Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM

Facility

$19.43

Service Code	NDC 00904535431
Hospital Charge Code	16299
Hospital Revenue Code	637
Min. Negotiated Rate	$12.63
Max. Negotiated Rate	$19.43
Rate for Payer: Aetna Commercial	$17.49
Rate for Payer: ASR ASR	$18.85
Rate for Payer: ASR Commercial	$18.85
Rate for Payer: BCBS Trust/PPO	$15.83
Rate for Payer: BCN Commercial	$15.06
Rate for Payer: Cash Price	$15.54
Rate for Payer: Cofinity Commercial	$18.26
Rate for Payer: Encore Health Key Benefits Commercial	$15.54
Rate for Payer: Healthscope Commercial	$19.43
Rate for Payer: Healthscope Whirlpool	$18.85
Rate for Payer: Mclaren Commercial	$17.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.52
Rate for Payer: Nomi Health Commercial	$15.93
Rate for Payer: Priority Health Cigna Priority Health	$12.63
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.10

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM

Facility

$19.43

Service Code	NDC 00904535431
Hospital Charge Code	16299
Hospital Revenue Code	637
Min. Negotiated Rate	$7.77
Max. Negotiated Rate	$19.43
Rate for Payer: Aetna Commercial	$17.49
Rate for Payer: Aetna Medicare	$9.71
Rate for Payer: ASR ASR	$18.85
Rate for Payer: ASR Commercial	$18.85
Rate for Payer: BCBS Complete	$7.77
Rate for Payer: BCBS Trust/PPO	$15.91
Rate for Payer: BCN Commercial	$15.06
Rate for Payer: Cash Price	$15.54
Rate for Payer: Cofinity Commercial	$18.26
Rate for Payer: Encore Health Key Benefits Commercial	$15.54
Rate for Payer: Healthscope Commercial	$19.43
Rate for Payer: Healthscope Whirlpool	$18.85
Rate for Payer: Mclaren Commercial	$17.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.52
Rate for Payer: Nomi Health Commercial	$15.93
Rate for Payer: Priority Health Cigna Priority Health	$12.63
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17.02
Rate for Payer: Priority Health Narrow Network	$13.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.10

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM

Facility

$14.45

Service Code	NDC 70000038801
Hospital Charge Code	16299
Hospital Revenue Code	637
Min. Negotiated Rate	$5.78
Max. Negotiated Rate	$14.45
Rate for Payer: Aetna Commercial	$13.01
Rate for Payer: Aetna Medicare	$7.22
Rate for Payer: ASR ASR	$14.02
Rate for Payer: ASR Commercial	$14.02
Rate for Payer: BCBS Complete	$5.78
Rate for Payer: BCBS Trust/PPO	$11.83
Rate for Payer: BCN Commercial	$11.20
Rate for Payer: Cash Price	$11.56
Rate for Payer: Cofinity Commercial	$13.58
Rate for Payer: Encore Health Key Benefits Commercial	$11.56
Rate for Payer: Healthscope Commercial	$14.45
Rate for Payer: Healthscope Whirlpool	$14.02
Rate for Payer: Mclaren Commercial	$13.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.28
Rate for Payer: Nomi Health Commercial	$11.85
Rate for Payer: Priority Health Cigna Priority Health	$9.39
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12.66
Rate for Payer: Priority Health Narrow Network	$10.13
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.72

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM

Facility

$14.45

Service Code	NDC 70000038801
Hospital Charge Code	16299
Hospital Revenue Code	637
Min. Negotiated Rate	$9.39
Max. Negotiated Rate	$14.45
Rate for Payer: Aetna Commercial	$13.01
Rate for Payer: ASR ASR	$14.02
Rate for Payer: ASR Commercial	$14.02
Rate for Payer: BCBS Trust/PPO	$11.78
Rate for Payer: BCN Commercial	$11.20
Rate for Payer: Cash Price	$11.56
Rate for Payer: Cofinity Commercial	$13.58
Rate for Payer: Encore Health Key Benefits Commercial	$11.56
Rate for Payer: Healthscope Commercial	$14.45
Rate for Payer: Healthscope Whirlpool	$14.02
Rate for Payer: Mclaren Commercial	$13.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.28
Rate for Payer: Nomi Health Commercial	$11.85
Rate for Payer: Priority Health Cigna Priority Health	$9.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.72

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$312.48

Service Code	NDC 00378041501
Hospital Charge Code	2516
Hospital Revenue Code	637
Min. Negotiated Rate	$203.11
Max. Negotiated Rate	$312.48
Rate for Payer: Aetna Commercial	$281.23
Rate for Payer: ASR ASR	$303.11
Rate for Payer: ASR Commercial	$303.11
Rate for Payer: BCBS Trust/PPO	$254.64
Rate for Payer: BCN Commercial	$242.27
Rate for Payer: Cash Price	$249.98
Rate for Payer: Cofinity Commercial	$293.73
Rate for Payer: Encore Health Key Benefits Commercial	$249.98
Rate for Payer: Healthscope Commercial	$312.48
Rate for Payer: Healthscope Whirlpool	$303.11
Rate for Payer: Mclaren Commercial	$281.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$265.61
Rate for Payer: Nomi Health Commercial	$256.23
Rate for Payer: Priority Health Cigna Priority Health	$203.11
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$274.98

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$294.50

Service Code	NDC 69315091001
Hospital Charge Code	2516
Hospital Revenue Code	637
Min. Negotiated Rate	$191.43
Max. Negotiated Rate	$294.50
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: ASR ASR	$285.67
Rate for Payer: ASR Commercial	$285.67
Rate for Payer: BCBS Trust/PPO	$239.99
Rate for Payer: BCN Commercial	$228.33
Rate for Payer: Cash Price	$235.60
Rate for Payer: Cofinity Commercial	$276.83
Rate for Payer: Encore Health Key Benefits Commercial	$235.60
Rate for Payer: Healthscope Commercial	$294.50
Rate for Payer: Healthscope Whirlpool	$285.67
Rate for Payer: Mclaren Commercial	$265.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$250.32
Rate for Payer: Nomi Health Commercial	$241.49
Rate for Payer: Priority Health Cigna Priority Health	$191.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$259.16

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$362.90

Service Code	NDC 59762106101
Hospital Charge Code	2516
Hospital Revenue Code	637
Min. Negotiated Rate	$235.88
Max. Negotiated Rate	$362.90
Rate for Payer: Aetna Commercial	$326.61
Rate for Payer: ASR ASR	$352.01
Rate for Payer: ASR Commercial	$352.01
Rate for Payer: BCBS Trust/PPO	$295.73
Rate for Payer: BCN Commercial	$281.36
Rate for Payer: Cash Price	$290.32
Rate for Payer: Cofinity Commercial	$341.13
Rate for Payer: Encore Health Key Benefits Commercial	$290.32
Rate for Payer: Healthscope Commercial	$362.90
Rate for Payer: Healthscope Whirlpool	$352.01
Rate for Payer: Mclaren Commercial	$326.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$308.46
Rate for Payer: Nomi Health Commercial	$297.58
Rate for Payer: Priority Health Cigna Priority Health	$235.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$319.35

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$312.48

Service Code	NDC 00378041501
Hospital Charge Code	2516
Hospital Revenue Code	637
Min. Negotiated Rate	$124.99
Max. Negotiated Rate	$312.48
Rate for Payer: Aetna Commercial	$281.23
Rate for Payer: Aetna Medicare	$156.24
Rate for Payer: ASR ASR	$303.11
Rate for Payer: ASR Commercial	$303.11
Rate for Payer: BCBS Complete	$124.99
Rate for Payer: BCBS Trust/PPO	$255.89
Rate for Payer: BCN Commercial	$242.27
Rate for Payer: Cash Price	$249.98
Rate for Payer: Cofinity Commercial	$293.73
Rate for Payer: Encore Health Key Benefits Commercial	$249.98
Rate for Payer: Healthscope Commercial	$312.48
Rate for Payer: Healthscope Whirlpool	$303.11
Rate for Payer: Mclaren Commercial	$281.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$265.61
Rate for Payer: Nomi Health Commercial	$256.23
Rate for Payer: Priority Health Cigna Priority Health	$203.11
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$273.79
Rate for Payer: Priority Health Narrow Network	$219.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$274.98

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$294.50

Service Code	NDC 69315091001
Hospital Charge Code	2516
Hospital Revenue Code	637
Min. Negotiated Rate	$117.80
Max. Negotiated Rate	$294.50
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$147.25
Rate for Payer: ASR ASR	$285.67
Rate for Payer: ASR Commercial	$285.67
Rate for Payer: BCBS Complete	$117.80
Rate for Payer: BCBS Trust/PPO	$241.17
Rate for Payer: BCN Commercial	$228.33
Rate for Payer: Cash Price	$235.60
Rate for Payer: Cofinity Commercial	$276.83
Rate for Payer: Encore Health Key Benefits Commercial	$235.60
Rate for Payer: Healthscope Commercial	$294.50
Rate for Payer: Healthscope Whirlpool	$285.67
Rate for Payer: Mclaren Commercial	$265.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$250.32
Rate for Payer: Nomi Health Commercial	$241.49
Rate for Payer: Priority Health Cigna Priority Health	$191.43
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$258.04
Rate for Payer: Priority Health Narrow Network	$206.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$259.16

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$362.90

Service Code	NDC 59762106101
Hospital Charge Code	2516
Hospital Revenue Code	637
Min. Negotiated Rate	$145.16
Max. Negotiated Rate	$362.90
Rate for Payer: Aetna Commercial	$326.61
Rate for Payer: Aetna Medicare	$181.45
Rate for Payer: ASR ASR	$352.01
Rate for Payer: ASR Commercial	$352.01
Rate for Payer: BCBS Complete	$145.16
Rate for Payer: BCBS Trust/PPO	$297.18
Rate for Payer: BCN Commercial	$281.36
Rate for Payer: Cash Price	$290.32
Rate for Payer: Cofinity Commercial	$341.13
Rate for Payer: Encore Health Key Benefits Commercial	$290.32
Rate for Payer: Healthscope Commercial	$362.90
Rate for Payer: Healthscope Whirlpool	$352.01
Rate for Payer: Mclaren Commercial	$326.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$308.46
Rate for Payer: Nomi Health Commercial	$297.58
Rate for Payer: Priority Health Cigna Priority Health	$235.88
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$317.97
Rate for Payer: Priority Health Narrow Network	$254.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$319.35

DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP

Facility

$94.87

Service Code	HCPCS 90700
Hospital Charge Code	118045
Hospital Revenue Code	636
Min. Negotiated Rate	$37.95
Max. Negotiated Rate	$94.87
Rate for Payer: Aetna Commercial	$85.38
Rate for Payer: Aetna Medicare	$47.44
Rate for Payer: ASR ASR	$92.02
Rate for Payer: ASR Commercial	$92.02
Rate for Payer: BCBS Complete	$37.95
Rate for Payer: BCBS Trust/PPO	$77.69
Rate for Payer: BCN Commercial	$73.55
Rate for Payer: Cash Price	$75.90
Rate for Payer: Cofinity Commercial	$89.18
Rate for Payer: Encore Health Key Benefits Commercial	$75.90
Rate for Payer: Healthscope Commercial	$94.87
Rate for Payer: Healthscope Whirlpool	$92.02
Rate for Payer: Mclaren Commercial	$85.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$80.64
Rate for Payer: Nomi Health Commercial	$77.79
Rate for Payer: Priority Health Cigna Priority Health	$61.67
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$83.13
Rate for Payer: Priority Health Narrow Network	$66.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$83.49

DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP

Facility

$94.87

Service Code	HCPCS 90700
Hospital Charge Code	118045
Hospital Revenue Code	636
Min. Negotiated Rate	$61.67
Max. Negotiated Rate	$94.87
Rate for Payer: Aetna Commercial	$85.38
Rate for Payer: ASR ASR	$92.02
Rate for Payer: ASR Commercial	$92.02
Rate for Payer: BCBS Trust/PPO	$77.31
Rate for Payer: BCN Commercial	$73.55
Rate for Payer: Cash Price	$75.90
Rate for Payer: Cofinity Commercial	$89.18
Rate for Payer: Encore Health Key Benefits Commercial	$75.90
Rate for Payer: Healthscope Commercial	$94.87
Rate for Payer: Healthscope Whirlpool	$92.02
Rate for Payer: Mclaren Commercial	$85.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$80.64
Rate for Payer: Nomi Health Commercial	$77.79
Rate for Payer: Priority Health Cigna Priority Health	$61.67
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$83.49

DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP

Facility

$165.70

Service Code	HCPCS 90715
Hospital Charge Code	41628
Hospital Revenue Code	636
Min. Negotiated Rate	$107.70
Max. Negotiated Rate	$165.70
Rate for Payer: Aetna Commercial	$149.13
Rate for Payer: ASR ASR	$160.73
Rate for Payer: ASR Commercial	$160.73
Rate for Payer: BCBS Trust/PPO	$135.03
Rate for Payer: BCN Commercial	$128.47
Rate for Payer: Cash Price	$132.56
Rate for Payer: Cofinity Commercial	$155.76
Rate for Payer: Encore Health Key Benefits Commercial	$132.56
Rate for Payer: Healthscope Commercial	$165.70
Rate for Payer: Healthscope Whirlpool	$160.73
Rate for Payer: Mclaren Commercial	$149.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$140.84
Rate for Payer: Nomi Health Commercial	$135.87
Rate for Payer: Priority Health Cigna Priority Health	$107.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$145.82

DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP

Facility

$165.70

Service Code	HCPCS 90715
Hospital Charge Code	41628
Hospital Revenue Code	636
Min. Negotiated Rate	$66.28
Max. Negotiated Rate	$165.70
Rate for Payer: Aetna Commercial	$149.13
Rate for Payer: Aetna Medicare	$82.85
Rate for Payer: ASR ASR	$160.73
Rate for Payer: ASR Commercial	$160.73
Rate for Payer: BCBS Complete	$66.28
Rate for Payer: BCBS Trust/PPO	$135.69
Rate for Payer: BCN Commercial	$128.47
Rate for Payer: Cash Price	$132.56
Rate for Payer: Cofinity Commercial	$155.76
Rate for Payer: Encore Health Key Benefits Commercial	$132.56
Rate for Payer: Healthscope Commercial	$165.70
Rate for Payer: Healthscope Whirlpool	$160.73
Rate for Payer: Mclaren Commercial	$149.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$140.84
Rate for Payer: Nomi Health Commercial	$135.87
Rate for Payer: Priority Health Cigna Priority Health	$107.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$145.19
Rate for Payer: Priority Health Narrow Network	$116.16
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$145.82

DIPHTH,PERTUSSIS(ACELL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5 ML IM SUSP

Facility

$196.04

Service Code	HCPCS 90715
Hospital Charge Code	166805
Hospital Revenue Code	636
Min. Negotiated Rate	$127.43
Max. Negotiated Rate	$196.04
Rate for Payer: Aetna Commercial	$176.44
Rate for Payer: ASR ASR	$190.16
Rate for Payer: ASR Commercial	$190.16
Rate for Payer: BCBS Trust/PPO	$159.75
Rate for Payer: BCN Commercial	$151.99
Rate for Payer: Cash Price	$156.83
Rate for Payer: Cofinity Commercial	$184.28
Rate for Payer: Encore Health Key Benefits Commercial	$156.83
Rate for Payer: Healthscope Commercial	$196.04
Rate for Payer: Healthscope Whirlpool	$190.16
Rate for Payer: Mclaren Commercial	$176.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$166.63
Rate for Payer: Nomi Health Commercial	$160.75
Rate for Payer: Priority Health Cigna Priority Health	$127.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$172.52

DIPHTH,PERTUSSIS(ACELL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5 ML IM SUSP

Facility

$196.04

Service Code	HCPCS 90715
Hospital Charge Code	166805
Hospital Revenue Code	636
Min. Negotiated Rate	$78.42
Max. Negotiated Rate	$196.04
Rate for Payer: Aetna Commercial	$176.44
Rate for Payer: Aetna Medicare	$98.02
Rate for Payer: ASR ASR	$190.16
Rate for Payer: ASR Commercial	$190.16
Rate for Payer: BCBS Complete	$78.42
Rate for Payer: BCBS Trust/PPO	$160.54
Rate for Payer: BCN Commercial	$151.99
Rate for Payer: Cash Price	$156.83
Rate for Payer: Cofinity Commercial	$184.28
Rate for Payer: Encore Health Key Benefits Commercial	$156.83
Rate for Payer: Healthscope Commercial	$196.04
Rate for Payer: Healthscope Whirlpool	$190.16
Rate for Payer: Mclaren Commercial	$176.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$166.63
Rate for Payer: Nomi Health Commercial	$160.75
Rate for Payer: Priority Health Cigna Priority Health	$127.43
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$171.77
Rate for Payer: Priority Health Narrow Network	$137.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$172.52

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$3.74

Service Code	NDC 00832712389
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$2.43
Max. Negotiated Rate	$3.74
Rate for Payer: Aetna Commercial	$3.37
Rate for Payer: ASR ASR	$3.63
Rate for Payer: ASR Commercial	$3.63
Rate for Payer: BCBS Trust/PPO	$3.05
Rate for Payer: BCN Commercial	$2.90
Rate for Payer: Cash Price	$2.99
Rate for Payer: Cofinity Commercial	$3.52
Rate for Payer: Encore Health Key Benefits Commercial	$2.99
Rate for Payer: Healthscope Commercial	$3.74
Rate for Payer: Healthscope Whirlpool	$3.63
Rate for Payer: Mclaren Commercial	$3.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.18
Rate for Payer: Nomi Health Commercial	$3.07
Rate for Payer: Priority Health Cigna Priority Health	$2.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.29

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$338.40

Service Code	NDC 00904686061
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$135.36
Max. Negotiated Rate	$338.40
Rate for Payer: Aetna Commercial	$304.56
Rate for Payer: Aetna Medicare	$169.20
Rate for Payer: ASR ASR	$328.25
Rate for Payer: ASR Commercial	$328.25
Rate for Payer: BCBS Complete	$135.36
Rate for Payer: BCBS Trust/PPO	$277.12
Rate for Payer: BCN Commercial	$262.36
Rate for Payer: Cash Price	$270.72
Rate for Payer: Cofinity Commercial	$318.10
Rate for Payer: Encore Health Key Benefits Commercial	$270.72
Rate for Payer: Healthscope Commercial	$338.40
Rate for Payer: Healthscope Whirlpool	$328.25
Rate for Payer: Mclaren Commercial	$304.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$287.64
Rate for Payer: Nomi Health Commercial	$277.49
Rate for Payer: Priority Health Cigna Priority Health	$219.96
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$296.51
Rate for Payer: Priority Health Narrow Network	$237.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$297.79

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$338.40

Service Code	NDC 00904686061
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$219.96
Max. Negotiated Rate	$338.40
Rate for Payer: Aetna Commercial	$304.56
Rate for Payer: ASR ASR	$328.25
Rate for Payer: ASR Commercial	$328.25
Rate for Payer: BCBS Trust/PPO	$275.76
Rate for Payer: BCN Commercial	$262.36
Rate for Payer: Cash Price	$270.72
Rate for Payer: Cofinity Commercial	$318.10
Rate for Payer: Encore Health Key Benefits Commercial	$270.72
Rate for Payer: Healthscope Commercial	$338.40
Rate for Payer: Healthscope Whirlpool	$328.25
Rate for Payer: Mclaren Commercial	$304.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$287.64
Rate for Payer: Nomi Health Commercial	$277.49
Rate for Payer: Priority Health Cigna Priority Health	$219.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$297.79

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$373.65

Service Code	NDC 00832712301
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$242.87
Max. Negotiated Rate	$373.65
Rate for Payer: Aetna Commercial	$336.29
Rate for Payer: ASR ASR	$362.44
Rate for Payer: ASR Commercial	$362.44
Rate for Payer: BCBS Trust/PPO	$304.49
Rate for Payer: BCN Commercial	$289.69
Rate for Payer: Cash Price	$298.92
Rate for Payer: Cofinity Commercial	$351.23
Rate for Payer: Encore Health Key Benefits Commercial	$298.92
Rate for Payer: Healthscope Commercial	$373.65
Rate for Payer: Healthscope Whirlpool	$362.44
Rate for Payer: Mclaren Commercial	$336.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$317.60
Rate for Payer: Nomi Health Commercial	$306.39
Rate for Payer: Priority Health Cigna Priority Health	$242.87
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$328.81

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$373.65

Service Code	NDC 68084077601
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$149.46
Max. Negotiated Rate	$373.65
Rate for Payer: Aetna Commercial	$336.29
Rate for Payer: Aetna Medicare	$186.82
Rate for Payer: ASR ASR	$362.44
Rate for Payer: ASR Commercial	$362.44
Rate for Payer: BCBS Complete	$149.46
Rate for Payer: BCBS Trust/PPO	$305.98
Rate for Payer: BCN Commercial	$289.69
Rate for Payer: Cash Price	$298.92
Rate for Payer: Cofinity Commercial	$351.23
Rate for Payer: Encore Health Key Benefits Commercial	$298.92
Rate for Payer: Healthscope Commercial	$373.65
Rate for Payer: Healthscope Whirlpool	$362.44
Rate for Payer: Mclaren Commercial	$336.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$317.60
Rate for Payer: Nomi Health Commercial	$306.39
Rate for Payer: Priority Health Cigna Priority Health	$242.87
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$327.39
Rate for Payer: Priority Health Narrow Network	$261.93
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$328.81

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$373.65

Service Code	NDC 68084077601
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$242.87
Max. Negotiated Rate	$373.65
Rate for Payer: Aetna Commercial	$336.29
Rate for Payer: ASR ASR	$362.44
Rate for Payer: ASR Commercial	$362.44
Rate for Payer: BCBS Trust/PPO	$304.49
Rate for Payer: BCN Commercial	$289.69
Rate for Payer: Cash Price	$298.92
Rate for Payer: Cofinity Commercial	$351.23
Rate for Payer: Encore Health Key Benefits Commercial	$298.92
Rate for Payer: Healthscope Commercial	$373.65
Rate for Payer: Healthscope Whirlpool	$362.44
Rate for Payer: Mclaren Commercial	$336.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$317.60
Rate for Payer: Nomi Health Commercial	$306.39
Rate for Payer: Priority Health Cigna Priority Health	$242.87
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$328.81

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$373.65

Service Code	NDC 00832712301
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$149.46
Max. Negotiated Rate	$373.65
Rate for Payer: Aetna Commercial	$336.29
Rate for Payer: Aetna Medicare	$186.82
Rate for Payer: ASR ASR	$362.44
Rate for Payer: ASR Commercial	$362.44
Rate for Payer: BCBS Complete	$149.46
Rate for Payer: BCBS Trust/PPO	$305.98
Rate for Payer: BCN Commercial	$289.69
Rate for Payer: Cash Price	$298.92
Rate for Payer: Cofinity Commercial	$351.23
Rate for Payer: Encore Health Key Benefits Commercial	$298.92
Rate for Payer: Healthscope Commercial	$373.65
Rate for Payer: Healthscope Whirlpool	$362.44
Rate for Payer: Mclaren Commercial	$336.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$317.60
Rate for Payer: Nomi Health Commercial	$306.39
Rate for Payer: Priority Health Cigna Priority Health	$242.87
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$327.39
Rate for Payer: Priority Health Narrow Network	$261.93
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$328.81

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$3.74

Service Code	NDC 68084077611
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$3.74
Rate for Payer: Aetna Commercial	$3.37
Rate for Payer: Aetna Medicare	$1.87
Rate for Payer: ASR ASR	$3.63
Rate for Payer: ASR Commercial	$3.63
Rate for Payer: BCBS Complete	$1.50
Rate for Payer: BCBS Trust/PPO	$3.06
Rate for Payer: BCN Commercial	$2.90
Rate for Payer: Cash Price	$2.99
Rate for Payer: Cofinity Commercial	$3.52
Rate for Payer: Encore Health Key Benefits Commercial	$2.99
Rate for Payer: Healthscope Commercial	$3.74
Rate for Payer: Healthscope Whirlpool	$3.63
Rate for Payer: Mclaren Commercial	$3.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.18
Rate for Payer: Nomi Health Commercial	$3.07
Rate for Payer: Priority Health Cigna Priority Health	$2.43
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.28
Rate for Payer: Priority Health Narrow Network	$2.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.29

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$3.74

Service Code	NDC 00832712389
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$3.74
Rate for Payer: Aetna Commercial	$3.37
Rate for Payer: Aetna Medicare	$1.87
Rate for Payer: ASR ASR	$3.63
Rate for Payer: ASR Commercial	$3.63
Rate for Payer: BCBS Complete	$1.50
Rate for Payer: BCBS Trust/PPO	$3.06
Rate for Payer: BCN Commercial	$2.90
Rate for Payer: Cash Price	$2.99
Rate for Payer: Cofinity Commercial	$3.52
Rate for Payer: Encore Health Key Benefits Commercial	$2.99
Rate for Payer: Healthscope Commercial	$3.74
Rate for Payer: Healthscope Whirlpool	$3.63
Rate for Payer: Mclaren Commercial	$3.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.18
Rate for Payer: Nomi Health Commercial	$3.07
Rate for Payer: Priority Health Cigna Priority Health	$2.43
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.28
Rate for Payer: Priority Health Narrow Network	$2.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.29

Know your out-of-pocket cost for care.

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