Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION

Facility

$7,943.89

Service Code	HCPCS J2182
Hospital Charge Code	176478
Hospital Revenue Code	636
Min. Negotiated Rate	$5,004.65
Max. Negotiated Rate	$7,149.50
Rate for Payer: Aetna Commercial	$6,752.31
Rate for Payer: Aetna New Business (MI Preferred)	$5,163.53
Rate for Payer: Cash Price	$6,355.11
Rate for Payer: Cofinity Commercial	$5,560.72
Rate for Payer: Cofinity Commercial	$6,831.75
Rate for Payer: Cofinity Medicare Advantage	$5,560.72
Rate for Payer: Encore Health Key Benefits Commercial	$6,355.11
Rate for Payer: Healthscope Commercial	$7,149.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6,752.31
Rate for Payer: PHP Commercial	$6,752.31
Rate for Payer: Priority Health Cigna Priority Health	$5,163.53
Rate for Payer: Priority Health SBD	$5,004.65

MEROPENEM 1 GRAM INTRAVENOUS MINI-BAG PLUS COMPONENT CUSTOM

Facility

$24.97

Service Code	HCPCS J2185
Hospital Charge Code	301713
Hospital Revenue Code	636
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$22.47
Rate for Payer: Aetna Commercial	$21.22
Rate for Payer: Aetna Medicare	$12.48
Rate for Payer: Aetna New Business (MI Preferred)	$16.23
Rate for Payer: BCBS Complete	$9.99
Rate for Payer: Cash Price	$19.98
Rate for Payer: Cofinity Commercial	$17.48
Rate for Payer: Cofinity Commercial	$21.47
Rate for Payer: Cofinity Medicare Advantage	$17.48
Rate for Payer: Encore Health Key Benefits Commercial	$19.98
Rate for Payer: Healthscope Commercial	$22.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.22
Rate for Payer: PHP Commercial	$21.22
Rate for Payer: Priority Health Cigna Priority Health	$16.23
Rate for Payer: Priority Health SBD	$15.73

MEROPENEM 1 GRAM INTRAVENOUS MINI-BAG PLUS COMPONENT CUSTOM

Facility

$24.97

Service Code	HCPCS J2185
Hospital Charge Code	301713
Hospital Revenue Code	636
Min. Negotiated Rate	$15.73
Max. Negotiated Rate	$22.47
Rate for Payer: Aetna Commercial	$21.22
Rate for Payer: Aetna New Business (MI Preferred)	$16.23
Rate for Payer: Cash Price	$19.98
Rate for Payer: Cofinity Commercial	$17.48
Rate for Payer: Cofinity Commercial	$21.47
Rate for Payer: Cofinity Medicare Advantage	$17.48
Rate for Payer: Encore Health Key Benefits Commercial	$19.98
Rate for Payer: Healthscope Commercial	$22.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.22
Rate for Payer: PHP Commercial	$21.22
Rate for Payer: Priority Health Cigna Priority Health	$16.23
Rate for Payer: Priority Health SBD	$15.73

MEROPENEM 1 GRAM INTRAVENOUS SOLUTION

Facility

$24.97

Service Code	HCPCS J2185
Hospital Charge Code	17380
Hospital Revenue Code	636
Min. Negotiated Rate	$15.73
Max. Negotiated Rate	$22.47
Rate for Payer: Aetna Commercial	$21.22
Rate for Payer: Aetna Commercial	$20.37
Rate for Payer: Aetna New Business (MI Preferred)	$15.58
Rate for Payer: Aetna New Business (MI Preferred)	$16.23
Rate for Payer: Cash Price	$19.18
Rate for Payer: Cash Price	$19.98
Rate for Payer: Cofinity Commercial	$16.78
Rate for Payer: Cofinity Commercial	$17.48
Rate for Payer: Cofinity Commercial	$21.47
Rate for Payer: Cofinity Commercial	$20.61
Rate for Payer: Cofinity Medicare Advantage	$17.48
Rate for Payer: Cofinity Medicare Advantage	$16.78
Rate for Payer: Encore Health Key Benefits Commercial	$19.18
Rate for Payer: Encore Health Key Benefits Commercial	$19.98
Rate for Payer: Healthscope Commercial	$21.57
Rate for Payer: Healthscope Commercial	$22.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.22
Rate for Payer: PHP Commercial	$20.37
Rate for Payer: PHP Commercial	$21.22
Rate for Payer: Priority Health Cigna Priority Health	$16.23
Rate for Payer: Priority Health Cigna Priority Health	$15.58
Rate for Payer: Priority Health SBD	$15.73
Rate for Payer: Priority Health SBD	$15.10

MEROPENEM 1 GRAM INTRAVENOUS SOLUTION

Facility

$24.97

Service Code	HCPCS J2185
Hospital Charge Code	17380
Hospital Revenue Code	636
Min. Negotiated Rate	$9.99
Max. Negotiated Rate	$22.47
Rate for Payer: Aetna Commercial	$21.22
Rate for Payer: Aetna Commercial	$20.37
Rate for Payer: Aetna Medicare	$11.98
Rate for Payer: Aetna Medicare	$12.48
Rate for Payer: Aetna New Business (MI Preferred)	$15.58
Rate for Payer: Aetna New Business (MI Preferred)	$16.23
Rate for Payer: BCBS Complete	$9.99
Rate for Payer: BCBS Complete	$9.59
Rate for Payer: Cash Price	$19.18
Rate for Payer: Cash Price	$19.98
Rate for Payer: Cofinity Commercial	$16.78
Rate for Payer: Cofinity Commercial	$17.48
Rate for Payer: Cofinity Commercial	$21.47
Rate for Payer: Cofinity Commercial	$20.61
Rate for Payer: Cofinity Medicare Advantage	$17.48
Rate for Payer: Cofinity Medicare Advantage	$16.78
Rate for Payer: Encore Health Key Benefits Commercial	$19.18
Rate for Payer: Encore Health Key Benefits Commercial	$19.98
Rate for Payer: Healthscope Commercial	$21.57
Rate for Payer: Healthscope Commercial	$22.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$21.22
Rate for Payer: PHP Commercial	$21.22
Rate for Payer: PHP Commercial	$20.37
Rate for Payer: Priority Health Cigna Priority Health	$15.58
Rate for Payer: Priority Health Cigna Priority Health	$16.23
Rate for Payer: Priority Health SBD	$15.73
Rate for Payer: Priority Health SBD	$15.10

MEROPENEM 500 MG INTRAVENOUS MINI-BAG PLUS COMPONENT CUSTOM

Facility

$21.13

Service Code	HCPCS J2185
Hospital Charge Code	301712
Hospital Revenue Code	636
Min. Negotiated Rate	$13.31
Max. Negotiated Rate	$19.02
Rate for Payer: Aetna Commercial	$17.96
Rate for Payer: Aetna New Business (MI Preferred)	$13.73
Rate for Payer: Cash Price	$16.90
Rate for Payer: Cofinity Commercial	$14.79
Rate for Payer: Cofinity Commercial	$18.17
Rate for Payer: Cofinity Medicare Advantage	$14.79
Rate for Payer: Encore Health Key Benefits Commercial	$16.90
Rate for Payer: Healthscope Commercial	$19.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.96
Rate for Payer: PHP Commercial	$17.96
Rate for Payer: Priority Health Cigna Priority Health	$13.73
Rate for Payer: Priority Health SBD	$13.31

MEROPENEM 500 MG INTRAVENOUS MINI-BAG PLUS COMPONENT CUSTOM

Facility

$21.13

Service Code	HCPCS J2185
Hospital Charge Code	301712
Hospital Revenue Code	636
Min. Negotiated Rate	$8.45
Max. Negotiated Rate	$19.02
Rate for Payer: Aetna Commercial	$17.96
Rate for Payer: Aetna Medicare	$10.56
Rate for Payer: Aetna New Business (MI Preferred)	$13.73
Rate for Payer: BCBS Complete	$8.45
Rate for Payer: Cash Price	$16.90
Rate for Payer: Cofinity Commercial	$14.79
Rate for Payer: Cofinity Commercial	$18.17
Rate for Payer: Cofinity Medicare Advantage	$14.79
Rate for Payer: Encore Health Key Benefits Commercial	$16.90
Rate for Payer: Healthscope Commercial	$19.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.96
Rate for Payer: PHP Commercial	$17.96
Rate for Payer: Priority Health Cigna Priority Health	$13.73
Rate for Payer: Priority Health SBD	$13.31

MEROPENEM 500 MG INTRAVENOUS SOLUTION

Facility

$21.13

Service Code	HCPCS J2185
Hospital Charge Code	17379
Hospital Revenue Code	636
Min. Negotiated Rate	$8.45
Max. Negotiated Rate	$19.02
Rate for Payer: Aetna Commercial	$17.96
Rate for Payer: Aetna Commercial	$16.91
Rate for Payer: Aetna Medicare	$9.95
Rate for Payer: Aetna Medicare	$10.56
Rate for Payer: Aetna New Business (MI Preferred)	$12.94
Rate for Payer: Aetna New Business (MI Preferred)	$13.73
Rate for Payer: BCBS Complete	$8.45
Rate for Payer: BCBS Complete	$7.96
Rate for Payer: Cash Price	$15.92
Rate for Payer: Cash Price	$16.90
Rate for Payer: Cofinity Commercial	$13.93
Rate for Payer: Cofinity Commercial	$14.79
Rate for Payer: Cofinity Commercial	$18.17
Rate for Payer: Cofinity Commercial	$17.11
Rate for Payer: Cofinity Medicare Advantage	$14.79
Rate for Payer: Cofinity Medicare Advantage	$13.93
Rate for Payer: Encore Health Key Benefits Commercial	$15.92
Rate for Payer: Encore Health Key Benefits Commercial	$16.90
Rate for Payer: Healthscope Commercial	$17.91
Rate for Payer: Healthscope Commercial	$19.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.96
Rate for Payer: PHP Commercial	$17.96
Rate for Payer: PHP Commercial	$16.91
Rate for Payer: Priority Health Cigna Priority Health	$12.94
Rate for Payer: Priority Health Cigna Priority Health	$13.73
Rate for Payer: Priority Health SBD	$13.31
Rate for Payer: Priority Health SBD	$12.54

MEROPENEM 500 MG INTRAVENOUS SOLUTION

Facility

$21.13

Service Code	HCPCS J2185
Hospital Charge Code	17379
Hospital Revenue Code	636
Min. Negotiated Rate	$13.31
Max. Negotiated Rate	$19.02
Rate for Payer: Aetna Commercial	$17.96
Rate for Payer: Aetna Commercial	$16.91
Rate for Payer: Aetna New Business (MI Preferred)	$12.94
Rate for Payer: Aetna New Business (MI Preferred)	$13.73
Rate for Payer: Cash Price	$15.92
Rate for Payer: Cash Price	$16.90
Rate for Payer: Cofinity Commercial	$13.93
Rate for Payer: Cofinity Commercial	$14.79
Rate for Payer: Cofinity Commercial	$18.17
Rate for Payer: Cofinity Commercial	$17.11
Rate for Payer: Cofinity Medicare Advantage	$14.79
Rate for Payer: Cofinity Medicare Advantage	$13.93
Rate for Payer: Encore Health Key Benefits Commercial	$15.92
Rate for Payer: Encore Health Key Benefits Commercial	$16.90
Rate for Payer: Healthscope Commercial	$17.91
Rate for Payer: Healthscope Commercial	$19.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.96
Rate for Payer: PHP Commercial	$16.91
Rate for Payer: PHP Commercial	$17.96
Rate for Payer: Priority Health Cigna Priority Health	$13.73
Rate for Payer: Priority Health Cigna Priority Health	$12.94
Rate for Payer: Priority Health SBD	$13.31
Rate for Payer: Priority Health SBD	$12.54

MEROPENEM IV 0.00001 MG/ML IVPB FOR DESENSITIZATION 50 ML

Facility

$1.25

Service Code	HCPCS J2185
Hospital Charge Code	180552
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna Commercial	$1.06
Rate for Payer: Aetna Medicare	$0.63
Rate for Payer: Aetna New Business (MI Preferred)	$0.81
Rate for Payer: BCBS Complete	$0.50
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cofinity Commercial	$0.88
Rate for Payer: Cofinity Commercial	$1.07
Rate for Payer: Cofinity Medicare Advantage	$0.88
Rate for Payer: Encore Health Key Benefits Commercial	$1.00
Rate for Payer: Healthscope Commercial	$1.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.06
Rate for Payer: PHP Commercial	$1.06
Rate for Payer: Priority Health Cigna Priority Health	$0.81
Rate for Payer: Priority Health SBD	$0.79

MEROPENEM IV 0.00001 MG/ML IVPB FOR DESENSITIZATION 50 ML

Facility

$1.25

Service Code	HCPCS J2185
Hospital Charge Code	180552
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna Commercial	$1.06
Rate for Payer: Aetna New Business (MI Preferred)	$0.81
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cofinity Commercial	$0.88
Rate for Payer: Cofinity Commercial	$1.07
Rate for Payer: Cofinity Medicare Advantage	$0.88
Rate for Payer: Encore Health Key Benefits Commercial	$1.00
Rate for Payer: Healthscope Commercial	$1.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.06
Rate for Payer: PHP Commercial	$1.06
Rate for Payer: Priority Health Cigna Priority Health	$0.81
Rate for Payer: Priority Health SBD	$0.79

MEROPENEM IV 0.0001 MG/ML IVPB FOR DESENSITIZATION 50 ML

Facility

$1.25

Service Code	HCPCS J2185
Hospital Charge Code	180553
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna Commercial	$1.06
Rate for Payer: Aetna New Business (MI Preferred)	$0.81
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cofinity Commercial	$0.88
Rate for Payer: Cofinity Commercial	$1.07
Rate for Payer: Cofinity Medicare Advantage	$0.88
Rate for Payer: Encore Health Key Benefits Commercial	$1.00
Rate for Payer: Healthscope Commercial	$1.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.06
Rate for Payer: PHP Commercial	$1.06
Rate for Payer: Priority Health Cigna Priority Health	$0.81
Rate for Payer: Priority Health SBD	$0.79

MEROPENEM IV 0.0001 MG/ML IVPB FOR DESENSITIZATION 50 ML

Facility

$1.25

Service Code	HCPCS J2185
Hospital Charge Code	180553
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna Commercial	$1.06
Rate for Payer: Aetna Medicare	$0.63
Rate for Payer: Aetna New Business (MI Preferred)	$0.81
Rate for Payer: BCBS Complete	$0.50
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cofinity Commercial	$0.88
Rate for Payer: Cofinity Commercial	$1.07
Rate for Payer: Cofinity Medicare Advantage	$0.88
Rate for Payer: Encore Health Key Benefits Commercial	$1.00
Rate for Payer: Healthscope Commercial	$1.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.06
Rate for Payer: PHP Commercial	$1.06
Rate for Payer: Priority Health Cigna Priority Health	$0.81
Rate for Payer: Priority Health SBD	$0.79

MEROPENEM IV 0.001 MG/ML IVPB FOR DESENSITIZATION 50 ML

Facility

$1.25

Service Code	HCPCS J2185
Hospital Charge Code	180554
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna Commercial	$1.06
Rate for Payer: Aetna New Business (MI Preferred)	$0.81
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cofinity Commercial	$0.88
Rate for Payer: Cofinity Commercial	$1.07
Rate for Payer: Cofinity Medicare Advantage	$0.88
Rate for Payer: Encore Health Key Benefits Commercial	$1.00
Rate for Payer: Healthscope Commercial	$1.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.06
Rate for Payer: PHP Commercial	$1.06
Rate for Payer: Priority Health Cigna Priority Health	$0.81
Rate for Payer: Priority Health SBD	$0.79

MEROPENEM IV 0.001 MG/ML IVPB FOR DESENSITIZATION 50 ML

Facility

$1.25

Service Code	HCPCS J2185
Hospital Charge Code	180554
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna Commercial	$1.06
Rate for Payer: Aetna Medicare	$0.63
Rate for Payer: Aetna New Business (MI Preferred)	$0.81
Rate for Payer: BCBS Complete	$0.50
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cofinity Commercial	$0.88
Rate for Payer: Cofinity Commercial	$1.07
Rate for Payer: Cofinity Medicare Advantage	$0.88
Rate for Payer: Encore Health Key Benefits Commercial	$1.00
Rate for Payer: Healthscope Commercial	$1.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.06
Rate for Payer: PHP Commercial	$1.06
Rate for Payer: Priority Health Cigna Priority Health	$0.81
Rate for Payer: Priority Health SBD	$0.79

MEROPENEM IV 0.01 MG/ML IVPB FOR DESENSITIZATION 50 ML

Facility

$1.25

Service Code	HCPCS J2185
Hospital Charge Code	180555
Hospital Revenue Code	636
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna Commercial	$1.06
Rate for Payer: Aetna New Business (MI Preferred)	$0.81
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cofinity Commercial	$0.88
Rate for Payer: Cofinity Commercial	$1.07
Rate for Payer: Cofinity Medicare Advantage	$0.88
Rate for Payer: Encore Health Key Benefits Commercial	$1.00
Rate for Payer: Healthscope Commercial	$1.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.06
Rate for Payer: PHP Commercial	$1.06
Rate for Payer: Priority Health Cigna Priority Health	$0.81
Rate for Payer: Priority Health SBD	$0.79

MEROPENEM IV 0.01 MG/ML IVPB FOR DESENSITIZATION 50 ML

Facility

$1.25

Service Code	HCPCS J2185
Hospital Charge Code	180555
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna Commercial	$1.06
Rate for Payer: Aetna Medicare	$0.63
Rate for Payer: Aetna New Business (MI Preferred)	$0.81
Rate for Payer: BCBS Complete	$0.50
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cofinity Commercial	$0.88
Rate for Payer: Cofinity Commercial	$1.07
Rate for Payer: Cofinity Medicare Advantage	$0.88
Rate for Payer: Encore Health Key Benefits Commercial	$1.00
Rate for Payer: Healthscope Commercial	$1.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.06
Rate for Payer: PHP Commercial	$1.06
Rate for Payer: Priority Health Cigna Priority Health	$0.81
Rate for Payer: Priority Health SBD	$0.79

MESALAMINE 1,000 MG RECTAL SUPPOSITORY

Facility

$344.10

Service Code	NDC 64980028203
Hospital Charge Code	40369
Hospital Revenue Code	637
Min. Negotiated Rate	$137.64
Max. Negotiated Rate	$309.69
Rate for Payer: Aetna Commercial	$292.49
Rate for Payer: Aetna Medicare	$172.05
Rate for Payer: Aetna New Business (MI Preferred)	$223.66
Rate for Payer: BCBS Complete	$137.64
Rate for Payer: Cash Price	$275.28
Rate for Payer: Cofinity Commercial	$240.87
Rate for Payer: Cofinity Commercial	$295.93
Rate for Payer: Cofinity Medicare Advantage	$240.87
Rate for Payer: Encore Health Key Benefits Commercial	$275.28
Rate for Payer: Healthscope Commercial	$309.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$292.49
Rate for Payer: PHP Commercial	$292.49
Rate for Payer: Priority Health Cigna Priority Health	$223.66
Rate for Payer: Priority Health SBD	$216.78

MESALAMINE 1,000 MG RECTAL SUPPOSITORY

Facility

$344.10

Service Code	NDC 64980028203
Hospital Charge Code	40369
Hospital Revenue Code	637
Min. Negotiated Rate	$216.78
Max. Negotiated Rate	$309.69
Rate for Payer: Aetna Commercial	$292.49
Rate for Payer: Aetna New Business (MI Preferred)	$223.66
Rate for Payer: Cash Price	$275.28
Rate for Payer: Cofinity Commercial	$240.87
Rate for Payer: Cofinity Commercial	$295.93
Rate for Payer: Cofinity Medicare Advantage	$240.87
Rate for Payer: Encore Health Key Benefits Commercial	$275.28
Rate for Payer: Healthscope Commercial	$309.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$292.49
Rate for Payer: PHP Commercial	$292.49
Rate for Payer: Priority Health Cigna Priority Health	$223.66
Rate for Payer: Priority Health SBD	$216.78

MESALAMINE 1,000 MG RECTAL SUPPOSITORY

Facility

$3,997.67

Service Code	NDC 58914050156
Hospital Charge Code	40369
Hospital Revenue Code	637
Min. Negotiated Rate	$2,518.53
Max. Negotiated Rate	$3,597.90
Rate for Payer: Aetna Commercial	$3,398.02
Rate for Payer: Aetna New Business (MI Preferred)	$2,598.49
Rate for Payer: Cash Price	$3,198.14
Rate for Payer: Cofinity Commercial	$2,798.37
Rate for Payer: Cofinity Commercial	$3,438.00
Rate for Payer: Cofinity Medicare Advantage	$2,798.37
Rate for Payer: Encore Health Key Benefits Commercial	$3,198.14
Rate for Payer: Healthscope Commercial	$3,597.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,398.02
Rate for Payer: PHP Commercial	$3,398.02
Rate for Payer: Priority Health Cigna Priority Health	$2,598.49
Rate for Payer: Priority Health SBD	$2,518.53

MESALAMINE 1,000 MG RECTAL SUPPOSITORY

Facility

$3,997.67

Service Code	NDC 58914050156
Hospital Charge Code	40369
Hospital Revenue Code	637
Min. Negotiated Rate	$1,599.07
Max. Negotiated Rate	$3,597.90
Rate for Payer: Aetna Commercial	$3,398.02
Rate for Payer: Aetna Medicare	$1,998.84
Rate for Payer: Aetna New Business (MI Preferred)	$2,598.49
Rate for Payer: BCBS Complete	$1,599.07
Rate for Payer: Cash Price	$3,198.14
Rate for Payer: Cofinity Commercial	$2,798.37
Rate for Payer: Cofinity Commercial	$3,438.00
Rate for Payer: Cofinity Medicare Advantage	$2,798.37
Rate for Payer: Encore Health Key Benefits Commercial	$3,198.14
Rate for Payer: Healthscope Commercial	$3,597.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,398.02
Rate for Payer: PHP Commercial	$3,398.02
Rate for Payer: Priority Health Cigna Priority Health	$2,598.49
Rate for Payer: Priority Health SBD	$2,518.53

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE

Facility

$1,835.94

Service Code	NDC 68382071119
Hospital Charge Code	78310
Hospital Revenue Code	637
Min. Negotiated Rate	$1,156.64
Max. Negotiated Rate	$1,652.35
Rate for Payer: Aetna Commercial	$1,560.55
Rate for Payer: Aetna New Business (MI Preferred)	$1,193.36
Rate for Payer: Cash Price	$1,468.75
Rate for Payer: Cofinity Commercial	$1,285.16
Rate for Payer: Cofinity Commercial	$1,578.91
Rate for Payer: Cofinity Medicare Advantage	$1,285.16
Rate for Payer: Encore Health Key Benefits Commercial	$1,468.75
Rate for Payer: Healthscope Commercial	$1,652.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,560.55
Rate for Payer: PHP Commercial	$1,560.55
Rate for Payer: Priority Health Cigna Priority Health	$1,193.36
Rate for Payer: Priority Health SBD	$1,156.64

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE

Facility

$1,835.94

Service Code	NDC 68382071119
Hospital Charge Code	78310
Hospital Revenue Code	637
Min. Negotiated Rate	$734.38
Max. Negotiated Rate	$1,652.35
Rate for Payer: Aetna Commercial	$1,560.55
Rate for Payer: Aetna Medicare	$917.97
Rate for Payer: Aetna New Business (MI Preferred)	$1,193.36
Rate for Payer: BCBS Complete	$734.38
Rate for Payer: Cash Price	$1,468.75
Rate for Payer: Cofinity Commercial	$1,285.16
Rate for Payer: Cofinity Commercial	$1,578.91
Rate for Payer: Cofinity Medicare Advantage	$1,285.16
Rate for Payer: Encore Health Key Benefits Commercial	$1,468.75
Rate for Payer: Healthscope Commercial	$1,652.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,560.55
Rate for Payer: PHP Commercial	$1,560.55
Rate for Payer: Priority Health Cigna Priority Health	$1,193.36
Rate for Payer: Priority Health SBD	$1,156.64

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE

Facility

$3,865.02

Service Code	NDC 54092047612
Hospital Charge Code	78310
Hospital Revenue Code	637
Min. Negotiated Rate	$1,546.01
Max. Negotiated Rate	$3,478.52
Rate for Payer: Aetna Commercial	$3,285.27
Rate for Payer: Aetna Medicare	$1,932.51
Rate for Payer: Aetna New Business (MI Preferred)	$2,512.26
Rate for Payer: BCBS Complete	$1,546.01
Rate for Payer: Cash Price	$3,092.02
Rate for Payer: Cofinity Commercial	$2,705.51
Rate for Payer: Cofinity Commercial	$3,323.92
Rate for Payer: Cofinity Medicare Advantage	$2,705.51
Rate for Payer: Encore Health Key Benefits Commercial	$3,092.02
Rate for Payer: Healthscope Commercial	$3,478.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,285.27
Rate for Payer: PHP Commercial	$3,285.27
Rate for Payer: Priority Health Cigna Priority Health	$2,512.26
Rate for Payer: Priority Health SBD	$2,434.96

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE

Facility

$3,865.02

Service Code	NDC 54092047612
Hospital Charge Code	78310
Hospital Revenue Code	637
Min. Negotiated Rate	$2,434.96
Max. Negotiated Rate	$3,478.52
Rate for Payer: Aetna Commercial	$3,285.27
Rate for Payer: Aetna New Business (MI Preferred)	$2,512.26
Rate for Payer: Cash Price	$3,092.02
Rate for Payer: Cofinity Commercial	$2,705.51
Rate for Payer: Cofinity Commercial	$3,323.92
Rate for Payer: Cofinity Medicare Advantage	$2,705.51
Rate for Payer: Encore Health Key Benefits Commercial	$3,092.02
Rate for Payer: Healthscope Commercial	$3,478.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,285.27
Rate for Payer: PHP Commercial	$3,285.27
Rate for Payer: Priority Health Cigna Priority Health	$2,512.26
Rate for Payer: Priority Health SBD	$2,434.96

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