Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

NELFINAVIR 250 MG TABLET [20032]

Facility

$4.86

Service Code	NDC 63010-010-30
Hospital Charge Code	1712238
Hospital Revenue Code	259
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.92
Rate for Payer: Aetna of CA Government/Medicare	$2.92
Rate for Payer: Cash Price	$2.19
Rate for Payer: Health Smart Auto/Commercial	$2.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.92
Rate for Payer: LLUH Dept of Risk Management WC	$2.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.64

NEOMY-BACIT-POLYMYX-PRAMOXINE 3.5 MG-500 UNIT-10,000 UNIT/G TOP OINT [21070]

Facility

$0.15

Service Code	NDC 0713-0622-31
Hospital Charge Code	NDG21070C
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

NEOMY-BACIT-POLYMYX-PRAMOXINE 3.5 MG-500 UNIT-10,000 UNIT/G TOP OINT [21070]

Facility

$0.15

Service Code	NDC 0713-0622-31
Hospital Charge Code	NDG21070C
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS [5474]

Facility

$6.13

Service Code	NDC 24208-790-62
Hospital Charge Code	1740124
Hospital Revenue Code	259
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$4.90
Rate for Payer: Cash Price	$2.76
Rate for Payer: Cigna of CA HMO/PPO	$4.90
Rate for Payer: Health Smart Auto/Commercial	$3.68
Rate for Payer: LLUH Dept of Risk Management WC	$3.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.60

NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS [5474]

Facility

$6.13

Service Code	NDC 24208-790-62
Hospital Charge Code	1740124
Hospital Revenue Code	259
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$4.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.68
Rate for Payer: Aetna of CA Government/Medicare	$3.68
Rate for Payer: Cash Price	$2.76
Rate for Payer: Health Smart Auto/Commercial	$3.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.68
Rate for Payer: LLUH Dept of Risk Management WC	$3.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.60

NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [106249]

Facility

$6.17

Service Code	NDC 61314-631-36
Hospital Charge Code	1740083
Hospital Revenue Code	259
Min. Negotiated Rate	$3.39
Max. Negotiated Rate	$4.63
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.70
Rate for Payer: Aetna of CA Government/Medicare	$3.70
Rate for Payer: Cash Price	$2.78
Rate for Payer: Health Smart Auto/Commercial	$3.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.70
Rate for Payer: LLUH Dept of Risk Management WC	$3.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.63

NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [106249]

Facility

$5.45

Service Code	NDC 24208-795-35
Hospital Charge Code	1740083
Hospital Revenue Code	259
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$4.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.27
Rate for Payer: Aetna of CA Government/Medicare	$3.27
Rate for Payer: Cash Price	$2.45
Rate for Payer: Health Smart Auto/Commercial	$3.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.27
Rate for Payer: LLUH Dept of Risk Management WC	$3.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.09

NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [106249]

Facility

$6.17

Service Code	NDC 61314-631-36
Hospital Charge Code	1740083
Hospital Revenue Code	259
Min. Negotiated Rate	$3.39
Max. Negotiated Rate	$4.94
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cigna of CA HMO/PPO	$4.94
Rate for Payer: Health Smart Auto/Commercial	$3.70
Rate for Payer: LLUH Dept of Risk Management WC	$3.39
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.63

NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT [106249]

Facility

$5.45

Service Code	NDC 24208-795-35
Hospital Charge Code	1740083
Hospital Revenue Code	259
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$4.36
Rate for Payer: Cash Price	$2.45
Rate for Payer: Cigna of CA HMO/PPO	$4.36
Rate for Payer: Health Smart Auto/Commercial	$3.27
Rate for Payer: LLUH Dept of Risk Management WC	$3.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.09

NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP [35126]

Facility

$21.79

Service Code	NDC 61314-641-75
Hospital Charge Code	1740204
Hospital Revenue Code	259
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$16.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.07
Rate for Payer: Aetna of CA Government/Medicare	$13.07
Rate for Payer: Cash Price	$9.81
Rate for Payer: Health Smart Auto/Commercial	$13.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.07
Rate for Payer: LLUH Dept of Risk Management WC	$11.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.34

NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP [35126]

Facility

$21.79

Service Code	NDC 61314-641-75
Hospital Charge Code	1740204
Hospital Revenue Code	259
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$17.43
Rate for Payer: Cash Price	$9.81
Rate for Payer: Cigna of CA HMO/PPO	$17.43
Rate for Payer: Health Smart Auto/Commercial	$13.07
Rate for Payer: LLUH Dept of Risk Management WC	$11.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.34

NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION [70678]

Facility

$12.33

Service Code	NDC 39822-1201-5
Hospital Charge Code	1756001
Hospital Revenue Code	250
Min. Negotiated Rate	$6.78
Max. Negotiated Rate	$9.86
Rate for Payer: Cash Price	$5.55
Rate for Payer: Cigna of CA HMO/PPO	$9.86
Rate for Payer: Health Smart Auto/Commercial	$7.40
Rate for Payer: LLUH Dept of Risk Management WC	$6.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.25

NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION [70678]

Facility

$13.11

Service Code	NDC 39822-1201-1
Hospital Charge Code	1756001
Hospital Revenue Code	250
Min. Negotiated Rate	$7.21
Max. Negotiated Rate	$10.49
Rate for Payer: Cash Price	$5.90
Rate for Payer: Cigna of CA HMO/PPO	$10.49
Rate for Payer: Health Smart Auto/Commercial	$7.87
Rate for Payer: LLUH Dept of Risk Management WC	$7.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.83

NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION [70678]

Facility

$12.33

Service Code	NDC 39822-1201-5
Hospital Charge Code	1756001
Hospital Revenue Code	250
Min. Negotiated Rate	$6.78
Max. Negotiated Rate	$9.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.40
Rate for Payer: Aetna of CA Government/Medicare	$7.40
Rate for Payer: Cash Price	$5.55
Rate for Payer: Health Smart Auto/Commercial	$7.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.40
Rate for Payer: LLUH Dept of Risk Management WC	$6.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.25

NEOMYCIN 40 MG-POLYMYXIN B 200,000 UNIT/ML GU IRRIGATION SOLUTION [70678]

Facility

$13.11

Service Code	NDC 39822-1201-1
Hospital Charge Code	1756001
Hospital Revenue Code	250
Min. Negotiated Rate	$7.21
Max. Negotiated Rate	$9.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.87
Rate for Payer: Aetna of CA Government/Medicare	$7.87
Rate for Payer: Cash Price	$5.90
Rate for Payer: Health Smart Auto/Commercial	$7.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.87
Rate for Payer: LLUH Dept of Risk Management WC	$7.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.83

NEOMYCIN 500 MG TABLET [5472]

Facility

$1.33

Service Code	NDC 0093-1177-01
Hospital Charge Code	1711310
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cigna of CA HMO/PPO	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.00

NEOMYCIN 500 MG TABLET [5472]

Facility

$1.33

Service Code	NDC 0093-1177-01
Hospital Charge Code	1711310
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.80
Rate for Payer: Aetna of CA Government/Medicare	$0.80
Rate for Payer: Cash Price	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.00

NEOMYCIN-BACITRACIN-POLY-HC 3.5 MG-400-10,000 UNIT/G-1 % EYE OINTMENT [849]

Facility

$17.84

Service Code	NDC 24208-785-55
Hospital Charge Code	1740051
Hospital Revenue Code	259
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$13.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.70
Rate for Payer: Aetna of CA Government/Medicare	$10.70
Rate for Payer: Cash Price	$8.03
Rate for Payer: Health Smart Auto/Commercial	$10.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.70
Rate for Payer: LLUH Dept of Risk Management WC	$9.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.38

NEOMYCIN-BACITRACIN-POLY-HC 3.5 MG-400-10,000 UNIT/G-1 % EYE OINTMENT [849]

Facility

$17.84

Service Code	NDC 24208-785-55
Hospital Charge Code	1740051
Hospital Revenue Code	259
Min. Negotiated Rate	$9.81
Max. Negotiated Rate	$14.27
Rate for Payer: Cash Price	$8.03
Rate for Payer: Cigna of CA HMO/PPO	$14.27
Rate for Payer: Health Smart Auto/Commercial	$10.70
Rate for Payer: LLUH Dept of Risk Management WC	$9.81
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$13.38

NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT [38701]

Facility

$15.62

Service Code	NDC 24208-780-55
Hospital Charge Code	1740126
Hospital Revenue Code	259
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$11.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.37
Rate for Payer: Aetna of CA Government/Medicare	$9.37
Rate for Payer: Cash Price	$7.03
Rate for Payer: Health Smart Auto/Commercial	$9.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.37
Rate for Payer: LLUH Dept of Risk Management WC	$8.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.72

NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT [38701]

Facility

$15.62

Service Code	NDC 24208-780-55
Hospital Charge Code	1740126
Hospital Revenue Code	259
Min. Negotiated Rate	$8.59
Max. Negotiated Rate	$12.50
Rate for Payer: Cash Price	$7.03
Rate for Payer: Cigna of CA HMO/PPO	$12.50
Rate for Payer: Health Smart Auto/Commercial	$9.37
Rate for Payer: LLUH Dept of Risk Management WC	$8.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$11.72

NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]

Facility

$0.17

Service Code	NDC 45802-143-01
Hospital Charge Code	1743108
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13

NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]

Facility

$0.12

Service Code	NDC 45802-143-03
Hospital Charge Code	1743560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]

Facility

$0.12

Service Code	NDC 0713-0268-31
Hospital Charge Code	1743560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT [854]

Facility

$0.09

Service Code	NDC 0904-0734-31
Hospital Charge Code	1743560
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

Know your out-of-pocket cost for care.

All Charges