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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

IP

$0.27

Service Code	NDC 62559-420-07
Hospital Charge Code	1748078
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

OP

$0.27

Service Code	NDC 45802-098-51
Hospital Charge Code	1748078
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
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	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

IP

$0.26

Service Code	NDC 45802-098-46
Hospital Charge Code	1748078
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

IP

$0.27

Service Code	NDC 45802-098-51
Hospital Charge Code	1748078
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

OP

$0.27

Service Code	NDC 62559-420-07
Hospital Charge Code	1748078
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
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	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

OP

$0.27

Service Code	NDC 62559-420-11
Hospital Charge Code	1748078
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
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	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

IP

$0.27

Service Code	NDC 62559-420-11
Hospital Charge Code	1748078
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.20

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

OP

$0.26

Service Code	NDC 45802-098-46
Hospital Charge Code	1748078
Hospital Revenue Code	259
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

MESALAMINE (BULK) POWDER [111265]

Facility

OP

$4.06

Service Code	NDC 62991-2705-2
Hospital Charge Code	NDG111265
Hospital Revenue Code	259
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$3.04
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	$1.83
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 Beech St/Commercial/PHCS	$3.04

MESALAMINE (BULK) POWDER [111265]

Facility

IP

$4.06

Service Code	NDC 62991-2705-2
Hospital Charge Code	NDG111265
Hospital Revenue Code	259
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$3.25
Rate for Payer: Cash Price	$1.83
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$3.04

MESALAMINE (BULK) POWDER [111265]

Facility

OP

$4.06

Service Code	NDC 62991-2705-1
Hospital Charge Code	NDG111265C
Hospital Revenue Code	259
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$3.04
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	$1.83
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 Beech St/Commercial/PHCS	$3.04

MESALAMINE (BULK) POWDER [111265]

Facility

IP

$4.06

Service Code	NDC 62991-2705-1
Hospital Charge Code	NDG111265C
Hospital Revenue Code	259
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$3.25
Rate for Payer: Cash Price	$1.83
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$3.04

MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE [10533]

Facility

IP

$3.64

Service Code	NDC 54092-189-81
Hospital Charge Code	1711798
Hospital Revenue Code	259
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.64
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.73

MESALAMINE ER 250 MG CAPSULE,EXTENDED RELEASE [10533]

Facility

OP

$3.64

Service Code	NDC 54092-189-81
Hospital Charge Code	1711798
Hospital Revenue Code	259
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.73
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	$1.64
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 Beech St/Commercial/PHCS	$2.73

MESALAMINE ER 500 MG CAPSULE,EXTENDED RELEASE [39575]

Facility

OP

$7.29

Service Code	NDC 54092-191-12
Hospital Charge Code	1711970
Hospital Revenue Code	259
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$5.47
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	$3.28
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 Beech St/Commercial/PHCS	$5.47

MESALAMINE ER 500 MG CAPSULE,EXTENDED RELEASE [39575]

Facility

IP

$7.29

Service Code	NDC 54092-191-12
Hospital Charge Code	1711970
Hospital Revenue Code	259
Min. Negotiated Rate	$4.01
Max. Negotiated Rate	$5.83
Rate for Payer: Cash Price	$3.28
Rate for Payer: Cigna of CA HMO/PPO	$5.83
Rate for Payer: Health Smart Auto/Commercial	$4.37
Rate for Payer: LLUH Dept of Risk Management WC	$4.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.47

MESALAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080297]

Facility

OP

$0.42

Service Code	NDC 9994-0802-97
Hospital Charge Code	1715255
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

MESALAMINE ORAL SUSPENSION COMPOUND 50 MG/ML [4080297]

Facility

IP

$0.42

Service Code	NDC 9994-0802-97
Hospital Charge Code	1715255
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

MESNA 100 MG/ML INTRAVENOUS SOLUTION [10537]

Facility

IP

$2.40

Service Code	CPT J9209
Hospital Charge Code	1758372
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of CA HMO/PPO	$1.92
Rate for Payer: Cigna of CA HMO/PPO	$2.40
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80

MESNA 100 MG/ML INTRAVENOUS SOLUTION [10537]

Facility

OP

$3.00

Service Code	CPT J9209
Hospital Charge Code	1758372
Hospital Revenue Code	636
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.80
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cash Price	$1.08
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: LLUH Dept of Risk Management WC	$1.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.25

METAXALONE 800 MG TABLET [33963]

Facility

OP

$0.72

Service Code	NDC 0527-1435-01
Hospital Charge Code	1712374
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

METAXALONE 800 MG TABLET [33963]

Facility

IP

$1.80

Service Code	NDC 55111-650-01
Hospital Charge Code	1712374
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Cash Price	$0.81
Rate for Payer: Cigna of CA HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.35

METAXALONE 800 MG TABLET [33963]

Facility

IP

$0.72

Service Code	NDC 0527-1435-01
Hospital Charge Code	1712374
Hospital Revenue Code	259
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

METAXALONE 800 MG TABLET [33963]

Facility

IP

$12.75

Service Code	NDC 60793-136-01
Hospital Charge Code	1712374
Hospital Revenue Code	259
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$10.20
Rate for Payer: Cash Price	$5.74
Rate for Payer: Cigna of CA HMO/PPO	$10.20
Rate for Payer: Health Smart Auto/Commercial	$7.65
Rate for Payer: LLUH Dept of Risk Management WC	$7.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.56

METAXALONE 800 MG TABLET [33963]

Facility

OP

$1.80

Service Code	NDC 55111-650-01
Hospital Charge Code	1712374
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.08
Rate for Payer: Aetna of CA Government/Medicare	$1.08
Rate for Payer: Cash Price	$0.81
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.35

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