|
ATROPINE 1 % EYE DROPS
|
Facility
|
IP
|
$125.62
|
|
|
Service Code
|
NDC 60219174802
|
| Hospital Charge Code |
736
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.27 |
| Max. Negotiated Rate |
$113.06 |
| Rate for Payer: Aetna American Axle |
$81.65
|
| Rate for Payer: Aetna Commercial |
$106.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.65
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cofinity Advantage |
$87.93
|
| Rate for Payer: Cofinity Commercial |
$108.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.50
|
| Rate for Payer: Healthscope Commercial |
$113.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$94.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$106.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$94.22
|
| Rate for Payer: PHP Commercial |
$106.78
|
| Rate for Payer: Priority Health SBD |
$79.14
|
| Rate for Payer: UMR Bronson Commercial |
$55.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$94.22
|
|
|
ATROPINE 1 % EYE DROPS
|
Facility
|
IP
|
$97.65
|
|
|
Service Code
|
NDC 17478021502
|
| Hospital Charge Code |
736
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.97 |
| Max. Negotiated Rate |
$87.89 |
| Rate for Payer: Aetna American Axle |
$63.47
|
| Rate for Payer: Aetna Commercial |
$83.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.47
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cofinity Advantage |
$68.36
|
| Rate for Payer: Cofinity Commercial |
$83.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.12
|
| Rate for Payer: Healthscope Commercial |
$87.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$73.24
|
| Rate for Payer: PHP Commercial |
$83.00
|
| Rate for Payer: Priority Health SBD |
$61.52
|
| Rate for Payer: UMR Bronson Commercial |
$42.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.24
|
|
|
ATROPINE 1 % EYE DROPS
|
Facility
|
OP
|
$97.65
|
|
|
Service Code
|
NDC 17478021502
|
| Hospital Charge Code |
736
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.13 |
| Max. Negotiated Rate |
$87.89 |
| Rate for Payer: Aetna American Axle |
$63.47
|
| Rate for Payer: Aetna Commercial |
$83.00
|
| Rate for Payer: Aetna Medicare |
$48.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.47
|
| Rate for Payer: BCBS Complete |
$39.06
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cofinity Advantage |
$68.36
|
| Rate for Payer: Cofinity Commercial |
$83.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.12
|
| Rate for Payer: Healthscope Commercial |
$87.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$78.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$73.24
|
| Rate for Payer: PHP Commercial |
$83.00
|
| Rate for Payer: Priority Health SBD |
$61.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63.47
|
| Rate for Payer: UHC Core |
$50.88
|
| Rate for Payer: UHC Exchange |
$38.38
|
| Rate for Payer: UMR Bronson Commercial |
$36.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.24
|
|
|
ATROPINE 1 % EYE DROPS
|
Facility
|
OP
|
$125.62
|
|
|
Service Code
|
NDC 60219174802
|
| Hospital Charge Code |
736
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.48 |
| Max. Negotiated Rate |
$113.06 |
| Rate for Payer: Aetna American Axle |
$81.65
|
| Rate for Payer: Aetna Commercial |
$106.78
|
| Rate for Payer: Aetna Medicare |
$62.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.65
|
| Rate for Payer: BCBS Complete |
$50.25
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cofinity Advantage |
$87.93
|
| Rate for Payer: Cofinity Commercial |
$108.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.50
|
| Rate for Payer: Healthscope Commercial |
$113.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$94.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$100.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$106.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$94.22
|
| Rate for Payer: PHP Commercial |
$106.78
|
| Rate for Payer: Priority Health SBD |
$79.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$81.65
|
| Rate for Payer: UHC Core |
$65.45
|
| Rate for Payer: UHC Exchange |
$49.37
|
| Rate for Payer: UMR Bronson Commercial |
$46.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$94.22
|
|
|
ATROPINE 1 % EYE OINTMENT
|
Facility
|
IP
|
$56.98
|
|
|
Service Code
|
NDC 24208082555
|
| Hospital Charge Code |
735
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.07 |
| Max. Negotiated Rate |
$51.28 |
| Rate for Payer: Aetna American Axle |
$37.04
|
| Rate for Payer: Aetna Commercial |
$48.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.04
|
| Rate for Payer: Cash Price |
$45.58
|
| Rate for Payer: Cofinity Advantage |
$39.89
|
| Rate for Payer: Cofinity Commercial |
$49.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.58
|
| Rate for Payer: Healthscope Commercial |
$51.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.73
|
| Rate for Payer: PHP Commercial |
$48.43
|
| Rate for Payer: Priority Health SBD |
$35.90
|
| Rate for Payer: UMR Bronson Commercial |
$25.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.73
|
|
|
ATROPINE 1 % EYE OINTMENT
|
Facility
|
OP
|
$56.98
|
|
|
Service Code
|
NDC 24208082555
|
| Hospital Charge Code |
735
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.08 |
| Max. Negotiated Rate |
$51.28 |
| Rate for Payer: Aetna American Axle |
$37.04
|
| Rate for Payer: Aetna Commercial |
$48.43
|
| Rate for Payer: Aetna Medicare |
$28.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.04
|
| Rate for Payer: BCBS Complete |
$22.79
|
| Rate for Payer: Cash Price |
$45.58
|
| Rate for Payer: Cofinity Advantage |
$39.89
|
| Rate for Payer: Cofinity Commercial |
$49.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.58
|
| Rate for Payer: Healthscope Commercial |
$51.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.73
|
| Rate for Payer: PHP Commercial |
$48.43
|
| Rate for Payer: Priority Health SBD |
$35.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.04
|
| Rate for Payer: UHC Core |
$29.69
|
| Rate for Payer: UHC Exchange |
$22.39
|
| Rate for Payer: UMR Bronson Commercial |
$21.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.73
|
|
|
ATROPINE 1 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$30.29
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
734
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$27.26 |
| Rate for Payer: Aetna American Axle |
$19.69
|
| Rate for Payer: Aetna Commercial |
$25.75
|
| Rate for Payer: Aetna Medicare |
$15.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.69
|
| Rate for Payer: BCBS Complete |
$12.12
|
| Rate for Payer: BCBS Trust/PPO |
$0.32
|
| Rate for Payer: BCN Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$24.23
|
| Rate for Payer: Cash Price |
$24.23
|
| Rate for Payer: Cofinity Advantage |
$21.20
|
| Rate for Payer: Cofinity Commercial |
$26.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.23
|
| Rate for Payer: Healthscope Commercial |
$27.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.72
|
| Rate for Payer: PHP Commercial |
$25.75
|
| Rate for Payer: Priority Health SBD |
$19.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.17
|
| Rate for Payer: UHC Core |
$0.17
|
| Rate for Payer: UHC Exchange |
$0.17
|
| Rate for Payer: UMR Bronson Commercial |
$11.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.72
|
|
|
ATROPINE 1 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$30.29
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
734
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$27.26 |
| Rate for Payer: Aetna American Axle |
$19.69
|
| Rate for Payer: Aetna Commercial |
$25.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.69
|
| Rate for Payer: Cash Price |
$24.23
|
| Rate for Payer: Cofinity Advantage |
$21.20
|
| Rate for Payer: Cofinity Commercial |
$26.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.23
|
| Rate for Payer: Healthscope Commercial |
$27.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.72
|
| Rate for Payer: PHP Commercial |
$25.75
|
| Rate for Payer: Priority Health SBD |
$19.08
|
| Rate for Payer: UMR Bronson Commercial |
$13.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.72
|
|
|
ATROPINE 1 MG/ML INJECTION SOLUTION WRAPPER
|
Facility
|
IP
|
$30.29
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
301597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.33 |
| Max. Negotiated Rate |
$27.26 |
| Rate for Payer: Aetna American Axle |
$19.69
|
| Rate for Payer: Aetna American Axle |
$30.82
|
| Rate for Payer: Aetna Commercial |
$25.75
|
| Rate for Payer: Aetna Commercial |
$40.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.82
|
| Rate for Payer: Cash Price |
$24.23
|
| Rate for Payer: Cash Price |
$37.93
|
| Rate for Payer: Cofinity Advantage |
$33.19
|
| Rate for Payer: Cofinity Advantage |
$21.20
|
| Rate for Payer: Cofinity Commercial |
$40.77
|
| Rate for Payer: Cofinity Commercial |
$26.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.93
|
| Rate for Payer: Healthscope Commercial |
$27.26
|
| Rate for Payer: Healthscope Commercial |
$42.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$33.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.56
|
| Rate for Payer: PHP Commercial |
$25.75
|
| Rate for Payer: PHP Commercial |
$40.30
|
| Rate for Payer: Priority Health SBD |
$29.87
|
| Rate for Payer: Priority Health SBD |
$19.08
|
| Rate for Payer: UMR Bronson Commercial |
$13.33
|
| Rate for Payer: UMR Bronson Commercial |
$20.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.56
|
|
|
ATROPINE 1 MG/ML INJECTION SOLUTION WRAPPER
|
Facility
|
OP
|
$30.29
|
|
|
Service Code
|
HCPCS J0461
|
| Hospital Charge Code |
301597
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$27.26 |
| Rate for Payer: Aetna American Axle |
$19.69
|
| Rate for Payer: Aetna American Axle |
$30.82
|
| Rate for Payer: Aetna Commercial |
$25.75
|
| Rate for Payer: Aetna Commercial |
$40.30
|
| Rate for Payer: Aetna Medicare |
$15.14
|
| Rate for Payer: Aetna Medicare |
$23.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.82
|
| Rate for Payer: BCBS Complete |
$18.96
|
| Rate for Payer: BCBS Complete |
$12.12
|
| Rate for Payer: BCBS Trust/PPO |
$0.32
|
| Rate for Payer: BCBS Trust/PPO |
$0.32
|
| Rate for Payer: BCN Commercial |
$0.32
|
| Rate for Payer: BCN Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$24.23
|
| Rate for Payer: Cash Price |
$37.93
|
| Rate for Payer: Cash Price |
$24.23
|
| Rate for Payer: Cash Price |
$37.93
|
| Rate for Payer: Cofinity Advantage |
$21.20
|
| Rate for Payer: Cofinity Advantage |
$33.19
|
| Rate for Payer: Cofinity Commercial |
$26.05
|
| Rate for Payer: Cofinity Commercial |
$40.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.93
|
| Rate for Payer: Healthscope Commercial |
$27.26
|
| Rate for Payer: Healthscope Commercial |
$42.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$33.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$37.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.72
|
| Rate for Payer: PHP Commercial |
$25.75
|
| Rate for Payer: PHP Commercial |
$40.30
|
| Rate for Payer: Priority Health SBD |
$19.08
|
| Rate for Payer: Priority Health SBD |
$29.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.17
|
| Rate for Payer: UHC Core |
$0.17
|
| Rate for Payer: UHC Core |
$0.17
|
| Rate for Payer: UHC Exchange |
$0.17
|
| Rate for Payer: UHC Exchange |
$0.17
|
| Rate for Payer: UMR Bronson Commercial |
$11.21
|
| Rate for Payer: UMR Bronson Commercial |
$17.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.56
|
|
|
ATROPINE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$47.41
|
|
|
Service Code
|
HCPCS J0462
|
| Hospital Charge Code |
195981
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$42.67 |
| Rate for Payer: Aetna American Axle |
$30.82
|
| Rate for Payer: Aetna Commercial |
$40.30
|
| Rate for Payer: Aetna Medicare |
$23.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.82
|
| Rate for Payer: BCBS Complete |
$18.96
|
| Rate for Payer: BCBS Trust/PPO |
$0.41
|
| Rate for Payer: BCN Commercial |
$0.41
|
| Rate for Payer: Cash Price |
$37.93
|
| Rate for Payer: Cash Price |
$37.93
|
| Rate for Payer: Cofinity Advantage |
$33.19
|
| Rate for Payer: Cofinity Commercial |
$40.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.93
|
| Rate for Payer: Healthscope Commercial |
$42.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$33.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$35.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$37.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$40.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$35.56
|
| Rate for Payer: PHP Commercial |
$40.30
|
| Rate for Payer: Priority Health SBD |
$29.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.21
|
| Rate for Payer: UHC Core |
$0.21
|
| Rate for Payer: UHC Exchange |
$0.21
|
| Rate for Payer: UMR Bronson Commercial |
$17.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$35.56
|
|
|
AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
Facility
|
OP
|
$448.61
|
|
|
Service Code
|
CPT 20936
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$448.61 |
| Max. Negotiated Rate |
$448.61 |
| Rate for Payer: BCBS Trust/PPO |
$448.61
|
| Rate for Payer: BCN Commercial |
$448.61
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$38,666.95
|
|
|
Service Code
|
APR-DRG 0083
|
| Min. Negotiated Rate |
$36,825.67 |
| Max. Negotiated Rate |
$38,666.95 |
| Rate for Payer: BCBS Complete |
$38,666.95
|
| Rate for Payer: Mclaren Medicaid |
$36,825.67
|
| Rate for Payer: Meridian Medicaid |
$38,666.95
|
| Rate for Payer: Priority Health Choice Medicaid |
$36,825.67
|
| Rate for Payer: UHC Medicaid |
$36,825.67
|
| Rate for Payer: UHCCP Medicaid |
$36,825.67
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$21,620.39
|
|
|
Service Code
|
APR-DRG 0081
|
| Min. Negotiated Rate |
$20,590.85 |
| Max. Negotiated Rate |
$21,620.39 |
| Rate for Payer: BCBS Complete |
$21,620.39
|
| Rate for Payer: Mclaren Medicaid |
$20,590.85
|
| Rate for Payer: Meridian Medicaid |
$21,620.39
|
| Rate for Payer: Priority Health Choice Medicaid |
$20,590.85
|
| Rate for Payer: UHC Medicaid |
$20,590.85
|
| Rate for Payer: UHCCP Medicaid |
$20,590.85
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$63,840.00
|
|
|
Service Code
|
APR-DRG 0084
|
| Min. Negotiated Rate |
$60,800.00 |
| Max. Negotiated Rate |
$63,840.00 |
| Rate for Payer: BCBS Complete |
$63,840.00
|
| Rate for Payer: Mclaren Medicaid |
$60,800.00
|
| Rate for Payer: Meridian Medicaid |
$63,840.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$60,800.00
|
| Rate for Payer: UHC Medicaid |
$60,800.00
|
| Rate for Payer: UHCCP Medicaid |
$60,800.00
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT
|
Facility
|
IP
|
$26,123.41
|
|
|
Service Code
|
APR-DRG 0082
|
| Min. Negotiated Rate |
$24,879.43 |
| Max. Negotiated Rate |
$26,123.41 |
| Rate for Payer: BCBS Complete |
$26,123.41
|
| Rate for Payer: Mclaren Medicaid |
$24,879.43
|
| Rate for Payer: Meridian Medicaid |
$26,123.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$24,879.43
|
| Rate for Payer: UHC Medicaid |
$24,879.43
|
| Rate for Payer: UHCCP Medicaid |
$24,879.43
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC
|
Facility
|
IP
|
$244,259.00
|
|
|
Service Code
|
MSDRG 016
|
| Min. Negotiated Rate |
$47,672.18 |
| Max. Negotiated Rate |
$244,259.00 |
| Rate for Payer: Aetna Medicare |
$52,188.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62,726.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62,726.55
|
| Rate for Payer: BCBS MAPPO |
$50,181.24
|
| Rate for Payer: BCBS Trust/PPO |
$244,259.00
|
| Rate for Payer: BCN Commercial |
$244,259.00
|
| Rate for Payer: BCN Medicare Advantage |
$50,181.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$50,181.24
|
| Rate for Payer: Mclaren Medicare |
$50,181.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$52,690.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57,708.43
|
| Rate for Payer: Molina Medicare/Medicaid |
$55,199.36
|
| Rate for Payer: Nomi Health Commercial |
$76,493.13
|
| Rate for Payer: PACE Medicare |
$47,672.18
|
| Rate for Payer: PACE SWMI |
$50,181.24
|
| Rate for Payer: PHP Medicare Advantage |
$50,181.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$95,599.45
|
| Rate for Payer: Priority Health Medicare |
$50,181.24
|
| Rate for Payer: Priority Health Tiered Network |
$76,479.55
|
| Rate for Payer: Railroad Medicare Medicare |
$50,181.24
|
| Rate for Payer: VA VA |
$50,181.24
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC
|
Facility
|
IP
|
$124,967.93
|
|
|
Service Code
|
MSDRG 017
|
| Min. Negotiated Rate |
$43,720.55 |
| Max. Negotiated Rate |
$124,967.93 |
| Rate for Payer: Aetna Medicare |
$47,862.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$57,527.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$57,527.04
|
| Rate for Payer: BCBS MAPPO |
$46,021.63
|
| Rate for Payer: BCBS Trust/PPO |
$124,967.93
|
| Rate for Payer: BCN Commercial |
$124,967.93
|
| Rate for Payer: BCN Medicare Advantage |
$46,021.63
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$46,021.63
|
| Rate for Payer: Mclaren Medicare |
$46,021.63
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$48,322.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$52,924.87
|
| Rate for Payer: Molina Medicare/Medicaid |
$50,623.79
|
| Rate for Payer: Nomi Health Commercial |
$62,414.07
|
| Rate for Payer: PACE Medicare |
$43,720.55
|
| Rate for Payer: PACE SWMI |
$46,021.63
|
| Rate for Payer: PHP Medicare Advantage |
$46,021.63
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$87,580.30
|
| Rate for Payer: Priority Health Medicare |
$46,021.63
|
| Rate for Payer: Priority Health Tiered Network |
$70,064.23
|
| Rate for Payer: Railroad Medicare Medicare |
$46,021.63
|
| Rate for Payer: VA VA |
$46,021.63
|
|
|
AVALGLUCOSIDASE ALFA-NGPT 100 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$5,268.80
|
|
|
Service Code
|
HCPCS J0219
|
| Hospital Charge Code |
198019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.47 |
| Max. Negotiated Rate |
$4,741.92 |
| Rate for Payer: Aetna American Axle |
$3,424.72
|
| Rate for Payer: Aetna Commercial |
$4,478.48
|
| Rate for Payer: Aetna Medicare |
$84.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,424.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$101.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$101.50
|
| Rate for Payer: BCBS Complete |
$44.60
|
| Rate for Payer: BCBS MAPPO |
$81.20
|
| Rate for Payer: BCBS Trust/PPO |
$263.58
|
| Rate for Payer: BCN Commercial |
$263.58
|
| Rate for Payer: BCN Medicare Advantage |
$81.20
|
| Rate for Payer: Cash Price |
$4,215.04
|
| Rate for Payer: Cash Price |
$4,215.04
|
| Rate for Payer: Cofinity Advantage |
$3,688.16
|
| Rate for Payer: Cofinity Commercial |
$4,531.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,215.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$81.20
|
| Rate for Payer: Healthscope Commercial |
$4,741.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,688.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,951.60
|
| Rate for Payer: Mclaren Medicaid |
$81.20
|
| Rate for Payer: Mclaren Medicare |
$81.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$85.26
|
| Rate for Payer: Meridian Medicaid |
$85.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.38
|
| Rate for Payer: Molina Medicare/Medicaid |
$89.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,478.48
|
| Rate for Payer: Nomi Health Commercial |
$243.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,951.60
|
| Rate for Payer: PACE Medicare |
$77.14
|
| Rate for Payer: PACE SWMI |
$81.20
|
| Rate for Payer: PHP Commercial |
$4,478.48
|
| Rate for Payer: PHP Medicare Advantage |
$81.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$42.47
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$255.19
|
| Rate for Payer: Priority Health Medicare |
$81.20
|
| Rate for Payer: Priority Health SBD |
$3,319.34
|
| Rate for Payer: Priority Health Tiered Network |
$204.15
|
| Rate for Payer: Railroad Medicare Medicare |
$81.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$134.15
|
| Rate for Payer: UHC Core |
$134.15
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$81.20
|
| Rate for Payer: UHC Exchange |
$134.15
|
| Rate for Payer: UHC Medicaid |
$42.47
|
| Rate for Payer: UHCCP Medicaid |
$42.47
|
| Rate for Payer: UMR Bronson Commercial |
$1,949.46
|
| Rate for Payer: VA VA |
$81.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,951.60
|
|
|
AVALGLUCOSIDASE ALFA-NGPT 100 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$5,268.80
|
|
|
Service Code
|
HCPCS J0219
|
| Hospital Charge Code |
198019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,318.27 |
| Max. Negotiated Rate |
$4,741.92 |
| Rate for Payer: Aetna American Axle |
$3,424.72
|
| Rate for Payer: Aetna Commercial |
$4,478.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,424.72
|
| Rate for Payer: Cash Price |
$4,215.04
|
| Rate for Payer: Cofinity Advantage |
$3,688.16
|
| Rate for Payer: Cofinity Commercial |
$4,531.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,215.04
|
| Rate for Payer: Healthscope Commercial |
$4,741.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,688.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,951.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,478.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,951.60
|
| Rate for Payer: PHP Commercial |
$4,478.48
|
| Rate for Payer: Priority Health SBD |
$3,319.34
|
| Rate for Payer: UMR Bronson Commercial |
$2,318.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,951.60
|
|
|
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$10,470.10
|
|
|
Service Code
|
HCPCS J9023
|
| Hospital Charge Code |
182436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.20 |
| Max. Negotiated Rate |
$9,423.09 |
| Rate for Payer: Aetna American Axle |
$6,805.56
|
| Rate for Payer: Aetna Commercial |
$8,899.58
|
| Rate for Payer: Aetna Medicare |
$109.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,805.56
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$131.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$131.94
|
| Rate for Payer: BCBS Complete |
$57.97
|
| Rate for Payer: BCBS MAPPO |
$105.55
|
| Rate for Payer: BCBS Trust/PPO |
$340.41
|
| Rate for Payer: BCN Commercial |
$340.41
|
| Rate for Payer: BCN Medicare Advantage |
$105.55
|
| Rate for Payer: Cash Price |
$8,376.08
|
| Rate for Payer: Cash Price |
$8,376.08
|
| Rate for Payer: Cofinity Advantage |
$7,329.07
|
| Rate for Payer: Cofinity Commercial |
$9,004.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,376.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$105.55
|
| Rate for Payer: Healthscope Commercial |
$9,423.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,329.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,852.57
|
| Rate for Payer: Mclaren Medicaid |
$105.55
|
| Rate for Payer: Mclaren Medicare |
$105.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$110.83
|
| Rate for Payer: Meridian Medicaid |
$110.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$121.38
|
| Rate for Payer: Molina Medicare/Medicaid |
$116.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,899.58
|
| Rate for Payer: Nomi Health Commercial |
$316.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7,852.57
|
| Rate for Payer: PACE Medicare |
$100.27
|
| Rate for Payer: PACE SWMI |
$105.55
|
| Rate for Payer: PHP Commercial |
$8,899.58
|
| Rate for Payer: PHP Medicare Advantage |
$105.55
|
| Rate for Payer: Priority Health Choice Medicaid |
$55.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$315.68
|
| Rate for Payer: Priority Health Medicare |
$105.55
|
| Rate for Payer: Priority Health SBD |
$6,596.16
|
| Rate for Payer: Priority Health Tiered Network |
$252.54
|
| Rate for Payer: Railroad Medicare Medicare |
$105.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$173.23
|
| Rate for Payer: UHC Core |
$173.23
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$105.55
|
| Rate for Payer: UHC Exchange |
$173.23
|
| Rate for Payer: UHC Medicaid |
$55.20
|
| Rate for Payer: UHCCP Medicaid |
$55.20
|
| Rate for Payer: UMR Bronson Commercial |
$3,873.94
|
| Rate for Payer: VA VA |
$105.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,852.57
|
|
|
AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$10,470.10
|
|
|
Service Code
|
HCPCS J9023
|
| Hospital Charge Code |
182436
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,606.84 |
| Max. Negotiated Rate |
$9,423.09 |
| Rate for Payer: Aetna American Axle |
$6,805.56
|
| Rate for Payer: Aetna Commercial |
$8,899.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,805.56
|
| Rate for Payer: Cash Price |
$8,376.08
|
| Rate for Payer: Cofinity Advantage |
$7,329.07
|
| Rate for Payer: Cofinity Commercial |
$9,004.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,376.08
|
| Rate for Payer: Healthscope Commercial |
$9,423.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,329.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,852.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,899.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7,852.57
|
| Rate for Payer: PHP Commercial |
$8,899.58
|
| Rate for Payer: Priority Health SBD |
$6,596.16
|
| Rate for Payer: UMR Bronson Commercial |
$4,606.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,852.57
|
|
|
AXATILIMAB-CSFR 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12,472.20
|
|
|
Service Code
|
HCPCS J9038
|
| Hospital Charge Code |
209986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.10 |
| Max. Negotiated Rate |
$11,224.98 |
| Rate for Payer: Aetna American Axle |
$8,106.93
|
| Rate for Payer: Aetna Commercial |
$10,601.37
|
| Rate for Payer: Aetna Medicare |
$57.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8,106.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$69.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$69.56
|
| Rate for Payer: BCBS Complete |
$30.56
|
| Rate for Payer: BCBS MAPPO |
$55.65
|
| Rate for Payer: BCBS Trust/PPO |
$180.45
|
| Rate for Payer: BCN Commercial |
$180.45
|
| Rate for Payer: BCN Medicare Advantage |
$55.65
|
| Rate for Payer: Cash Price |
$9,977.76
|
| Rate for Payer: Cash Price |
$9,977.76
|
| Rate for Payer: Cofinity Advantage |
$8,730.54
|
| Rate for Payer: Cofinity Commercial |
$10,726.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,977.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$55.65
|
| Rate for Payer: Healthscope Commercial |
$11,224.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,730.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,354.15
|
| Rate for Payer: Mclaren Medicaid |
$55.65
|
| Rate for Payer: Mclaren Medicare |
$55.65
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$58.43
|
| Rate for Payer: Meridian Medicaid |
$58.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$64.00
|
| Rate for Payer: Molina Medicare/Medicaid |
$61.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,601.37
|
| Rate for Payer: Nomi Health Commercial |
$166.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9,354.15
|
| Rate for Payer: PACE Medicare |
$52.87
|
| Rate for Payer: PACE SWMI |
$55.65
|
| Rate for Payer: PHP Commercial |
$10,601.37
|
| Rate for Payer: PHP Medicare Advantage |
$55.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$175.53
|
| Rate for Payer: Priority Health Medicare |
$55.65
|
| Rate for Payer: Priority Health SBD |
$7,857.49
|
| Rate for Payer: Priority Health Tiered Network |
$140.42
|
| Rate for Payer: Railroad Medicare Medicare |
$55.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$91.82
|
| Rate for Payer: UHC Core |
$91.82
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$55.65
|
| Rate for Payer: UHC Exchange |
$91.82
|
| Rate for Payer: UHC Medicaid |
$29.10
|
| Rate for Payer: UHCCP Medicaid |
$29.10
|
| Rate for Payer: UMR Bronson Commercial |
$4,614.71
|
| Rate for Payer: VA VA |
$55.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,354.15
|
|
|
AXATILIMAB-CSFR 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12,472.20
|
|
|
Service Code
|
HCPCS J9038
|
| Hospital Charge Code |
209986
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,487.77 |
| Max. Negotiated Rate |
$11,224.98 |
| Rate for Payer: Aetna American Axle |
$8,106.93
|
| Rate for Payer: Aetna Commercial |
$10,601.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8,106.93
|
| Rate for Payer: Cash Price |
$9,977.76
|
| Rate for Payer: Cofinity Advantage |
$8,730.54
|
| Rate for Payer: Cofinity Commercial |
$10,726.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9,977.76
|
| Rate for Payer: Healthscope Commercial |
$11,224.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8,730.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9,354.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10,601.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$9,354.15
|
| Rate for Payer: PHP Commercial |
$10,601.37
|
| Rate for Payer: Priority Health SBD |
$7,857.49
|
| Rate for Payer: UMR Bronson Commercial |
$5,487.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9,354.15
|
|
|
AXILLARY LYMPHADENECTOMY; COMPLETE
|
Facility
|
OP
|
$19,480.40
|
|
|
Service Code
|
CPT 38745
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,150.44 |
| Max. Negotiated Rate |
$19,480.40 |
| Rate for Payer: Aetna Medicare |
$6,264.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,529.74
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,529.74
|
| Rate for Payer: BCBS Complete |
$3,308.27
|
| Rate for Payer: BCBS MAPPO |
$6,023.79
|
| Rate for Payer: BCBS Trust/PPO |
$4,475.86
|
| Rate for Payer: BCN Commercial |
$4,475.86
|
| Rate for Payer: BCN Medicare Advantage |
$6,023.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6,023.79
|
| Rate for Payer: Mclaren Medicaid |
$6,023.79
|
| Rate for Payer: Mclaren Medicare |
$6,023.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,324.98
|
| Rate for Payer: Meridian Medicaid |
$6,324.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,927.36
|
| Rate for Payer: Molina Medicare/Medicaid |
$6,626.17
|
| Rate for Payer: Nomi Health Commercial |
$18,071.37
|
| Rate for Payer: PACE Medicare |
$5,722.60
|
| Rate for Payer: PACE SWMI |
$6,023.79
|
| Rate for Payer: PHP Medicare Advantage |
$6,023.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,150.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$19,480.40
|
| Rate for Payer: Priority Health Medicare |
$6,023.79
|
| Rate for Payer: Priority Health Tiered Network |
$15,584.32
|
| Rate for Payer: Railroad Medicare Medicare |
$6,023.79
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$6,023.79
|
| Rate for Payer: UHC Medicaid |
$3,150.44
|
| Rate for Payer: UHCCP Medicaid |
$3,150.44
|
| Rate for Payer: VA VA |
$6,023.79
|
|
