|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION
|
Facility
|
OP
|
$191.49
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
11565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.85 |
| Max. Negotiated Rate |
$172.34 |
| Rate for Payer: Aetna American Axle |
$124.47
|
| Rate for Payer: Aetna American Axle |
$120.50
|
| Rate for Payer: Aetna American Axle |
$116.37
|
| Rate for Payer: Aetna American Axle |
$108.97
|
| Rate for Payer: Aetna American Axle |
$120.18
|
| Rate for Payer: Aetna American Axle |
$92.20
|
| Rate for Payer: Aetna American Axle |
$138.06
|
| Rate for Payer: Aetna American Axle |
$136.99
|
| Rate for Payer: Aetna Commercial |
$179.15
|
| Rate for Payer: Aetna Commercial |
$157.58
|
| Rate for Payer: Aetna Commercial |
$162.77
|
| Rate for Payer: Aetna Commercial |
$120.57
|
| Rate for Payer: Aetna Commercial |
$180.54
|
| Rate for Payer: Aetna Commercial |
$142.50
|
| Rate for Payer: Aetna Commercial |
$157.16
|
| Rate for Payer: Aetna Commercial |
$152.18
|
| Rate for Payer: Aetna Medicare |
$89.52
|
| Rate for Payer: Aetna Medicare |
$70.92
|
| Rate for Payer: Aetna Medicare |
$92.44
|
| Rate for Payer: Aetna Medicare |
$83.83
|
| Rate for Payer: Aetna Medicare |
$95.75
|
| Rate for Payer: Aetna Medicare |
$106.20
|
| Rate for Payer: Aetna Medicare |
$92.69
|
| Rate for Payer: Aetna Medicare |
$105.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$124.47
|
| Rate for Payer: BCBS Complete |
$67.06
|
| Rate for Payer: BCBS Complete |
$56.74
|
| Rate for Payer: BCBS Complete |
$73.96
|
| Rate for Payer: BCBS Complete |
$71.61
|
| Rate for Payer: BCBS Complete |
$74.16
|
| Rate for Payer: BCBS Complete |
$76.60
|
| Rate for Payer: BCBS Complete |
$84.30
|
| Rate for Payer: BCBS Complete |
$84.96
|
| Rate for Payer: Cash Price |
$143.22
|
| Rate for Payer: Cash Price |
$113.48
|
| Rate for Payer: Cash Price |
$134.12
|
| Rate for Payer: Cash Price |
$168.61
|
| Rate for Payer: Cash Price |
$147.91
|
| Rate for Payer: Cash Price |
$148.31
|
| Rate for Payer: Cash Price |
$153.19
|
| Rate for Payer: Cash Price |
$169.92
|
| Rate for Payer: Cofinity Commercial |
$129.77
|
| Rate for Payer: Cofinity Commercial |
$182.66
|
| Rate for Payer: Cofinity Commercial |
$148.68
|
| Rate for Payer: Cofinity Commercial |
$181.25
|
| Rate for Payer: Cofinity Commercial |
$147.53
|
| Rate for Payer: Cofinity Commercial |
$144.18
|
| Rate for Payer: Cofinity Commercial |
$159.01
|
| Rate for Payer: Cofinity Commercial |
$121.99
|
| Rate for Payer: Cofinity Commercial |
$153.97
|
| Rate for Payer: Cofinity Commercial |
$164.68
|
| Rate for Payer: Cofinity Commercial |
$134.04
|
| Rate for Payer: Cofinity Commercial |
$125.32
|
| Rate for Payer: Cofinity Commercial |
$129.42
|
| Rate for Payer: Cofinity Commercial |
$99.30
|
| Rate for Payer: Cofinity Commercial |
$117.36
|
| Rate for Payer: Cofinity Commercial |
$159.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$99.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$125.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$117.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$129.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$134.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$129.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$147.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$143.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.19
|
| Rate for Payer: Healthscope Commercial |
$127.67
|
| Rate for Payer: Healthscope Commercial |
$166.40
|
| Rate for Payer: Healthscope Commercial |
$166.85
|
| Rate for Payer: Healthscope Commercial |
$172.34
|
| Rate for Payer: Healthscope Commercial |
$189.68
|
| Rate for Payer: Healthscope Commercial |
$191.16
|
| Rate for Payer: Healthscope Commercial |
$161.13
|
| Rate for Payer: Healthscope Commercial |
$150.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$134.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$129.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$129.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$117.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$134.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$143.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$139.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$125.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$162.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$152.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.15
|
| Rate for Payer: PHP Commercial |
$157.16
|
| Rate for Payer: PHP Commercial |
$157.58
|
| Rate for Payer: PHP Commercial |
$180.54
|
| Rate for Payer: PHP Commercial |
$162.77
|
| Rate for Payer: PHP Commercial |
$152.18
|
| Rate for Payer: PHP Commercial |
$179.15
|
| Rate for Payer: PHP Commercial |
$120.57
|
| Rate for Payer: PHP Commercial |
$142.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$124.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.06
|
| Rate for Payer: Priority Health SBD |
$89.37
|
| Rate for Payer: Priority Health SBD |
$133.81
|
| Rate for Payer: Priority Health SBD |
$132.78
|
| Rate for Payer: Priority Health SBD |
$116.48
|
| Rate for Payer: Priority Health SBD |
$112.79
|
| Rate for Payer: Priority Health SBD |
$116.80
|
| Rate for Payer: Priority Health SBD |
$105.62
|
| Rate for Payer: Priority Health SBD |
$120.64
|
| Rate for Payer: UMR Bronson Commercial |
$70.85
|
| Rate for Payer: UMR Bronson Commercial |
$77.98
|
| Rate for Payer: UMR Bronson Commercial |
$62.03
|
| Rate for Payer: UMR Bronson Commercial |
$78.59
|
| Rate for Payer: UMR Bronson Commercial |
$68.59
|
| Rate for Payer: UMR Bronson Commercial |
$68.41
|
| Rate for Payer: UMR Bronson Commercial |
$66.24
|
| Rate for Payer: UMR Bronson Commercial |
$52.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$139.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$143.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$125.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$134.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.67
|
|
|
TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION
|
Facility
|
IP
|
$210.76
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
11565
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.73 |
| Max. Negotiated Rate |
$189.68 |
| Rate for Payer: Aetna American Axle |
$136.99
|
| Rate for Payer: Aetna American Axle |
$124.47
|
| Rate for Payer: Aetna American Axle |
$120.50
|
| Rate for Payer: Aetna American Axle |
$116.37
|
| Rate for Payer: Aetna American Axle |
$92.20
|
| Rate for Payer: Aetna American Axle |
$108.97
|
| Rate for Payer: Aetna American Axle |
$120.18
|
| Rate for Payer: Aetna American Axle |
$138.06
|
| Rate for Payer: Aetna Commercial |
$180.54
|
| Rate for Payer: Aetna Commercial |
$179.15
|
| Rate for Payer: Aetna Commercial |
$152.18
|
| Rate for Payer: Aetna Commercial |
$157.16
|
| Rate for Payer: Aetna Commercial |
$142.50
|
| Rate for Payer: Aetna Commercial |
$120.57
|
| Rate for Payer: Aetna Commercial |
$162.77
|
| Rate for Payer: Aetna Commercial |
$157.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$124.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$136.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.50
|
| Rate for Payer: Cash Price |
$147.91
|
| Rate for Payer: Cash Price |
$168.61
|
| Rate for Payer: Cash Price |
$148.31
|
| Rate for Payer: Cash Price |
$169.92
|
| Rate for Payer: Cash Price |
$134.12
|
| Rate for Payer: Cash Price |
$143.22
|
| Rate for Payer: Cash Price |
$113.48
|
| Rate for Payer: Cash Price |
$153.19
|
| Rate for Payer: Cofinity Commercial |
$159.01
|
| Rate for Payer: Cofinity Commercial |
$121.99
|
| Rate for Payer: Cofinity Commercial |
$129.42
|
| Rate for Payer: Cofinity Commercial |
$125.32
|
| Rate for Payer: Cofinity Commercial |
$117.36
|
| Rate for Payer: Cofinity Commercial |
$144.18
|
| Rate for Payer: Cofinity Commercial |
$153.97
|
| Rate for Payer: Cofinity Commercial |
$99.30
|
| Rate for Payer: Cofinity Commercial |
$129.77
|
| Rate for Payer: Cofinity Commercial |
$159.44
|
| Rate for Payer: Cofinity Commercial |
$134.04
|
| Rate for Payer: Cofinity Commercial |
$164.68
|
| Rate for Payer: Cofinity Commercial |
$147.53
|
| Rate for Payer: Cofinity Commercial |
$181.25
|
| Rate for Payer: Cofinity Commercial |
$148.68
|
| Rate for Payer: Cofinity Commercial |
$182.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$147.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$148.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$117.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$125.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$129.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$99.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$129.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$134.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$168.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$147.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$134.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$153.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$169.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$143.22
|
| Rate for Payer: Healthscope Commercial |
$127.67
|
| Rate for Payer: Healthscope Commercial |
$191.16
|
| Rate for Payer: Healthscope Commercial |
$189.68
|
| Rate for Payer: Healthscope Commercial |
$166.85
|
| Rate for Payer: Healthscope Commercial |
$172.34
|
| Rate for Payer: Healthscope Commercial |
$166.40
|
| Rate for Payer: Healthscope Commercial |
$161.13
|
| Rate for Payer: Healthscope Commercial |
$150.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$129.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$134.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$147.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$129.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$117.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$158.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$125.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$134.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$143.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$139.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$179.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$162.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$142.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$152.18
|
| Rate for Payer: PHP Commercial |
$179.15
|
| Rate for Payer: PHP Commercial |
$152.18
|
| Rate for Payer: PHP Commercial |
$162.77
|
| Rate for Payer: PHP Commercial |
$157.16
|
| Rate for Payer: PHP Commercial |
$180.54
|
| Rate for Payer: PHP Commercial |
$120.57
|
| Rate for Payer: PHP Commercial |
$157.58
|
| Rate for Payer: PHP Commercial |
$142.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$124.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.37
|
| Rate for Payer: Priority Health SBD |
$112.79
|
| Rate for Payer: Priority Health SBD |
$105.62
|
| Rate for Payer: Priority Health SBD |
$89.37
|
| Rate for Payer: Priority Health SBD |
$116.48
|
| Rate for Payer: Priority Health SBD |
$120.64
|
| Rate for Payer: Priority Health SBD |
$116.80
|
| Rate for Payer: Priority Health SBD |
$133.81
|
| Rate for Payer: Priority Health SBD |
$132.78
|
| Rate for Payer: UMR Bronson Commercial |
$78.77
|
| Rate for Payer: UMR Bronson Commercial |
$81.35
|
| Rate for Payer: UMR Bronson Commercial |
$84.26
|
| Rate for Payer: UMR Bronson Commercial |
$92.73
|
| Rate for Payer: UMR Bronson Commercial |
$73.77
|
| Rate for Payer: UMR Bronson Commercial |
$93.46
|
| Rate for Payer: UMR Bronson Commercial |
$81.57
|
| Rate for Payer: UMR Bronson Commercial |
$62.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$143.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$158.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$134.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$125.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$139.04
|
|
|
TOBRAMYCIN 14 MG/ML FORTIFIED OPHTHALMIC DROPS
|
Facility
|
OP
|
$170.74
|
|
|
Service Code
|
NDC 09900000090
|
| Hospital Charge Code |
500595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.17 |
| Max. Negotiated Rate |
$153.67 |
| Rate for Payer: Aetna American Axle |
$110.98
|
| Rate for Payer: Aetna Commercial |
$145.13
|
| Rate for Payer: Aetna Medicare |
$85.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.98
|
| Rate for Payer: BCBS Complete |
$68.30
|
| Rate for Payer: Cash Price |
$136.59
|
| Rate for Payer: Cofinity Commercial |
$119.52
|
| Rate for Payer: Cofinity Commercial |
$146.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$119.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.59
|
| Rate for Payer: Healthscope Commercial |
$153.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$128.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$145.13
|
| Rate for Payer: PHP Commercial |
$145.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.98
|
| Rate for Payer: Priority Health SBD |
$107.57
|
| Rate for Payer: UMR Bronson Commercial |
$63.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$128.06
|
|
|
TOBRAMYCIN 14 MG/ML FORTIFIED OPHTHALMIC DROPS
|
Facility
|
IP
|
$170.74
|
|
|
Service Code
|
NDC 09900000090
|
| Hospital Charge Code |
500595
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.13 |
| Max. Negotiated Rate |
$153.67 |
| Rate for Payer: Aetna American Axle |
$110.98
|
| Rate for Payer: Aetna Commercial |
$145.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.98
|
| Rate for Payer: Cash Price |
$136.59
|
| Rate for Payer: Cofinity Commercial |
$119.52
|
| Rate for Payer: Cofinity Commercial |
$146.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$119.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.59
|
| Rate for Payer: Healthscope Commercial |
$153.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$128.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$145.13
|
| Rate for Payer: PHP Commercial |
$145.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.98
|
| Rate for Payer: Priority Health SBD |
$107.57
|
| Rate for Payer: UMR Bronson Commercial |
$75.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$128.06
|
|
|
TOBRAMYCIN 300 MG/5 ML NEBULIZATION CUSTOM
|
Facility
|
OP
|
$50.66
|
|
|
Service Code
|
HCPCS J7682
|
| Hospital Charge Code |
168920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.74 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Aetna American Axle |
$32.93
|
| Rate for Payer: Aetna Commercial |
$43.06
|
| Rate for Payer: Aetna Medicare |
$25.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.93
|
| Rate for Payer: BCBS Complete |
$20.26
|
| Rate for Payer: Cash Price |
$40.53
|
| Rate for Payer: Cofinity Commercial |
$35.46
|
| Rate for Payer: Cofinity Commercial |
$43.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.53
|
| Rate for Payer: Healthscope Commercial |
$45.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.06
|
| Rate for Payer: PHP Commercial |
$43.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.93
|
| Rate for Payer: Priority Health SBD |
$31.92
|
| Rate for Payer: UMR Bronson Commercial |
$18.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.99
|
|
|
TOBRAMYCIN 300 MG/5 ML NEBULIZATION CUSTOM
|
Facility
|
IP
|
$50.66
|
|
|
Service Code
|
HCPCS J7682
|
| Hospital Charge Code |
168920
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.29 |
| Max. Negotiated Rate |
$45.59 |
| Rate for Payer: Aetna American Axle |
$32.93
|
| Rate for Payer: Aetna Commercial |
$43.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.93
|
| Rate for Payer: Cash Price |
$40.53
|
| Rate for Payer: Cofinity Commercial |
$35.46
|
| Rate for Payer: Cofinity Commercial |
$43.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.53
|
| Rate for Payer: Healthscope Commercial |
$45.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.06
|
| Rate for Payer: PHP Commercial |
$43.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.93
|
| Rate for Payer: Priority Health SBD |
$31.92
|
| Rate for Payer: UMR Bronson Commercial |
$22.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.99
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$189.35
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.31 |
| Max. Negotiated Rate |
$170.41 |
| Rate for Payer: Aetna American Axle |
$123.08
|
| Rate for Payer: Aetna American Axle |
$33.15
|
| Rate for Payer: Aetna American Axle |
$58.49
|
| Rate for Payer: Aetna Commercial |
$43.35
|
| Rate for Payer: Aetna Commercial |
$160.95
|
| Rate for Payer: Aetna Commercial |
$76.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.15
|
| Rate for Payer: Cash Price |
$71.98
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$151.48
|
| Rate for Payer: Cofinity Commercial |
$162.84
|
| Rate for Payer: Cofinity Commercial |
$43.86
|
| Rate for Payer: Cofinity Commercial |
$35.70
|
| Rate for Payer: Cofinity Commercial |
$77.38
|
| Rate for Payer: Cofinity Commercial |
$62.99
|
| Rate for Payer: Cofinity Commercial |
$132.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$132.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.80
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Healthscope Commercial |
$170.41
|
| Rate for Payer: Healthscope Commercial |
$80.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$132.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.35
|
| Rate for Payer: PHP Commercial |
$76.48
|
| Rate for Payer: PHP Commercial |
$43.35
|
| Rate for Payer: PHP Commercial |
$160.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.08
|
| Rate for Payer: Priority Health SBD |
$56.69
|
| Rate for Payer: Priority Health SBD |
$32.13
|
| Rate for Payer: Priority Health SBD |
$119.29
|
| Rate for Payer: UMR Bronson Commercial |
$83.31
|
| Rate for Payer: UMR Bronson Commercial |
$39.59
|
| Rate for Payer: UMR Bronson Commercial |
$22.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.25
|
|
|
TOBRAMYCIN 40 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$189.35
|
|
|
Service Code
|
HCPCS J3260
|
| Hospital Charge Code |
7994
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.06 |
| Max. Negotiated Rate |
$170.41 |
| Rate for Payer: Aetna American Axle |
$123.08
|
| Rate for Payer: Aetna American Axle |
$33.15
|
| Rate for Payer: Aetna American Axle |
$58.49
|
| Rate for Payer: Aetna American Axle |
$12.18
|
| Rate for Payer: Aetna American Axle |
$12.94
|
| Rate for Payer: Aetna Commercial |
$15.93
|
| Rate for Payer: Aetna Commercial |
$76.48
|
| Rate for Payer: Aetna Commercial |
$16.92
|
| Rate for Payer: Aetna Commercial |
$43.35
|
| Rate for Payer: Aetna Commercial |
$160.95
|
| Rate for Payer: Aetna Medicare |
$25.50
|
| Rate for Payer: Aetna Medicare |
$94.67
|
| Rate for Payer: Aetna Medicare |
$44.99
|
| Rate for Payer: Aetna Medicare |
$9.96
|
| Rate for Payer: Aetna Medicare |
$9.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.15
|
| Rate for Payer: BCBS Complete |
$35.99
|
| Rate for Payer: BCBS Complete |
$7.50
|
| Rate for Payer: BCBS Complete |
$20.40
|
| Rate for Payer: BCBS Complete |
$7.96
|
| Rate for Payer: BCBS Complete |
$75.74
|
| Rate for Payer: Cash Price |
$71.98
|
| Rate for Payer: Cash Price |
$14.99
|
| Rate for Payer: Cash Price |
$151.48
|
| Rate for Payer: Cash Price |
$40.80
|
| Rate for Payer: Cash Price |
$15.93
|
| Rate for Payer: Cofinity Commercial |
$62.99
|
| Rate for Payer: Cofinity Commercial |
$162.84
|
| Rate for Payer: Cofinity Commercial |
$43.86
|
| Rate for Payer: Cofinity Commercial |
$13.12
|
| Rate for Payer: Cofinity Commercial |
$17.12
|
| Rate for Payer: Cofinity Commercial |
$13.94
|
| Rate for Payer: Cofinity Commercial |
$35.70
|
| Rate for Payer: Cofinity Commercial |
$16.12
|
| Rate for Payer: Cofinity Commercial |
$132.54
|
| Rate for Payer: Cofinity Commercial |
$77.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$132.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.93
|
| Rate for Payer: Healthscope Commercial |
$16.87
|
| Rate for Payer: Healthscope Commercial |
$17.92
|
| Rate for Payer: Healthscope Commercial |
$80.98
|
| Rate for Payer: Healthscope Commercial |
$45.90
|
| Rate for Payer: Healthscope Commercial |
$170.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$132.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.48
|
| Rate for Payer: PHP Commercial |
$43.35
|
| Rate for Payer: PHP Commercial |
$16.92
|
| Rate for Payer: PHP Commercial |
$15.93
|
| Rate for Payer: PHP Commercial |
$160.95
|
| Rate for Payer: PHP Commercial |
$76.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.08
|
| Rate for Payer: Priority Health SBD |
$119.29
|
| Rate for Payer: Priority Health SBD |
$11.81
|
| Rate for Payer: Priority Health SBD |
$12.54
|
| Rate for Payer: Priority Health SBD |
$32.13
|
| Rate for Payer: Priority Health SBD |
$56.69
|
| Rate for Payer: UMR Bronson Commercial |
$33.29
|
| Rate for Payer: UMR Bronson Commercial |
$18.87
|
| Rate for Payer: UMR Bronson Commercial |
$70.06
|
| Rate for Payer: UMR Bronson Commercial |
$6.93
|
| Rate for Payer: UMR Bronson Commercial |
$7.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.93
|
|
|
TOBRAMYCIN 9 MG/ML FORTIFIED OPHTHALMIC DROPS
|
Facility
|
OP
|
$128.05
|
|
|
Service Code
|
NDC 09900000089
|
| Hospital Charge Code |
500594
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.38 |
| Max. Negotiated Rate |
$115.25 |
| Rate for Payer: Aetna American Axle |
$83.23
|
| Rate for Payer: Aetna Commercial |
$108.84
|
| Rate for Payer: Aetna Medicare |
$64.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.23
|
| Rate for Payer: BCBS Complete |
$51.22
|
| Rate for Payer: Cash Price |
$102.44
|
| Rate for Payer: Cofinity Commercial |
$110.12
|
| Rate for Payer: Cofinity Commercial |
$89.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$89.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.44
|
| Rate for Payer: Healthscope Commercial |
$115.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$89.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$108.84
|
| Rate for Payer: PHP Commercial |
$108.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.23
|
| Rate for Payer: Priority Health SBD |
$80.67
|
| Rate for Payer: UMR Bronson Commercial |
$47.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.04
|
|
|
TOBRAMYCIN 9 MG/ML FORTIFIED OPHTHALMIC DROPS
|
Facility
|
IP
|
$128.05
|
|
|
Service Code
|
NDC 09900000089
|
| Hospital Charge Code |
500594
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.34 |
| Max. Negotiated Rate |
$115.25 |
| Rate for Payer: Aetna American Axle |
$83.23
|
| Rate for Payer: Aetna Commercial |
$108.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.23
|
| Rate for Payer: Cash Price |
$102.44
|
| Rate for Payer: Cofinity Commercial |
$110.12
|
| Rate for Payer: Cofinity Commercial |
$89.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$89.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.44
|
| Rate for Payer: Healthscope Commercial |
$115.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$89.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$108.84
|
| Rate for Payer: PHP Commercial |
$108.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$83.23
|
| Rate for Payer: Priority Health SBD |
$80.67
|
| Rate for Payer: UMR Bronson Commercial |
$56.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.04
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$4,143.08
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
119445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,822.96 |
| Max. Negotiated Rate |
$3,728.77 |
| Rate for Payer: Aetna American Axle |
$2,693.00
|
| Rate for Payer: Aetna Commercial |
$3,521.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,693.00
|
| Rate for Payer: Cash Price |
$3,314.46
|
| Rate for Payer: Cofinity Commercial |
$2,900.16
|
| Rate for Payer: Cofinity Commercial |
$3,563.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,900.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,314.46
|
| Rate for Payer: Healthscope Commercial |
$3,728.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,900.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,107.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,521.62
|
| Rate for Payer: PHP Commercial |
$3,521.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,693.00
|
| Rate for Payer: Priority Health SBD |
$2,610.14
|
| Rate for Payer: UMR Bronson Commercial |
$1,822.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,107.31
|
|
|
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$4,143.08
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
119445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$3,728.77 |
| Rate for Payer: Aetna American Axle |
$2,693.00
|
| Rate for Payer: Aetna Commercial |
$3,521.62
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,693.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.14
|
| Rate for Payer: BCBS Complete |
$3.21
|
| Rate for Payer: BCBS MAPPO |
$5.71
|
| Rate for Payer: BCN Medicare Advantage |
$5.71
|
| Rate for Payer: Cash Price |
$3,314.46
|
| Rate for Payer: Cash Price |
$3,314.46
|
| Rate for Payer: Cofinity Commercial |
$3,563.05
|
| Rate for Payer: Cofinity Commercial |
$2,900.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,900.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,314.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.71
|
| Rate for Payer: Healthscope Commercial |
$3,728.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,900.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,107.31
|
| Rate for Payer: Mclaren Medicaid |
$3.06
|
| Rate for Payer: Mclaren Medicare |
$5.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.00
|
| Rate for Payer: Meridian Medicaid |
$3.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,521.62
|
| Rate for Payer: PACE Medicare |
$5.42
|
| Rate for Payer: PACE SWMI |
$5.71
|
| Rate for Payer: PHP Commercial |
$3,521.62
|
| Rate for Payer: PHP Medicare Advantage |
$5.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,693.00
|
| Rate for Payer: Priority Health Medicare |
$5.71
|
| Rate for Payer: Priority Health SBD |
$2,610.14
|
| Rate for Payer: Railroad Medicare Medicare |
$5.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.71
|
| Rate for Payer: UHC Exchange |
$10.91
|
| Rate for Payer: UHC Medicare Advantage |
$5.71
|
| Rate for Payer: UHCCP Medicaid |
$3.06
|
| Rate for Payer: UMR Bronson Commercial |
$1,532.94
|
| Rate for Payer: VA VA |
$5.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,107.31
|
|
|
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$6,732.50
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
119446
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$6,059.25 |
| Rate for Payer: Aetna American Axle |
$4,376.12
|
| Rate for Payer: Aetna Commercial |
$5,722.62
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,376.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.14
|
| Rate for Payer: BCBS Complete |
$3.21
|
| Rate for Payer: BCBS MAPPO |
$5.71
|
| Rate for Payer: BCN Medicare Advantage |
$5.71
|
| Rate for Payer: Cash Price |
$5,386.00
|
| Rate for Payer: Cash Price |
$5,386.00
|
| Rate for Payer: Cofinity Commercial |
$4,712.75
|
| Rate for Payer: Cofinity Commercial |
$5,789.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$4,712.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5,386.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.71
|
| Rate for Payer: Healthscope Commercial |
$6,059.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4,712.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,049.38
|
| Rate for Payer: Mclaren Medicaid |
$3.06
|
| Rate for Payer: Mclaren Medicare |
$5.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.00
|
| Rate for Payer: Meridian Medicaid |
$3.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5,722.62
|
| Rate for Payer: PACE Medicare |
$5.42
|
| Rate for Payer: PACE SWMI |
$5.71
|
| Rate for Payer: PHP Commercial |
$5,722.62
|
| Rate for Payer: PHP Medicare Advantage |
$5.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4,376.12
|
| Rate for Payer: Priority Health Medicare |
$5.71
|
| Rate for Payer: Priority Health SBD |
$4,241.48
|
| Rate for Payer: Railroad Medicare Medicare |
$5.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.71
|
| Rate for Payer: UHC Exchange |
$10.91
|
| Rate for Payer: UHC Medicare Advantage |
$5.71
|
| Rate for Payer: UHCCP Medicaid |
$3.06
|
| Rate for Payer: UMR Bronson Commercial |
$2,491.03
|
| Rate for Payer: VA VA |
$5.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,049.38
|
|
|
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,657.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
99452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$1,491.50 |
| Rate for Payer: Aetna American Axle |
$1,077.19
|
| Rate for Payer: Aetna Commercial |
$1,408.64
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.14
|
| Rate for Payer: BCBS Complete |
$3.21
|
| Rate for Payer: BCBS MAPPO |
$5.71
|
| Rate for Payer: BCN Medicare Advantage |
$5.71
|
| Rate for Payer: Cash Price |
$1,325.78
|
| Rate for Payer: Cash Price |
$1,325.78
|
| Rate for Payer: Cofinity Commercial |
$1,160.05
|
| Rate for Payer: Cofinity Commercial |
$1,425.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,160.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,325.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.71
|
| Rate for Payer: Healthscope Commercial |
$1,491.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,160.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,242.91
|
| Rate for Payer: Mclaren Medicaid |
$3.06
|
| Rate for Payer: Mclaren Medicare |
$5.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.00
|
| Rate for Payer: Meridian Medicaid |
$3.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,408.64
|
| Rate for Payer: PACE Medicare |
$5.42
|
| Rate for Payer: PACE SWMI |
$5.71
|
| Rate for Payer: PHP Commercial |
$1,408.64
|
| Rate for Payer: PHP Medicare Advantage |
$5.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$3.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,077.19
|
| Rate for Payer: Priority Health Medicare |
$5.71
|
| Rate for Payer: Priority Health SBD |
$1,044.05
|
| Rate for Payer: Railroad Medicare Medicare |
$5.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.07
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.71
|
| Rate for Payer: UHC Exchange |
$10.91
|
| Rate for Payer: UHC Medicare Advantage |
$5.71
|
| Rate for Payer: UHCCP Medicaid |
$3.06
|
| Rate for Payer: UMR Bronson Commercial |
$613.17
|
| Rate for Payer: VA VA |
$5.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,242.91
|
|
|
TOFERSEN 100 MG/15 ML (6.7 MG/ML) INTRATHECAL SOLUTION
|
Facility
|
OP
|
$448.70
|
|
|
Service Code
|
HCPCS J1304
|
| Hospital Charge Code |
203701
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.44 |
| Max. Negotiated Rate |
$448.70 |
| Rate for Payer: Aetna Medicare |
$165.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$199.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$199.25
|
| Rate for Payer: BCBS Complete |
$89.71
|
| Rate for Payer: BCBS MAPPO |
$159.40
|
| Rate for Payer: BCN Medicare Advantage |
$159.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$159.40
|
| Rate for Payer: Mclaren Medicaid |
$85.44
|
| Rate for Payer: Mclaren Medicare |
$159.40
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$167.37
|
| Rate for Payer: Meridian Medicaid |
$89.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$183.31
|
| Rate for Payer: PACE Medicare |
$151.43
|
| Rate for Payer: PACE SWMI |
$159.40
|
| Rate for Payer: PHP Medicare Advantage |
$159.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$85.44
|
| Rate for Payer: Priority Health Medicare |
$159.40
|
| Rate for Payer: Railroad Medicare Medicare |
$159.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$448.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$159.40
|
| Rate for Payer: UHC Exchange |
$304.63
|
| Rate for Payer: UHC Medicare Advantage |
$159.40
|
| Rate for Payer: UHCCP Medicaid |
$85.44
|
| Rate for Payer: VA VA |
$159.40
|
|
|
TOLTERODINE 1 MG TABLET
|
Facility
|
OP
|
$546.57
|
|
|
Service Code
|
NDC 00093001006
|
| Hospital Charge Code |
22782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$202.23 |
| Max. Negotiated Rate |
$491.91 |
| Rate for Payer: Aetna American Axle |
$355.27
|
| Rate for Payer: Aetna Commercial |
$464.58
|
| Rate for Payer: Aetna Medicare |
$273.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$355.27
|
| Rate for Payer: BCBS Complete |
$218.63
|
| Rate for Payer: Cash Price |
$437.26
|
| Rate for Payer: Cofinity Commercial |
$382.60
|
| Rate for Payer: Cofinity Commercial |
$470.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$382.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$437.26
|
| Rate for Payer: Healthscope Commercial |
$491.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$382.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$409.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$464.58
|
| Rate for Payer: PHP Commercial |
$464.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$355.27
|
| Rate for Payer: Priority Health SBD |
$344.34
|
| Rate for Payer: UMR Bronson Commercial |
$202.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$409.93
|
|
|
TOLTERODINE 1 MG TABLET
|
Facility
|
IP
|
$546.57
|
|
|
Service Code
|
NDC 00093001006
|
| Hospital Charge Code |
22782
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.49 |
| Max. Negotiated Rate |
$491.91 |
| Rate for Payer: Aetna American Axle |
$355.27
|
| Rate for Payer: Aetna Commercial |
$464.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$355.27
|
| Rate for Payer: Cash Price |
$437.26
|
| Rate for Payer: Cofinity Commercial |
$382.60
|
| Rate for Payer: Cofinity Commercial |
$470.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$382.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$437.26
|
| Rate for Payer: Healthscope Commercial |
$491.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$382.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$409.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$464.58
|
| Rate for Payer: PHP Commercial |
$464.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$355.27
|
| Rate for Payer: Priority Health SBD |
$344.34
|
| Rate for Payer: UMR Bronson Commercial |
$240.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$409.93
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
IP
|
$206.46
|
|
|
Service Code
|
NDC 49884076852
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.84 |
| Max. Negotiated Rate |
$185.81 |
| Rate for Payer: Aetna American Axle |
$134.20
|
| Rate for Payer: Aetna Commercial |
$175.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.20
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$144.52
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$185.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health SBD |
$130.07
|
| Rate for Payer: UMR Bronson Commercial |
$90.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.84
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
OP
|
$206.46
|
|
|
Service Code
|
NDC 49884076852
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.39 |
| Max. Negotiated Rate |
$185.81 |
| Rate for Payer: Aetna American Axle |
$134.20
|
| Rate for Payer: Aetna Commercial |
$175.49
|
| Rate for Payer: Aetna Medicare |
$103.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.20
|
| Rate for Payer: BCBS Complete |
$82.58
|
| Rate for Payer: Cash Price |
$165.17
|
| Rate for Payer: Cofinity Commercial |
$144.52
|
| Rate for Payer: Cofinity Commercial |
$177.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$144.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$165.17
|
| Rate for Payer: Healthscope Commercial |
$185.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$175.49
|
| Rate for Payer: PHP Commercial |
$175.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.20
|
| Rate for Payer: Priority Health SBD |
$130.07
|
| Rate for Payer: UMR Bronson Commercial |
$76.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.84
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
IP
|
$19,247.29
|
|
|
Service Code
|
NDC 59148002050
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8,468.81 |
| Max. Negotiated Rate |
$17,322.56 |
| Rate for Payer: Aetna American Axle |
$12,510.74
|
| Rate for Payer: Aetna Commercial |
$16,360.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,510.74
|
| Rate for Payer: Cash Price |
$15,397.83
|
| Rate for Payer: Cofinity Commercial |
$13,473.10
|
| Rate for Payer: Cofinity Commercial |
$16,552.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,473.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,397.83
|
| Rate for Payer: Healthscope Commercial |
$17,322.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,473.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,435.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,360.20
|
| Rate for Payer: PHP Commercial |
$16,360.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,510.74
|
| Rate for Payer: Priority Health SBD |
$12,125.79
|
| Rate for Payer: UMR Bronson Commercial |
$8,468.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,435.47
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
IP
|
$2,064.60
|
|
|
Service Code
|
NDC 49884076854
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$908.42 |
| Max. Negotiated Rate |
$1,858.14 |
| Rate for Payer: Aetna American Axle |
$1,341.99
|
| Rate for Payer: Aetna Commercial |
$1,754.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,341.99
|
| Rate for Payer: Cash Price |
$1,651.68
|
| Rate for Payer: Cofinity Commercial |
$1,445.22
|
| Rate for Payer: Cofinity Commercial |
$1,775.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,445.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,651.68
|
| Rate for Payer: Healthscope Commercial |
$1,858.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,445.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,548.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,754.91
|
| Rate for Payer: PHP Commercial |
$1,754.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,341.99
|
| Rate for Payer: Priority Health SBD |
$1,300.70
|
| Rate for Payer: UMR Bronson Commercial |
$908.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,548.45
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
OP
|
$2,064.60
|
|
|
Service Code
|
NDC 49884076854
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$763.90 |
| Max. Negotiated Rate |
$1,858.14 |
| Rate for Payer: Aetna American Axle |
$1,341.99
|
| Rate for Payer: Aetna Commercial |
$1,754.91
|
| Rate for Payer: Aetna Medicare |
$1,032.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,341.99
|
| Rate for Payer: BCBS Complete |
$825.84
|
| Rate for Payer: Cash Price |
$1,651.68
|
| Rate for Payer: Cofinity Commercial |
$1,445.22
|
| Rate for Payer: Cofinity Commercial |
$1,775.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,445.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,651.68
|
| Rate for Payer: Healthscope Commercial |
$1,858.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,445.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,548.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,754.91
|
| Rate for Payer: PHP Commercial |
$1,754.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,341.99
|
| Rate for Payer: Priority Health SBD |
$1,300.70
|
| Rate for Payer: UMR Bronson Commercial |
$763.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,548.45
|
|
|
TOLVAPTAN 15 MG TABLET
|
Facility
|
OP
|
$19,247.29
|
|
|
Service Code
|
NDC 59148002050
|
| Hospital Charge Code |
97893
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,121.50 |
| Max. Negotiated Rate |
$17,322.56 |
| Rate for Payer: Aetna American Axle |
$12,510.74
|
| Rate for Payer: Aetna Commercial |
$16,360.20
|
| Rate for Payer: Aetna Medicare |
$9,623.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,510.74
|
| Rate for Payer: BCBS Complete |
$7,698.92
|
| Rate for Payer: Cash Price |
$15,397.83
|
| Rate for Payer: Cofinity Commercial |
$13,473.10
|
| Rate for Payer: Cofinity Commercial |
$16,552.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,473.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,397.83
|
| Rate for Payer: Healthscope Commercial |
$17,322.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,473.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,435.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,360.20
|
| Rate for Payer: PHP Commercial |
$16,360.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,510.74
|
| Rate for Payer: Priority Health SBD |
$12,125.79
|
| Rate for Payer: UMR Bronson Commercial |
$7,121.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,435.47
|
|
|
TOLVAPTAN 30 MG TABLET
|
Facility
|
IP
|
$444.00
|
|
|
Service Code
|
NDC 31722086901
|
| Hospital Charge Code |
97894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.36 |
| Max. Negotiated Rate |
$399.60 |
| Rate for Payer: Aetna American Axle |
$288.60
|
| Rate for Payer: Aetna Commercial |
$377.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.60
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cofinity Commercial |
$310.80
|
| Rate for Payer: Cofinity Commercial |
$381.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.20
|
| Rate for Payer: Healthscope Commercial |
$399.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.40
|
| Rate for Payer: PHP Commercial |
$377.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.60
|
| Rate for Payer: Priority Health SBD |
$279.72
|
| Rate for Payer: UMR Bronson Commercial |
$195.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.00
|
|
|
TOLVAPTAN 30 MG TABLET
|
Facility
|
OP
|
$444.00
|
|
|
Service Code
|
NDC 31722086901
|
| Hospital Charge Code |
97894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.28 |
| Max. Negotiated Rate |
$399.60 |
| Rate for Payer: Aetna American Axle |
$288.60
|
| Rate for Payer: Aetna Commercial |
$377.40
|
| Rate for Payer: Aetna Medicare |
$222.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$288.60
|
| Rate for Payer: BCBS Complete |
$177.60
|
| Rate for Payer: Cash Price |
$355.20
|
| Rate for Payer: Cofinity Commercial |
$310.80
|
| Rate for Payer: Cofinity Commercial |
$381.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$310.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$355.20
|
| Rate for Payer: Healthscope Commercial |
$399.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$310.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$333.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$377.40
|
| Rate for Payer: PHP Commercial |
$377.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$288.60
|
| Rate for Payer: Priority Health SBD |
$279.72
|
| Rate for Payer: UMR Bronson Commercial |
$164.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$333.00
|
|
