Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]

Facility

$7.02

Service Code	NDC 70710-1302-6
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.86
Max. Negotiated Rate	$5.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.21
Rate for Payer: Aetna of CA Government/Medicare	$4.21
Rate for Payer: Cash Price	$3.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.62
Rate for Payer: Health Smart Auto/Commercial	$4.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.21
Rate for Payer: LLUH Dept of Risk Management WC	$3.86
Rate for Payer: Multiplan Commercial	$5.26

MESALAMINE 1,000 MG RECTAL SUPPOSITORY [40369]

Facility

$6.77

Service Code	NDC 59762-0118-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.72
Max. Negotiated Rate	$5.42
Rate for Payer: Cash Price	$3.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.42
Rate for Payer: Health Smart Auto/Commercial	$4.06
Rate for Payer: LLUH Dept of Risk Management WC	$3.72
Rate for Payer: Multiplan Commercial	$5.08

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]

Facility

$12.48

Service Code	NDC 60687-397-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.86
Max. Negotiated Rate	$9.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.49
Rate for Payer: Aetna of CA Government/Medicare	$7.49
Rate for Payer: Cash Price	$6.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.98
Rate for Payer: Health Smart Auto/Commercial	$7.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.49
Rate for Payer: LLUH Dept of Risk Management WC	$6.86
Rate for Payer: Multiplan Commercial	$9.36

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]

Facility

$12.48

Service Code	NDC 60687-397-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.86
Max. Negotiated Rate	$9.98
Rate for Payer: Cash Price	$6.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.98
Rate for Payer: Health Smart Auto/Commercial	$7.49
Rate for Payer: LLUH Dept of Risk Management WC	$6.86
Rate for Payer: Multiplan Commercial	$9.36

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]

Facility

$12.48

Service Code	NDC 60687-397-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.86
Max. Negotiated Rate	$9.98
Rate for Payer: Cash Price	$6.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.98
Rate for Payer: Health Smart Auto/Commercial	$7.49
Rate for Payer: LLUH Dept of Risk Management WC	$6.86
Rate for Payer: Multiplan Commercial	$9.36

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]

Facility

$12.48

Service Code	NDC 60687-397-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.86
Max. Negotiated Rate	$9.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.49
Rate for Payer: Aetna of CA Government/Medicare	$7.49
Rate for Payer: Cash Price	$6.86
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.98
Rate for Payer: Health Smart Auto/Commercial	$7.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.49
Rate for Payer: LLUH Dept of Risk Management WC	$6.86
Rate for Payer: Multiplan Commercial	$9.36

MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]

Facility

$8.33

Service Code	NDC 60687-556-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$6.66
Rate for Payer: Cash Price	$4.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.66
Rate for Payer: Health Smart Auto/Commercial	$5.00
Rate for Payer: LLUH Dept of Risk Management WC	$4.58
Rate for Payer: Multiplan Commercial	$6.25

MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]

Facility

$8.33

Service Code	NDC 60687-556-32
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$6.66
Rate for Payer: Cash Price	$4.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.66
Rate for Payer: Health Smart Auto/Commercial	$5.00
Rate for Payer: LLUH Dept of Risk Management WC	$4.58
Rate for Payer: Multiplan Commercial	$6.25

MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]

Facility

$8.33

Service Code	NDC 60687-556-32
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$6.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.00
Rate for Payer: Aetna of CA Government/Medicare	$5.00
Rate for Payer: Cash Price	$4.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.66
Rate for Payer: Health Smart Auto/Commercial	$5.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.00
Rate for Payer: LLUH Dept of Risk Management WC	$4.58
Rate for Payer: Multiplan Commercial	$6.25

MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [214804]

Facility

$8.33

Service Code	NDC 60687-556-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.58
Max. Negotiated Rate	$6.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.00
Rate for Payer: Aetna of CA Government/Medicare	$5.00
Rate for Payer: Cash Price	$4.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.66
Rate for Payer: Health Smart Auto/Commercial	$5.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.00
Rate for Payer: LLUH Dept of Risk Management WC	$4.58
Rate for Payer: Multiplan Commercial	$6.25

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$0.20

Service Code	NDC 45802-098-51
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.15

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$0.27

Service Code	NDC 62559-420-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$0.27

Service Code	NDC 62559-420-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
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	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
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	$0.15
Rate for Payer: Multiplan Commercial	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$0.20

Service Code	NDC 45802-098-51
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
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	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
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 Commercial	$0.15

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$0.27

Service Code	NDC 62559-420-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
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	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
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	$0.15
Rate for Payer: Multiplan Commercial	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$0.27

Service Code	NDC 62559-420-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$0.26

Service Code	NDC 45802-098-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
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	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
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 Commercial	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$0.26

Service Code	NDC 45802-098-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$0.20

MESALAMINE (BULK) POWDER [111265]

Facility

$4.06

Service Code	NDC 62991-2705-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$3.25
Rate for Payer: Cash Price	$2.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.25
Rate for Payer: Health Smart Auto/Commercial	$2.44
Rate for Payer: LLUH Dept of Risk Management WC	$2.23
Rate for Payer: Multiplan Commercial	$3.04

MESALAMINE (BULK) POWDER [111265]

Facility

$4.06

Service Code	NDC 62991-2705-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.44
Rate for Payer: Aetna of CA Government/Medicare	$2.44
Rate for Payer: Cash Price	$2.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.25
Rate for Payer: Health Smart Auto/Commercial	$2.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.44
Rate for Payer: LLUH Dept of Risk Management WC	$2.23
Rate for Payer: Multiplan Commercial	$3.04

MESALAMINE (BULK) POWDER [111265]

Facility

$4.06

Service Code	NDC 62991-2705-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$3.25
Rate for Payer: Cash Price	$2.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.25
Rate for Payer: Health Smart Auto/Commercial	$2.44
Rate for Payer: LLUH Dept of Risk Management WC	$2.23
Rate for Payer: Multiplan Commercial	$3.04

MESALAMINE (BULK) POWDER [111265]

Facility

$4.06

Service Code	NDC 62991-2705-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.44
Rate for Payer: Aetna of CA Government/Medicare	$2.44
Rate for Payer: Cash Price	$2.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.25
Rate for Payer: Health Smart Auto/Commercial	$2.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.44
Rate for Payer: LLUH Dept of Risk Management WC	$2.23
Rate for Payer: Multiplan Commercial	$3.04

MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE [10533]

Facility

$3.64

Service Code	NDC 54092-189-81
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$2.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.91
Rate for Payer: Health Smart Auto/Commercial	$2.18
Rate for Payer: LLUH Dept of Risk Management WC	$2.00
Rate for Payer: Multiplan Commercial	$2.73

MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE [10533]

Facility

$3.64

Service Code	NDC 54092-189-81
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.18
Rate for Payer: Aetna of CA Government/Medicare	$2.18
Rate for Payer: Cash Price	$2.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.91
Rate for Payer: Health Smart Auto/Commercial	$2.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.18
Rate for Payer: LLUH Dept of Risk Management WC	$2.00
Rate for Payer: Multiplan Commercial	$2.73

MESALAMINE ER 500 MG CAPSULE,EXTENDED RELEASE [39575]

Facility

$7.29

Service Code	NDC 54092-191-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$5.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.37
Rate for Payer: Aetna of CA Government/Medicare	$4.37
Rate for Payer: Cash Price	$4.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.83
Rate for Payer: Health Smart Auto/Commercial	$4.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.37
Rate for Payer: LLUH Dept of Risk Management WC	$4.01
Rate for Payer: Multiplan Commercial	$5.47

Know your out-of-pocket cost for care.

All Charges