate for Payer: Cash Price	$5,475.38
Rate for Payer: Cigna of CA HMO/PPO	$9,734.01
Rate for Payer: Health Smart Auto/Commercial	$7,300.51
Rate for Payer: LLUH Dept of Risk Management WC	$6,692.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9,125.63

HEMIN 350 MG INTRAVENOUS POWDER FOR SOLUTION [218818]

Facility

$12,167.51

Service Code	CPT J1640
Hospital Charge Code	ERX218818
Hospital Revenue Code	636
Min. Negotiated Rate	$6,692.13
Max. Negotiated Rate	$9,125.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7,300.51
Rate for Payer: Aetna of CA Government/Medicare	$7,300.51
Rate for Payer: Cash Price	$5,475.38
Rate for Payer: Health Smart Auto/Commercial	$7,300.51
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7,300.51
Rate for Payer: LLUH Dept of Risk Management WC	$6,692.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9,125.63

HEPARIN 1000 UNIT/ML INJECTION SOLUTION. [408117968]

Facility

$3.44

Service Code	CPT J1644
Hospital Charge Code	1720392
Hospital Revenue Code	636
Min. Negotiated Rate	$1.89
Max. Negotiated Rate	$2.75
Rate for Payer: Cash Price	$1.55
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cash Price	$1.30
Rate for Payer: Cigna of CA HMO/PPO	$2.75
Rate for Payer: Cigna of CA HMO/PPO	$2.30
Rate for Payer: Cigna of CA HMO/PPO	$1.78
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Health Smart Auto/Commercial	$2.06
Rate for Payer: Health Smart Auto/Commercial	$1.73
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: LLUH Dept of Risk Management WC	$1.58
Rate for Payer: LLUH Dept of Risk Management WC	$1.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.67

HEPARIN 1000 UNIT/ML INJECTION SOLUTION. [408117968]

Facility

$2.88

Service Code	CPT J1644
Hospital Charge Code	1720392
Hospital Revenue Code	636
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$2.06
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.73
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cash Price	$1.55
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Smart Auto/Commercial	$2.06
Rate for Payer: Health Smart Auto/Commercial	$1.73
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: LLUH Dept of Risk Management WC	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$1.58
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.16
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.58

Know your out-of-pocket cost for care.

All Charges