|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
OP
|
$1,011.84
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna Medicare |
$9.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.62
|
| Rate for Payer: BCBS Complete |
$5.11
|
| Rate for Payer: BCBS MAPPO |
$9.30
|
| Rate for Payer: BCBS Trust/PPO |
$31.32
|
| Rate for Payer: BCN Commercial |
$31.32
|
| Rate for Payer: BCN Medicare Advantage |
$9.30
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Advantage |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.30
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Mclaren Medicaid |
$9.30
|
| Rate for Payer: Mclaren Medicare |
$9.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.77
|
| Rate for Payer: Meridian Medicaid |
$9.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.70
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: Nomi Health Commercial |
$27.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$758.88
|
| Rate for Payer: PACE Medicare |
$8.84
|
| Rate for Payer: PACE SWMI |
$9.30
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: PHP Medicare Advantage |
$9.30
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$31.40
|
| Rate for Payer: Priority Health Medicare |
$9.30
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: Priority Health Tiered Network |
$25.12
|
| Rate for Payer: Railroad Medicare Medicare |
$9.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.35
|
| Rate for Payer: UHC Core |
$15.35
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9.30
|
| Rate for Payer: UHC Exchange |
$15.35
|
| Rate for Payer: UHC Medicaid |
$4.86
|
| Rate for Payer: UHCCP Medicaid |
$4.86
|
| Rate for Payer: UMR Bronson Commercial |
$374.38
|
| Rate for Payer: VA VA |
$9.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION CUSTOM WRAPPER
|
Facility
|
IP
|
$1,011.84
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
301555
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$445.21 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Advantage |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$758.88
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$445.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
OP
|
$475.17
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna American Axle |
$308.86
|
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna Medicare |
$9.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.62
|
| Rate for Payer: BCBS Complete |
$5.11
|
| Rate for Payer: BCBS MAPPO |
$9.30
|
| Rate for Payer: BCBS Trust/PPO |
$31.32
|
| Rate for Payer: BCN Commercial |
$31.32
|
| Rate for Payer: BCN Medicare Advantage |
$9.30
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Advantage |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.30
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$332.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.38
|
| Rate for Payer: Mclaren Medicaid |
$9.30
|
| Rate for Payer: Mclaren Medicare |
$9.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.77
|
| Rate for Payer: Meridian Medicaid |
$9.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.70
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: Nomi Health Commercial |
$27.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.38
|
| Rate for Payer: PACE Medicare |
$8.84
|
| Rate for Payer: PACE SWMI |
$9.30
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: PHP Medicare Advantage |
$9.30
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$31.40
|
| Rate for Payer: Priority Health Medicare |
$9.30
|
| Rate for Payer: Priority Health SBD |
$299.36
|
| Rate for Payer: Priority Health Tiered Network |
$25.12
|
| Rate for Payer: Railroad Medicare Medicare |
$9.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.35
|
| Rate for Payer: UHC Core |
$15.35
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9.30
|
| Rate for Payer: UHC Exchange |
$15.35
|
| Rate for Payer: UHC Medicaid |
$4.86
|
| Rate for Payer: UHCCP Medicaid |
$4.86
|
| Rate for Payer: UMR Bronson Commercial |
$175.81
|
| Rate for Payer: VA VA |
$9.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.38
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION
|
Facility
|
IP
|
$475.17
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
108702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$209.07 |
| Max. Negotiated Rate |
$427.65 |
| Rate for Payer: Aetna American Axle |
$308.86
|
| Rate for Payer: Aetna Commercial |
$403.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$308.86
|
| Rate for Payer: Cash Price |
$380.14
|
| Rate for Payer: Cofinity Advantage |
$332.62
|
| Rate for Payer: Cofinity Commercial |
$408.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.14
|
| Rate for Payer: Healthscope Commercial |
$427.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$332.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.38
|
| Rate for Payer: PHP Commercial |
$403.89
|
| Rate for Payer: Priority Health SBD |
$299.36
|
| Rate for Payer: UMR Bronson Commercial |
$209.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.38
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,011.84
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna Medicare |
$9.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$11.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$11.62
|
| Rate for Payer: BCBS Complete |
$5.11
|
| Rate for Payer: BCBS MAPPO |
$9.30
|
| Rate for Payer: BCBS Trust/PPO |
$31.32
|
| Rate for Payer: BCN Commercial |
$31.32
|
| Rate for Payer: BCN Medicare Advantage |
$9.30
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Advantage |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.30
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Mclaren Medicaid |
$9.30
|
| Rate for Payer: Mclaren Medicare |
$9.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$9.77
|
| Rate for Payer: Meridian Medicaid |
$9.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$10.70
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: Nomi Health Commercial |
$27.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$758.88
|
| Rate for Payer: PACE Medicare |
$8.84
|
| Rate for Payer: PACE SWMI |
$9.30
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: PHP Medicare Advantage |
$9.30
|
| Rate for Payer: Priority Health Choice Medicaid |
$4.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$31.40
|
| Rate for Payer: Priority Health Medicare |
$9.30
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: Priority Health Tiered Network |
$25.12
|
| Rate for Payer: Railroad Medicare Medicare |
$9.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.35
|
| Rate for Payer: UHC Core |
$15.35
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$9.30
|
| Rate for Payer: UHC Exchange |
$15.35
|
| Rate for Payer: UHC Medicaid |
$4.86
|
| Rate for Payer: UHCCP Medicaid |
$4.86
|
| Rate for Payer: UMR Bronson Commercial |
$374.38
|
| Rate for Payer: VA VA |
$9.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$1,011.84
|
|
|
Service Code
|
HCPCS J9220
|
| Hospital Charge Code |
201498
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$445.21 |
| Max. Negotiated Rate |
$910.66 |
| Rate for Payer: Aetna American Axle |
$657.70
|
| Rate for Payer: Aetna Commercial |
$860.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$657.70
|
| Rate for Payer: Cash Price |
$809.47
|
| Rate for Payer: Cofinity Advantage |
$708.29
|
| Rate for Payer: Cofinity Commercial |
$870.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$809.47
|
| Rate for Payer: Healthscope Commercial |
$910.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$708.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$758.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$860.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$758.88
|
| Rate for Payer: PHP Commercial |
$860.06
|
| Rate for Payer: Priority Health SBD |
$637.46
|
| Rate for Payer: UMR Bronson Commercial |
$445.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$758.88
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$681.21
|
|
|
Service Code
|
NDC 70100082502
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$252.05 |
| Max. Negotiated Rate |
$613.09 |
| Rate for Payer: Aetna American Axle |
$442.79
|
| Rate for Payer: Aetna Commercial |
$579.03
|
| Rate for Payer: Aetna Medicare |
$340.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$442.79
|
| Rate for Payer: BCBS Complete |
$272.48
|
| Rate for Payer: Cash Price |
$544.97
|
| Rate for Payer: Cofinity Advantage |
$476.85
|
| Rate for Payer: Cofinity Commercial |
$585.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$544.97
|
| Rate for Payer: Healthscope Commercial |
$613.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$476.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$510.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$544.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$579.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$510.91
|
| Rate for Payer: PHP Commercial |
$579.03
|
| Rate for Payer: Priority Health SBD |
$429.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$442.79
|
| Rate for Payer: UHC Core |
$354.91
|
| Rate for Payer: UHC Exchange |
$267.72
|
| Rate for Payer: UMR Bronson Commercial |
$252.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$510.91
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$325.64
|
|
|
Service Code
|
NDC 17478070102
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.49 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna Medicare |
$162.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: BCBS Complete |
$130.26
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Advantage |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$260.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$244.23
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$211.67
|
| Rate for Payer: UHC Core |
$169.66
|
| Rate for Payer: UHC Exchange |
$127.98
|
| Rate for Payer: UMR Bronson Commercial |
$120.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$523.96
|
|
|
Service Code
|
NDC 70100042402
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$230.54 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Advantage |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$392.97
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UMR Bronson Commercial |
$230.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$681.21
|
|
|
Service Code
|
NDC 70100072501
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$252.05 |
| Max. Negotiated Rate |
$613.09 |
| Rate for Payer: Aetna American Axle |
$442.79
|
| Rate for Payer: Aetna Commercial |
$579.03
|
| Rate for Payer: Aetna Medicare |
$340.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$442.79
|
| Rate for Payer: BCBS Complete |
$272.48
|
| Rate for Payer: Cash Price |
$544.97
|
| Rate for Payer: Cofinity Advantage |
$476.85
|
| Rate for Payer: Cofinity Commercial |
$585.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$544.97
|
| Rate for Payer: Healthscope Commercial |
$613.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$476.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$510.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$544.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$579.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$510.91
|
| Rate for Payer: PHP Commercial |
$579.03
|
| Rate for Payer: Priority Health SBD |
$429.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$442.79
|
| Rate for Payer: UHC Core |
$354.91
|
| Rate for Payer: UHC Exchange |
$267.72
|
| Rate for Payer: UMR Bronson Commercial |
$252.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$510.91
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$523.96
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$230.54 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Advantage |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$392.97
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UMR Bronson Commercial |
$230.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$325.64
|
|
|
Service Code
|
NDC 17478070125
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.28 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Advantage |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$244.23
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$143.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$681.21
|
|
|
Service Code
|
NDC 70100072501
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$299.73 |
| Max. Negotiated Rate |
$613.09 |
| Rate for Payer: Aetna American Axle |
$442.79
|
| Rate for Payer: Aetna Commercial |
$579.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$442.79
|
| Rate for Payer: Cash Price |
$544.97
|
| Rate for Payer: Cofinity Advantage |
$476.85
|
| Rate for Payer: Cofinity Commercial |
$585.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$544.97
|
| Rate for Payer: Healthscope Commercial |
$613.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$476.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$510.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$579.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$510.91
|
| Rate for Payer: PHP Commercial |
$579.03
|
| Rate for Payer: Priority Health SBD |
$429.16
|
| Rate for Payer: UMR Bronson Commercial |
$299.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$510.91
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$325.64
|
|
|
Service Code
|
NDC 17478070102
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$143.28 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Advantage |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$244.23
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UMR Bronson Commercial |
$143.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$523.96
|
|
|
Service Code
|
NDC 70100042401
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.87 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna Medicare |
$261.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: BCBS Complete |
$209.58
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Advantage |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$419.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$392.97
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.57
|
| Rate for Payer: UHC Core |
$272.98
|
| Rate for Payer: UHC Exchange |
$205.92
|
| Rate for Payer: UMR Bronson Commercial |
$193.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$325.64
|
|
|
Service Code
|
NDC 17478070125
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$120.49 |
| Max. Negotiated Rate |
$293.08 |
| Rate for Payer: Aetna American Axle |
$211.67
|
| Rate for Payer: Aetna Commercial |
$276.79
|
| Rate for Payer: Aetna Medicare |
$162.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.67
|
| Rate for Payer: BCBS Complete |
$130.26
|
| Rate for Payer: Cash Price |
$260.51
|
| Rate for Payer: Cofinity Advantage |
$227.95
|
| Rate for Payer: Cofinity Commercial |
$280.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.51
|
| Rate for Payer: Healthscope Commercial |
$293.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$260.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$276.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$244.23
|
| Rate for Payer: PHP Commercial |
$276.79
|
| Rate for Payer: Priority Health SBD |
$205.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$211.67
|
| Rate for Payer: UHC Core |
$169.66
|
| Rate for Payer: UHC Exchange |
$127.98
|
| Rate for Payer: UMR Bronson Commercial |
$120.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.23
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$523.96
|
|
|
Service Code
|
NDC 70100042402
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$193.87 |
| Max. Negotiated Rate |
$471.56 |
| Rate for Payer: Aetna American Axle |
$340.57
|
| Rate for Payer: Aetna Commercial |
$445.37
|
| Rate for Payer: Aetna Medicare |
$261.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.57
|
| Rate for Payer: BCBS Complete |
$209.58
|
| Rate for Payer: Cash Price |
$419.17
|
| Rate for Payer: Cofinity Advantage |
$366.77
|
| Rate for Payer: Cofinity Commercial |
$450.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$419.17
|
| Rate for Payer: Healthscope Commercial |
$471.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$419.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$445.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$392.97
|
| Rate for Payer: PHP Commercial |
$445.37
|
| Rate for Payer: Priority Health SBD |
$330.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.57
|
| Rate for Payer: UHC Core |
$272.98
|
| Rate for Payer: UHC Exchange |
$205.92
|
| Rate for Payer: UMR Bronson Commercial |
$193.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.97
|
|
|
INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$681.21
|
|
|
Service Code
|
NDC 70100082502
|
| Hospital Charge Code |
10266
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$299.73 |
| Max. Negotiated Rate |
$613.09 |
| Rate for Payer: Aetna American Axle |
$442.79
|
| Rate for Payer: Aetna Commercial |
$579.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$442.79
|
| Rate for Payer: Cash Price |
$544.97
|
| Rate for Payer: Cofinity Advantage |
$476.85
|
| Rate for Payer: Cofinity Commercial |
$585.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$544.97
|
| Rate for Payer: Healthscope Commercial |
$613.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$476.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$510.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$579.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$510.91
|
| Rate for Payer: PHP Commercial |
$579.03
|
| Rate for Payer: Priority Health SBD |
$429.16
|
| Rate for Payer: UMR Bronson Commercial |
$299.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$510.91
|
|
|
INDOMETHACIN 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$7,707.72
|
|
|
Service Code
|
NDC 69344010101
|
| Hospital Charge Code |
3900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,391.40 |
| Max. Negotiated Rate |
$6,936.95 |
| Rate for Payer: Aetna American Axle |
$5,010.02
|
| Rate for Payer: Aetna Commercial |
$6,551.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,010.02
|
| Rate for Payer: Cash Price |
$6,166.18
|
| Rate for Payer: Cofinity Advantage |
$5,395.40
|
| Rate for Payer: Cofinity Commercial |
$6,628.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,166.18
|
| Rate for Payer: Healthscope Commercial |
$6,936.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,395.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,780.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,551.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5,780.79
|
| Rate for Payer: PHP Commercial |
$6,551.56
|
| Rate for Payer: Priority Health SBD |
$4,855.86
|
| Rate for Payer: UMR Bronson Commercial |
$3,391.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,780.79
|
|
|
INDOMETHACIN 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$7,707.72
|
|
|
Service Code
|
NDC 69344010101
|
| Hospital Charge Code |
3900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,851.86 |
| Max. Negotiated Rate |
$6,936.95 |
| Rate for Payer: Aetna American Axle |
$5,010.02
|
| Rate for Payer: Aetna Commercial |
$6,551.56
|
| Rate for Payer: Aetna Medicare |
$3,853.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,010.02
|
| Rate for Payer: BCBS Complete |
$3,083.09
|
| Rate for Payer: Cash Price |
$6,166.18
|
| Rate for Payer: Cofinity Advantage |
$5,395.40
|
| Rate for Payer: Cofinity Commercial |
$6,628.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,166.18
|
| Rate for Payer: Healthscope Commercial |
$6,936.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$5,395.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5,780.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,166.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,551.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5,780.79
|
| Rate for Payer: PHP Commercial |
$6,551.56
|
| Rate for Payer: Priority Health SBD |
$4,855.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5,010.02
|
| Rate for Payer: UHC Core |
$4,015.72
|
| Rate for Payer: UHC Exchange |
$3,029.13
|
| Rate for Payer: UMR Bronson Commercial |
$2,851.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5,780.79
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$2.58
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna American Axle |
$1.68
|
| Rate for Payer: Aetna Commercial |
$2.19
|
| Rate for Payer: Aetna Medicare |
$1.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.68
|
| Rate for Payer: BCBS Complete |
$1.03
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Advantage |
$1.81
|
| Rate for Payer: Cofinity Commercial |
$2.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.94
|
| Rate for Payer: PHP Commercial |
$2.19
|
| Rate for Payer: Priority Health SBD |
$1.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.68
|
| Rate for Payer: UHC Core |
$1.34
|
| Rate for Payer: UHC Exchange |
$1.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.94
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$420.65
|
|
|
Service Code
|
NDC 23155001001
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.09 |
| Max. Negotiated Rate |
$378.58 |
| Rate for Payer: Aetna American Axle |
$273.42
|
| Rate for Payer: Aetna Commercial |
$357.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$273.42
|
| Rate for Payer: Cash Price |
$336.52
|
| Rate for Payer: Cofinity Advantage |
$294.45
|
| Rate for Payer: Cofinity Commercial |
$361.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$336.52
|
| Rate for Payer: Healthscope Commercial |
$378.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$294.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$315.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$357.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$315.49
|
| Rate for Payer: PHP Commercial |
$357.55
|
| Rate for Payer: Priority Health SBD |
$265.01
|
| Rate for Payer: UMR Bronson Commercial |
$185.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$315.49
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$2.58
|
|
|
Service Code
|
NDC 50268043011
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna American Axle |
$1.68
|
| Rate for Payer: Aetna Commercial |
$2.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.68
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Advantage |
$1.81
|
| Rate for Payer: Cofinity Commercial |
$2.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.94
|
| Rate for Payer: PHP Commercial |
$2.19
|
| Rate for Payer: Priority Health SBD |
$1.63
|
| Rate for Payer: UMR Bronson Commercial |
$1.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.94
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
IP
|
$128.73
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.64 |
| Max. Negotiated Rate |
$115.86 |
| Rate for Payer: Aetna American Axle |
$83.67
|
| Rate for Payer: Aetna Commercial |
$109.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.67
|
| Rate for Payer: Cash Price |
$102.98
|
| Rate for Payer: Cofinity Advantage |
$90.11
|
| Rate for Payer: Cofinity Commercial |
$110.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.98
|
| Rate for Payer: Healthscope Commercial |
$115.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$96.55
|
| Rate for Payer: PHP Commercial |
$109.42
|
| Rate for Payer: Priority Health SBD |
$81.10
|
| Rate for Payer: UMR Bronson Commercial |
$56.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.55
|
|
|
INDOMETHACIN 25 MG CAPSULE
|
Facility
|
OP
|
$128.73
|
|
|
Service Code
|
NDC 50268043015
|
| Hospital Charge Code |
3897
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.63 |
| Max. Negotiated Rate |
$115.86 |
| Rate for Payer: Aetna American Axle |
$83.67
|
| Rate for Payer: Aetna Commercial |
$109.42
|
| Rate for Payer: Aetna Medicare |
$64.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.67
|
| Rate for Payer: BCBS Complete |
$51.49
|
| Rate for Payer: Cash Price |
$102.98
|
| Rate for Payer: Cofinity Advantage |
$90.11
|
| Rate for Payer: Cofinity Commercial |
$110.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$102.98
|
| Rate for Payer: Healthscope Commercial |
$115.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$102.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$96.55
|
| Rate for Payer: PHP Commercial |
$109.42
|
| Rate for Payer: Priority Health SBD |
$81.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$83.67
|
| Rate for Payer: UHC Core |
$67.07
|
| Rate for Payer: UHC Exchange |
$50.59
|
| Rate for Payer: UMR Bronson Commercial |
$47.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.55
|
|
