Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]

Facility

$10.07

Service Code	NDC 24208-635-62
Hospital Charge Code	1740060
Hospital Revenue Code	259
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$7.55
Rate for Payer: Adventist Health Commercial	$2.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$6.92
Rate for Payer: Cash Price	$4.53
Rate for Payer: EPIC Health Plan Commercial	$5.44
Rate for Payer: Heritage Provider Network Commercial	$6.82
Rate for Payer: Heritage Provider Network Senior	$6.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$2.52
Rate for Payer: Multiplan Commercial	$7.55

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP [28810]

Facility

$10.07

Service Code	NDC 24208-635-62
Hospital Charge Code	1740060
Hospital Revenue Code	259
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$8.56
Rate for Payer: Adventist Health Commercial	$2.01
Rate for Payer: Aetna of CA Gatekeeper	$5.38
Rate for Payer: Aetna of CA Non-Gatekeeper	$6.92
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$8.56
Rate for Payer: Alpha Care Medical Group Medi-Cal	$5.54
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$7.55
Rate for Payer: Blue Shield of California Commercial	$6.25
Rate for Payer: Blue Shield of California EPN	$5.91
Rate for Payer: Cash Price	$4.53
Rate for Payer: Cigna of CA HMO/PPO	$6.55
Rate for Payer: Dignity Health Commercial/Exchange	$8.56
Rate for Payer: Dignity Health Medi-Cal	$8.56
Rate for Payer: Dignity Health Senior	$8.56
Rate for Payer: EPIC Health Plan Commercial	$6.44
Rate for Payer: Heritage Provider Network Commercial	$6.23
Rate for Payer: Heritage Provider Network Senior	$6.23
Rate for Payer: Kaiser Permanente of CA Commercial	$4.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$2.52
Rate for Payer: Multiplan Commercial	$7.55
Rate for Payer: TriValley Medical Group Commercial	$4.03
Rate for Payer: TriValley Medical Group Senior	$4.03
Rate for Payer: Vantage Medical Group Medi-Cal	$8.56
Rate for Payer: Vantage Medical Group Senior	$8.56

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]

Facility

$10.07

Service Code	NDC 24208-631-10
Hospital Charge Code	1740064
Hospital Revenue Code	259
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$8.56
Rate for Payer: Adventist Health Commercial	$2.01
Rate for Payer: Aetna of CA Gatekeeper	$5.38
Rate for Payer: Aetna of CA Non-Gatekeeper	$6.92
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$8.56
Rate for Payer: Alpha Care Medical Group Medi-Cal	$5.54
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$7.55
Rate for Payer: Blue Shield of California Commercial	$6.25
Rate for Payer: Blue Shield of California EPN	$5.91
Rate for Payer: Cash Price	$4.53
Rate for Payer: Cigna of CA HMO/PPO	$6.55
Rate for Payer: Dignity Health Commercial/Exchange	$8.56
Rate for Payer: Dignity Health Medi-Cal	$8.56
Rate for Payer: Dignity Health Senior	$8.56
Rate for Payer: EPIC Health Plan Commercial	$6.44
Rate for Payer: Heritage Provider Network Commercial	$6.23
Rate for Payer: Heritage Provider Network Senior	$6.23
Rate for Payer: Kaiser Permanente of CA Commercial	$4.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$2.52
Rate for Payer: Multiplan Commercial	$7.55
Rate for Payer: TriValley Medical Group Commercial	$4.03
Rate for Payer: TriValley Medical Group Senior	$4.03
Rate for Payer: Vantage Medical Group Medi-Cal	$8.56
Rate for Payer: Vantage Medical Group Senior	$8.56

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]

Facility

$10.07

Service Code	NDC 24208-631-10
Hospital Charge Code	1740064
Hospital Revenue Code	259
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$7.55
Rate for Payer: Adventist Health Commercial	$2.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$6.92
Rate for Payer: Cash Price	$4.53
Rate for Payer: EPIC Health Plan Commercial	$5.44
Rate for Payer: Heritage Provider Network Commercial	$6.82
Rate for Payer: Heritage Provider Network Senior	$6.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$2.52
Rate for Payer: Multiplan Commercial	$7.55

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]

Facility

$10.07

Service Code	NDC 61314-646-10
Hospital Charge Code	1740064
Hospital Revenue Code	259
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$8.56
Rate for Payer: Adventist Health Commercial	$2.01
Rate for Payer: Aetna of CA Gatekeeper	$5.38
Rate for Payer: Aetna of CA Non-Gatekeeper	$6.92
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$8.56
Rate for Payer: Alpha Care Medical Group Medi-Cal	$5.54
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$7.55
Rate for Payer: Blue Shield of California Commercial	$6.25
Rate for Payer: Blue Shield of California EPN	$5.91
Rate for Payer: Cash Price	$4.53
Rate for Payer: Cigna of CA HMO/PPO	$6.55
Rate for Payer: Dignity Health Commercial/Exchange	$8.56
Rate for Payer: Dignity Health Medi-Cal	$8.56
Rate for Payer: Dignity Health Senior	$8.56
Rate for Payer: EPIC Health Plan Commercial	$6.44
Rate for Payer: Heritage Provider Network Commercial	$6.23
Rate for Payer: Heritage Provider Network Senior	$6.23
Rate for Payer: Kaiser Permanente of CA Commercial	$4.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$2.52
Rate for Payer: Multiplan Commercial	$7.55
Rate for Payer: TriValley Medical Group Commercial	$4.03
Rate for Payer: TriValley Medical Group Senior	$4.03
Rate for Payer: Vantage Medical Group Medi-Cal	$8.56
Rate for Payer: Vantage Medical Group Senior	$8.56

NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION [34814]

Facility

$10.07

Service Code	NDC 61314-646-10
Hospital Charge Code	1740064
Hospital Revenue Code	259
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$7.55
Rate for Payer: Adventist Health Commercial	$2.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$6.92
Rate for Payer: Cash Price	$4.53
Rate for Payer: EPIC Health Plan Commercial	$5.44
Rate for Payer: Heritage Provider Network Commercial	$6.82
Rate for Payer: Heritage Provider Network Senior	$6.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.82
Rate for Payer: LLUH Dept of Risk Management WC	$2.52
Rate for Payer: Multiplan Commercial	$7.55

NEONATAL AFTERCARE

Facility

$105,905.09

Service Code	APR-DRG 8634
Min. Negotiated Rate	$105,905.09
Max. Negotiated Rate	$105,905.09
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$105,905.09

NEONATAL AFTERCARE

Facility

$9,517.42

Service Code	APR-DRG 8631
Min. Negotiated Rate	$9,517.42
Max. Negotiated Rate	$9,517.42
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$9,517.42

NEONATAL AFTERCARE

Facility

$47,189.16

Service Code	APR-DRG 8633
Min. Negotiated Rate	$47,189.16
Max. Negotiated Rate	$47,189.16
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$47,189.16

NEONATAL AFTERCARE

Facility

$24,212.03

Service Code	APR-DRG 8632
Min. Negotiated Rate	$24,212.03
Max. Negotiated Rate	$24,212.03
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$24,212.03

NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION

Facility

$70,137.68

Service Code	APR-DRG 6033
Min. Negotiated Rate	$70,137.68
Max. Negotiated Rate	$70,137.68
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$70,137.68

NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION

Facility

$34,604.97

Service Code	APR-DRG 6032
Min. Negotiated Rate	$34,604.97
Max. Negotiated Rate	$34,604.97
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$34,604.97

NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION

Facility

$207,546.25

Service Code	APR-DRG 6034
Min. Negotiated Rate	$207,546.25
Max. Negotiated Rate	$207,546.25
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$207,546.25

NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION

Facility

$1,680.13

Service Code	APR-DRG 6031
Min. Negotiated Rate	$1,680.13
Max. Negotiated Rate	$1,680.13
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$1,680.13

NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY

Facility

$185,075.13

Service Code	APR-DRG 6024
Min. Negotiated Rate	$185,075.13
Max. Negotiated Rate	$185,075.13
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$185,075.13

NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY

Facility

$101,345.08

Service Code	APR-DRG 6023
Min. Negotiated Rate	$101,345.08
Max. Negotiated Rate	$101,345.08
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$101,345.08

NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY

Facility

$77,328.29

Service Code	APR-DRG 6022
Min. Negotiated Rate	$77,328.29
Max. Negotiated Rate	$77,328.29
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$77,328.29

NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY

Facility

$15,205.74

Service Code	APR-DRG 6021
Min. Negotiated Rate	$15,205.74
Max. Negotiated Rate	$15,205.74
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$15,205.74

NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION

Facility

$90,006.25

Service Code	APR-DRG 6084
Min. Negotiated Rate	$90,006.25
Max. Negotiated Rate	$90,006.25
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$90,006.25

NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION

Facility

$59,528.36

Service Code	APR-DRG 6083
Min. Negotiated Rate	$59,528.36
Max. Negotiated Rate	$59,528.36
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$59,528.36

NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION

Facility

$5,953.21

Service Code	APR-DRG 6081
Min. Negotiated Rate	$5,953.21
Max. Negotiated Rate	$5,953.21
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$5,953.21

NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION

Facility

$43,944.55

Service Code	APR-DRG 6082
Min. Negotiated Rate	$43,944.55
Max. Negotiated Rate	$43,944.55
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$43,944.55

NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY

Facility

$76,797.27

Service Code	APR-DRG 6073
Min. Negotiated Rate	$76,797.27
Max. Negotiated Rate	$76,797.27
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$76,797.27

NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY

Facility

$59,466.18

Service Code	APR-DRG 6072
Min. Negotiated Rate	$59,466.18
Max. Negotiated Rate	$59,466.18
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$59,466.18

NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY

Facility

$24,613.73

Service Code	APR-DRG 6071
Min. Negotiated Rate	$24,613.73
Max. Negotiated Rate	$24,613.73
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$24,613.73

Know your out-of-pocket cost for care.

All Charges