|
DIPHENHYDRAMINE 12.5 MG CUSTOM TAB
|
Facility
|
IP
|
$5.52
|
|
|
Service Code
|
NDC 09900000982
|
| Hospital Charge Code |
181103
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$4.97 |
| Rate for Payer: Aetna American Axle |
$3.59
|
| Rate for Payer: Aetna Commercial |
$4.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.59
|
| Rate for Payer: Cash Price |
$4.42
|
| Rate for Payer: Cofinity Commercial |
$3.86
|
| Rate for Payer: Cofinity Commercial |
$4.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.42
|
| Rate for Payer: Healthscope Commercial |
$4.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.69
|
| Rate for Payer: PHP Commercial |
$4.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.59
|
| Rate for Payer: Priority Health SBD |
$3.48
|
| Rate for Payer: UMR Bronson Commercial |
$2.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.14
|
|
|
DIPHENHYDRAMINE 25 MG CAPSULE
|
Facility
|
IP
|
$7.52
|
|
|
Service Code
|
NDC 00904530661
|
| Hospital Charge Code |
2509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$6.77 |
| Rate for Payer: Aetna American Axle |
$4.89
|
| Rate for Payer: Aetna Commercial |
$6.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.89
|
| Rate for Payer: Cash Price |
$6.02
|
| Rate for Payer: Cofinity Commercial |
$5.26
|
| Rate for Payer: Cofinity Commercial |
$6.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.02
|
| Rate for Payer: Healthscope Commercial |
$6.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.39
|
| Rate for Payer: PHP Commercial |
$6.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.89
|
| Rate for Payer: Priority Health SBD |
$4.74
|
| Rate for Payer: UMR Bronson Commercial |
$3.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.64
|
|
|
DIPHENHYDRAMINE 25 MG CAPSULE
|
Facility
|
OP
|
$7.52
|
|
|
Service Code
|
NDC 00904530661
|
| Hospital Charge Code |
2509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$6.77 |
| Rate for Payer: Aetna American Axle |
$4.89
|
| Rate for Payer: Aetna Commercial |
$6.39
|
| Rate for Payer: Aetna Medicare |
$3.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.89
|
| Rate for Payer: BCBS Complete |
$3.01
|
| Rate for Payer: Cash Price |
$6.02
|
| Rate for Payer: Cofinity Commercial |
$5.26
|
| Rate for Payer: Cofinity Commercial |
$6.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$5.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.02
|
| Rate for Payer: Healthscope Commercial |
$6.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.39
|
| Rate for Payer: PHP Commercial |
$6.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.89
|
| Rate for Payer: Priority Health SBD |
$4.74
|
| Rate for Payer: UMR Bronson Commercial |
$2.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.64
|
|
|
DIPHENHYDRAMINE 25 MG CAPSULE
|
Facility
|
IP
|
$86.95
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.26 |
| Max. Negotiated Rate |
$78.25 |
| Rate for Payer: Aetna American Axle |
$56.52
|
| Rate for Payer: Aetna Commercial |
$73.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.52
|
| Rate for Payer: Cash Price |
$69.56
|
| Rate for Payer: Cofinity Commercial |
$60.87
|
| Rate for Payer: Cofinity Commercial |
$74.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$60.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.56
|
| Rate for Payer: Healthscope Commercial |
$78.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$60.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.91
|
| Rate for Payer: PHP Commercial |
$73.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.52
|
| Rate for Payer: Priority Health SBD |
$54.78
|
| Rate for Payer: UMR Bronson Commercial |
$38.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.21
|
|
|
DIPHENHYDRAMINE 25 MG CAPSULE
|
Facility
|
OP
|
$86.95
|
|
|
Service Code
|
NDC 00904723761
|
| Hospital Charge Code |
2509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.17 |
| Max. Negotiated Rate |
$78.25 |
| Rate for Payer: Aetna American Axle |
$56.52
|
| Rate for Payer: Aetna Commercial |
$73.91
|
| Rate for Payer: Aetna Medicare |
$43.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.52
|
| Rate for Payer: BCBS Complete |
$34.78
|
| Rate for Payer: Cash Price |
$69.56
|
| Rate for Payer: Cofinity Commercial |
$60.87
|
| Rate for Payer: Cofinity Commercial |
$74.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$60.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.56
|
| Rate for Payer: Healthscope Commercial |
$78.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$60.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.91
|
| Rate for Payer: PHP Commercial |
$73.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.52
|
| Rate for Payer: Priority Health SBD |
$54.78
|
| Rate for Payer: UMR Bronson Commercial |
$32.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.21
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$170.10
|
|
|
Service Code
|
NDC 96295012933
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.84 |
| Max. Negotiated Rate |
$153.09 |
| Rate for Payer: Aetna American Axle |
$110.56
|
| Rate for Payer: Aetna Commercial |
$144.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.56
|
| Rate for Payer: Cash Price |
$136.08
|
| Rate for Payer: Cofinity Commercial |
$119.07
|
| Rate for Payer: Cofinity Commercial |
$146.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$119.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.08
|
| Rate for Payer: Healthscope Commercial |
$153.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.59
|
| Rate for Payer: PHP Commercial |
$144.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.56
|
| Rate for Payer: Priority Health SBD |
$107.16
|
| Rate for Payer: UMR Bronson Commercial |
$74.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.58
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$142.80
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.84 |
| Max. Negotiated Rate |
$128.52 |
| Rate for Payer: Aetna American Axle |
$92.82
|
| Rate for Payer: Aetna Commercial |
$121.38
|
| Rate for Payer: Aetna Medicare |
$71.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.82
|
| Rate for Payer: BCBS Complete |
$57.12
|
| Rate for Payer: Cash Price |
$114.24
|
| Rate for Payer: Cofinity Commercial |
$122.81
|
| Rate for Payer: Cofinity Commercial |
$99.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$99.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.24
|
| Rate for Payer: Healthscope Commercial |
$128.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.38
|
| Rate for Payer: PHP Commercial |
$121.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.82
|
| Rate for Payer: Priority Health SBD |
$89.96
|
| Rate for Payer: UMR Bronson Commercial |
$52.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.10
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$142.80
|
|
|
Service Code
|
NDC 68094001861
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.83 |
| Max. Negotiated Rate |
$128.52 |
| Rate for Payer: Aetna American Axle |
$92.82
|
| Rate for Payer: Aetna Commercial |
$121.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.82
|
| Rate for Payer: Cash Price |
$114.24
|
| Rate for Payer: Cofinity Commercial |
$122.81
|
| Rate for Payer: Cofinity Commercial |
$99.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$99.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.24
|
| Rate for Payer: Healthscope Commercial |
$128.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.38
|
| Rate for Payer: PHP Commercial |
$121.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.82
|
| Rate for Payer: Priority Health SBD |
$89.96
|
| Rate for Payer: UMR Bronson Commercial |
$62.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.10
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$1.43
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna American Axle |
$0.93
|
| Rate for Payer: Aetna Commercial |
$1.22
|
| Rate for Payer: Aetna Medicare |
$0.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.93
|
| Rate for Payer: BCBS Complete |
$0.57
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Cofinity Commercial |
$1.00
|
| Rate for Payer: Cofinity Commercial |
$1.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.14
|
| Rate for Payer: Healthscope Commercial |
$1.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.22
|
| Rate for Payer: PHP Commercial |
$1.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.93
|
| Rate for Payer: Priority Health SBD |
$0.90
|
| Rate for Payer: UMR Bronson Commercial |
$0.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.07
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$1.43
|
|
|
Service Code
|
NDC 68094001859
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna American Axle |
$0.93
|
| Rate for Payer: Aetna Commercial |
$1.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.93
|
| Rate for Payer: Cash Price |
$1.14
|
| Rate for Payer: Cofinity Commercial |
$1.00
|
| Rate for Payer: Cofinity Commercial |
$1.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.14
|
| Rate for Payer: Healthscope Commercial |
$1.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.22
|
| Rate for Payer: PHP Commercial |
$1.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.93
|
| Rate for Payer: Priority Health SBD |
$0.90
|
| Rate for Payer: UMR Bronson Commercial |
$0.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.07
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$170.10
|
|
|
Service Code
|
NDC 96295012933
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.94 |
| Max. Negotiated Rate |
$153.09 |
| Rate for Payer: Aetna American Axle |
$110.56
|
| Rate for Payer: Aetna Commercial |
$144.59
|
| Rate for Payer: Aetna Medicare |
$85.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$110.56
|
| Rate for Payer: BCBS Complete |
$68.04
|
| Rate for Payer: Cash Price |
$136.08
|
| Rate for Payer: Cofinity Commercial |
$119.07
|
| Rate for Payer: Cofinity Commercial |
$146.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$119.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$136.08
|
| Rate for Payer: Healthscope Commercial |
$153.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$119.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$127.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$144.59
|
| Rate for Payer: PHP Commercial |
$144.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.56
|
| Rate for Payer: Priority Health SBD |
$107.16
|
| Rate for Payer: UMR Bronson Commercial |
$62.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$127.58
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
OP
|
$100.80
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.30 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Aetna American Axle |
$65.52
|
| Rate for Payer: Aetna Commercial |
$85.68
|
| Rate for Payer: Aetna Medicare |
$50.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.52
|
| Rate for Payer: BCBS Complete |
$40.32
|
| Rate for Payer: Cash Price |
$80.64
|
| Rate for Payer: Cofinity Commercial |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$86.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.64
|
| Rate for Payer: Healthscope Commercial |
$90.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.68
|
| Rate for Payer: PHP Commercial |
$85.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.52
|
| Rate for Payer: Priority Health SBD |
$63.50
|
| Rate for Payer: UMR Bronson Commercial |
$37.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.60
|
|
|
DIPHENHYDRAMINE 25 MG TABLET
|
Facility
|
IP
|
$100.80
|
|
|
Service Code
|
NDC 00904555159
|
| Hospital Charge Code |
2505
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.35 |
| Max. Negotiated Rate |
$90.72 |
| Rate for Payer: Aetna American Axle |
$65.52
|
| Rate for Payer: Aetna Commercial |
$85.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.52
|
| Rate for Payer: Cash Price |
$80.64
|
| Rate for Payer: Cofinity Commercial |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$86.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.64
|
| Rate for Payer: Healthscope Commercial |
$90.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.68
|
| Rate for Payer: PHP Commercial |
$85.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.52
|
| Rate for Payer: Priority Health SBD |
$63.50
|
| Rate for Payer: UMR Bronson Commercial |
$44.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.60
|
|
|
DIPHENHYDRAMINE 50 MG CAPSULE
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
2510
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.89
|
| Rate for Payer: Aetna Medicare |
$49.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: BCBS Complete |
$39.48
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$69.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.89
|
| Rate for Payer: PHP Commercial |
$83.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.16
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UMR Bronson Commercial |
$36.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.03
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.34 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna American Axle |
$7.88
|
| Rate for Payer: Aetna American Axle |
$13.42
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$8.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: Priority Health SBD |
$13.01
|
| Rate for Payer: UMR Bronson Commercial |
$5.34
|
| Rate for Payer: UMR Bronson Commercial |
$9.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION (CODE)
|
Facility
|
OP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
163710
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.49 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna American Axle |
$7.88
|
| Rate for Payer: Aetna American Axle |
$13.42
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Medicare |
$6.07
|
| Rate for Payer: Aetna Medicare |
$10.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: BCBS Complete |
$4.85
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$8.49
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health SBD |
$13.01
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: UMR Bronson Commercial |
$4.49
|
| Rate for Payer: UMR Bronson Commercial |
$7.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$20.65
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.64 |
| Max. Negotiated Rate |
$18.59 |
| Rate for Payer: Aetna American Axle |
$13.42
|
| Rate for Payer: Aetna American Axle |
$7.88
|
| Rate for Payer: Aetna American Axle |
$100.85
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$131.88
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna Medicare |
$10.32
|
| Rate for Payer: Aetna Medicare |
$77.58
|
| Rate for Payer: Aetna Medicare |
$6.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: BCBS Complete |
$4.85
|
| Rate for Payer: BCBS Complete |
$62.06
|
| Rate for Payer: BCBS Complete |
$8.26
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cofinity Commercial |
$133.43
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$8.49
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$108.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$108.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$139.63
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$131.88
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.88
|
| Rate for Payer: Priority Health SBD |
$97.74
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: Priority Health SBD |
$13.01
|
| Rate for Payer: UMR Bronson Commercial |
$7.64
|
| Rate for Payer: UMR Bronson Commercial |
$4.49
|
| Rate for Payer: UMR Bronson Commercial |
$57.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
|
|
DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$12.13
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
2508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.34 |
| Max. Negotiated Rate |
$10.92 |
| Rate for Payer: Aetna American Axle |
$7.88
|
| Rate for Payer: Aetna American Axle |
$100.85
|
| Rate for Payer: Aetna American Axle |
$13.42
|
| Rate for Payer: Aetna Commercial |
$17.55
|
| Rate for Payer: Aetna Commercial |
$131.88
|
| Rate for Payer: Aetna Commercial |
$10.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.42
|
| Rate for Payer: Cash Price |
$124.12
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cofinity Commercial |
$14.46
|
| Rate for Payer: Cofinity Commercial |
$8.49
|
| Rate for Payer: Cofinity Commercial |
$10.43
|
| Rate for Payer: Cofinity Commercial |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$108.61
|
| Rate for Payer: Cofinity Commercial |
$133.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$108.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.70
|
| Rate for Payer: Healthscope Commercial |
$10.92
|
| Rate for Payer: Healthscope Commercial |
$139.63
|
| Rate for Payer: Healthscope Commercial |
$18.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$131.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$17.55
|
| Rate for Payer: PHP Commercial |
$10.31
|
| Rate for Payer: PHP Commercial |
$131.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.42
|
| Rate for Payer: Priority Health SBD |
$13.01
|
| Rate for Payer: Priority Health SBD |
$97.74
|
| Rate for Payer: Priority Health SBD |
$7.64
|
| Rate for Payer: UMR Bronson Commercial |
$68.27
|
| Rate for Payer: UMR Bronson Commercial |
$5.34
|
| Rate for Payer: UMR Bronson Commercial |
$9.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.36
|
|
|
DIPHENHYDRAMINE (BULK) POWDER
|
Facility
|
OP
|
$37.80
|
|
|
Service Code
|
NDC 38779028202
|
| Hospital Charge Code |
12308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.99 |
| Max. Negotiated Rate |
$34.02 |
| Rate for Payer: Aetna American Axle |
$24.57
|
| Rate for Payer: Aetna Commercial |
$32.13
|
| Rate for Payer: Aetna Medicare |
$18.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.57
|
| Rate for Payer: BCBS Complete |
$15.12
|
| Rate for Payer: Cash Price |
$30.24
|
| Rate for Payer: Cofinity Commercial |
$26.46
|
| Rate for Payer: Cofinity Commercial |
$32.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.24
|
| Rate for Payer: Healthscope Commercial |
$34.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.13
|
| Rate for Payer: PHP Commercial |
$32.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.57
|
| Rate for Payer: Priority Health SBD |
$23.81
|
| Rate for Payer: UMR Bronson Commercial |
$13.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.35
|
|
|
DIPHENHYDRAMINE (BULK) POWDER
|
Facility
|
IP
|
$37.80
|
|
|
Service Code
|
NDC 38779028202
|
| Hospital Charge Code |
12308
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.63 |
| Max. Negotiated Rate |
$34.02 |
| Rate for Payer: Aetna American Axle |
$24.57
|
| Rate for Payer: Aetna Commercial |
$32.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.57
|
| Rate for Payer: Cash Price |
$30.24
|
| Rate for Payer: Cofinity Commercial |
$26.46
|
| Rate for Payer: Cofinity Commercial |
$32.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.24
|
| Rate for Payer: Healthscope Commercial |
$34.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.13
|
| Rate for Payer: PHP Commercial |
$32.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.57
|
| Rate for Payer: Priority Health SBD |
$23.81
|
| Rate for Payer: UMR Bronson Commercial |
$16.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.35
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$21.17
|
|
|
Service Code
|
NDC 45802035803
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$19.05 |
| Rate for Payer: Aetna American Axle |
$13.76
|
| Rate for Payer: Aetna Commercial |
$17.99
|
| Rate for Payer: Aetna Medicare |
$10.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.76
|
| Rate for Payer: BCBS Complete |
$8.47
|
| Rate for Payer: Cash Price |
$16.94
|
| Rate for Payer: Cofinity Commercial |
$14.82
|
| Rate for Payer: Cofinity Commercial |
$18.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.94
|
| Rate for Payer: Healthscope Commercial |
$19.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.99
|
| Rate for Payer: PHP Commercial |
$17.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.76
|
| Rate for Payer: Priority Health SBD |
$13.34
|
| Rate for Payer: UMR Bronson Commercial |
$7.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.88
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$19.43
|
|
|
Service Code
|
NDC 00904535431
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$17.49 |
| Rate for Payer: Aetna American Axle |
$12.63
|
| Rate for Payer: Aetna Commercial |
$16.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.63
|
| Rate for Payer: Cash Price |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$13.60
|
| Rate for Payer: Cofinity Commercial |
$16.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.54
|
| Rate for Payer: Healthscope Commercial |
$17.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.52
|
| Rate for Payer: PHP Commercial |
$16.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.63
|
| Rate for Payer: Priority Health SBD |
$12.24
|
| Rate for Payer: UMR Bronson Commercial |
$8.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.57
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$14.45
|
|
|
Service Code
|
NDC 70000038801
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$13.01 |
| Rate for Payer: Aetna American Axle |
$9.39
|
| Rate for Payer: Aetna Commercial |
$12.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.39
|
| Rate for Payer: Cash Price |
$11.56
|
| Rate for Payer: Cofinity Commercial |
$10.12
|
| Rate for Payer: Cofinity Commercial |
$12.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.56
|
| Rate for Payer: Healthscope Commercial |
$13.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.28
|
| Rate for Payer: PHP Commercial |
$12.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.39
|
| Rate for Payer: Priority Health SBD |
$9.10
|
| Rate for Payer: UMR Bronson Commercial |
$6.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.84
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
IP
|
$21.17
|
|
|
Service Code
|
NDC 45802035803
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$19.05 |
| Rate for Payer: Aetna American Axle |
$13.76
|
| Rate for Payer: Aetna Commercial |
$17.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.76
|
| Rate for Payer: Cash Price |
$16.94
|
| Rate for Payer: Cofinity Commercial |
$14.82
|
| Rate for Payer: Cofinity Commercial |
$18.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.94
|
| Rate for Payer: Healthscope Commercial |
$19.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.99
|
| Rate for Payer: PHP Commercial |
$17.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.76
|
| Rate for Payer: Priority Health SBD |
$13.34
|
| Rate for Payer: UMR Bronson Commercial |
$9.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.88
|
|
|
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM
|
Facility
|
OP
|
$55.56
|
|
|
Service Code
|
NDC 12547017167
|
| Hospital Charge Code |
16299
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.56 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: Aetna American Axle |
$36.11
|
| Rate for Payer: Aetna Commercial |
$47.23
|
| Rate for Payer: Aetna Medicare |
$27.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.11
|
| Rate for Payer: BCBS Complete |
$22.22
|
| Rate for Payer: Cash Price |
$44.45
|
| Rate for Payer: Cofinity Commercial |
$38.89
|
| Rate for Payer: Cofinity Commercial |
$47.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$38.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.45
|
| Rate for Payer: Healthscope Commercial |
$50.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$38.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.23
|
| Rate for Payer: PHP Commercial |
$47.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.11
|
| Rate for Payer: Priority Health SBD |
$35.00
|
| Rate for Payer: UMR Bronson Commercial |
$20.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.67
|
|
