|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$251.52
|
|
|
Service Code
|
NDC 00378800801
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.67 |
| Max. Negotiated Rate |
$226.37 |
| Rate for Payer: Aetna American Axle |
$163.49
|
| Rate for Payer: Aetna Commercial |
$213.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.49
|
| Rate for Payer: Cash Price |
$201.22
|
| Rate for Payer: Cofinity Advantage |
$176.06
|
| Rate for Payer: Cofinity Commercial |
$216.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.22
|
| Rate for Payer: Healthscope Commercial |
$226.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.64
|
| Rate for Payer: PHP Commercial |
$213.79
|
| Rate for Payer: Priority Health SBD |
$158.46
|
| Rate for Payer: UMR Bronson Commercial |
$110.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.64
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$372.96
|
|
|
Service Code
|
NDC 63739099510
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.00 |
| Max. Negotiated Rate |
$335.66 |
| Rate for Payer: Aetna American Axle |
$242.42
|
| Rate for Payer: Aetna Commercial |
$317.02
|
| Rate for Payer: Aetna Medicare |
$186.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.42
|
| Rate for Payer: BCBS Complete |
$149.18
|
| Rate for Payer: Cash Price |
$298.37
|
| Rate for Payer: Cofinity Advantage |
$261.07
|
| Rate for Payer: Cofinity Commercial |
$320.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.37
|
| Rate for Payer: Healthscope Commercial |
$335.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$298.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$279.72
|
| Rate for Payer: PHP Commercial |
$317.02
|
| Rate for Payer: Priority Health SBD |
$234.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$242.42
|
| Rate for Payer: UHC Core |
$194.31
|
| Rate for Payer: UHC Exchange |
$146.57
|
| Rate for Payer: UMR Bronson Commercial |
$138.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.72
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$251.52
|
|
|
Service Code
|
NDC 00378800801
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.06 |
| Max. Negotiated Rate |
$226.37 |
| Rate for Payer: Aetna American Axle |
$163.49
|
| Rate for Payer: Aetna Commercial |
$213.79
|
| Rate for Payer: Aetna Medicare |
$125.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.49
|
| Rate for Payer: BCBS Complete |
$100.61
|
| Rate for Payer: Cash Price |
$201.22
|
| Rate for Payer: Cofinity Advantage |
$176.06
|
| Rate for Payer: Cofinity Commercial |
$216.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$201.22
|
| Rate for Payer: Healthscope Commercial |
$226.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$176.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$201.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$213.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$188.64
|
| Rate for Payer: PHP Commercial |
$213.79
|
| Rate for Payer: Priority Health SBD |
$158.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$163.49
|
| Rate for Payer: UHC Core |
$131.04
|
| Rate for Payer: UHC Exchange |
$98.85
|
| Rate for Payer: UMR Bronson Commercial |
$93.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.64
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$441.75
|
|
|
Service Code
|
NDC 55111053201
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.37 |
| Max. Negotiated Rate |
$397.57 |
| Rate for Payer: Aetna American Axle |
$287.14
|
| Rate for Payer: Aetna Commercial |
$375.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.14
|
| Rate for Payer: Cash Price |
$353.40
|
| Rate for Payer: Cofinity Advantage |
$309.23
|
| Rate for Payer: Cofinity Commercial |
$379.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.40
|
| Rate for Payer: Healthscope Commercial |
$397.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$309.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$331.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$331.31
|
| Rate for Payer: PHP Commercial |
$375.49
|
| Rate for Payer: Priority Health SBD |
$278.30
|
| Rate for Payer: UMR Bronson Commercial |
$194.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.31
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$451.20
|
|
|
Service Code
|
NDC 68084031301
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.94 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna American Axle |
$293.28
|
| Rate for Payer: Aetna Commercial |
$383.52
|
| Rate for Payer: Aetna Medicare |
$225.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.28
|
| Rate for Payer: BCBS Complete |
$180.48
|
| Rate for Payer: Cash Price |
$360.96
|
| Rate for Payer: Cofinity Advantage |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$388.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$360.96
|
| Rate for Payer: Healthscope Commercial |
$406.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$315.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$338.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$360.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$383.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$338.40
|
| Rate for Payer: PHP Commercial |
$383.52
|
| Rate for Payer: Priority Health SBD |
$284.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$293.28
|
| Rate for Payer: UHC Core |
$235.08
|
| Rate for Payer: UHC Exchange |
$177.32
|
| Rate for Payer: UMR Bronson Commercial |
$166.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$338.40
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$372.96
|
|
|
Service Code
|
NDC 63739099510
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.10 |
| Max. Negotiated Rate |
$335.66 |
| Rate for Payer: Aetna American Axle |
$242.42
|
| Rate for Payer: Aetna Commercial |
$317.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.42
|
| Rate for Payer: Cash Price |
$298.37
|
| Rate for Payer: Cofinity Advantage |
$261.07
|
| Rate for Payer: Cofinity Commercial |
$320.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.37
|
| Rate for Payer: Healthscope Commercial |
$335.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$279.72
|
| Rate for Payer: PHP Commercial |
$317.02
|
| Rate for Payer: Priority Health SBD |
$234.96
|
| Rate for Payer: UMR Bronson Commercial |
$164.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.72
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
NDC 68084031311
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna American Axle |
$2.94
|
| Rate for Payer: Aetna Commercial |
$3.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.94
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cofinity Advantage |
$3.16
|
| Rate for Payer: Cofinity Commercial |
$3.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.62
|
| Rate for Payer: Healthscope Commercial |
$4.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.39
|
| Rate for Payer: PHP Commercial |
$3.84
|
| Rate for Payer: Priority Health SBD |
$2.85
|
| Rate for Payer: UMR Bronson Commercial |
$1.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.39
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$302.10
|
|
|
Service Code
|
NDC 68382010601
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.78 |
| Max. Negotiated Rate |
$271.89 |
| Rate for Payer: Aetna American Axle |
$196.37
|
| Rate for Payer: Aetna Commercial |
$256.79
|
| Rate for Payer: Aetna Medicare |
$151.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$196.37
|
| Rate for Payer: BCBS Complete |
$120.84
|
| Rate for Payer: Cash Price |
$241.68
|
| Rate for Payer: Cofinity Advantage |
$211.47
|
| Rate for Payer: Cofinity Commercial |
$259.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.68
|
| Rate for Payer: Healthscope Commercial |
$271.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$211.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$226.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$241.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$256.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$226.57
|
| Rate for Payer: PHP Commercial |
$256.79
|
| Rate for Payer: Priority Health SBD |
$190.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$196.37
|
| Rate for Payer: UHC Core |
$157.39
|
| Rate for Payer: UHC Exchange |
$118.73
|
| Rate for Payer: UMR Bronson Commercial |
$111.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$226.57
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
IP
|
$302.10
|
|
|
Service Code
|
NDC 68382010601
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.92 |
| Max. Negotiated Rate |
$271.89 |
| Rate for Payer: Aetna American Axle |
$196.37
|
| Rate for Payer: Aetna Commercial |
$256.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$196.37
|
| Rate for Payer: Cash Price |
$241.68
|
| Rate for Payer: Cofinity Advantage |
$211.47
|
| Rate for Payer: Cofinity Commercial |
$259.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.68
|
| Rate for Payer: Healthscope Commercial |
$271.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$211.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$226.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$256.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$226.57
|
| Rate for Payer: PHP Commercial |
$256.79
|
| Rate for Payer: Priority Health SBD |
$190.32
|
| Rate for Payer: UMR Bronson Commercial |
$132.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$226.57
|
|
|
DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE
|
Facility
|
OP
|
$441.75
|
|
|
Service Code
|
NDC 55111053201
|
| Hospital Charge Code |
27631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.45 |
| Max. Negotiated Rate |
$397.57 |
| Rate for Payer: Aetna American Axle |
$287.14
|
| Rate for Payer: Aetna Commercial |
$375.49
|
| Rate for Payer: Aetna Medicare |
$220.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.14
|
| Rate for Payer: BCBS Complete |
$176.70
|
| Rate for Payer: Cash Price |
$353.40
|
| Rate for Payer: Cofinity Advantage |
$309.23
|
| Rate for Payer: Cofinity Commercial |
$379.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.40
|
| Rate for Payer: Healthscope Commercial |
$397.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$309.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$331.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$353.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$331.31
|
| Rate for Payer: PHP Commercial |
$375.49
|
| Rate for Payer: Priority Health SBD |
$278.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$287.14
|
| Rate for Payer: UHC Core |
$230.15
|
| Rate for Payer: UHC Exchange |
$173.61
|
| Rate for Payer: UMR Bronson Commercial |
$163.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.31
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$136.30
|
|
|
Service Code
|
NDC 57237010601
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.43 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna American Axle |
$88.59
|
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna Medicare |
$68.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.59
|
| Rate for Payer: BCBS Complete |
$54.52
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Advantage |
$95.41
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$109.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$102.22
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health SBD |
$85.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$88.59
|
| Rate for Payer: UHC Core |
$71.01
|
| Rate for Payer: UHC Exchange |
$53.57
|
| Rate for Payer: UMR Bronson Commercial |
$50.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$87.99
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.56 |
| Max. Negotiated Rate |
$79.19 |
| Rate for Payer: Aetna American Axle |
$57.19
|
| Rate for Payer: Aetna Commercial |
$74.79
|
| Rate for Payer: Aetna Medicare |
$43.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.19
|
| Rate for Payer: BCBS Complete |
$35.20
|
| Rate for Payer: Cash Price |
$70.39
|
| Rate for Payer: Cofinity Advantage |
$61.59
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.39
|
| Rate for Payer: Healthscope Commercial |
$79.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$70.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$65.99
|
| Rate for Payer: PHP Commercial |
$74.79
|
| Rate for Payer: Priority Health SBD |
$55.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$57.19
|
| Rate for Payer: UHC Core |
$45.84
|
| Rate for Payer: UHC Exchange |
$34.58
|
| Rate for Payer: UMR Bronson Commercial |
$32.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.99
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$87.99
|
|
|
Service Code
|
NDC 60687021121
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.72 |
| Max. Negotiated Rate |
$79.19 |
| Rate for Payer: Aetna American Axle |
$57.19
|
| Rate for Payer: Aetna Commercial |
$74.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.19
|
| Rate for Payer: Cash Price |
$70.39
|
| Rate for Payer: Cofinity Advantage |
$61.59
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.39
|
| Rate for Payer: Healthscope Commercial |
$79.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$65.99
|
| Rate for Payer: PHP Commercial |
$74.79
|
| Rate for Payer: Priority Health SBD |
$55.43
|
| Rate for Payer: UMR Bronson Commercial |
$38.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.99
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$138.65
|
|
|
Service Code
|
NDC 62756079688
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.30 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna American Axle |
$90.12
|
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna Medicare |
$69.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: BCBS Complete |
$55.46
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Advantage |
$97.06
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$110.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.99
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health SBD |
$87.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$90.12
|
| Rate for Payer: UHC Core |
$72.24
|
| Rate for Payer: UHC Exchange |
$54.49
|
| Rate for Payer: UMR Bronson Commercial |
$51.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.99
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$2.94
|
|
|
Service Code
|
NDC 60687021111
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna American Axle |
$1.91
|
| Rate for Payer: Aetna Commercial |
$2.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.91
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cofinity Advantage |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.35
|
| Rate for Payer: Healthscope Commercial |
$2.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.21
|
| Rate for Payer: PHP Commercial |
$2.50
|
| Rate for Payer: Priority Health SBD |
$1.85
|
| Rate for Payer: UMR Bronson Commercial |
$1.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.21
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$136.30
|
|
|
Service Code
|
NDC 57237010601
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.97 |
| Max. Negotiated Rate |
$122.67 |
| Rate for Payer: Aetna American Axle |
$88.59
|
| Rate for Payer: Aetna Commercial |
$115.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.59
|
| Rate for Payer: Cash Price |
$109.04
|
| Rate for Payer: Cofinity Advantage |
$95.41
|
| Rate for Payer: Cofinity Commercial |
$117.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.04
|
| Rate for Payer: Healthscope Commercial |
$122.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$102.22
|
| Rate for Payer: PHP Commercial |
$115.86
|
| Rate for Payer: Priority Health SBD |
$85.87
|
| Rate for Payer: UMR Bronson Commercial |
$59.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.22
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$2.94
|
|
|
Service Code
|
NDC 60687021111
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$2.65 |
| Rate for Payer: Aetna American Axle |
$1.91
|
| Rate for Payer: Aetna Commercial |
$2.50
|
| Rate for Payer: Aetna Medicare |
$1.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.91
|
| Rate for Payer: BCBS Complete |
$1.18
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cofinity Advantage |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.35
|
| Rate for Payer: Healthscope Commercial |
$2.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.21
|
| Rate for Payer: PHP Commercial |
$2.50
|
| Rate for Payer: Priority Health SBD |
$1.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.91
|
| Rate for Payer: UHC Core |
$1.53
|
| Rate for Payer: UHC Exchange |
$1.16
|
| Rate for Payer: UMR Bronson Commercial |
$1.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.21
|
|
|
DIVALPROEX 125 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$138.65
|
|
|
Service Code
|
NDC 62756079688
|
| Hospital Charge Code |
2551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.01 |
| Max. Negotiated Rate |
$124.78 |
| Rate for Payer: Aetna American Axle |
$90.12
|
| Rate for Payer: Aetna Commercial |
$117.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.12
|
| Rate for Payer: Cash Price |
$110.92
|
| Rate for Payer: Cofinity Advantage |
$97.06
|
| Rate for Payer: Cofinity Commercial |
$119.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.92
|
| Rate for Payer: Healthscope Commercial |
$124.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$103.99
|
| Rate for Payer: PHP Commercial |
$117.85
|
| Rate for Payer: Priority Health SBD |
$87.35
|
| Rate for Payer: UMR Bronson Commercial |
$61.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.99
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3.74
|
|
|
Service Code
|
NDC 68084077611
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$3.37 |
| Rate for Payer: Aetna American Axle |
$2.43
|
| Rate for Payer: Aetna Commercial |
$3.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.43
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Advantage |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.81
|
| Rate for Payer: PHP Commercial |
$3.18
|
| Rate for Payer: Priority Health SBD |
$2.36
|
| Rate for Payer: UMR Bronson Commercial |
$1.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.81
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$3.67
|
|
|
Service Code
|
NDC 60687086811
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$3.30 |
| Rate for Payer: Aetna American Axle |
$2.39
|
| Rate for Payer: Aetna Commercial |
$3.12
|
| Rate for Payer: Aetna Medicare |
$1.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.39
|
| Rate for Payer: BCBS Complete |
$1.47
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cofinity Advantage |
$2.57
|
| Rate for Payer: Cofinity Commercial |
$3.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.94
|
| Rate for Payer: Healthscope Commercial |
$3.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.75
|
| Rate for Payer: PHP Commercial |
$3.12
|
| Rate for Payer: Priority Health SBD |
$2.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.39
|
| Rate for Payer: UHC Core |
$1.91
|
| Rate for Payer: UHC Exchange |
$1.44
|
| Rate for Payer: UMR Bronson Commercial |
$1.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.75
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$373.65
|
|
|
Service Code
|
NDC 68084077601
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.25 |
| Max. Negotiated Rate |
$336.29 |
| Rate for Payer: Aetna American Axle |
$242.87
|
| Rate for Payer: Aetna Commercial |
$317.60
|
| Rate for Payer: Aetna Medicare |
$186.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.87
|
| Rate for Payer: BCBS Complete |
$149.46
|
| Rate for Payer: Cash Price |
$298.92
|
| Rate for Payer: Cofinity Advantage |
$261.56
|
| Rate for Payer: Cofinity Commercial |
$321.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.92
|
| Rate for Payer: Healthscope Commercial |
$336.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$298.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$280.24
|
| Rate for Payer: PHP Commercial |
$317.60
|
| Rate for Payer: Priority Health SBD |
$235.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$242.87
|
| Rate for Payer: UHC Core |
$194.67
|
| Rate for Payer: UHC Exchange |
$146.84
|
| Rate for Payer: UMR Bronson Commercial |
$138.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.24
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$366.60
|
|
|
Service Code
|
NDC 60687086801
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.30 |
| Max. Negotiated Rate |
$329.94 |
| Rate for Payer: Aetna American Axle |
$238.29
|
| Rate for Payer: Aetna Commercial |
$311.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$238.29
|
| Rate for Payer: Cash Price |
$293.28
|
| Rate for Payer: Cofinity Advantage |
$256.62
|
| Rate for Payer: Cofinity Commercial |
$315.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$293.28
|
| Rate for Payer: Healthscope Commercial |
$329.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$256.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$274.95
|
| Rate for Payer: PHP Commercial |
$311.61
|
| Rate for Payer: Priority Health SBD |
$230.96
|
| Rate for Payer: UMR Bronson Commercial |
$161.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.95
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$3.67
|
|
|
Service Code
|
NDC 60687086811
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$3.30 |
| Rate for Payer: Aetna American Axle |
$2.39
|
| Rate for Payer: Aetna Commercial |
$3.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.39
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cofinity Advantage |
$2.57
|
| Rate for Payer: Cofinity Commercial |
$3.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.94
|
| Rate for Payer: Healthscope Commercial |
$3.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.75
|
| Rate for Payer: PHP Commercial |
$3.12
|
| Rate for Payer: Priority Health SBD |
$2.31
|
| Rate for Payer: UMR Bronson Commercial |
$1.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.75
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
OP
|
$366.60
|
|
|
Service Code
|
NDC 60687086801
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.64 |
| Max. Negotiated Rate |
$329.94 |
| Rate for Payer: Aetna American Axle |
$238.29
|
| Rate for Payer: Aetna Commercial |
$311.61
|
| Rate for Payer: Aetna Medicare |
$183.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$238.29
|
| Rate for Payer: BCBS Complete |
$146.64
|
| Rate for Payer: Cash Price |
$293.28
|
| Rate for Payer: Cofinity Advantage |
$256.62
|
| Rate for Payer: Cofinity Commercial |
$315.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$293.28
|
| Rate for Payer: Healthscope Commercial |
$329.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$256.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$293.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$274.95
|
| Rate for Payer: PHP Commercial |
$311.61
|
| Rate for Payer: Priority Health SBD |
$230.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$238.29
|
| Rate for Payer: UHC Core |
$191.00
|
| Rate for Payer: UHC Exchange |
$144.07
|
| Rate for Payer: UMR Bronson Commercial |
$135.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.95
|
|
|
DIVALPROEX 250 MG TABLET,DELAYED RELEASE
|
Facility
|
IP
|
$373.65
|
|
|
Service Code
|
NDC 68084077601
|
| Hospital Charge Code |
2552
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.41 |
| Max. Negotiated Rate |
$336.29 |
| Rate for Payer: Aetna American Axle |
$242.87
|
| Rate for Payer: Aetna Commercial |
$317.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.87
|
| Rate for Payer: Cash Price |
$298.92
|
| Rate for Payer: Cofinity Advantage |
$261.56
|
| Rate for Payer: Cofinity Commercial |
$321.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.92
|
| Rate for Payer: Healthscope Commercial |
$336.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$261.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$280.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$317.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$280.24
|
| Rate for Payer: PHP Commercial |
$317.60
|
| Rate for Payer: Priority Health SBD |
$235.40
|
| Rate for Payer: UMR Bronson Commercial |
$164.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$280.24
|
|
