|
ESCITALOPRAM 20 MG TABLET
|
Facility
|
IP
|
$2.74
|
|
|
Service Code
|
NDC 51079054401
|
| Hospital Charge Code |
33513
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: BCBS Trust/PPO |
$2.26
|
| Rate for Payer: BCN Commercial |
$2.26
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$2.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.33
|
| Rate for Payer: Nomi Health Commercial |
$2.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.06
|
| Rate for Payer: PHP Commercial |
$2.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.41
|
| Rate for Payer: UHC Core |
$2.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.06
|
|
|
ESCITALOPRAM 20 MG TABLET
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
NDC 51079054401
|
| Hospital Charge Code |
33513
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: Aetna Medicare |
$0.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.86
|
| Rate for Payer: BCBS Complete |
$0.51
|
| Rate for Payer: BCBS MAPPO |
$0.69
|
| Rate for Payer: BCBS Trust/PPO |
$2.25
|
| Rate for Payer: BCN Commercial |
$2.25
|
| Rate for Payer: BCN Medicare Advantage |
$0.69
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.69
|
| Rate for Payer: Healthscope Commercial |
$2.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.06
|
| Rate for Payer: Mclaren Medicaid |
$0.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.72
|
| Rate for Payer: Meridian Medicaid |
$0.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.79
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.33
|
| Rate for Payer: Nomi Health Commercial |
$2.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.06
|
| Rate for Payer: PACE Senior Care Partners |
$0.65
|
| Rate for Payer: PACE SWMI |
$0.69
|
| Rate for Payer: PHP Commercial |
$2.33
|
| Rate for Payer: PHP Medicare Advantage |
$0.69
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.48
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.38
|
| Rate for Payer: Priority Health Medicare |
$0.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.91
|
| Rate for Payer: Railroad Medicare Medicare |
$0.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.41
|
| Rate for Payer: UHC Core |
$2.29
|
| Rate for Payer: UHC Exchange |
$0.69
|
| Rate for Payer: UHC Medicaid |
$0.48
|
| Rate for Payer: UHC Medicare Advantage |
$0.69
|
| Rate for Payer: UHCCP Medicaid |
$0.48
|
| Rate for Payer: VA VA |
$0.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.06
|
|
|
ESCITALOPRAM 5 MG TABLET
|
Facility
|
IP
|
$86.95
|
|
|
Service Code
|
NDC 43547028010
|
| Hospital Charge Code |
37635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.52 |
| Max. Negotiated Rate |
$78.25 |
| Rate for Payer: Aetna Commercial |
$73.91
|
| Rate for Payer: BCBS Trust/PPO |
$71.81
|
| Rate for Payer: BCN Commercial |
$71.81
|
| Rate for Payer: Cash Price |
$69.56
|
| Rate for Payer: Cofinity Commercial |
$74.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.56
|
| Rate for Payer: Healthscope Commercial |
$78.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.91
|
| Rate for Payer: Nomi Health Commercial |
$71.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$65.21
|
| Rate for Payer: PHP Commercial |
$73.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$75.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$60.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$76.52
|
| Rate for Payer: UHC Core |
$72.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.21
|
|
|
ESCITALOPRAM 5 MG TABLET
|
Facility
|
OP
|
$86.95
|
|
|
Service Code
|
NDC 43547028010
|
| Hospital Charge Code |
37635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.33 |
| Max. Negotiated Rate |
$78.25 |
| Rate for Payer: Aetna Commercial |
$73.91
|
| Rate for Payer: Aetna Medicare |
$22.61
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27.17
|
| Rate for Payer: BCBS Complete |
$16.09
|
| Rate for Payer: BCBS MAPPO |
$21.74
|
| Rate for Payer: BCBS Trust/PPO |
$71.48
|
| Rate for Payer: BCN Commercial |
$71.48
|
| Rate for Payer: BCN Medicare Advantage |
$21.74
|
| Rate for Payer: Cash Price |
$69.56
|
| Rate for Payer: Cofinity Commercial |
$74.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$21.74
|
| Rate for Payer: Healthscope Commercial |
$78.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.21
|
| Rate for Payer: Mclaren Medicaid |
$15.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$22.82
|
| Rate for Payer: Meridian Medicaid |
$16.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.00
|
| Rate for Payer: Molina Medicare/Medicaid |
$23.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.91
|
| Rate for Payer: Nomi Health Commercial |
$71.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$65.21
|
| Rate for Payer: PACE Senior Care Partners |
$20.65
|
| Rate for Payer: PACE SWMI |
$21.74
|
| Rate for Payer: PHP Commercial |
$73.91
|
| Rate for Payer: PHP Medicare Advantage |
$21.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$15.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$75.65
|
| Rate for Payer: Priority Health Medicare |
$21.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$60.52
|
| Rate for Payer: Railroad Medicare Medicare |
$21.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$76.52
|
| Rate for Payer: UHC Core |
$72.60
|
| Rate for Payer: UHC Exchange |
$21.74
|
| Rate for Payer: UHC Medicaid |
$15.33
|
| Rate for Payer: UHC Medicare Advantage |
$21.74
|
| Rate for Payer: UHCCP Medicaid |
$15.33
|
| Rate for Payer: VA VA |
$21.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.21
|
|
|
ESCITALOPRAM 5 MG TABLET
|
Facility
|
OP
|
$218.55
|
|
|
Service Code
|
NDC 65862037301
|
| Hospital Charge Code |
37635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.53 |
| Max. Negotiated Rate |
$196.69 |
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: Aetna Medicare |
$56.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$68.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$68.30
|
| Rate for Payer: BCBS Complete |
$40.45
|
| Rate for Payer: BCBS MAPPO |
$54.64
|
| Rate for Payer: BCBS Trust/PPO |
$179.67
|
| Rate for Payer: BCN Commercial |
$179.67
|
| Rate for Payer: BCN Medicare Advantage |
$54.64
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$54.64
|
| Rate for Payer: Healthscope Commercial |
$196.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.91
|
| Rate for Payer: Mclaren Medicaid |
$38.53
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$57.37
|
| Rate for Payer: Meridian Medicaid |
$40.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$62.83
|
| Rate for Payer: Molina Medicare/Medicaid |
$60.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$185.77
|
| Rate for Payer: Nomi Health Commercial |
$179.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$163.91
|
| Rate for Payer: PACE Senior Care Partners |
$51.91
|
| Rate for Payer: PACE SWMI |
$54.64
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: PHP Medicare Advantage |
$54.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$38.53
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$190.14
|
| Rate for Payer: Priority Health Medicare |
$55.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$152.11
|
| Rate for Payer: Railroad Medicare Medicare |
$54.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$192.32
|
| Rate for Payer: UHC Core |
$182.49
|
| Rate for Payer: UHC Exchange |
$54.64
|
| Rate for Payer: UHC Medicaid |
$38.53
|
| Rate for Payer: UHC Medicare Advantage |
$54.64
|
| Rate for Payer: UHCCP Medicaid |
$38.53
|
| Rate for Payer: VA VA |
$54.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.91
|
|
|
ESCITALOPRAM 5 MG TABLET
|
Facility
|
IP
|
$218.55
|
|
|
Service Code
|
NDC 65862037301
|
| Hospital Charge Code |
37635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.11 |
| Max. Negotiated Rate |
$196.69 |
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: BCBS Trust/PPO |
$180.50
|
| Rate for Payer: BCN Commercial |
$180.50
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.84
|
| Rate for Payer: Healthscope Commercial |
$196.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$185.77
|
| Rate for Payer: Nomi Health Commercial |
$179.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$163.91
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$190.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$152.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$192.32
|
| Rate for Payer: UHC Core |
$182.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.91
|
|
|
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$50.33
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
9957
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.03 |
| Max. Negotiated Rate |
$45.30 |
| Rate for Payer: Aetna Commercial |
$42.78
|
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Aetna Commercial |
$22.18
|
| Rate for Payer: Aetna Commercial |
$63.14
|
| Rate for Payer: BCBS Trust/PPO |
$41.57
|
| Rate for Payer: BCBS Trust/PPO |
$61.35
|
| Rate for Payer: BCBS Trust/PPO |
$22.72
|
| Rate for Payer: BCBS Trust/PPO |
$21.56
|
| Rate for Payer: BCN Commercial |
$41.57
|
| Rate for Payer: BCN Commercial |
$21.56
|
| Rate for Payer: BCN Commercial |
$61.35
|
| Rate for Payer: BCN Commercial |
$22.72
|
| Rate for Payer: Cash Price |
$22.01
|
| Rate for Payer: Cash Price |
$40.26
|
| Rate for Payer: Cash Price |
$59.42
|
| Rate for Payer: Cash Price |
$20.88
|
| Rate for Payer: Cofinity Commercial |
$22.45
|
| Rate for Payer: Cofinity Commercial |
$63.88
|
| Rate for Payer: Cofinity Commercial |
$43.28
|
| Rate for Payer: Cofinity Commercial |
$23.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.42
|
| Rate for Payer: Healthscope Commercial |
$66.85
|
| Rate for Payer: Healthscope Commercial |
$24.76
|
| Rate for Payer: Healthscope Commercial |
$45.30
|
| Rate for Payer: Healthscope Commercial |
$23.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.14
|
| Rate for Payer: Nomi Health Commercial |
$21.40
|
| Rate for Payer: Nomi Health Commercial |
$22.56
|
| Rate for Payer: Nomi Health Commercial |
$60.91
|
| Rate for Payer: Nomi Health Commercial |
$41.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$37.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.71
|
| Rate for Payer: PHP Commercial |
$63.14
|
| Rate for Payer: PHP Commercial |
$22.18
|
| Rate for Payer: PHP Commercial |
$23.38
|
| Rate for Payer: PHP Commercial |
$42.78
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$43.79
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$64.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$22.71
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$23.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$51.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$44.29
|
| Rate for Payer: UHC Core |
$42.03
|
| Rate for Payer: UHC Core |
$62.02
|
| Rate for Payer: UHC Core |
$22.97
|
| Rate for Payer: UHC Core |
$21.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.75
|
|
|
ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26.10
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
9957
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.60 |
| Max. Negotiated Rate |
$23.49 |
| Rate for Payer: Aetna Commercial |
$22.18
|
| Rate for Payer: Aetna Commercial |
$42.78
|
| Rate for Payer: Aetna Commercial |
$63.14
|
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Aetna Medicare |
$7.15
|
| Rate for Payer: Aetna Medicare |
$6.79
|
| Rate for Payer: Aetna Medicare |
$13.09
|
| Rate for Payer: Aetna Medicare |
$19.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$15.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$15.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.16
|
| Rate for Payer: BCBS Complete |
$13.75
|
| Rate for Payer: BCBS Complete |
$5.09
|
| Rate for Payer: BCBS Complete |
$4.83
|
| Rate for Payer: BCBS Complete |
$9.32
|
| Rate for Payer: BCBS MAPPO |
$6.53
|
| Rate for Payer: BCBS MAPPO |
$6.88
|
| Rate for Payer: BCBS MAPPO |
$18.57
|
| Rate for Payer: BCBS MAPPO |
$12.58
|
| Rate for Payer: BCBS Trust/PPO |
$41.38
|
| Rate for Payer: BCBS Trust/PPO |
$21.46
|
| Rate for Payer: BCBS Trust/PPO |
$61.07
|
| Rate for Payer: BCBS Trust/PPO |
$22.62
|
| Rate for Payer: BCN Commercial |
$41.38
|
| Rate for Payer: BCN Commercial |
$61.07
|
| Rate for Payer: BCN Commercial |
$22.62
|
| Rate for Payer: BCN Commercial |
$21.46
|
| Rate for Payer: BCN Medicare Advantage |
$12.58
|
| Rate for Payer: BCN Medicare Advantage |
$6.88
|
| Rate for Payer: BCN Medicare Advantage |
$18.57
|
| Rate for Payer: BCN Medicare Advantage |
$6.53
|
| Rate for Payer: Cash Price |
$59.42
|
| Rate for Payer: Cash Price |
$40.26
|
| Rate for Payer: Cash Price |
$20.88
|
| Rate for Payer: Cash Price |
$22.01
|
| Rate for Payer: Cofinity Commercial |
$23.66
|
| Rate for Payer: Cofinity Commercial |
$22.45
|
| Rate for Payer: Cofinity Commercial |
$43.28
|
| Rate for Payer: Cofinity Commercial |
$63.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.53
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$12.58
|
| Rate for Payer: Healthscope Commercial |
$23.49
|
| Rate for Payer: Healthscope Commercial |
$66.85
|
| Rate for Payer: Healthscope Commercial |
$45.30
|
| Rate for Payer: Healthscope Commercial |
$24.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.57
|
| Rate for Payer: Mclaren Medicaid |
$8.87
|
| Rate for Payer: Mclaren Medicaid |
$4.85
|
| Rate for Payer: Mclaren Medicaid |
$4.60
|
| Rate for Payer: Mclaren Medicaid |
$13.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$13.21
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.85
|
| Rate for Payer: Meridian Medicaid |
$4.83
|
| Rate for Payer: Meridian Medicaid |
$9.32
|
| Rate for Payer: Meridian Medicaid |
$13.75
|
| Rate for Payer: Meridian Medicaid |
$5.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.91
|
| Rate for Payer: Molina Medicare/Medicaid |
$7.57
|
| Rate for Payer: Molina Medicare/Medicaid |
$7.18
|
| Rate for Payer: Molina Medicare/Medicaid |
$13.84
|
| Rate for Payer: Molina Medicare/Medicaid |
$20.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.14
|
| Rate for Payer: Nomi Health Commercial |
$41.27
|
| Rate for Payer: Nomi Health Commercial |
$21.40
|
| Rate for Payer: Nomi Health Commercial |
$22.56
|
| Rate for Payer: Nomi Health Commercial |
$60.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$37.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.57
|
| Rate for Payer: PACE Senior Care Partners |
$11.95
|
| Rate for Payer: PACE Senior Care Partners |
$17.64
|
| Rate for Payer: PACE Senior Care Partners |
$6.20
|
| Rate for Payer: PACE Senior Care Partners |
$6.53
|
| Rate for Payer: PACE SWMI |
$6.53
|
| Rate for Payer: PACE SWMI |
$18.57
|
| Rate for Payer: PACE SWMI |
$6.88
|
| Rate for Payer: PACE SWMI |
$12.58
|
| Rate for Payer: PHP Commercial |
$22.18
|
| Rate for Payer: PHP Commercial |
$23.38
|
| Rate for Payer: PHP Commercial |
$42.78
|
| Rate for Payer: PHP Commercial |
$63.14
|
| Rate for Payer: PHP Medicare Advantage |
$6.53
|
| Rate for Payer: PHP Medicare Advantage |
$18.57
|
| Rate for Payer: PHP Medicare Advantage |
$6.88
|
| Rate for Payer: PHP Medicare Advantage |
$12.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.85
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.60
|
| Rate for Payer: Priority Health Choice Medicaid |
$13.10
|
| Rate for Payer: Priority Health Choice Medicaid |
$8.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$43.79
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$64.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$23.93
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$22.71
|
| Rate for Payer: Priority Health Medicare |
$6.95
|
| Rate for Payer: Priority Health Medicare |
$6.59
|
| Rate for Payer: Priority Health Medicare |
$12.71
|
| Rate for Payer: Priority Health Medicare |
$18.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$51.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$35.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.17
|
| Rate for Payer: Railroad Medicare Medicare |
$12.58
|
| Rate for Payer: Railroad Medicare Medicare |
$6.53
|
| Rate for Payer: Railroad Medicare Medicare |
$18.57
|
| Rate for Payer: Railroad Medicare Medicare |
$6.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$44.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.37
|
| Rate for Payer: UHC Core |
$21.79
|
| Rate for Payer: UHC Core |
$42.03
|
| Rate for Payer: UHC Core |
$22.97
|
| Rate for Payer: UHC Core |
$62.02
|
| Rate for Payer: UHC Exchange |
$12.58
|
| Rate for Payer: UHC Exchange |
$6.88
|
| Rate for Payer: UHC Exchange |
$18.57
|
| Rate for Payer: UHC Exchange |
$6.53
|
| Rate for Payer: UHC Medicaid |
$4.60
|
| Rate for Payer: UHC Medicaid |
$4.85
|
| Rate for Payer: UHC Medicaid |
$8.87
|
| Rate for Payer: UHC Medicaid |
$13.10
|
| Rate for Payer: UHC Medicare Advantage |
$6.88
|
| Rate for Payer: UHC Medicare Advantage |
$6.53
|
| Rate for Payer: UHC Medicare Advantage |
$18.57
|
| Rate for Payer: UHC Medicare Advantage |
$12.58
|
| Rate for Payer: UHCCP Medicaid |
$8.87
|
| Rate for Payer: UHCCP Medicaid |
$13.10
|
| Rate for Payer: UHCCP Medicaid |
$4.85
|
| Rate for Payer: UHCCP Medicaid |
$4.60
|
| Rate for Payer: VA VA |
$6.53
|
| Rate for Payer: VA VA |
$18.57
|
| Rate for Payer: VA VA |
$12.58
|
| Rate for Payer: VA VA |
$6.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.71
|
|
|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV
|
Facility
|
OP
|
$366.56
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
29805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$64.62 |
| Max. Negotiated Rate |
$329.90 |
| Rate for Payer: Aetna Commercial |
$311.58
|
| Rate for Payer: Aetna Medicare |
$95.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.55
|
| Rate for Payer: BCBS Complete |
$67.85
|
| Rate for Payer: BCBS MAPPO |
$91.64
|
| Rate for Payer: BCBS Trust/PPO |
$301.35
|
| Rate for Payer: BCN Commercial |
$301.35
|
| Rate for Payer: BCN Medicare Advantage |
$91.64
|
| Rate for Payer: Cash Price |
$293.25
|
| Rate for Payer: Cofinity Commercial |
$315.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$293.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.64
|
| Rate for Payer: Healthscope Commercial |
$329.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.92
|
| Rate for Payer: Mclaren Medicaid |
$64.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.22
|
| Rate for Payer: Meridian Medicaid |
$67.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.39
|
| Rate for Payer: Molina Medicare/Medicaid |
$100.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.58
|
| Rate for Payer: Nomi Health Commercial |
$300.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$274.92
|
| Rate for Payer: PACE Senior Care Partners |
$87.06
|
| Rate for Payer: PACE SWMI |
$91.64
|
| Rate for Payer: PHP Commercial |
$311.58
|
| Rate for Payer: PHP Medicare Advantage |
$91.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$64.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$318.91
|
| Rate for Payer: Priority Health Medicare |
$92.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$255.13
|
| Rate for Payer: Railroad Medicare Medicare |
$91.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$322.57
|
| Rate for Payer: UHC Core |
$306.08
|
| Rate for Payer: UHC Exchange |
$91.64
|
| Rate for Payer: UHC Medicaid |
$64.62
|
| Rate for Payer: UHC Medicare Advantage |
$91.64
|
| Rate for Payer: UHCCP Medicaid |
$64.62
|
| Rate for Payer: VA VA |
$91.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.92
|
|
|
ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV
|
Facility
|
IP
|
$366.56
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
29805
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$255.13 |
| Max. Negotiated Rate |
$329.90 |
| Rate for Payer: Aetna Commercial |
$311.58
|
| Rate for Payer: BCBS Trust/PPO |
$302.74
|
| Rate for Payer: BCN Commercial |
$302.74
|
| Rate for Payer: Cash Price |
$293.25
|
| Rate for Payer: Cofinity Commercial |
$315.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$293.25
|
| Rate for Payer: Healthscope Commercial |
$329.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$274.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$311.58
|
| Rate for Payer: Nomi Health Commercial |
$300.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$274.92
|
| Rate for Payer: PHP Commercial |
$311.58
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$318.91
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$255.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$322.57
|
| Rate for Payer: UHC Core |
$306.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$274.92
|
|
|
ESTRADIOL 0.5 MG TABLET
|
Facility
|
IP
|
$143.35
|
|
|
Service Code
|
NDC 70954056410
|
| Hospital Charge Code |
12491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.77 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Aetna Commercial |
$121.85
|
| Rate for Payer: BCBS Trust/PPO |
$118.39
|
| Rate for Payer: BCN Commercial |
$118.39
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Commercial |
$123.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Healthscope Commercial |
$129.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.85
|
| Rate for Payer: Nomi Health Commercial |
$117.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$107.51
|
| Rate for Payer: PHP Commercial |
$121.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$124.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.15
|
| Rate for Payer: UHC Core |
$119.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.51
|
|
|
ESTRADIOL 0.5 MG TABLET
|
Facility
|
OP
|
$238.45
|
|
|
Service Code
|
NDC 00555089902
|
| Hospital Charge Code |
12491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.04 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna Medicare |
$62.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$74.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$74.52
|
| Rate for Payer: BCBS Complete |
$44.14
|
| Rate for Payer: BCBS MAPPO |
$59.61
|
| Rate for Payer: BCBS Trust/PPO |
$196.03
|
| Rate for Payer: BCN Commercial |
$196.03
|
| Rate for Payer: BCN Medicare Advantage |
$59.61
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$59.61
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Mclaren Medicaid |
$42.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$62.59
|
| Rate for Payer: Meridian Medicaid |
$44.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.55
|
| Rate for Payer: Molina Medicare/Medicaid |
$65.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Nomi Health Commercial |
$195.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: PACE Senior Care Partners |
$56.63
|
| Rate for Payer: PACE SWMI |
$59.61
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: PHP Medicare Advantage |
$59.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$42.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$207.45
|
| Rate for Payer: Priority Health Medicare |
$60.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$165.96
|
| Rate for Payer: Railroad Medicare Medicare |
$59.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.84
|
| Rate for Payer: UHC Core |
$199.11
|
| Rate for Payer: UHC Exchange |
$59.61
|
| Rate for Payer: UHC Medicaid |
$42.04
|
| Rate for Payer: UHC Medicare Advantage |
$59.61
|
| Rate for Payer: UHCCP Medicaid |
$42.04
|
| Rate for Payer: VA VA |
$59.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
ESTRADIOL 0.5 MG TABLET
|
Facility
|
OP
|
$143.35
|
|
|
Service Code
|
NDC 70954056410
|
| Hospital Charge Code |
12491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.27 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Aetna Commercial |
$121.85
|
| Rate for Payer: Aetna Medicare |
$37.27
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$44.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$44.80
|
| Rate for Payer: BCBS Complete |
$26.53
|
| Rate for Payer: BCBS MAPPO |
$35.84
|
| Rate for Payer: BCBS Trust/PPO |
$117.85
|
| Rate for Payer: BCN Commercial |
$117.85
|
| Rate for Payer: BCN Medicare Advantage |
$35.84
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Commercial |
$123.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$35.84
|
| Rate for Payer: Healthscope Commercial |
$129.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.51
|
| Rate for Payer: Mclaren Medicaid |
$25.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$37.63
|
| Rate for Payer: Meridian Medicaid |
$26.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.21
|
| Rate for Payer: Molina Medicare/Medicaid |
$39.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.85
|
| Rate for Payer: Nomi Health Commercial |
$117.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$107.51
|
| Rate for Payer: PACE Senior Care Partners |
$34.05
|
| Rate for Payer: PACE SWMI |
$35.84
|
| Rate for Payer: PHP Commercial |
$121.85
|
| Rate for Payer: PHP Medicare Advantage |
$35.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$25.27
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$124.71
|
| Rate for Payer: Priority Health Medicare |
$36.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$99.77
|
| Rate for Payer: Railroad Medicare Medicare |
$35.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.15
|
| Rate for Payer: UHC Core |
$119.70
|
| Rate for Payer: UHC Exchange |
$35.84
|
| Rate for Payer: UHC Medicaid |
$25.27
|
| Rate for Payer: UHC Medicare Advantage |
$35.84
|
| Rate for Payer: UHCCP Medicaid |
$25.27
|
| Rate for Payer: VA VA |
$35.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.51
|
|
|
ESTRADIOL 0.5 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 00555089902
|
| Hospital Charge Code |
12491
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.96 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: BCBS Trust/PPO |
$196.94
|
| Rate for Payer: BCN Commercial |
$196.94
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Nomi Health Commercial |
$195.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$207.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$165.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$209.84
|
| Rate for Payer: UHC Core |
$199.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
IP
|
$213.01
|
|
|
Service Code
|
NDC 00386000111
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.25 |
| Max. Negotiated Rate |
$191.71 |
| Rate for Payer: Aetna Commercial |
$181.06
|
| Rate for Payer: BCBS Trust/PPO |
$175.92
|
| Rate for Payer: BCN Commercial |
$175.92
|
| Rate for Payer: Cash Price |
$170.41
|
| Rate for Payer: Cofinity Commercial |
$183.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.41
|
| Rate for Payer: Healthscope Commercial |
$191.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.06
|
| Rate for Payer: Nomi Health Commercial |
$174.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$159.76
|
| Rate for Payer: PHP Commercial |
$181.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$185.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$148.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$187.45
|
| Rate for Payer: UHC Core |
$177.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.76
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
OP
|
$118.96
|
|
|
Service Code
|
NDC 00386000103
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.97 |
| Max. Negotiated Rate |
$107.06 |
| Rate for Payer: Aetna Commercial |
$101.12
|
| Rate for Payer: Aetna Medicare |
$30.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$37.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$37.17
|
| Rate for Payer: BCBS Complete |
$22.02
|
| Rate for Payer: BCBS MAPPO |
$29.74
|
| Rate for Payer: BCBS Trust/PPO |
$97.80
|
| Rate for Payer: BCN Commercial |
$97.80
|
| Rate for Payer: BCN Medicare Advantage |
$29.74
|
| Rate for Payer: Cash Price |
$95.17
|
| Rate for Payer: Cofinity Commercial |
$102.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$29.74
|
| Rate for Payer: Healthscope Commercial |
$107.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.22
|
| Rate for Payer: Mclaren Medicaid |
$20.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$31.23
|
| Rate for Payer: Meridian Medicaid |
$22.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34.20
|
| Rate for Payer: Molina Medicare/Medicaid |
$32.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.12
|
| Rate for Payer: Nomi Health Commercial |
$97.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.22
|
| Rate for Payer: PACE Senior Care Partners |
$28.25
|
| Rate for Payer: PACE SWMI |
$29.74
|
| Rate for Payer: PHP Commercial |
$101.12
|
| Rate for Payer: PHP Medicare Advantage |
$29.74
|
| Rate for Payer: Priority Health Choice Medicaid |
$20.97
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$103.50
|
| Rate for Payer: Priority Health Medicare |
$30.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$82.80
|
| Rate for Payer: Railroad Medicare Medicare |
$29.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.68
|
| Rate for Payer: UHC Core |
$99.33
|
| Rate for Payer: UHC Exchange |
$29.74
|
| Rate for Payer: UHC Medicaid |
$20.97
|
| Rate for Payer: UHC Medicare Advantage |
$29.74
|
| Rate for Payer: UHCCP Medicaid |
$20.97
|
| Rate for Payer: VA VA |
$29.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.22
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
OP
|
$213.01
|
|
|
Service Code
|
NDC 00386000111
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.55 |
| Max. Negotiated Rate |
$191.71 |
| Rate for Payer: Aetna Commercial |
$181.06
|
| Rate for Payer: Aetna Medicare |
$55.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$66.57
|
| Rate for Payer: Amish Plain Church Group Commercial |
$66.57
|
| Rate for Payer: BCBS Complete |
$39.43
|
| Rate for Payer: BCBS MAPPO |
$53.25
|
| Rate for Payer: BCBS Trust/PPO |
$175.12
|
| Rate for Payer: BCN Commercial |
$175.12
|
| Rate for Payer: BCN Medicare Advantage |
$53.25
|
| Rate for Payer: Cash Price |
$170.41
|
| Rate for Payer: Cofinity Commercial |
$183.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$53.25
|
| Rate for Payer: Healthscope Commercial |
$191.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.76
|
| Rate for Payer: Mclaren Medicaid |
$37.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$55.92
|
| Rate for Payer: Meridian Medicaid |
$39.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$61.24
|
| Rate for Payer: Molina Medicare/Medicaid |
$58.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.06
|
| Rate for Payer: Nomi Health Commercial |
$174.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$159.76
|
| Rate for Payer: PACE Senior Care Partners |
$50.59
|
| Rate for Payer: PACE SWMI |
$53.25
|
| Rate for Payer: PHP Commercial |
$181.06
|
| Rate for Payer: PHP Medicare Advantage |
$53.25
|
| Rate for Payer: Priority Health Choice Medicaid |
$37.55
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$185.32
|
| Rate for Payer: Priority Health Medicare |
$53.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$148.25
|
| Rate for Payer: Railroad Medicare Medicare |
$53.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$187.45
|
| Rate for Payer: UHC Core |
$177.86
|
| Rate for Payer: UHC Exchange |
$53.25
|
| Rate for Payer: UHC Medicaid |
$37.55
|
| Rate for Payer: UHC Medicare Advantage |
$53.25
|
| Rate for Payer: UHCCP Medicaid |
$37.55
|
| Rate for Payer: VA VA |
$53.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.76
|
|
|
ETHYL CHLORIDE 100 % TOPICAL SPRAY
|
Facility
|
IP
|
$118.96
|
|
|
Service Code
|
NDC 00386000103
|
| Hospital Charge Code |
2951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.80 |
| Max. Negotiated Rate |
$107.06 |
| Rate for Payer: Aetna Commercial |
$101.12
|
| Rate for Payer: BCBS Trust/PPO |
$98.25
|
| Rate for Payer: BCN Commercial |
$98.25
|
| Rate for Payer: Cash Price |
$95.17
|
| Rate for Payer: Cofinity Commercial |
$102.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.17
|
| Rate for Payer: Healthscope Commercial |
$107.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.12
|
| Rate for Payer: Nomi Health Commercial |
$97.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.22
|
| Rate for Payer: PHP Commercial |
$101.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$103.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$82.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$104.68
|
| Rate for Payer: UHC Core |
$99.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.22
|
|
|
ETODOLAC 400 MG TABLET
|
Facility
|
IP
|
$284.55
|
|
|
Service Code
|
NDC 63629137705
|
| Hospital Charge Code |
9999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.05 |
| Max. Negotiated Rate |
$256.10 |
| Rate for Payer: Aetna Commercial |
$241.87
|
| Rate for Payer: BCBS Trust/PPO |
$235.01
|
| Rate for Payer: BCN Commercial |
$235.01
|
| Rate for Payer: Cash Price |
$227.64
|
| Rate for Payer: Cofinity Commercial |
$244.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.64
|
| Rate for Payer: Healthscope Commercial |
$256.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.87
|
| Rate for Payer: Nomi Health Commercial |
$233.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$213.41
|
| Rate for Payer: PHP Commercial |
$241.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$247.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$198.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$250.40
|
| Rate for Payer: UHC Core |
$237.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.41
|
|
|
ETODOLAC 400 MG TABLET
|
Facility
|
OP
|
$284.55
|
|
|
Service Code
|
NDC 63629137705
|
| Hospital Charge Code |
9999
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.17 |
| Max. Negotiated Rate |
$256.10 |
| Rate for Payer: Aetna Commercial |
$241.87
|
| Rate for Payer: Aetna Medicare |
$73.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$88.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$88.92
|
| Rate for Payer: BCBS Complete |
$52.67
|
| Rate for Payer: BCBS MAPPO |
$71.14
|
| Rate for Payer: BCBS Trust/PPO |
$233.93
|
| Rate for Payer: BCN Commercial |
$233.93
|
| Rate for Payer: BCN Medicare Advantage |
$71.14
|
| Rate for Payer: Cash Price |
$227.64
|
| Rate for Payer: Cofinity Commercial |
$244.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$71.14
|
| Rate for Payer: Healthscope Commercial |
$256.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.41
|
| Rate for Payer: Mclaren Medicaid |
$50.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$74.69
|
| Rate for Payer: Meridian Medicaid |
$52.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$81.81
|
| Rate for Payer: Molina Medicare/Medicaid |
$78.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.87
|
| Rate for Payer: Nomi Health Commercial |
$233.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$213.41
|
| Rate for Payer: PACE Senior Care Partners |
$67.58
|
| Rate for Payer: PACE SWMI |
$71.14
|
| Rate for Payer: PHP Commercial |
$241.87
|
| Rate for Payer: PHP Medicare Advantage |
$71.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$50.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$247.56
|
| Rate for Payer: Priority Health Medicare |
$71.85
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$198.05
|
| Rate for Payer: Railroad Medicare Medicare |
$71.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$250.40
|
| Rate for Payer: UHC Core |
$237.60
|
| Rate for Payer: UHC Exchange |
$71.14
|
| Rate for Payer: UHC Medicaid |
$50.17
|
| Rate for Payer: UHC Medicare Advantage |
$71.14
|
| Rate for Payer: UHCCP Medicaid |
$50.17
|
| Rate for Payer: VA VA |
$71.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.41
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$21.54
|
|
|
Service Code
|
NDC 72266014701
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.99 |
| Max. Negotiated Rate |
$19.39 |
| Rate for Payer: Aetna Commercial |
$18.31
|
| Rate for Payer: BCBS Trust/PPO |
$17.79
|
| Rate for Payer: BCN Commercial |
$17.79
|
| Rate for Payer: Cash Price |
$17.23
|
| Rate for Payer: Cofinity Commercial |
$18.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.23
|
| Rate for Payer: Healthscope Commercial |
$19.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.31
|
| Rate for Payer: Nomi Health Commercial |
$17.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.16
|
| Rate for Payer: PHP Commercial |
$18.31
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$18.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.96
|
| Rate for Payer: UHC Core |
$17.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.16
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$26.05
|
|
|
Service Code
|
NDC 65219044702
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$23.45 |
| Rate for Payer: Aetna Commercial |
$22.14
|
| Rate for Payer: BCBS Trust/PPO |
$21.51
|
| Rate for Payer: BCN Commercial |
$21.51
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Cofinity Commercial |
$22.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.84
|
| Rate for Payer: Healthscope Commercial |
$23.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.14
|
| Rate for Payer: Nomi Health Commercial |
$21.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.54
|
| Rate for Payer: PHP Commercial |
$22.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$22.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.92
|
| Rate for Payer: UHC Core |
$21.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.54
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$19.54
|
|
|
Service Code
|
NDC 00143931101
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.44 |
| Max. Negotiated Rate |
$17.59 |
| Rate for Payer: Aetna Commercial |
$16.61
|
| Rate for Payer: Aetna Medicare |
$5.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.11
|
| Rate for Payer: BCBS Complete |
$3.62
|
| Rate for Payer: BCBS MAPPO |
$4.88
|
| Rate for Payer: BCBS Trust/PPO |
$16.06
|
| Rate for Payer: BCN Commercial |
$16.06
|
| Rate for Payer: BCN Medicare Advantage |
$4.88
|
| Rate for Payer: Cash Price |
$15.63
|
| Rate for Payer: Cofinity Commercial |
$16.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.88
|
| Rate for Payer: Healthscope Commercial |
$17.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.65
|
| Rate for Payer: Mclaren Medicaid |
$3.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.13
|
| Rate for Payer: Meridian Medicaid |
$3.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.62
|
| Rate for Payer: Molina Medicare/Medicaid |
$5.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.61
|
| Rate for Payer: Nomi Health Commercial |
$16.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.65
|
| Rate for Payer: PACE Senior Care Partners |
$4.64
|
| Rate for Payer: PACE SWMI |
$4.88
|
| Rate for Payer: PHP Commercial |
$16.61
|
| Rate for Payer: PHP Medicare Advantage |
$4.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$17.00
|
| Rate for Payer: Priority Health Medicare |
$4.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.60
|
| Rate for Payer: Railroad Medicare Medicare |
$4.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.20
|
| Rate for Payer: UHC Core |
$16.32
|
| Rate for Payer: UHC Exchange |
$4.88
|
| Rate for Payer: UHC Medicaid |
$3.44
|
| Rate for Payer: UHC Medicare Advantage |
$4.88
|
| Rate for Payer: UHCCP Medicaid |
$3.44
|
| Rate for Payer: VA VA |
$4.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.65
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$26.05
|
|
|
Service Code
|
NDC 65219044702
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$23.45 |
| Rate for Payer: Aetna Commercial |
$22.14
|
| Rate for Payer: Aetna Medicare |
$6.77
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.14
|
| Rate for Payer: BCBS Complete |
$4.82
|
| Rate for Payer: BCBS MAPPO |
$6.51
|
| Rate for Payer: BCBS Trust/PPO |
$21.42
|
| Rate for Payer: BCN Commercial |
$21.42
|
| Rate for Payer: BCN Medicare Advantage |
$6.51
|
| Rate for Payer: Cash Price |
$20.84
|
| Rate for Payer: Cofinity Commercial |
$22.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.51
|
| Rate for Payer: Healthscope Commercial |
$23.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.54
|
| Rate for Payer: Mclaren Medicaid |
$4.59
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.84
|
| Rate for Payer: Meridian Medicaid |
$4.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.49
|
| Rate for Payer: Molina Medicare/Medicaid |
$7.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.14
|
| Rate for Payer: Nomi Health Commercial |
$21.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.54
|
| Rate for Payer: PACE Senior Care Partners |
$6.19
|
| Rate for Payer: PACE SWMI |
$6.51
|
| Rate for Payer: PHP Commercial |
$22.14
|
| Rate for Payer: PHP Medicare Advantage |
$6.51
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.59
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$22.66
|
| Rate for Payer: Priority Health Medicare |
$6.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.13
|
| Rate for Payer: Railroad Medicare Medicare |
$6.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.92
|
| Rate for Payer: UHC Core |
$21.75
|
| Rate for Payer: UHC Exchange |
$6.51
|
| Rate for Payer: UHC Medicaid |
$4.59
|
| Rate for Payer: UHC Medicare Advantage |
$6.51
|
| Rate for Payer: UHCCP Medicaid |
$4.59
|
| Rate for Payer: VA VA |
$6.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.54
|
|
|
ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$25.31
|
|
|
Service Code
|
NDC 55150022220
|
| Hospital Charge Code |
20472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$22.78 |
| Rate for Payer: Aetna Commercial |
$21.51
|
| Rate for Payer: Aetna Medicare |
$6.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.91
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.91
|
| Rate for Payer: BCBS Complete |
$4.68
|
| Rate for Payer: BCBS MAPPO |
$6.33
|
| Rate for Payer: BCBS Trust/PPO |
$20.81
|
| Rate for Payer: BCN Commercial |
$20.81
|
| Rate for Payer: BCN Medicare Advantage |
$6.33
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cofinity Commercial |
$21.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.33
|
| Rate for Payer: Healthscope Commercial |
$22.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.98
|
| Rate for Payer: Mclaren Medicaid |
$4.46
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.64
|
| Rate for Payer: Meridian Medicaid |
$4.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.28
|
| Rate for Payer: Molina Medicare/Medicaid |
$6.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.51
|
| Rate for Payer: Nomi Health Commercial |
$20.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.98
|
| Rate for Payer: PACE Senior Care Partners |
$6.01
|
| Rate for Payer: PACE SWMI |
$6.33
|
| Rate for Payer: PHP Commercial |
$21.51
|
| Rate for Payer: PHP Medicare Advantage |
$6.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$22.02
|
| Rate for Payer: Priority Health Medicare |
$6.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.62
|
| Rate for Payer: Railroad Medicare Medicare |
$6.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.27
|
| Rate for Payer: UHC Core |
$21.13
|
| Rate for Payer: UHC Exchange |
$6.33
|
| Rate for Payer: UHC Medicaid |
$4.46
|
| Rate for Payer: UHC Medicare Advantage |
$6.33
|
| Rate for Payer: UHCCP Medicaid |
$4.46
|
| Rate for Payer: VA VA |
$6.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.98
|
|
