Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MAGNESIUM SULFATE 40 GRAM/1,000 ML (4 %) IN WATER INTRAVENOUS SOLUTION [119529]

Facility

$0.01

Service Code	CPT J3475
Hospital Charge Code	1771231
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 Government/Medicare	$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: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

MAGNESIUM SULFATE 40 GRAM/1,000 ML (4 %) IN WATER INTRAVENOUS SOLUTION [119529]

Facility

$0.01

Service Code	CPT J3475
Hospital Charge Code	1771231
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$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: Multiplan Beech St/Commercial/PHCS	$0.01

MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [4719]

Facility

$0.10

Service Code	CPT J3475
Hospital Charge Code	1759121
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
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 Government/Medicare	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
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	$0.05
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.03
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: 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	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
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: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
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	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK [4719]

Facility

$0.09

Service Code	CPT J3475
Hospital Charge Code	1759121
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	$0.05
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.07
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	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

MAGNESIUM SULFATE 4 GRAM/50 ML (8 %) IN WATER INTRAVENOUS PIGGYBACK [4721]

Facility

$0.20

Service Code	CPT J3475
Hospital Charge Code	NDG4721
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

MAGNESIUM SULFATE 4 GRAM/50 ML (8 %) IN WATER INTRAVENOUS PIGGYBACK [4721]

Facility

$0.20

Service Code	CPT J3475
Hospital Charge Code	NDG4721
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION SOLUTION [4720]

Facility

$0.67

Service Code	CPT J3475
Hospital Charge Code	1757224
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION SOLUTION [4720]

Facility

$0.65

Service Code	CPT J3475
Hospital Charge Code	1720064
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.39
Rate for Payer: Aetna of CA Government/Medicare	$0.39
Rate for Payer: Cash Price	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.49

MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION SOLUTION [4720]

Facility

$0.65

Service Code	CPT J3475
Hospital Charge Code	1720064
Hospital Revenue Code	636
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.49

MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION SOLUTION [4720]

Facility

$0.67

Service Code	CPT J3475
Hospital Charge Code	1757224
Hospital Revenue Code	636
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]

Facility

$0.26

Service Code	CPT J3475
Hospital Charge Code	1720064
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]

Facility

$0.26

Service Code	CPT J3475
Hospital Charge Code	1720064
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]

Facility

$1.19

Service Code	CPT J3475
Hospital Charge Code	1757224
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cash Price	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]

Facility

$1.19

Service Code	CPT J3475
Hospital Charge Code	1757224
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.95
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.95
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]

Facility

$0.24

Service Code	CPT J3475
Hospital Charge Code	NDG4720A
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

MAGNESIUM SULFATE 5 GRAM/10 ML (500 MG/ML) INTRAVENOUS SOLUTION. [408197359]

Facility

$0.24

Service Code	CPT J3475
Hospital Charge Code	NDG4720A
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

MAGNESIUM SULFATE (BULK) 100 % CRYSTALS [4722]

Facility

$0.01

Service Code	NDC 11068-01006
Hospital Revenue Code	259
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 Government/Medicare	$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: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.01

MAGNESIUM SULFATE (BULK) 100 % CRYSTALS [4722]

Facility

$0.01

Service Code	NDC 11068-01006
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$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: Multiplan Beech St/Commercial/PHCS	$0.01

MAGNESIUM SULFATE ORAL SOLUTION (IV FORM) 0.5 G/ML [4080434]

Facility

$1.04

Service Code	NDC 9994-0804-34
Hospital Charge Code	1715016
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.83
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cigna of CA HMO/PPO	$0.83
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.78

MAGNESIUM SULFATE ORAL SOLUTION (IV FORM) 0.5 G/ML [4080434]

Facility

$1.04

Service Code	NDC 9994-0804-34
Hospital Charge Code	1715016
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.78

MANGO FLAVOR LIQUID [213757]

Facility

$2.86

Service Code	NDC 3877929822
Hospital Charge Code	NDG213757
Hospital Revenue Code	259
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.72
Rate for Payer: Aetna of CA Government/Medicare	$1.72
Rate for Payer: Cash Price	$1.29
Rate for Payer: Health Smart Auto/Commercial	$1.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.72
Rate for Payer: LLUH Dept of Risk Management WC	$1.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.14

MANGO FLAVOR LIQUID [213757]

Facility

$2.86

Service Code	NDC 3877929822
Hospital Charge Code	NDG213757
Hospital Revenue Code	259
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.29
Rate for Payer: Cash Price	$1.29
Rate for Payer: Cigna of CA HMO/PPO	$2.29
Rate for Payer: Health Smart Auto/Commercial	$1.72
Rate for Payer: LLUH Dept of Risk Management WC	$1.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.14

MANGO FLAVOR LIQUID [213757]

Facility

$2.86

Service Code	NDC 78573-00081
Hospital Charge Code	NDG10056
Hospital Revenue Code	259
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.72
Rate for Payer: Aetna of CA Government/Medicare	$1.72
Rate for Payer: Cash Price	$1.29
Rate for Payer: Health Smart Auto/Commercial	$1.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.72
Rate for Payer: LLUH Dept of Risk Management WC	$1.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.14

MANGO FLAVOR LIQUID [213757]

Facility

$2.86

Service Code	NDC 78573-00081
Hospital Charge Code	NDG10056
Hospital Revenue Code	259
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.29
Rate for Payer: Cash Price	$1.29
Rate for Payer: Cigna of CA HMO/PPO	$2.29
Rate for Payer: Health Smart Auto/Commercial	$1.72
Rate for Payer: LLUH Dept of Risk Management WC	$1.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.14

MANNITOL 20 % INTRAVENOUS SOLUTION [4749]

Facility

$0.11

Service Code	NDC 0990-7715-12
Hospital Charge Code	NDG4749
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
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	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

Know your out-of-pocket cost for care.

All Charges