Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM

Facility

$19.09

Service Code	NDC 0904-5354-31
Hospital Charge Code	16299
Hospital Revenue Code	637
Min. Negotiated Rate	$13.36
Max. Negotiated Rate	$19.09
Rate for Payer: Aetna Commercial	$17.18
Rate for Payer: ASR ASR	$18.52
Rate for Payer: BCBS Trust/PPO	$14.80
Rate for Payer: BCN Commercial	$14.80
Rate for Payer: Cash Price	$15.27
Rate for Payer: Cofinity Commercial	$17.94
Rate for Payer: Encore Health Key Benefits Commercial	$15.27
Rate for Payer: Healthscope Commercial	$19.09
Rate for Payer: Healthscope Whirlpool	$18.52
Rate for Payer: Mclaren Commercial	$17.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.23
Rate for Payer: Priority Health Cigna Priority Health	$13.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$16.80

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$361.95

Service Code	NDC 59762-1061-1
Hospital Charge Code	2516
Hospital Revenue Code	637
Min. Negotiated Rate	$253.36
Max. Negotiated Rate	$361.95
Rate for Payer: Aetna Commercial	$325.76
Rate for Payer: ASR ASR	$351.09
Rate for Payer: BCBS Trust/PPO	$280.62
Rate for Payer: BCN Commercial	$280.62
Rate for Payer: Cash Price	$289.56
Rate for Payer: Cofinity Commercial	$340.23
Rate for Payer: Encore Health Key Benefits Commercial	$289.56
Rate for Payer: Healthscope Commercial	$361.95
Rate for Payer: Healthscope Whirlpool	$351.09
Rate for Payer: Mclaren Commercial	$325.76
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$307.66
Rate for Payer: Priority Health Cigna Priority Health	$253.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$318.52

DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET

Facility

$312.48

Service Code	NDC 0378-0415-01
Hospital Charge Code	2516
Hospital Revenue Code	637
Min. Negotiated Rate	$218.74
Max. Negotiated Rate	$312.48
Rate for Payer: Aetna Commercial	$281.23
Rate for Payer: ASR ASR	$303.11
Rate for Payer: BCBS Trust/PPO	$242.27
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 Multiplan/Beech St/PHCS	$265.61
Rate for Payer: Priority Health Cigna Priority Health	$218.74
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$274.98

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

Facility

$90.22

Service Code	HCPCS 90700
Hospital Charge Code	118045
Hospital Revenue Code	636
Min. Negotiated Rate	$63.15
Max. Negotiated Rate	$90.22
Rate for Payer: Aetna Commercial	$81.20
Rate for Payer: ASR ASR	$87.51
Rate for Payer: BCBS Trust/PPO	$69.95
Rate for Payer: BCN Commercial	$69.95
Rate for Payer: Cash Price	$72.17
Rate for Payer: Cofinity Commercial	$84.81
Rate for Payer: Encore Health Key Benefits Commercial	$72.18
Rate for Payer: Healthscope Commercial	$90.22
Rate for Payer: Healthscope Whirlpool	$87.51
Rate for Payer: Mclaren Commercial	$81.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$76.69
Rate for Payer: Priority Health Cigna Priority Health	$63.15
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$79.39

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

Facility

$161.17

Service Code	HCPCS 90715
Hospital Charge Code	41628
Hospital Revenue Code	636
Min. Negotiated Rate	$112.82
Max. Negotiated Rate	$161.17
Rate for Payer: Aetna Commercial	$145.05
Rate for Payer: ASR ASR	$156.33
Rate for Payer: BCBS Trust/PPO	$124.96
Rate for Payer: BCN Commercial	$124.96
Rate for Payer: Cash Price	$128.93
Rate for Payer: Cofinity Commercial	$151.50
Rate for Payer: Encore Health Key Benefits Commercial	$128.94
Rate for Payer: Healthscope Commercial	$161.17
Rate for Payer: Healthscope Whirlpool	$156.33
Rate for Payer: Mclaren Commercial	$145.05
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$136.99
Rate for Payer: Priority Health Cigna Priority Health	$112.82
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$141.83

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

Facility

$194.97

Service Code	HCPCS 90715
Hospital Charge Code	166805
Hospital Revenue Code	636
Min. Negotiated Rate	$136.48
Max. Negotiated Rate	$194.97
Rate for Payer: Aetna Commercial	$175.47
Rate for Payer: ASR ASR	$189.12
Rate for Payer: BCBS Trust/PPO	$151.16
Rate for Payer: BCN Commercial	$151.16
Rate for Payer: Cash Price	$155.97
Rate for Payer: Cofinity Commercial	$183.27
Rate for Payer: Encore Health Key Benefits Commercial	$155.98
Rate for Payer: Healthscope Commercial	$194.97
Rate for Payer: Healthscope Whirlpool	$189.12
Rate for Payer: Mclaren Commercial	$175.47
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$165.72
Rate for Payer: Priority Health Cigna Priority Health	$136.48
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$171.57

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC

Facility

$12,217.26

Service Code	MS-DRG 442
Min. Negotiated Rate	$9,249.87
Max. Negotiated Rate	$12,217.26
Rate for Payer: Aetna Medicare	$9,736.71
Rate for Payer: Allen County Amish Medical Aid Commercial	$12,170.89
Rate for Payer: Amish Plain Church Group Commercial	$12,170.89
Rate for Payer: BCBS MAPPO	$9,736.71
Rate for Payer: BCN Medicare Advantage	$9,736.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$9,736.71
Rate for Payer: Humana Choice PPO Medicare	$9,736.71
Rate for Payer: Mclaren Medicare	$9,736.71
Rate for Payer: Meridian Wellcare - Medicare Advantage	$10,223.55
Rate for Payer: MI Amish Medical Board Commercial	$11,197.22
Rate for Payer: PACE Medicare	$9,249.87
Rate for Payer: PACE SWMI	$9,736.71
Rate for Payer: PHP Commercial	$10,710.38
Rate for Payer: PHP Medicare Advantage	$9,736.71
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12,217.26
Rate for Payer: Priority Health Medicare	$9,736.71
Rate for Payer: Priority Health Narrow Network	$9,773.81
Rate for Payer: Railroad Medicare Medicare	$9,736.71
Rate for Payer: UHC Medicare Advantage	$10,028.81
Rate for Payer: VA VA	$9,736.71

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC

Facility

$23,474.09

Service Code	MS-DRG 441
Min. Negotiated Rate	$16,301.25
Max. Negotiated Rate	$23,474.09
Rate for Payer: Aetna Medicare	$17,159.21
Rate for Payer: Allen County Amish Medical Aid Commercial	$21,449.01
Rate for Payer: Amish Plain Church Group Commercial	$21,449.01
Rate for Payer: BCBS MAPPO	$17,159.21
Rate for Payer: BCN Medicare Advantage	$17,159.21
Rate for Payer: Health Alliance Plan Medicare Advantage	$17,159.21
Rate for Payer: Humana Choice PPO Medicare	$17,159.21
Rate for Payer: Mclaren Medicare	$17,159.21
Rate for Payer: Meridian Wellcare - Medicare Advantage	$18,017.17
Rate for Payer: MI Amish Medical Board Commercial	$19,733.09
Rate for Payer: PACE Medicare	$16,301.25
Rate for Payer: PACE SWMI	$17,159.21
Rate for Payer: PHP Commercial	$18,875.13
Rate for Payer: PHP Medicare Advantage	$17,159.21
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$23,474.09
Rate for Payer: Priority Health Medicare	$17,159.21
Rate for Payer: Priority Health Narrow Network	$18,779.27
Rate for Payer: Railroad Medicare Medicare	$17,159.21
Rate for Payer: UHC Medicare Advantage	$17,673.99
Rate for Payer: VA VA	$17,159.21

DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$9,664.85

Service Code	MS-DRG 443
Min. Negotiated Rate	$7,341.40
Max. Negotiated Rate	$9,664.85
Rate for Payer: Aetna Medicare	$7,731.88
Rate for Payer: Allen County Amish Medical Aid Commercial	$9,664.85
Rate for Payer: Amish Plain Church Group Commercial	$9,664.85
Rate for Payer: BCBS MAPPO	$7,731.88
Rate for Payer: BCN Medicare Advantage	$7,731.88
Rate for Payer: Health Alliance Plan Medicare Advantage	$7,731.88
Rate for Payer: Humana Choice PPO Medicare	$7,731.88
Rate for Payer: Mclaren Medicare	$7,731.88
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,118.47
Rate for Payer: MI Amish Medical Board Commercial	$8,891.66
Rate for Payer: PACE Medicare	$7,345.29
Rate for Payer: PACE SWMI	$7,731.88
Rate for Payer: PHP Commercial	$8,505.07
Rate for Payer: PHP Medicare Advantage	$7,731.88
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,176.75
Rate for Payer: Priority Health Medicare	$7,731.88
Rate for Payer: Priority Health Narrow Network	$7,341.40
Rate for Payer: Railroad Medicare Medicare	$7,731.88
Rate for Payer: UHC Medicare Advantage	$7,963.84
Rate for Payer: VA VA	$7,731.88

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC

Facility

$11,151.75

Service Code	MS-DRG 439
Min. Negotiated Rate	$8,475.33
Max. Negotiated Rate	$11,151.75
Rate for Payer: Aetna Medicare	$8,921.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$11,151.75
Rate for Payer: Amish Plain Church Group Commercial	$11,151.75
Rate for Payer: BCBS MAPPO	$8,921.40
Rate for Payer: BCN Medicare Advantage	$8,921.40
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,921.40
Rate for Payer: Humana Choice PPO Medicare	$8,921.40
Rate for Payer: Mclaren Medicare	$8,921.40
Rate for Payer: Meridian Wellcare - Medicare Advantage	$9,367.47
Rate for Payer: MI Amish Medical Board Commercial	$10,259.61
Rate for Payer: PACE Medicare	$8,475.33
Rate for Payer: PACE SWMI	$8,921.40
Rate for Payer: PHP Commercial	$9,813.54
Rate for Payer: PHP Medicare Advantage	$8,921.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,980.77
Rate for Payer: Priority Health Medicare	$8,921.40
Rate for Payer: Priority Health Narrow Network	$8,784.62
Rate for Payer: Railroad Medicare Medicare	$8,921.40
Rate for Payer: UHC Medicare Advantage	$9,189.04
Rate for Payer: VA VA	$8,921.40

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC

Facility

$21,427.39

Service Code	MS-DRG 438
Min. Negotiated Rate	$15,019.18
Max. Negotiated Rate	$21,427.39
Rate for Payer: Aetna Medicare	$15,809.66
Rate for Payer: Allen County Amish Medical Aid Commercial	$19,762.08
Rate for Payer: Amish Plain Church Group Commercial	$19,762.08
Rate for Payer: BCBS MAPPO	$15,809.66
Rate for Payer: BCN Medicare Advantage	$15,809.66
Rate for Payer: Health Alliance Plan Medicare Advantage	$15,809.66
Rate for Payer: Humana Choice PPO Medicare	$15,809.66
Rate for Payer: Mclaren Medicare	$15,809.66
Rate for Payer: Meridian Wellcare - Medicare Advantage	$16,600.14
Rate for Payer: MI Amish Medical Board Commercial	$18,181.11
Rate for Payer: PACE Medicare	$15,019.18
Rate for Payer: PACE SWMI	$15,809.66
Rate for Payer: PHP Commercial	$17,390.63
Rate for Payer: PHP Medicare Advantage	$15,809.66
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$21,427.39
Rate for Payer: Priority Health Medicare	$15,809.66
Rate for Payer: Priority Health Narrow Network	$17,141.91
Rate for Payer: Railroad Medicare Medicare	$15,809.66
Rate for Payer: UHC Medicare Advantage	$16,283.95
Rate for Payer: VA VA	$15,809.66

DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC

Facility

$8,616.06

Service Code	MS-DRG 440
Min. Negotiated Rate	$6,323.44
Max. Negotiated Rate	$8,616.06
Rate for Payer: Aetna Medicare	$6,892.85
Rate for Payer: Allen County Amish Medical Aid Commercial	$8,616.06
Rate for Payer: Amish Plain Church Group Commercial	$8,616.06
Rate for Payer: BCBS MAPPO	$6,892.85
Rate for Payer: BCN Medicare Advantage	$6,892.85
Rate for Payer: Health Alliance Plan Medicare Advantage	$6,892.85
Rate for Payer: Humana Choice PPO Medicare	$6,892.85
Rate for Payer: Mclaren Medicare	$6,892.85
Rate for Payer: Meridian Wellcare - Medicare Advantage	$7,237.49
Rate for Payer: MI Amish Medical Board Commercial	$7,926.78
Rate for Payer: PACE Medicare	$6,548.21
Rate for Payer: PACE SWMI	$6,892.85
Rate for Payer: PHP Commercial	$7,582.14
Rate for Payer: PHP Medicare Advantage	$6,892.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$7,904.30
Rate for Payer: Priority Health Medicare	$6,892.85
Rate for Payer: Priority Health Narrow Network	$6,323.44
Rate for Payer: Railroad Medicare Medicare	$6,892.85
Rate for Payer: UHC Medicare Advantage	$7,099.64
Rate for Payer: VA VA	$6,892.85

DISORDERS OF PERSONALITY AND IMPULSE CONTROL

Facility

$24,080.14

Service Code	MS-DRG 883
Min. Negotiated Rate	$16,680.89
Max. Negotiated Rate	$24,080.14
Rate for Payer: Aetna Medicare	$17,558.83
Rate for Payer: Allen County Amish Medical Aid Commercial	$21,948.54
Rate for Payer: Amish Plain Church Group Commercial	$21,948.54
Rate for Payer: BCBS MAPPO	$17,558.83
Rate for Payer: BCN Medicare Advantage	$17,558.83
Rate for Payer: Health Alliance Plan Medicare Advantage	$17,558.83
Rate for Payer: Humana Choice PPO Medicare	$17,558.83
Rate for Payer: Mclaren Medicare	$17,558.83
Rate for Payer: Meridian Wellcare - Medicare Advantage	$18,436.77
Rate for Payer: MI Amish Medical Board Commercial	$20,192.65
Rate for Payer: PACE Medicare	$16,680.89
Rate for Payer: PACE SWMI	$17,558.83
Rate for Payer: PHP Commercial	$19,314.71
Rate for Payer: PHP Medicare Advantage	$17,558.83
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$24,080.14
Rate for Payer: Priority Health Medicare	$17,558.83
Rate for Payer: Priority Health Narrow Network	$19,264.11
Rate for Payer: Railroad Medicare Medicare	$17,558.83
Rate for Payer: UHC Medicare Advantage	$18,085.59
Rate for Payer: VA VA	$17,558.83

DISORDERS OF THE BILIARY TRACT WITH CC

Facility

$13,954.51

Service Code	MS-DRG 445
Min. Negotiated Rate	$10,338.10
Max. Negotiated Rate	$13,954.51
Rate for Payer: Aetna Medicare	$10,882.21
Rate for Payer: Allen County Amish Medical Aid Commercial	$13,602.76
Rate for Payer: Amish Plain Church Group Commercial	$13,602.76
Rate for Payer: BCBS MAPPO	$10,882.21
Rate for Payer: BCN Medicare Advantage	$10,882.21
Rate for Payer: Health Alliance Plan Medicare Advantage	$10,882.21
Rate for Payer: Humana Choice PPO Medicare	$10,882.21
Rate for Payer: Mclaren Medicare	$10,882.21
Rate for Payer: Meridian Wellcare - Medicare Advantage	$11,426.32
Rate for Payer: MI Amish Medical Board Commercial	$12,514.54
Rate for Payer: PACE Medicare	$10,338.10
Rate for Payer: PACE SWMI	$10,882.21
Rate for Payer: PHP Commercial	$11,970.43
Rate for Payer: PHP Medicare Advantage	$10,882.21
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$13,954.51
Rate for Payer: Priority Health Medicare	$10,882.21
Rate for Payer: Priority Health Narrow Network	$11,163.61
Rate for Payer: Railroad Medicare Medicare	$10,882.21
Rate for Payer: UHC Medicare Advantage	$11,208.68
Rate for Payer: VA VA	$10,882.21

DISORDERS OF THE BILIARY TRACT WITH MCC

Facility

$20,970.29

Service Code	MS-DRG 444
Min. Negotiated Rate	$14,732.84
Max. Negotiated Rate	$20,970.29
Rate for Payer: Aetna Medicare	$15,508.25
Rate for Payer: Allen County Amish Medical Aid Commercial	$19,385.31
Rate for Payer: Amish Plain Church Group Commercial	$19,385.31
Rate for Payer: BCBS MAPPO	$15,508.25
Rate for Payer: BCN Medicare Advantage	$15,508.25
Rate for Payer: Health Alliance Plan Medicare Advantage	$15,508.25
Rate for Payer: Humana Choice PPO Medicare	$15,508.25
Rate for Payer: Mclaren Medicare	$15,508.25
Rate for Payer: Meridian Wellcare - Medicare Advantage	$16,283.66
Rate for Payer: MI Amish Medical Board Commercial	$17,834.49
Rate for Payer: PACE Medicare	$14,732.84
Rate for Payer: PACE SWMI	$15,508.25
Rate for Payer: PHP Commercial	$17,059.08
Rate for Payer: PHP Medicare Advantage	$15,508.25
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$20,970.29
Rate for Payer: Priority Health Medicare	$15,508.25
Rate for Payer: Priority Health Narrow Network	$16,776.23
Rate for Payer: Railroad Medicare Medicare	$15,508.25
Rate for Payer: UHC Medicare Advantage	$15,973.50
Rate for Payer: VA VA	$15,508.25

DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC

Facility

$10,583.44

Service Code	MS-DRG 446
Min. Negotiated Rate	$8,043.41
Max. Negotiated Rate	$10,583.44
Rate for Payer: Aetna Medicare	$8,466.75
Rate for Payer: Allen County Amish Medical Aid Commercial	$10,583.44
Rate for Payer: Amish Plain Church Group Commercial	$10,583.44
Rate for Payer: BCBS MAPPO	$8,466.75
Rate for Payer: BCN Medicare Advantage	$8,466.75
Rate for Payer: Health Alliance Plan Medicare Advantage	$8,466.75
Rate for Payer: Humana Choice PPO Medicare	$8,466.75
Rate for Payer: Mclaren Medicare	$8,466.75
Rate for Payer: Meridian Wellcare - Medicare Advantage	$8,890.09
Rate for Payer: MI Amish Medical Board Commercial	$9,736.76
Rate for Payer: PACE Medicare	$8,043.41
Rate for Payer: PACE SWMI	$8,466.75
Rate for Payer: PHP Commercial	$9,313.42
Rate for Payer: PHP Medicare Advantage	$8,466.75
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10,291.26
Rate for Payer: Priority Health Medicare	$8,466.75
Rate for Payer: Priority Health Narrow Network	$8,233.01
Rate for Payer: Railroad Medicare Medicare	$8,466.75
Rate for Payer: UHC Medicare Advantage	$8,720.75
Rate for Payer: VA VA	$8,466.75

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$3.81

Service Code	NDC 0832-7123-89
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.81
Rate for Payer: Aetna Commercial	$3.43
Rate for Payer: ASR ASR	$3.70
Rate for Payer: BCBS Trust/PPO	$2.95
Rate for Payer: BCN Commercial	$2.95
Rate for Payer: Cash Price	$3.05
Rate for Payer: Cofinity Commercial	$3.58
Rate for Payer: Encore Health Key Benefits Commercial	$3.05
Rate for Payer: Healthscope Commercial	$3.81
Rate for Payer: Healthscope Whirlpool	$3.70
Rate for Payer: Mclaren Commercial	$3.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.24
Rate for Payer: Priority Health Cigna Priority Health	$2.67
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.35

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$333.70

Service Code	NDC 0904-6860-61
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$233.59
Max. Negotiated Rate	$333.70
Rate for Payer: Aetna Commercial	$300.33
Rate for Payer: ASR ASR	$323.69
Rate for Payer: BCBS Trust/PPO	$258.72
Rate for Payer: BCN Commercial	$258.72
Rate for Payer: Cash Price	$266.96
Rate for Payer: Cofinity Commercial	$313.68
Rate for Payer: Encore Health Key Benefits Commercial	$266.96
Rate for Payer: Healthscope Commercial	$333.70
Rate for Payer: Healthscope Whirlpool	$323.69
Rate for Payer: Mclaren Commercial	$300.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$283.64
Rate for Payer: Priority Health Cigna Priority Health	$233.59
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$293.66

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$380.70

Service Code	NDC 0832-7123-01
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$266.49
Max. Negotiated Rate	$380.70
Rate for Payer: Aetna Commercial	$342.63
Rate for Payer: ASR ASR	$369.28
Rate for Payer: BCBS Trust/PPO	$295.16
Rate for Payer: BCN Commercial	$295.16
Rate for Payer: Cash Price	$304.56
Rate for Payer: Cofinity Commercial	$357.86
Rate for Payer: Encore Health Key Benefits Commercial	$304.56
Rate for Payer: Healthscope Commercial	$380.70
Rate for Payer: Healthscope Whirlpool	$369.28
Rate for Payer: Mclaren Commercial	$342.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$323.60
Rate for Payer: Priority Health Cigna Priority Health	$266.49
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$335.02

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$333.70

Service Code	NDC 68084-776-01
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$233.59
Max. Negotiated Rate	$333.70
Rate for Payer: Aetna Commercial	$300.33
Rate for Payer: ASR ASR	$323.69
Rate for Payer: BCBS Trust/PPO	$258.72
Rate for Payer: BCN Commercial	$258.72
Rate for Payer: Cash Price	$266.96
Rate for Payer: Cofinity Commercial	$313.68
Rate for Payer: Encore Health Key Benefits Commercial	$266.96
Rate for Payer: Healthscope Commercial	$333.70
Rate for Payer: Healthscope Whirlpool	$323.69
Rate for Payer: Mclaren Commercial	$300.33
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$283.64
Rate for Payer: Priority Health Cigna Priority Health	$233.59
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$293.66

DIVALPROEX 250 MG TABLET,DELAYED RELEASE

Facility

$3.34

Service Code	NDC 68084-776-11
Hospital Charge Code	2552
Hospital Revenue Code	637
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$3.34
Rate for Payer: Aetna Commercial	$3.01
Rate for Payer: ASR ASR	$3.24
Rate for Payer: BCBS Trust/PPO	$2.59
Rate for Payer: BCN Commercial	$2.59
Rate for Payer: Cash Price	$2.67
Rate for Payer: Cofinity Commercial	$3.14
Rate for Payer: Encore Health Key Benefits Commercial	$2.67
Rate for Payer: Healthscope Commercial	$3.34
Rate for Payer: Healthscope Whirlpool	$3.24
Rate for Payer: Mclaren Commercial	$3.01
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.84
Rate for Payer: Priority Health Cigna Priority Health	$2.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.94

DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$211.85

Service Code	NDC 65162-755-10
Hospital Charge Code	34418
Hospital Revenue Code	637
Min. Negotiated Rate	$148.30
Max. Negotiated Rate	$211.85
Rate for Payer: Aetna Commercial	$190.66
Rate for Payer: ASR ASR	$205.49
Rate for Payer: BCBS Trust/PPO	$164.25
Rate for Payer: BCN Commercial	$164.25
Rate for Payer: Cash Price	$169.48
Rate for Payer: Cofinity Commercial	$199.14
Rate for Payer: Encore Health Key Benefits Commercial	$169.48
Rate for Payer: Healthscope Commercial	$211.85
Rate for Payer: Healthscope Whirlpool	$205.49
Rate for Payer: Mclaren Commercial	$190.66
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$180.07
Rate for Payer: Priority Health Cigna Priority Health	$148.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$186.43

DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$404.16

Service Code	NDC 68084-310-01
Hospital Charge Code	34418
Hospital Revenue Code	637
Min. Negotiated Rate	$282.91
Max. Negotiated Rate	$404.16
Rate for Payer: Aetna Commercial	$363.74
Rate for Payer: ASR ASR	$392.04
Rate for Payer: BCBS Trust/PPO	$313.35
Rate for Payer: BCN Commercial	$313.35
Rate for Payer: Cash Price	$323.33
Rate for Payer: Cofinity Commercial	$379.91
Rate for Payer: Encore Health Key Benefits Commercial	$323.33
Rate for Payer: Healthscope Commercial	$404.16
Rate for Payer: Healthscope Whirlpool	$392.04
Rate for Payer: Mclaren Commercial	$363.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$343.54
Rate for Payer: Priority Health Cigna Priority Health	$282.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$355.66

DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$4.04

Service Code	NDC 68084-310-11
Hospital Charge Code	34418
Hospital Revenue Code	637
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$4.04
Rate for Payer: Aetna Commercial	$3.64
Rate for Payer: ASR ASR	$3.92
Rate for Payer: BCBS Trust/PPO	$3.13
Rate for Payer: BCN Commercial	$3.13
Rate for Payer: Cash Price	$3.23
Rate for Payer: Cofinity Commercial	$3.80
Rate for Payer: Encore Health Key Benefits Commercial	$3.23
Rate for Payer: Healthscope Commercial	$4.04
Rate for Payer: Healthscope Whirlpool	$3.92
Rate for Payer: Mclaren Commercial	$3.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.43
Rate for Payer: Priority Health Cigna Priority Health	$2.83
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.56

DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION

Facility

$20.02

Service Code	HCPCS J1250
Hospital Charge Code	9892
Hospital Revenue Code	636
Min. Negotiated Rate	$14.01
Max. Negotiated Rate	$20.02
Rate for Payer: Aetna Commercial	$18.02
Rate for Payer: Aetna Commercial	$18.34
Rate for Payer: ASR ASR	$19.77
Rate for Payer: ASR ASR	$19.42
Rate for Payer: BCBS Trust/PPO	$15.80
Rate for Payer: BCBS Trust/PPO	$15.52
Rate for Payer: BCN Commercial	$15.52
Rate for Payer: BCN Commercial	$15.80
Rate for Payer: Cash Price	$16.30
Rate for Payer: Cash Price	$16.02
Rate for Payer: Cofinity Commercial	$19.16
Rate for Payer: Cofinity Commercial	$18.82
Rate for Payer: Encore Health Key Benefits Commercial	$16.30
Rate for Payer: Encore Health Key Benefits Commercial	$16.02
Rate for Payer: Healthscope Commercial	$20.38
Rate for Payer: Healthscope Commercial	$20.02
Rate for Payer: Healthscope Whirlpool	$19.42
Rate for Payer: Healthscope Whirlpool	$19.77
Rate for Payer: Mclaren Commercial	$18.34
Rate for Payer: Mclaren Commercial	$18.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.02
Rate for Payer: Priority Health Cigna Priority Health	$14.27
Rate for Payer: Priority Health Cigna Priority Health	$14.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.93
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.62

Know your out-of-pocket cost for care.

All Charges