|
HC PUNCTURE WITH INJECTION CERVICAL
|
Facility
|
OP
|
$777.71
|
|
|
Service Code
|
CPT 61055
|
| Hospital Charge Code |
36100269
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$113.23 |
| Max. Negotiated Rate |
$909.03 |
| Rate for Payer: Aetna American Axle |
$505.51
|
| Rate for Payer: Aetna Commercial |
$661.05
|
| Rate for Payer: Aetna Medicare |
$300.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$505.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$361.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$361.52
|
| Rate for Payer: BCBS Complete |
$162.77
|
| Rate for Payer: BCBS MAPPO |
$289.22
|
| Rate for Payer: BCBS Trust/PPO |
$496.62
|
| Rate for Payer: BCN Commercial |
$496.62
|
| Rate for Payer: BCN Medicare Advantage |
$289.22
|
| Rate for Payer: Cash Price |
$622.17
|
| Rate for Payer: Cash Price |
$622.17
|
| Rate for Payer: Cash Price |
$622.17
|
| Rate for Payer: Cofinity Commercial |
$668.83
|
| Rate for Payer: Cofinity Commercial |
$544.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$544.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$622.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$289.22
|
| Rate for Payer: Healthscope Commercial |
$699.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$544.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$583.28
|
| Rate for Payer: Mclaren Medicaid |
$155.02
|
| Rate for Payer: Mclaren Medicare |
$289.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$303.68
|
| Rate for Payer: Meridian Medicaid |
$162.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$332.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$661.05
|
| Rate for Payer: Nomi Health Commercial |
$607.36
|
| Rate for Payer: PACE Medicare |
$274.76
|
| Rate for Payer: PACE SWMI |
$289.22
|
| Rate for Payer: PHP Commercial |
$661.05
|
| Rate for Payer: PHP Medicare Advantage |
$289.22
|
| Rate for Payer: Priority Health Choice Medicaid |
$155.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$505.51
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$909.03
|
| Rate for Payer: Priority Health Medicare |
$289.22
|
| Rate for Payer: Priority Health Narrow Network |
$727.22
|
| Rate for Payer: Priority Health SBD |
$489.96
|
| Rate for Payer: Railroad Medicare Medicare |
$289.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$124.55
|
| Rate for Payer: UHC Core |
$700.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$289.22
|
| Rate for Payer: UHC Exchange |
$113.23
|
| Rate for Payer: UHC Medicare Advantage |
$289.22
|
| Rate for Payer: UHCCP Medicaid |
$155.02
|
| Rate for Payer: UMR Bronson Commercial |
$287.75
|
| Rate for Payer: VA VA |
$289.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$583.28
|
|
|
HC PUNCTURE WITH INJECTION CERVICAL
|
Facility
|
IP
|
$777.71
|
|
|
Service Code
|
CPT 61055
|
| Hospital Charge Code |
36100269
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$342.19 |
| Max. Negotiated Rate |
$699.94 |
| Rate for Payer: Aetna American Axle |
$505.51
|
| Rate for Payer: Aetna Commercial |
$661.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$505.51
|
| Rate for Payer: Cash Price |
$622.17
|
| Rate for Payer: Cofinity Commercial |
$544.40
|
| Rate for Payer: Cofinity Commercial |
$668.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$544.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$622.17
|
| Rate for Payer: Healthscope Commercial |
$699.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$544.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$583.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$661.05
|
| Rate for Payer: PHP Commercial |
$661.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$505.51
|
| Rate for Payer: Priority Health SBD |
$489.96
|
| Rate for Payer: UMR Bronson Commercial |
$342.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$583.28
|
|
|
HC PURAPLY AM (1.6 SQ CM DISC) PER SQ CM
|
Facility
|
IP
|
$737.39
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$324.45 |
| Max. Negotiated Rate |
$663.65 |
| Rate for Payer: Aetna American Axle |
$479.30
|
| Rate for Payer: Aetna Commercial |
$626.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$479.30
|
| Rate for Payer: Cash Price |
$589.91
|
| Rate for Payer: Cofinity Commercial |
$516.17
|
| Rate for Payer: Cofinity Commercial |
$634.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$516.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$589.91
|
| Rate for Payer: Healthscope Commercial |
$663.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$516.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$553.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$626.78
|
| Rate for Payer: PHP Commercial |
$626.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$479.30
|
| Rate for Payer: Priority Health SBD |
$464.56
|
| Rate for Payer: UMR Bronson Commercial |
$324.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$553.04
|
|
|
HC PURAPLY AM (1.6 SQ CM DISC) PER SQ CM
|
Facility
|
OP
|
$737.39
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600128
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.48 |
| Max. Negotiated Rate |
$663.65 |
| Rate for Payer: Aetna American Axle |
$479.30
|
| Rate for Payer: Aetna Commercial |
$626.78
|
| Rate for Payer: Aetna Medicare |
$368.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$479.30
|
| Rate for Payer: BCBS Complete |
$294.96
|
| Rate for Payer: BCBS Trust/PPO |
$110.48
|
| Rate for Payer: BCN Commercial |
$110.48
|
| Rate for Payer: Cash Price |
$589.91
|
| Rate for Payer: Cash Price |
$589.91
|
| Rate for Payer: Cofinity Commercial |
$516.17
|
| Rate for Payer: Cofinity Commercial |
$634.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$516.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$589.91
|
| Rate for Payer: Healthscope Commercial |
$663.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$516.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$553.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$626.78
|
| Rate for Payer: PHP Commercial |
$626.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$479.30
|
| Rate for Payer: Priority Health SBD |
$464.56
|
| Rate for Payer: UMR Bronson Commercial |
$272.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$553.04
|
|
|
HC PURAPLY AM 2X2 PER SQ CM
|
Facility
|
OP
|
$512.07
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.48 |
| Max. Negotiated Rate |
$460.86 |
| Rate for Payer: Aetna American Axle |
$332.85
|
| Rate for Payer: Aetna Commercial |
$435.26
|
| Rate for Payer: Aetna Medicare |
$256.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$332.85
|
| Rate for Payer: BCBS Complete |
$204.83
|
| Rate for Payer: BCBS Trust/PPO |
$110.48
|
| Rate for Payer: BCN Commercial |
$110.48
|
| Rate for Payer: Cash Price |
$409.66
|
| Rate for Payer: Cash Price |
$409.66
|
| Rate for Payer: Cofinity Commercial |
$358.45
|
| Rate for Payer: Cofinity Commercial |
$440.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$358.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$409.66
|
| Rate for Payer: Healthscope Commercial |
$460.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$358.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$384.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$435.26
|
| Rate for Payer: PHP Commercial |
$435.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.85
|
| Rate for Payer: Priority Health SBD |
$322.60
|
| Rate for Payer: UMR Bronson Commercial |
$189.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$384.05
|
|
|
HC PURAPLY AM 2X2 PER SQ CM
|
Facility
|
IP
|
$512.07
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600115
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$225.31 |
| Max. Negotiated Rate |
$460.86 |
| Rate for Payer: Aetna American Axle |
$332.85
|
| Rate for Payer: Aetna Commercial |
$435.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$332.85
|
| Rate for Payer: Cash Price |
$409.66
|
| Rate for Payer: Cofinity Commercial |
$358.45
|
| Rate for Payer: Cofinity Commercial |
$440.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$358.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$409.66
|
| Rate for Payer: Healthscope Commercial |
$460.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$358.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$384.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$435.26
|
| Rate for Payer: PHP Commercial |
$435.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$332.85
|
| Rate for Payer: Priority Health SBD |
$322.60
|
| Rate for Payer: UMR Bronson Commercial |
$225.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$384.05
|
|
|
HC PURAPLY AM 2X4 PER SQ CM
|
Facility
|
OP
|
$324.31
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.48 |
| Max. Negotiated Rate |
$291.88 |
| Rate for Payer: Aetna American Axle |
$210.80
|
| Rate for Payer: Aetna Commercial |
$275.66
|
| Rate for Payer: Aetna Medicare |
$162.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.80
|
| Rate for Payer: BCBS Complete |
$129.72
|
| Rate for Payer: BCBS Trust/PPO |
$110.48
|
| Rate for Payer: BCN Commercial |
$110.48
|
| Rate for Payer: Cash Price |
$259.45
|
| Rate for Payer: Cash Price |
$259.45
|
| Rate for Payer: Cofinity Commercial |
$227.02
|
| Rate for Payer: Cofinity Commercial |
$278.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.45
|
| Rate for Payer: Healthscope Commercial |
$291.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.66
|
| Rate for Payer: PHP Commercial |
$275.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.80
|
| Rate for Payer: Priority Health SBD |
$204.32
|
| Rate for Payer: UMR Bronson Commercial |
$119.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.23
|
|
|
HC PURAPLY AM 2X4 PER SQ CM
|
Facility
|
IP
|
$324.31
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600116
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$142.70 |
| Max. Negotiated Rate |
$291.88 |
| Rate for Payer: Aetna American Axle |
$210.80
|
| Rate for Payer: Aetna Commercial |
$275.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.80
|
| Rate for Payer: Cash Price |
$259.45
|
| Rate for Payer: Cofinity Commercial |
$227.02
|
| Rate for Payer: Cofinity Commercial |
$278.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$227.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.45
|
| Rate for Payer: Healthscope Commercial |
$291.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.66
|
| Rate for Payer: PHP Commercial |
$275.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.80
|
| Rate for Payer: Priority Health SBD |
$204.32
|
| Rate for Payer: UMR Bronson Commercial |
$142.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.23
|
|
|
HC PURAPLY AM 3X4 PER SQ CM
|
Facility
|
IP
|
$270.94
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$119.21 |
| Max. Negotiated Rate |
$243.85 |
| Rate for Payer: Aetna American Axle |
$176.11
|
| Rate for Payer: Aetna Commercial |
$230.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.11
|
| Rate for Payer: Cash Price |
$216.75
|
| Rate for Payer: Cofinity Commercial |
$189.66
|
| Rate for Payer: Cofinity Commercial |
$233.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$189.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.75
|
| Rate for Payer: Healthscope Commercial |
$243.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$189.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.30
|
| Rate for Payer: PHP Commercial |
$230.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.11
|
| Rate for Payer: Priority Health SBD |
$170.69
|
| Rate for Payer: UMR Bronson Commercial |
$119.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.20
|
|
|
HC PURAPLY AM 3X4 PER SQ CM
|
Facility
|
OP
|
$270.94
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600185
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$100.25 |
| Max. Negotiated Rate |
$243.85 |
| Rate for Payer: Aetna American Axle |
$176.11
|
| Rate for Payer: Aetna Commercial |
$230.30
|
| Rate for Payer: Aetna Medicare |
$135.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.11
|
| Rate for Payer: BCBS Complete |
$108.38
|
| Rate for Payer: BCBS Trust/PPO |
$110.48
|
| Rate for Payer: BCN Commercial |
$110.48
|
| Rate for Payer: Cash Price |
$216.75
|
| Rate for Payer: Cash Price |
$216.75
|
| Rate for Payer: Cofinity Commercial |
$189.66
|
| Rate for Payer: Cofinity Commercial |
$233.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$189.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.75
|
| Rate for Payer: Healthscope Commercial |
$243.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$189.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$230.30
|
| Rate for Payer: PHP Commercial |
$230.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$176.11
|
| Rate for Payer: Priority Health SBD |
$170.69
|
| Rate for Payer: UMR Bronson Commercial |
$100.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.20
|
|
|
HC PURAPLY AM 4X3 PER SQ CM EXTRA FENESTRATED
|
Facility
|
OP
|
$286.11
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$105.86 |
| Max. Negotiated Rate |
$257.50 |
| Rate for Payer: Aetna American Axle |
$185.97
|
| Rate for Payer: Aetna Commercial |
$243.19
|
| Rate for Payer: Aetna Medicare |
$143.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.97
|
| Rate for Payer: BCBS Complete |
$114.44
|
| Rate for Payer: BCBS Trust/PPO |
$110.48
|
| Rate for Payer: BCN Commercial |
$110.48
|
| Rate for Payer: Cash Price |
$228.89
|
| Rate for Payer: Cash Price |
$228.89
|
| Rate for Payer: Cofinity Commercial |
$200.28
|
| Rate for Payer: Cofinity Commercial |
$246.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$200.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.89
|
| Rate for Payer: Healthscope Commercial |
$257.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$200.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$214.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.19
|
| Rate for Payer: PHP Commercial |
$243.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.97
|
| Rate for Payer: Priority Health SBD |
$180.25
|
| Rate for Payer: UMR Bronson Commercial |
$105.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$214.58
|
|
|
HC PURAPLY AM 4X3 PER SQ CM EXTRA FENESTRATED
|
Facility
|
IP
|
$286.11
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600183
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$125.89 |
| Max. Negotiated Rate |
$257.50 |
| Rate for Payer: Aetna American Axle |
$185.97
|
| Rate for Payer: Aetna Commercial |
$243.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.97
|
| Rate for Payer: Cash Price |
$228.89
|
| Rate for Payer: Cofinity Commercial |
$200.28
|
| Rate for Payer: Cofinity Commercial |
$246.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$200.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.89
|
| Rate for Payer: Healthscope Commercial |
$257.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$200.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$214.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.19
|
| Rate for Payer: PHP Commercial |
$243.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.97
|
| Rate for Payer: Priority Health SBD |
$180.25
|
| Rate for Payer: UMR Bronson Commercial |
$125.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$214.58
|
|
|
HC PURAPLY AM 4X4 PER SQ CM
|
Facility
|
IP
|
$224.73
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.88 |
| Max. Negotiated Rate |
$202.26 |
| Rate for Payer: Aetna American Axle |
$146.07
|
| Rate for Payer: Aetna Commercial |
$191.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.07
|
| Rate for Payer: Cash Price |
$179.78
|
| Rate for Payer: Cofinity Commercial |
$157.31
|
| Rate for Payer: Cofinity Commercial |
$193.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.78
|
| Rate for Payer: Healthscope Commercial |
$202.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.02
|
| Rate for Payer: PHP Commercial |
$191.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.07
|
| Rate for Payer: Priority Health SBD |
$141.58
|
| Rate for Payer: UMR Bronson Commercial |
$98.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.55
|
|
|
HC PURAPLY AM 4X4 PER SQ CM
|
Facility
|
OP
|
$224.73
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600186
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.15 |
| Max. Negotiated Rate |
$202.26 |
| Rate for Payer: Aetna American Axle |
$146.07
|
| Rate for Payer: Aetna Commercial |
$191.02
|
| Rate for Payer: Aetna Medicare |
$112.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.07
|
| Rate for Payer: BCBS Complete |
$89.89
|
| Rate for Payer: BCBS Trust/PPO |
$110.48
|
| Rate for Payer: BCN Commercial |
$110.48
|
| Rate for Payer: Cash Price |
$179.78
|
| Rate for Payer: Cash Price |
$179.78
|
| Rate for Payer: Cofinity Commercial |
$157.31
|
| Rate for Payer: Cofinity Commercial |
$193.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.78
|
| Rate for Payer: Healthscope Commercial |
$202.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.02
|
| Rate for Payer: PHP Commercial |
$191.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.07
|
| Rate for Payer: Priority Health SBD |
$141.58
|
| Rate for Payer: UMR Bronson Commercial |
$83.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.55
|
|
|
HC PURAPLY AM 4X4 PER SQ CM EXTRA FENESTRATED
|
Facility
|
IP
|
$224.73
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600184
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.88 |
| Max. Negotiated Rate |
$202.26 |
| Rate for Payer: Aetna American Axle |
$146.07
|
| Rate for Payer: Aetna Commercial |
$191.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.07
|
| Rate for Payer: Cash Price |
$179.78
|
| Rate for Payer: Cofinity Commercial |
$157.31
|
| Rate for Payer: Cofinity Commercial |
$193.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.78
|
| Rate for Payer: Healthscope Commercial |
$202.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.02
|
| Rate for Payer: PHP Commercial |
$191.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.07
|
| Rate for Payer: Priority Health SBD |
$141.58
|
| Rate for Payer: UMR Bronson Commercial |
$98.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.55
|
|
|
HC PURAPLY AM 4X4 PER SQ CM EXTRA FENESTRATED
|
Facility
|
OP
|
$224.73
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600184
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$83.15 |
| Max. Negotiated Rate |
$202.26 |
| Rate for Payer: Aetna American Axle |
$146.07
|
| Rate for Payer: Aetna Commercial |
$191.02
|
| Rate for Payer: Aetna Medicare |
$112.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.07
|
| Rate for Payer: BCBS Complete |
$89.89
|
| Rate for Payer: BCBS Trust/PPO |
$110.48
|
| Rate for Payer: BCN Commercial |
$110.48
|
| Rate for Payer: Cash Price |
$179.78
|
| Rate for Payer: Cash Price |
$179.78
|
| Rate for Payer: Cofinity Commercial |
$157.31
|
| Rate for Payer: Cofinity Commercial |
$193.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.78
|
| Rate for Payer: Healthscope Commercial |
$202.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.02
|
| Rate for Payer: PHP Commercial |
$191.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.07
|
| Rate for Payer: Priority Health SBD |
$141.58
|
| Rate for Payer: UMR Bronson Commercial |
$83.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.55
|
|
|
HC PURAPLY AM 5X5 PER SQ CM
|
Facility
|
OP
|
$155.62
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.58 |
| Max. Negotiated Rate |
$140.06 |
| Rate for Payer: Aetna American Axle |
$101.15
|
| Rate for Payer: Aetna Commercial |
$132.28
|
| Rate for Payer: Aetna Medicare |
$77.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.15
|
| Rate for Payer: BCBS Complete |
$62.25
|
| Rate for Payer: BCBS Trust/PPO |
$110.48
|
| Rate for Payer: BCN Commercial |
$110.48
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cofinity Commercial |
$108.93
|
| Rate for Payer: Cofinity Commercial |
$133.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$108.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.50
|
| Rate for Payer: Healthscope Commercial |
$140.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.28
|
| Rate for Payer: PHP Commercial |
$132.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.15
|
| Rate for Payer: Priority Health SBD |
$98.04
|
| Rate for Payer: UMR Bronson Commercial |
$57.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.72
|
|
|
HC PURAPLY AM 5X5 PER SQ CM
|
Facility
|
IP
|
$155.62
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$68.47 |
| Max. Negotiated Rate |
$140.06 |
| Rate for Payer: Aetna American Axle |
$101.15
|
| Rate for Payer: Aetna Commercial |
$132.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$101.15
|
| Rate for Payer: Cash Price |
$124.50
|
| Rate for Payer: Cofinity Commercial |
$108.93
|
| Rate for Payer: Cofinity Commercial |
$133.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$108.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.50
|
| Rate for Payer: Healthscope Commercial |
$140.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.28
|
| Rate for Payer: PHP Commercial |
$132.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.15
|
| Rate for Payer: Priority Health SBD |
$98.04
|
| Rate for Payer: UMR Bronson Commercial |
$68.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.72
|
|
|
HC PURAPLY AM 6X9 PER SQ CM
|
Facility
|
IP
|
$204.07
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$89.79 |
| Max. Negotiated Rate |
$183.66 |
| Rate for Payer: Aetna American Axle |
$132.65
|
| Rate for Payer: Aetna Commercial |
$173.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.65
|
| Rate for Payer: Cash Price |
$163.26
|
| Rate for Payer: Cofinity Commercial |
$142.85
|
| Rate for Payer: Cofinity Commercial |
$175.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$142.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.26
|
| Rate for Payer: Healthscope Commercial |
$183.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.46
|
| Rate for Payer: PHP Commercial |
$173.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.65
|
| Rate for Payer: Priority Health SBD |
$128.56
|
| Rate for Payer: UMR Bronson Commercial |
$89.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.05
|
|
|
HC PURAPLY AM 6X9 PER SQ CM
|
Facility
|
OP
|
$204.07
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
63600118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.51 |
| Max. Negotiated Rate |
$183.66 |
| Rate for Payer: Aetna American Axle |
$132.65
|
| Rate for Payer: Aetna Commercial |
$173.46
|
| Rate for Payer: Aetna Medicare |
$102.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.65
|
| Rate for Payer: BCBS Complete |
$81.63
|
| Rate for Payer: BCBS Trust/PPO |
$110.48
|
| Rate for Payer: BCN Commercial |
$110.48
|
| Rate for Payer: Cash Price |
$163.26
|
| Rate for Payer: Cash Price |
$163.26
|
| Rate for Payer: Cofinity Commercial |
$142.85
|
| Rate for Payer: Cofinity Commercial |
$175.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$142.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.26
|
| Rate for Payer: Healthscope Commercial |
$183.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$153.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.46
|
| Rate for Payer: PHP Commercial |
$173.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.65
|
| Rate for Payer: Priority Health SBD |
$128.56
|
| Rate for Payer: UMR Bronson Commercial |
$75.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$153.05
|
|
|
HC PURAPLY XT PER SQ CM
|
Facility
|
OP
|
$136.00
|
|
|
Service Code
|
HCPCS Q4197
|
| Hospital Charge Code |
63600245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.32 |
| Max. Negotiated Rate |
$122.40 |
| Rate for Payer: Aetna American Axle |
$88.40
|
| Rate for Payer: Aetna Commercial |
$115.60
|
| Rate for Payer: Aetna Medicare |
$68.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.40
|
| Rate for Payer: BCBS Complete |
$54.40
|
| Rate for Payer: Cash Price |
$108.80
|
| Rate for Payer: Cofinity Commercial |
$116.96
|
| Rate for Payer: Cofinity Commercial |
$95.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.80
|
| Rate for Payer: Healthscope Commercial |
$122.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.60
|
| Rate for Payer: PHP Commercial |
$115.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.40
|
| Rate for Payer: Priority Health SBD |
$85.68
|
| Rate for Payer: UMR Bronson Commercial |
$50.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.00
|
|
|
HC PURAPLY XT PER SQ CM
|
Facility
|
IP
|
$136.00
|
|
|
Service Code
|
HCPCS Q4197
|
| Hospital Charge Code |
63600245
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.84 |
| Max. Negotiated Rate |
$122.40 |
| Rate for Payer: Aetna American Axle |
$88.40
|
| Rate for Payer: Aetna Commercial |
$115.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.40
|
| Rate for Payer: Cash Price |
$108.80
|
| Rate for Payer: Cofinity Commercial |
$116.96
|
| Rate for Payer: Cofinity Commercial |
$95.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.80
|
| Rate for Payer: Healthscope Commercial |
$122.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.60
|
| Rate for Payer: PHP Commercial |
$115.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.40
|
| Rate for Payer: Priority Health SBD |
$85.68
|
| Rate for Payer: UMR Bronson Commercial |
$59.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.00
|
|
|
HC PURE TONE AUDIOMETRY AIR
|
Facility
|
OP
|
$166.17
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
47100009
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$34.09 |
| Max. Negotiated Rate |
$396.95 |
| Rate for Payer: Aetna American Axle |
$108.01
|
| Rate for Payer: Aetna Commercial |
$141.24
|
| Rate for Payer: Aetna Medicare |
$131.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$157.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$157.86
|
| Rate for Payer: BCBS Complete |
$71.08
|
| Rate for Payer: BCBS MAPPO |
$126.29
|
| Rate for Payer: BCBS Trust/PPO |
$159.26
|
| Rate for Payer: BCN Commercial |
$159.26
|
| Rate for Payer: BCN Medicare Advantage |
$126.29
|
| Rate for Payer: Cash Price |
$132.94
|
| Rate for Payer: Cash Price |
$132.94
|
| Rate for Payer: Cash Price |
$132.94
|
| Rate for Payer: Cofinity Commercial |
$116.32
|
| Rate for Payer: Cofinity Commercial |
$142.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$126.29
|
| Rate for Payer: Healthscope Commercial |
$149.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$116.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.63
|
| Rate for Payer: Mclaren Medicaid |
$67.69
|
| Rate for Payer: Mclaren Medicare |
$126.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$132.60
|
| Rate for Payer: Meridian Medicaid |
$71.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$145.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.24
|
| Rate for Payer: Nomi Health Commercial |
$378.87
|
| Rate for Payer: PACE Medicare |
$119.98
|
| Rate for Payer: PACE SWMI |
$126.29
|
| Rate for Payer: PHP Commercial |
$141.24
|
| Rate for Payer: PHP Medicare Advantage |
$126.29
|
| Rate for Payer: Priority Health Choice Medicaid |
$67.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$396.95
|
| Rate for Payer: Priority Health Medicare |
$126.29
|
| Rate for Payer: Priority Health Narrow Network |
$317.56
|
| Rate for Payer: Priority Health SBD |
$104.69
|
| Rate for Payer: Railroad Medicare Medicare |
$126.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.50
|
| Rate for Payer: UHC Core |
$294.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$126.29
|
| Rate for Payer: UHC Exchange |
$34.09
|
| Rate for Payer: UHC Medicare Advantage |
$126.29
|
| Rate for Payer: UHCCP Medicaid |
$67.69
|
| Rate for Payer: UMR Bronson Commercial |
$61.48
|
| Rate for Payer: VA VA |
$126.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.63
|
|
|
HC PURE TONE AUDIOMETRY AIR
|
Facility
|
IP
|
$166.17
|
|
|
Service Code
|
CPT 92552
|
| Hospital Charge Code |
47100009
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$73.11 |
| Max. Negotiated Rate |
$149.55 |
| Rate for Payer: Aetna American Axle |
$108.01
|
| Rate for Payer: Aetna Commercial |
$141.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.01
|
| Rate for Payer: Cash Price |
$132.94
|
| Rate for Payer: Cofinity Commercial |
$116.32
|
| Rate for Payer: Cofinity Commercial |
$142.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$116.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.94
|
| Rate for Payer: Healthscope Commercial |
$149.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$116.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.24
|
| Rate for Payer: PHP Commercial |
$141.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$108.01
|
| Rate for Payer: Priority Health SBD |
$104.69
|
| Rate for Payer: UMR Bronson Commercial |
$73.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.63
|
|
|
HC PV JAK2V617F
|
Facility
|
OP
|
$329.51
|
|
|
Service Code
|
CPT 81270
|
| Hospital Charge Code |
31000147
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$49.13 |
| Max. Negotiated Rate |
$296.56 |
| Rate for Payer: Aetna American Axle |
$214.18
|
| Rate for Payer: Aetna Commercial |
$280.08
|
| Rate for Payer: Aetna Medicare |
$95.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.18
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$114.58
|
| Rate for Payer: Amish Plain Church Group Commercial |
$114.58
|
| Rate for Payer: BCBS Complete |
$51.59
|
| Rate for Payer: BCBS MAPPO |
$91.66
|
| Rate for Payer: BCBS Trust/PPO |
$88.32
|
| Rate for Payer: BCN Commercial |
$88.32
|
| Rate for Payer: BCN Medicare Advantage |
$91.66
|
| Rate for Payer: Cash Price |
$263.61
|
| Rate for Payer: Cash Price |
$263.61
|
| Rate for Payer: Cofinity Commercial |
$283.38
|
| Rate for Payer: Cofinity Commercial |
$230.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$230.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.61
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$91.66
|
| Rate for Payer: Healthscope Commercial |
$296.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$247.13
|
| Rate for Payer: Mclaren Medicaid |
$49.13
|
| Rate for Payer: Mclaren Medicare |
$91.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$96.24
|
| Rate for Payer: Meridian Medicaid |
$51.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$105.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$280.08
|
| Rate for Payer: Nomi Health Commercial |
$274.98
|
| Rate for Payer: PACE Medicare |
$87.08
|
| Rate for Payer: PACE SWMI |
$91.66
|
| Rate for Payer: PHP Commercial |
$280.08
|
| Rate for Payer: PHP Medicare Advantage |
$91.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$49.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$94.31
|
| Rate for Payer: Priority Health Medicare |
$91.66
|
| Rate for Payer: Priority Health Narrow Network |
$75.45
|
| Rate for Payer: Priority Health SBD |
$207.59
|
| Rate for Payer: Railroad Medicare Medicare |
$91.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$109.99
|
| Rate for Payer: UHC Core |
$164.40
|
| Rate for Payer: UHC Dual Complete DSNP |
$91.66
|
| Rate for Payer: UHC Exchange |
$91.66
|
| Rate for Payer: UHC Medicare Advantage |
$91.66
|
| Rate for Payer: UHCCP Medicaid |
$49.13
|
| Rate for Payer: UMR Bronson Commercial |
$121.92
|
| Rate for Payer: VA VA |
$91.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$247.13
|
|
