Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MAGNESIUM L-LACTATE ER 84 MG TABLET,EXTENDED RELEASE [4715]

Facility

$0.25

Service Code	NDC 7132180010
Hospital Charge Code	1712208
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19

MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET [10491]

Facility

$0.06

Service Code	NDC 69543-217-12
Hospital Charge Code	1711550
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET [10491]

Facility

$0.04

Service Code	NDC 0603-0209-22
Hospital Charge Code	1711550
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET [10491]

Facility

$0.06

Service Code	NDC 69543-217-12
Hospital Charge Code	1711550
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) TABLET [10491]

Facility

$0.04

Service Code	NDC 0603-0209-22
Hospital Charge Code	1711550
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

MAGNESIUM OXIDE CRUSHED TABLET < 200 MG [4080938]

Facility

$0.04

Service Code	NDC 0603-0209-22
Hospital Charge Code	1712589
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

MAGNESIUM OXIDE CRUSHED TABLET < 200 MG [4080938]

Facility

$0.06

Service Code	NDC 69543-217-12
Hospital Charge Code	1712589
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

MAGNESIUM OXIDE CRUSHED TABLET < 200 MG [4080938]

Facility

$0.04

Service Code	NDC 0603-0209-22
Hospital Charge Code	1712589
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

MAGNESIUM OXIDE CRUSHED TABLET < 200 MG [4080938]

Facility

$0.06

Service Code	NDC 69543-217-12
Hospital Charge Code	1712589
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

MAGNESIUM OXIDE-MAGNESIUM AMINO ACID CHELATE 133 MG TABLET [120703]

Facility

$0.08

Service Code	NDC 9697400002
Hospital Charge Code	1710930
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

MAGNESIUM OXIDE-MAGNESIUM AMINO ACID CHELATE 133 MG TABLET [120703]

Facility

$0.08

Service Code	NDC 9697400002
Hospital Charge Code	1710930
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

MAGNESIUM OXIDE-MAGNESIUM AMINO ACID CHELATE 133 MG TABLET [120703]

Facility

$0.07

Service Code	NDC 17204-587-95
Hospital Charge Code	1710930
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

MAGNESIUM OXIDE-MAGNESIUM AMINO ACID CHELATE 133 MG TABLET [120703]

Facility

$0.06

Service Code	NDC 9697400003
Hospital Charge Code	1710930
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

MAGNESIUM OXIDE-MAGNESIUM AMINO ACID CHELATE 133 MG TABLET [120703]

Facility

$0.07

Service Code	NDC 17204-587-95
Hospital Charge Code	1710930
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

MAGNESIUM OXIDE-MAGNESIUM AMINO ACID CHELATE 133 MG TABLET [120703]

Facility

$0.06

Service Code	NDC 9697400003
Hospital Charge Code	1710930
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

MAGNESIUM SULFATE 1 G/2 ML VIAL - CODE [4080570]

Facility

$0.95

Service Code	CPT J3475
Hospital Charge Code	1757224
Hospital Revenue Code	636
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.57
Rate for Payer: Aetna of CA Government/Medicare	$0.57
Rate for Payer: Cash Price	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71

MAGNESIUM SULFATE 1 G/2 ML VIAL - CODE [4080570]

Facility

$0.95

Service Code	CPT J3475
Hospital Charge Code	1757224
Hospital Revenue Code	636
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.76
Rate for Payer: Cash Price	$0.43
Rate for Payer: Cigna of CA HMO/PPO	$0.76
Rate for Payer: Health Smart Auto/Commercial	$0.57
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71

MAGNESIUM SULFATE 1 G/2 ML VIAL - CODE [4080570]

Facility

$0.21

Service Code	CPT J3475
Hospital Charge Code	1720064
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

MAGNESIUM SULFATE 1 G/2 ML VIAL - CODE [4080570]

Facility

$0.21

Service Code	CPT J3475
Hospital Charge Code	1720064
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]

Facility

$0.08

Service Code	CPT J3475
Hospital Charge Code	1759120
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [16162]

Facility

$0.09

Service Code	CPT J3475
Hospital Charge Code	1759120
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION [119528]

Facility

$0.02

Service Code	CPT J3475
Hospital Charge Code	1771307
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION [119528]

Facility

$0.01

Service Code	CPT J3475
Hospital Charge Code	1771307
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [119442]

Facility

$0.30

Service Code	CPT J3475
Hospital Charge Code	1759135
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Cigna of CA HMO/PPO	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [119442]

Facility

$0.30

Service Code	CPT J3475
Hospital Charge Code	1759135
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.30

Know your out-of-pocket cost for care.

All Charges