|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM
|
Facility
|
IP
|
$1,572.69
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
9977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$691.98 |
| Max. Negotiated Rate |
$1,415.42 |
| Rate for Payer: Aetna American Axle |
$1,022.25
|
| Rate for Payer: Aetna Commercial |
$1,336.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,022.25
|
| Rate for Payer: Cash Price |
$1,258.15
|
| Rate for Payer: Cofinity Commercial |
$1,100.88
|
| Rate for Payer: Cofinity Commercial |
$1,352.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,100.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,258.15
|
| Rate for Payer: Healthscope Commercial |
$1,415.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,100.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,179.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,336.79
|
| Rate for Payer: PHP Commercial |
$1,336.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,022.25
|
| Rate for Payer: Priority Health SBD |
$990.79
|
| Rate for Payer: UMR Bronson Commercial |
$691.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,179.52
|
|
|
CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM
|
Facility
|
OP
|
$1,572.69
|
|
|
Service Code
|
NDC 00046087221
|
| Hospital Charge Code |
9977
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$581.90 |
| Max. Negotiated Rate |
$1,415.42 |
| Rate for Payer: Aetna American Axle |
$1,022.25
|
| Rate for Payer: Aetna Commercial |
$1,336.79
|
| Rate for Payer: Aetna Medicare |
$786.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,022.25
|
| Rate for Payer: BCBS Complete |
$629.08
|
| Rate for Payer: Cash Price |
$1,258.15
|
| Rate for Payer: Cofinity Commercial |
$1,100.88
|
| Rate for Payer: Cofinity Commercial |
$1,352.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,100.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,258.15
|
| Rate for Payer: Healthscope Commercial |
$1,415.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,100.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,179.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,336.79
|
| Rate for Payer: PHP Commercial |
$1,336.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,022.25
|
| Rate for Payer: Priority Health SBD |
$990.79
|
| Rate for Payer: UMR Bronson Commercial |
$581.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,179.52
|
|
|
CONJUGATED ESTROGENS 0.625 MG TABLET
|
Facility
|
OP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110281
|
| Hospital Charge Code |
9974
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$943.93 |
| Max. Negotiated Rate |
$2,296.03 |
| Rate for Payer: Aetna American Axle |
$1,658.25
|
| Rate for Payer: Aetna Commercial |
$2,168.48
|
| Rate for Payer: Aetna Medicare |
$1,275.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,658.25
|
| Rate for Payer: BCBS Complete |
$1,020.46
|
| Rate for Payer: Cash Price |
$2,040.92
|
| Rate for Payer: Cofinity Commercial |
$1,785.81
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,913.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,168.48
|
| Rate for Payer: PHP Commercial |
$2,168.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,658.25
|
| Rate for Payer: Priority Health SBD |
$1,607.22
|
| Rate for Payer: UMR Bronson Commercial |
$943.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,913.36
|
|
|
CONJUGATED ESTROGENS 0.625 MG TABLET
|
Facility
|
IP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110281
|
| Hospital Charge Code |
9974
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,122.51 |
| Max. Negotiated Rate |
$2,296.03 |
| Rate for Payer: Aetna American Axle |
$1,658.25
|
| Rate for Payer: Aetna Commercial |
$2,168.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,658.25
|
| Rate for Payer: Cash Price |
$2,040.92
|
| Rate for Payer: Cofinity Commercial |
$1,785.81
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,913.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,168.48
|
| Rate for Payer: PHP Commercial |
$2,168.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,658.25
|
| Rate for Payer: Priority Health SBD |
$1,607.22
|
| Rate for Payer: UMR Bronson Commercial |
$1,122.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,913.36
|
|
|
CONJUGATED ESTROGENS 1.25 MG TABLET
|
Facility
|
IP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110481
|
| Hospital Charge Code |
2938
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,122.51 |
| Max. Negotiated Rate |
$2,296.03 |
| Rate for Payer: Aetna American Axle |
$1,658.25
|
| Rate for Payer: Aetna Commercial |
$2,168.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,658.25
|
| Rate for Payer: Cash Price |
$2,040.92
|
| Rate for Payer: Cofinity Commercial |
$1,785.81
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,913.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,168.48
|
| Rate for Payer: PHP Commercial |
$2,168.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,658.25
|
| Rate for Payer: Priority Health SBD |
$1,607.22
|
| Rate for Payer: UMR Bronson Commercial |
$1,122.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,913.36
|
|
|
CONJUGATED ESTROGENS 1.25 MG TABLET
|
Facility
|
OP
|
$2,551.15
|
|
|
Service Code
|
NDC 00046110481
|
| Hospital Charge Code |
2938
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$943.93 |
| Max. Negotiated Rate |
$2,296.03 |
| Rate for Payer: Aetna American Axle |
$1,658.25
|
| Rate for Payer: Aetna Commercial |
$2,168.48
|
| Rate for Payer: Aetna Medicare |
$1,275.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,658.25
|
| Rate for Payer: BCBS Complete |
$1,020.46
|
| Rate for Payer: Cash Price |
$2,040.92
|
| Rate for Payer: Cofinity Commercial |
$1,785.81
|
| Rate for Payer: Cofinity Commercial |
$2,193.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,785.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,040.92
|
| Rate for Payer: Healthscope Commercial |
$2,296.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,785.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,913.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,168.48
|
| Rate for Payer: PHP Commercial |
$2,168.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,658.25
|
| Rate for Payer: Priority Health SBD |
$1,607.22
|
| Rate for Payer: UMR Bronson Commercial |
$943.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,913.36
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$1,175.88
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
9972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$517.39 |
| Max. Negotiated Rate |
$1,058.29 |
| Rate for Payer: Aetna American Axle |
$764.32
|
| Rate for Payer: Aetna Commercial |
$999.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$764.32
|
| Rate for Payer: Cash Price |
$940.70
|
| Rate for Payer: Cofinity Commercial |
$1,011.26
|
| Rate for Payer: Cofinity Commercial |
$823.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$823.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$940.70
|
| Rate for Payer: Healthscope Commercial |
$1,058.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$823.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$881.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$999.50
|
| Rate for Payer: PHP Commercial |
$999.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$764.32
|
| Rate for Payer: Priority Health SBD |
$740.80
|
| Rate for Payer: UMR Bronson Commercial |
$517.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$881.91
|
|
|
CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$1,175.88
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
9972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.14 |
| Max. Negotiated Rate |
$1,103.61 |
| Rate for Payer: Aetna American Axle |
$764.32
|
| Rate for Payer: Aetna Commercial |
$999.50
|
| Rate for Payer: Aetna Medicare |
$407.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$764.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$490.07
|
| Rate for Payer: Amish Plain Church Group Commercial |
$490.07
|
| Rate for Payer: BCBS Complete |
$220.65
|
| Rate for Payer: BCBS MAPPO |
$392.06
|
| Rate for Payer: BCN Medicare Advantage |
$392.06
|
| Rate for Payer: Cash Price |
$940.70
|
| Rate for Payer: Cash Price |
$940.70
|
| Rate for Payer: Cofinity Commercial |
$823.12
|
| Rate for Payer: Cofinity Commercial |
$1,011.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$823.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$940.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$392.06
|
| Rate for Payer: Healthscope Commercial |
$1,058.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$823.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$881.91
|
| Rate for Payer: Mclaren Medicaid |
$210.14
|
| Rate for Payer: Mclaren Medicare |
$392.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$411.66
|
| Rate for Payer: Meridian Medicaid |
$220.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$450.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$999.50
|
| Rate for Payer: PACE Medicare |
$372.46
|
| Rate for Payer: PACE SWMI |
$392.06
|
| Rate for Payer: PHP Commercial |
$999.50
|
| Rate for Payer: PHP Medicare Advantage |
$392.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$210.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$764.32
|
| Rate for Payer: Priority Health Medicare |
$392.06
|
| Rate for Payer: Priority Health SBD |
$740.80
|
| Rate for Payer: Railroad Medicare Medicare |
$392.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,103.61
|
| Rate for Payer: UHC Dual Complete DSNP |
$392.06
|
| Rate for Payer: UHC Exchange |
$749.27
|
| Rate for Payer: UHC Medicare Advantage |
$392.06
|
| Rate for Payer: UHCCP Medicaid |
$210.14
|
| Rate for Payer: UMR Bronson Commercial |
$435.08
|
| Rate for Payer: VA VA |
$392.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$881.91
|
|
|
CONJUNCTIVAL FLAP; BRIDGE OR PARTIAL (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$10,352.58
|
|
|
Service Code
|
CPT 68360
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,971.29 |
| Max. Negotiated Rate |
$10,352.58 |
| Rate for Payer: Aetna Medicare |
$3,824.89
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,597.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,597.23
|
| Rate for Payer: BCBS Complete |
$2,069.85
|
| Rate for Payer: BCBS MAPPO |
$3,677.78
|
| Rate for Payer: BCN Medicare Advantage |
$3,677.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,677.78
|
| Rate for Payer: Mclaren Medicaid |
$1,971.29
|
| Rate for Payer: Mclaren Medicare |
$3,677.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,861.67
|
| Rate for Payer: Meridian Medicaid |
$2,069.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,229.45
|
| Rate for Payer: PACE Medicare |
$3,493.89
|
| Rate for Payer: PACE SWMI |
$3,677.78
|
| Rate for Payer: PHP Medicare Advantage |
$3,677.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,971.29
|
| Rate for Payer: Priority Health Medicare |
$3,677.78
|
| Rate for Payer: Railroad Medicare Medicare |
$3,677.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10,352.58
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,677.78
|
| Rate for Payer: UHC Exchange |
$7,028.61
|
| Rate for Payer: UHC Medicare Advantage |
$3,677.78
|
| Rate for Payer: UHCCP Medicaid |
$1,971.29
|
| Rate for Payer: VA VA |
$3,677.78
|
|
|
CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT
|
Facility
|
OP
|
$6,404.71
|
|
|
Service Code
|
CPT 68320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,219.56 |
| Max. Negotiated Rate |
$6,404.71 |
| Rate for Payer: Aetna Medicare |
$2,366.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,844.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,844.11
|
| Rate for Payer: BCBS Complete |
$1,280.53
|
| Rate for Payer: BCBS MAPPO |
$2,275.29
|
| Rate for Payer: BCN Medicare Advantage |
$2,275.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,275.29
|
| Rate for Payer: Mclaren Medicaid |
$1,219.56
|
| Rate for Payer: Mclaren Medicare |
$2,275.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,389.05
|
| Rate for Payer: Meridian Medicaid |
$1,280.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,616.58
|
| Rate for Payer: PACE Medicare |
$2,161.53
|
| Rate for Payer: PACE SWMI |
$2,275.29
|
| Rate for Payer: PHP Medicare Advantage |
$2,275.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,219.56
|
| Rate for Payer: Priority Health Medicare |
$2,275.29
|
| Rate for Payer: Railroad Medicare Medicare |
$2,275.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6,404.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,275.29
|
| Rate for Payer: UHC Exchange |
$4,348.31
|
| Rate for Payer: UHC Medicare Advantage |
$2,275.29
|
| Rate for Payer: UHCCP Medicaid |
$1,219.56
|
| Rate for Payer: VA VA |
$2,275.29
|
|
|
CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY;
|
Facility
|
OP
|
$6,404.71
|
|
|
Service Code
|
CPT 67880
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,219.56 |
| Max. Negotiated Rate |
$6,404.71 |
| Rate for Payer: Aetna Medicare |
$2,366.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,844.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,844.11
|
| Rate for Payer: BCBS Complete |
$1,280.53
|
| Rate for Payer: BCBS MAPPO |
$2,275.29
|
| Rate for Payer: BCN Medicare Advantage |
$2,275.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,275.29
|
| Rate for Payer: Mclaren Medicaid |
$1,219.56
|
| Rate for Payer: Mclaren Medicare |
$2,275.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2,389.05
|
| Rate for Payer: Meridian Medicaid |
$1,280.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,616.58
|
| Rate for Payer: PACE Medicare |
$2,161.53
|
| Rate for Payer: PACE SWMI |
$2,275.29
|
| Rate for Payer: PHP Medicare Advantage |
$2,275.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,219.56
|
| Rate for Payer: Priority Health Medicare |
$2,275.29
|
| Rate for Payer: Railroad Medicare Medicare |
$2,275.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6,404.71
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,275.29
|
| Rate for Payer: UHC Exchange |
$4,348.31
|
| Rate for Payer: UHC Medicare Advantage |
$2,275.29
|
| Rate for Payer: UHCCP Medicaid |
$1,219.56
|
| Rate for Payer: VA VA |
$2,275.29
|
|
|
CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD
|
Facility
|
OP
|
$353.86
|
|
|
Service Code
|
CPT 30903
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$67.38 |
| Max. Negotiated Rate |
$353.86 |
| Rate for Payer: Aetna Medicare |
$130.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$157.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$157.14
|
| Rate for Payer: BCBS Complete |
$70.75
|
| Rate for Payer: BCBS MAPPO |
$125.71
|
| Rate for Payer: BCN Medicare Advantage |
$125.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$125.71
|
| Rate for Payer: Mclaren Medicaid |
$67.38
|
| Rate for Payer: Mclaren Medicare |
$125.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$132.00
|
| Rate for Payer: Meridian Medicaid |
$70.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$144.57
|
| Rate for Payer: PACE Medicare |
$119.42
|
| Rate for Payer: PACE SWMI |
$125.71
|
| Rate for Payer: PHP Medicare Advantage |
$125.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.38
|
| Rate for Payer: Priority Health Medicare |
$125.71
|
| Rate for Payer: Railroad Medicare Medicare |
$125.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$353.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$125.71
|
| Rate for Payer: UHC Exchange |
$240.24
|
| Rate for Payer: UHC Medicare Advantage |
$125.71
|
| Rate for Payer: UHCCP Medicaid |
$67.38
|
| Rate for Payer: VA VA |
$125.71
|
|
|
CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) ANY METHOD
|
Facility
|
OP
|
$353.86
|
|
|
Service Code
|
CPT 30901
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$67.38 |
| Max. Negotiated Rate |
$353.86 |
| Rate for Payer: Aetna Medicare |
$130.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$157.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$157.14
|
| Rate for Payer: BCBS Complete |
$70.75
|
| Rate for Payer: BCBS MAPPO |
$125.71
|
| Rate for Payer: BCN Medicare Advantage |
$125.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$125.71
|
| Rate for Payer: Mclaren Medicaid |
$67.38
|
| Rate for Payer: Mclaren Medicare |
$125.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$132.00
|
| Rate for Payer: Meridian Medicaid |
$70.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$144.57
|
| Rate for Payer: PACE Medicare |
$119.42
|
| Rate for Payer: PACE SWMI |
$125.71
|
| Rate for Payer: PHP Medicare Advantage |
$125.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.38
|
| Rate for Payer: Priority Health Medicare |
$125.71
|
| Rate for Payer: Railroad Medicare Medicare |
$125.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$353.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$125.71
|
| Rate for Payer: UHC Exchange |
$240.24
|
| Rate for Payer: UHC Medicare Advantage |
$125.71
|
| Rate for Payer: UHCCP Medicaid |
$67.38
|
| Rate for Payer: VA VA |
$125.71
|
|
|
CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; INITIAL
|
Facility
|
OP
|
$353.86
|
|
|
Service Code
|
CPT 30905
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$67.38 |
| Max. Negotiated Rate |
$353.86 |
| Rate for Payer: Aetna Medicare |
$130.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$157.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$157.14
|
| Rate for Payer: BCBS Complete |
$70.75
|
| Rate for Payer: BCBS MAPPO |
$125.71
|
| Rate for Payer: BCN Medicare Advantage |
$125.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$125.71
|
| Rate for Payer: Mclaren Medicaid |
$67.38
|
| Rate for Payer: Mclaren Medicare |
$125.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$132.00
|
| Rate for Payer: Meridian Medicaid |
$70.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$144.57
|
| Rate for Payer: PACE Medicare |
$119.42
|
| Rate for Payer: PACE SWMI |
$125.71
|
| Rate for Payer: PHP Medicare Advantage |
$125.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.38
|
| Rate for Payer: Priority Health Medicare |
$125.71
|
| Rate for Payer: Railroad Medicare Medicare |
$125.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$353.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$125.71
|
| Rate for Payer: UHC Exchange |
$240.24
|
| Rate for Payer: UHC Medicare Advantage |
$125.71
|
| Rate for Payer: UHCCP Medicaid |
$67.38
|
| Rate for Payer: VA VA |
$125.71
|
|
|
CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; INITIAL
|
Facility
|
OP
|
$353.86
|
|
|
Service Code
|
CPT 30905
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$67.38 |
| Max. Negotiated Rate |
$353.86 |
| Rate for Payer: Aetna Medicare |
$130.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$157.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$157.14
|
| Rate for Payer: BCBS Complete |
$70.75
|
| Rate for Payer: BCBS MAPPO |
$125.71
|
| Rate for Payer: BCN Medicare Advantage |
$125.71
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$125.71
|
| Rate for Payer: Mclaren Medicaid |
$67.38
|
| Rate for Payer: Mclaren Medicare |
$125.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$132.00
|
| Rate for Payer: Meridian Medicaid |
$70.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$144.57
|
| Rate for Payer: PACE Medicare |
$119.42
|
| Rate for Payer: PACE SWMI |
$125.71
|
| Rate for Payer: PHP Medicare Advantage |
$125.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.38
|
| Rate for Payer: Priority Health Medicare |
$125.71
|
| Rate for Payer: Railroad Medicare Medicare |
$125.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$353.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$125.71
|
| Rate for Payer: UHC Exchange |
$240.24
|
| Rate for Payer: UHC Medicare Advantage |
$125.71
|
| Rate for Payer: UHCCP Medicaid |
$67.38
|
| Rate for Payer: VA VA |
$125.71
|
|
|
CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT
|
Facility
|
OP
|
$637.52
|
|
|
Service Code
|
CPT 30906
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$121.39 |
| Max. Negotiated Rate |
$637.52 |
| Rate for Payer: Aetna Medicare |
$235.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$283.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$283.10
|
| Rate for Payer: BCBS Complete |
$127.46
|
| Rate for Payer: BCBS MAPPO |
$226.48
|
| Rate for Payer: BCN Medicare Advantage |
$226.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$226.48
|
| Rate for Payer: Mclaren Medicaid |
$121.39
|
| Rate for Payer: Mclaren Medicare |
$226.48
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$237.80
|
| Rate for Payer: Meridian Medicaid |
$127.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$260.45
|
| Rate for Payer: PACE Medicare |
$215.16
|
| Rate for Payer: PACE SWMI |
$226.48
|
| Rate for Payer: PHP Medicare Advantage |
$226.48
|
| Rate for Payer: Priority Health Choice Medicaid |
$121.39
|
| Rate for Payer: Priority Health Medicare |
$226.48
|
| Rate for Payer: Railroad Medicare Medicare |
$226.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$637.52
|
| Rate for Payer: UHC Dual Complete DSNP |
$226.48
|
| Rate for Payer: UHC Exchange |
$432.83
|
| Rate for Payer: UHC Medicare Advantage |
$226.48
|
| Rate for Payer: UHCCP Medicaid |
$121.39
|
| Rate for Payer: VA VA |
$226.48
|
|
|
CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE
|
Facility
|
OP
|
$1,398.05
|
|
|
Service Code
|
CPT 42960
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$266.21 |
| Max. Negotiated Rate |
$1,398.05 |
| Rate for Payer: Aetna Medicare |
$516.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$620.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$620.83
|
| Rate for Payer: BCBS Complete |
$279.52
|
| Rate for Payer: BCBS MAPPO |
$496.66
|
| Rate for Payer: BCN Medicare Advantage |
$496.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$496.66
|
| Rate for Payer: Mclaren Medicaid |
$266.21
|
| Rate for Payer: Mclaren Medicare |
$496.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$521.49
|
| Rate for Payer: Meridian Medicaid |
$279.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$571.16
|
| Rate for Payer: PACE Medicare |
$471.83
|
| Rate for Payer: PACE SWMI |
$496.66
|
| Rate for Payer: PHP Medicare Advantage |
$496.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$266.21
|
| Rate for Payer: Priority Health Medicare |
$496.66
|
| Rate for Payer: Railroad Medicare Medicare |
$496.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,398.05
|
| Rate for Payer: UHC Dual Complete DSNP |
$496.66
|
| Rate for Payer: UHC Exchange |
$949.17
|
| Rate for Payer: UHC Medicare Advantage |
$496.66
|
| Rate for Payer: UHCCP Medicaid |
$266.21
|
| Rate for Payer: VA VA |
$496.66
|
|
|
CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION
|
Facility
|
OP
|
$8,903.25
|
|
|
Service Code
|
CPT 42962
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,695.31 |
| Max. Negotiated Rate |
$8,903.25 |
| Rate for Payer: Aetna Medicare |
$3,289.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,953.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,953.62
|
| Rate for Payer: BCBS Complete |
$1,780.08
|
| Rate for Payer: BCBS MAPPO |
$3,162.90
|
| Rate for Payer: BCN Medicare Advantage |
$3,162.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,162.90
|
| Rate for Payer: Mclaren Medicaid |
$1,695.31
|
| Rate for Payer: Mclaren Medicare |
$3,162.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,321.05
|
| Rate for Payer: Meridian Medicaid |
$1,780.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,637.34
|
| Rate for Payer: PACE Medicare |
$3,004.76
|
| Rate for Payer: PACE SWMI |
$3,162.90
|
| Rate for Payer: PHP Medicare Advantage |
$3,162.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,695.31
|
| Rate for Payer: Priority Health Medicare |
$3,162.90
|
| Rate for Payer: Railroad Medicare Medicare |
$3,162.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,903.25
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,162.90
|
| Rate for Payer: UHC Exchange |
$6,044.62
|
| Rate for Payer: UHC Medicare Advantage |
$3,162.90
|
| Rate for Payer: UHCCP Medicaid |
$1,695.31
|
| Rate for Payer: VA VA |
$3,162.90
|
|
|
COPANLISIB 60 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23,588.67
|
|
|
Service Code
|
HCPCS J9057
|
| Hospital Charge Code |
184552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,379.01 |
| Max. Negotiated Rate |
$21,229.80 |
| Rate for Payer: Aetna American Axle |
$15,332.64
|
| Rate for Payer: Aetna Commercial |
$20,050.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15,332.64
|
| Rate for Payer: Cash Price |
$18,870.94
|
| Rate for Payer: Cofinity Commercial |
$16,512.07
|
| Rate for Payer: Cofinity Commercial |
$20,286.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$16,512.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,870.94
|
| Rate for Payer: Healthscope Commercial |
$21,229.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16,512.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17,691.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20,050.37
|
| Rate for Payer: PHP Commercial |
$20,050.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15,332.64
|
| Rate for Payer: Priority Health SBD |
$14,860.86
|
| Rate for Payer: UMR Bronson Commercial |
$10,379.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17,691.50
|
|
|
COPANLISIB 60 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$23,588.67
|
|
|
Service Code
|
HCPCS J9057
|
| Hospital Charge Code |
184552
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8,727.81 |
| Max. Negotiated Rate |
$21,229.80 |
| Rate for Payer: Aetna American Axle |
$15,332.64
|
| Rate for Payer: Aetna Commercial |
$20,050.37
|
| Rate for Payer: Aetna Medicare |
$11,794.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15,332.64
|
| Rate for Payer: BCBS Complete |
$9,435.47
|
| Rate for Payer: Cash Price |
$18,870.94
|
| Rate for Payer: Cofinity Commercial |
$16,512.07
|
| Rate for Payer: Cofinity Commercial |
$20,286.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$16,512.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,870.94
|
| Rate for Payer: Healthscope Commercial |
$21,229.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16,512.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17,691.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20,050.37
|
| Rate for Payer: PHP Commercial |
$20,050.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15,332.64
|
| Rate for Payer: Priority Health SBD |
$14,860.86
|
| Rate for Payer: UMR Bronson Commercial |
$8,727.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17,691.50
|
|
|
COPPER 380 SQUARE MM INTRAUTERINE DEVICE
|
Facility
|
IP
|
$2,689.90
|
|
|
Service Code
|
HCPCS J7300
|
| Hospital Charge Code |
167586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,183.56 |
| Max. Negotiated Rate |
$2,420.91 |
| Rate for Payer: Aetna American Axle |
$1,748.43
|
| Rate for Payer: Aetna Commercial |
$2,286.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,748.43
|
| Rate for Payer: Cash Price |
$2,151.92
|
| Rate for Payer: Cofinity Commercial |
$1,882.93
|
| Rate for Payer: Cofinity Commercial |
$2,313.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,882.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,151.92
|
| Rate for Payer: Healthscope Commercial |
$2,420.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,882.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,017.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,286.41
|
| Rate for Payer: PHP Commercial |
$2,286.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,748.43
|
| Rate for Payer: Priority Health SBD |
$1,694.64
|
| Rate for Payer: UMR Bronson Commercial |
$1,183.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,017.42
|
|
|
COPPER 380 SQUARE MM INTRAUTERINE DEVICE
|
Facility
|
OP
|
$2,689.90
|
|
|
Service Code
|
HCPCS J7300
|
| Hospital Charge Code |
167586
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$995.26 |
| Max. Negotiated Rate |
$2,420.91 |
| Rate for Payer: Aetna American Axle |
$1,748.43
|
| Rate for Payer: Aetna Commercial |
$2,286.41
|
| Rate for Payer: Aetna Medicare |
$1,344.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,748.43
|
| Rate for Payer: BCBS Complete |
$1,075.96
|
| Rate for Payer: Cash Price |
$2,151.92
|
| Rate for Payer: Cofinity Commercial |
$1,882.93
|
| Rate for Payer: Cofinity Commercial |
$2,313.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,882.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,151.92
|
| Rate for Payer: Healthscope Commercial |
$2,420.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,882.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,017.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,286.41
|
| Rate for Payer: PHP Commercial |
$2,286.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,748.43
|
| Rate for Payer: Priority Health SBD |
$1,694.64
|
| Rate for Payer: UMR Bronson Commercial |
$995.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,017.42
|
|
|
COPPER GLYCINATE AMINO ACID CHELATE 2.5 MG TABLET
|
Facility
|
IP
|
$209.15
|
|
|
Service Code
|
NDC 09900000385
|
| Hospital Charge Code |
163478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.03 |
| Max. Negotiated Rate |
$188.24 |
| Rate for Payer: Aetna American Axle |
$135.95
|
| Rate for Payer: Aetna Commercial |
$177.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.95
|
| Rate for Payer: Cash Price |
$167.32
|
| Rate for Payer: Cofinity Commercial |
$146.41
|
| Rate for Payer: Cofinity Commercial |
$179.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.32
|
| Rate for Payer: Healthscope Commercial |
$188.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.78
|
| Rate for Payer: PHP Commercial |
$177.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.95
|
| Rate for Payer: Priority Health SBD |
$131.76
|
| Rate for Payer: UMR Bronson Commercial |
$92.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.86
|
|
|
COPPER GLYCINATE AMINO ACID CHELATE 2.5 MG TABLET
|
Facility
|
IP
|
$209.15
|
|
|
Service Code
|
NDC 03398400640
|
| Hospital Charge Code |
163478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.03 |
| Max. Negotiated Rate |
$188.24 |
| Rate for Payer: Aetna American Axle |
$135.95
|
| Rate for Payer: Aetna Commercial |
$177.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.95
|
| Rate for Payer: Cash Price |
$167.32
|
| Rate for Payer: Cofinity Commercial |
$146.41
|
| Rate for Payer: Cofinity Commercial |
$179.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.32
|
| Rate for Payer: Healthscope Commercial |
$188.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.78
|
| Rate for Payer: PHP Commercial |
$177.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.95
|
| Rate for Payer: Priority Health SBD |
$131.76
|
| Rate for Payer: UMR Bronson Commercial |
$92.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.86
|
|
|
COPPER GLYCINATE AMINO ACID CHELATE 2.5 MG TABLET
|
Facility
|
OP
|
$209.15
|
|
|
Service Code
|
NDC 03398400640
|
| Hospital Charge Code |
163478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.39 |
| Max. Negotiated Rate |
$188.24 |
| Rate for Payer: Aetna American Axle |
$135.95
|
| Rate for Payer: Aetna Commercial |
$177.78
|
| Rate for Payer: Aetna Medicare |
$104.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.95
|
| Rate for Payer: BCBS Complete |
$83.66
|
| Rate for Payer: Cash Price |
$167.32
|
| Rate for Payer: Cofinity Commercial |
$146.41
|
| Rate for Payer: Cofinity Commercial |
$179.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.32
|
| Rate for Payer: Healthscope Commercial |
$188.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.78
|
| Rate for Payer: PHP Commercial |
$177.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.95
|
| Rate for Payer: Priority Health SBD |
$131.76
|
| Rate for Payer: UMR Bronson Commercial |
$77.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.86
|
|
