|
CLINDAMYCIN IN NS 30 MG/0.5 ML FOR DISCOGRAM
|
Facility
|
IP
|
$9.96
|
|
|
Service Code
|
NDC 9900-0003-90
|
| Hospital Charge Code |
163511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.38 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna American Axle |
$6.47
|
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.47
|
| Rate for Payer: Cash Price |
$7.97
|
| Rate for Payer: Cofinity Commercial |
$8.57
|
| Rate for Payer: Cofinity Commercial |
$6.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.97
|
| Rate for Payer: Healthscope Commercial |
$8.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.47
|
| Rate for Payer: PHP Commercial |
$8.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.97
|
| Rate for Payer: Priority Health SBD |
$6.27
|
| Rate for Payer: UMR Bronson Commercial |
$4.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.47
|
|
|
CLOBAZAM 10 MG TABLET
|
Facility
|
IP
|
$976.50
|
|
|
Service Code
|
NDC 51991-900-01
|
| Hospital Charge Code |
150910
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$429.66 |
| Max. Negotiated Rate |
$878.85 |
| Rate for Payer: Aetna American Axle |
$634.72
|
| Rate for Payer: Aetna Commercial |
$830.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$634.72
|
| Rate for Payer: Cash Price |
$781.20
|
| Rate for Payer: Cofinity Commercial |
$683.55
|
| Rate for Payer: Cofinity Commercial |
$839.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$781.20
|
| Rate for Payer: Healthscope Commercial |
$878.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$683.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$732.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$830.02
|
| Rate for Payer: PHP Commercial |
$830.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$683.55
|
| Rate for Payer: Priority Health SBD |
$615.20
|
| Rate for Payer: UMR Bronson Commercial |
$429.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$732.38
|
|
|
CLOBAZAM 10 MG TABLET
|
Facility
|
IP
|
$9,150.57
|
|
|
Service Code
|
NDC 67386-314-01
|
| Hospital Charge Code |
150910
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4,026.25 |
| Max. Negotiated Rate |
$8,235.51 |
| Rate for Payer: Aetna American Axle |
$5,947.87
|
| Rate for Payer: Aetna Commercial |
$7,777.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5,947.87
|
| Rate for Payer: Cash Price |
$7,320.46
|
| Rate for Payer: Cofinity Commercial |
$6,405.40
|
| Rate for Payer: Cofinity Commercial |
$7,869.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,320.46
|
| Rate for Payer: Healthscope Commercial |
$8,235.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,405.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6,862.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7,777.98
|
| Rate for Payer: PHP Commercial |
$7,777.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,405.40
|
| Rate for Payer: Priority Health SBD |
$5,764.86
|
| Rate for Payer: UMR Bronson Commercial |
$4,026.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6,862.93
|
|
|
CLOBAZAM 10 MG TABLET
|
Facility
|
IP
|
$547.75
|
|
|
Service Code
|
NDC 0832-0580-11
|
| Hospital Charge Code |
150910
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.01 |
| Max. Negotiated Rate |
$492.98 |
| Rate for Payer: Aetna American Axle |
$356.04
|
| Rate for Payer: Aetna Commercial |
$465.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$356.04
|
| Rate for Payer: Cash Price |
$438.20
|
| Rate for Payer: Cofinity Commercial |
$383.42
|
| Rate for Payer: Cofinity Commercial |
$471.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$438.20
|
| Rate for Payer: Healthscope Commercial |
$492.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$383.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$410.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$465.59
|
| Rate for Payer: PHP Commercial |
$465.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$383.42
|
| Rate for Payer: Priority Health SBD |
$345.08
|
| Rate for Payer: UMR Bronson Commercial |
$241.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$410.81
|
|
|
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$485.64
|
|
|
Service Code
|
NDC 67877-658-61
|
| Hospital Charge Code |
167603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$213.68 |
| Max. Negotiated Rate |
$437.08 |
| Rate for Payer: Aetna American Axle |
$315.67
|
| Rate for Payer: Aetna Commercial |
$412.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$315.67
|
| Rate for Payer: Cash Price |
$388.51
|
| Rate for Payer: Cofinity Commercial |
$339.95
|
| Rate for Payer: Cofinity Commercial |
$417.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$388.51
|
| Rate for Payer: Healthscope Commercial |
$437.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$339.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$364.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$412.79
|
| Rate for Payer: PHP Commercial |
$412.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$339.95
|
| Rate for Payer: Priority Health SBD |
$305.95
|
| Rate for Payer: UMR Bronson Commercial |
$213.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$364.23
|
|
|
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$5,390.61
|
|
|
Service Code
|
NDC 67386-313-21
|
| Hospital Charge Code |
167603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,371.87 |
| Max. Negotiated Rate |
$4,851.55 |
| Rate for Payer: Aetna American Axle |
$3,503.90
|
| Rate for Payer: Aetna Commercial |
$4,582.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,503.90
|
| Rate for Payer: Cash Price |
$4,312.49
|
| Rate for Payer: Cofinity Commercial |
$3,773.43
|
| Rate for Payer: Cofinity Commercial |
$4,635.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,312.49
|
| Rate for Payer: Healthscope Commercial |
$4,851.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,773.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,042.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,582.02
|
| Rate for Payer: PHP Commercial |
$4,582.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,773.43
|
| Rate for Payer: Priority Health SBD |
$3,396.08
|
| Rate for Payer: UMR Bronson Commercial |
$2,371.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,042.96
|
|
|
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$14.28
|
|
|
Service Code
|
NDC 9900-0005-97
|
| Hospital Charge Code |
167603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$12.85 |
| Rate for Payer: Aetna American Axle |
$9.28
|
| Rate for Payer: Aetna Commercial |
$12.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.28
|
| Rate for Payer: Cash Price |
$11.42
|
| Rate for Payer: Cofinity Commercial |
$10.00
|
| Rate for Payer: Cofinity Commercial |
$12.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.42
|
| Rate for Payer: Healthscope Commercial |
$12.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.14
|
| Rate for Payer: PHP Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.00
|
| Rate for Payer: Priority Health SBD |
$9.00
|
| Rate for Payer: UMR Bronson Commercial |
$6.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.71
|
|
|
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$615.75
|
|
|
Service Code
|
NDC 69452-116-45
|
| Hospital Charge Code |
167603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$270.93 |
| Max. Negotiated Rate |
$554.18 |
| Rate for Payer: Aetna American Axle |
$400.24
|
| Rate for Payer: Aetna Commercial |
$523.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$400.24
|
| Rate for Payer: Cash Price |
$492.60
|
| Rate for Payer: Cofinity Commercial |
$431.02
|
| Rate for Payer: Cofinity Commercial |
$529.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$492.60
|
| Rate for Payer: Healthscope Commercial |
$554.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$431.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$461.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$523.39
|
| Rate for Payer: PHP Commercial |
$523.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$431.02
|
| Rate for Payer: Priority Health SBD |
$387.92
|
| Rate for Payer: UMR Bronson Commercial |
$270.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$461.81
|
|
|
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$417.24
|
|
|
Service Code
|
NDC 69238-1535-2
|
| Hospital Charge Code |
167603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.59 |
| Max. Negotiated Rate |
$375.52 |
| Rate for Payer: Aetna American Axle |
$271.21
|
| Rate for Payer: Aetna Commercial |
$354.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.21
|
| Rate for Payer: Cash Price |
$333.79
|
| Rate for Payer: Cofinity Commercial |
$292.07
|
| Rate for Payer: Cofinity Commercial |
$358.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$333.79
|
| Rate for Payer: Healthscope Commercial |
$375.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$312.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$354.65
|
| Rate for Payer: PHP Commercial |
$354.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$292.07
|
| Rate for Payer: Priority Health SBD |
$262.86
|
| Rate for Payer: UMR Bronson Commercial |
$183.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$312.93
|
|
|
CLOBAZAM 2.5 MG/ML ORAL SUSPENSION
|
Facility
|
IP
|
$101.03
|
|
|
Service Code
|
NDC 9900-0006-26
|
| Hospital Charge Code |
167603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.45 |
| Max. Negotiated Rate |
$90.93 |
| Rate for Payer: Aetna American Axle |
$65.67
|
| Rate for Payer: Aetna Commercial |
$85.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.67
|
| Rate for Payer: Cash Price |
$80.82
|
| Rate for Payer: Cofinity Commercial |
$70.72
|
| Rate for Payer: Cofinity Commercial |
$86.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.82
|
| Rate for Payer: Healthscope Commercial |
$90.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.88
|
| Rate for Payer: PHP Commercial |
$85.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.72
|
| Rate for Payer: Priority Health SBD |
$63.65
|
| Rate for Payer: UMR Bronson Commercial |
$44.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.77
|
|
|
CLOBETASOL 0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$20.86
|
|
|
Service Code
|
NDC 21922-016-04
|
| Hospital Charge Code |
9630
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$18.77 |
| Rate for Payer: Aetna American Axle |
$13.56
|
| Rate for Payer: Aetna Commercial |
$17.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.56
|
| Rate for Payer: Cash Price |
$16.69
|
| Rate for Payer: Cofinity Commercial |
$14.60
|
| Rate for Payer: Cofinity Commercial |
$17.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.69
|
| Rate for Payer: Healthscope Commercial |
$18.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.73
|
| Rate for Payer: PHP Commercial |
$17.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.60
|
| Rate for Payer: Priority Health SBD |
$13.14
|
| Rate for Payer: UMR Bronson Commercial |
$9.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.64
|
|
|
CLOBETASOL 0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$32.55
|
|
|
Service Code
|
NDC 51672-1258-1
|
| Hospital Charge Code |
9630
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna American Axle |
$21.16
|
| Rate for Payer: Aetna Commercial |
$27.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.16
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cofinity Commercial |
$22.78
|
| Rate for Payer: Cofinity Commercial |
$27.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.04
|
| Rate for Payer: Healthscope Commercial |
$29.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.67
|
| Rate for Payer: PHP Commercial |
$27.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.78
|
| Rate for Payer: Priority Health SBD |
$20.51
|
| Rate for Payer: UMR Bronson Commercial |
$14.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.41
|
|
|
CLOBETASOL 0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$32.71
|
|
|
Service Code
|
NDC 52565-051-15
|
| Hospital Charge Code |
9630
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$29.44 |
| Rate for Payer: Aetna American Axle |
$21.26
|
| Rate for Payer: Aetna Commercial |
$27.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.26
|
| Rate for Payer: Cash Price |
$26.17
|
| Rate for Payer: Cofinity Commercial |
$22.90
|
| Rate for Payer: Cofinity Commercial |
$28.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.17
|
| Rate for Payer: Healthscope Commercial |
$29.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.80
|
| Rate for Payer: PHP Commercial |
$27.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.90
|
| Rate for Payer: Priority Health SBD |
$20.61
|
| Rate for Payer: UMR Bronson Commercial |
$14.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.53
|
|
|
CLOBETASOL 0.05 % TOPICAL CREAM
|
Facility
|
IP
|
$52.61
|
|
|
Service Code
|
NDC 0168-0163-15
|
| Hospital Charge Code |
9630
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$47.35 |
| Rate for Payer: Aetna American Axle |
$34.20
|
| Rate for Payer: Aetna Commercial |
$44.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.20
|
| Rate for Payer: Cash Price |
$42.09
|
| Rate for Payer: Cofinity Commercial |
$36.83
|
| Rate for Payer: Cofinity Commercial |
$45.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.09
|
| Rate for Payer: Healthscope Commercial |
$47.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.72
|
| Rate for Payer: PHP Commercial |
$44.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.83
|
| Rate for Payer: Priority Health SBD |
$33.14
|
| Rate for Payer: UMR Bronson Commercial |
$23.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.46
|
|
|
CLOBETASOL 0.05 % TOPICAL OINTMENT
|
Facility
|
IP
|
$15.87
|
|
|
Service Code
|
NDC 51672-1259-1
|
| Hospital Charge Code |
9631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.98 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Aetna American Axle |
$10.32
|
| Rate for Payer: Aetna Commercial |
$13.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.32
|
| Rate for Payer: Cash Price |
$12.70
|
| Rate for Payer: Cofinity Commercial |
$11.11
|
| Rate for Payer: Cofinity Commercial |
$13.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.70
|
| Rate for Payer: Healthscope Commercial |
$14.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.49
|
| Rate for Payer: PHP Commercial |
$13.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.11
|
| Rate for Payer: Priority Health SBD |
$10.00
|
| Rate for Payer: UMR Bronson Commercial |
$6.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.90
|
|
|
CLOBETASOL 0.05 % TOPICAL OINTMENT
|
Facility
|
IP
|
$39.06
|
|
|
Service Code
|
NDC 70700-106-15
|
| Hospital Charge Code |
9631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna American Axle |
$25.39
|
| Rate for Payer: Aetna Commercial |
$33.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.39
|
| Rate for Payer: Cash Price |
$31.25
|
| Rate for Payer: Cofinity Commercial |
$27.34
|
| Rate for Payer: Cofinity Commercial |
$33.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.25
|
| Rate for Payer: Healthscope Commercial |
$35.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.20
|
| Rate for Payer: PHP Commercial |
$33.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.34
|
| Rate for Payer: Priority Health SBD |
$24.61
|
| Rate for Payer: UMR Bronson Commercial |
$17.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.30
|
|
|
CLOBETASOL 0.05 % TOPICAL OINTMENT
|
Facility
|
IP
|
$78.12
|
|
|
Service Code
|
NDC 0713-0656-15
|
| Hospital Charge Code |
9631
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.37 |
| Max. Negotiated Rate |
$70.31 |
| Rate for Payer: Aetna American Axle |
$50.78
|
| Rate for Payer: Aetna Commercial |
$66.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.78
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cofinity Commercial |
$54.68
|
| Rate for Payer: Cofinity Commercial |
$67.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.50
|
| Rate for Payer: Healthscope Commercial |
$70.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$66.40
|
| Rate for Payer: PHP Commercial |
$66.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.68
|
| Rate for Payer: Priority Health SBD |
$49.22
|
| Rate for Payer: UMR Bronson Commercial |
$34.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.59
|
|
|
CLOFARABINE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,112.00
|
|
|
Service Code
|
HCPCS J9027
|
| Hospital Charge Code |
40404
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$1,000.80 |
| Rate for Payer: Aetna American Axle |
$722.80
|
| Rate for Payer: Aetna American Axle |
$1,511.03
|
| Rate for Payer: Aetna American Axle |
$964.08
|
| Rate for Payer: Aetna Commercial |
$1,260.72
|
| Rate for Payer: Aetna Commercial |
$945.20
|
| Rate for Payer: Aetna Commercial |
$1,975.96
|
| Rate for Payer: Aetna Medicare |
$22.24
|
| Rate for Payer: Aetna Medicare |
$22.24
|
| Rate for Payer: Aetna Medicare |
$22.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$722.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$964.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,511.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$26.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$26.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$26.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$26.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$26.73
|
| Rate for Payer: Amish Plain Church Group Commercial |
$26.73
|
| Rate for Payer: BCBS Complete |
$12.28
|
| Rate for Payer: BCBS Complete |
$12.28
|
| Rate for Payer: BCBS Complete |
$12.28
|
| Rate for Payer: BCBS MAPPO |
$21.38
|
| Rate for Payer: BCBS MAPPO |
$21.38
|
| Rate for Payer: BCBS MAPPO |
$21.38
|
| Rate for Payer: BCBS Trust/PPO |
$69.08
|
| Rate for Payer: BCBS Trust/PPO |
$69.08
|
| Rate for Payer: BCBS Trust/PPO |
$69.08
|
| Rate for Payer: BCN Medicare Advantage |
$21.38
|
| Rate for Payer: BCN Medicare Advantage |
$21.38
|
| Rate for Payer: BCN Medicare Advantage |
$21.38
|
| Rate for Payer: Cash Price |
$889.60
|
| Rate for Payer: Cash Price |
$1,859.73
|
| Rate for Payer: Cash Price |
$1,186.56
|
| Rate for Payer: Cash Price |
$1,859.73
|
| Rate for Payer: Cash Price |
$889.60
|
| Rate for Payer: Cash Price |
$1,186.56
|
| Rate for Payer: Cofinity Commercial |
$778.40
|
| Rate for Payer: Cofinity Commercial |
$1,999.21
|
| Rate for Payer: Cofinity Commercial |
$1,627.26
|
| Rate for Payer: Cofinity Commercial |
$956.32
|
| Rate for Payer: Cofinity Commercial |
$1,275.55
|
| Rate for Payer: Cofinity Commercial |
$1,038.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$889.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,186.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,859.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$21.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$21.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$21.38
|
| Rate for Payer: Healthscope Commercial |
$1,000.80
|
| Rate for Payer: Healthscope Commercial |
$2,092.19
|
| Rate for Payer: Healthscope Commercial |
$1,334.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,038.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$778.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,627.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,743.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$834.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,112.40
|
| Rate for Payer: Mclaren Medicaid |
$11.70
|
| Rate for Payer: Mclaren Medicaid |
$11.70
|
| Rate for Payer: Mclaren Medicaid |
$11.70
|
| Rate for Payer: Mclaren Medicare |
$21.38
|
| Rate for Payer: Mclaren Medicare |
$21.38
|
| Rate for Payer: Mclaren Medicare |
$21.38
|
| Rate for Payer: Meridian Medicaid |
$12.28
|
| Rate for Payer: Meridian Medicaid |
$12.28
|
| Rate for Payer: Meridian Medicaid |
$12.28
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$22.45
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$22.45
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$22.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$945.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,975.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,260.72
|
| Rate for Payer: PACE Medicare |
$20.32
|
| Rate for Payer: PACE Medicare |
$20.32
|
| Rate for Payer: PACE Medicare |
$20.32
|
| Rate for Payer: PACE SWMI |
$21.38
|
| Rate for Payer: PACE SWMI |
$21.38
|
| Rate for Payer: PACE SWMI |
$21.38
|
| Rate for Payer: PHP Commercial |
$945.20
|
| Rate for Payer: PHP Commercial |
$1,260.72
|
| Rate for Payer: PHP Commercial |
$1,975.96
|
| Rate for Payer: PHP Medicare Advantage |
$21.38
|
| Rate for Payer: PHP Medicare Advantage |
$21.38
|
| Rate for Payer: PHP Medicare Advantage |
$21.38
|
| Rate for Payer: Priority Health Choice Medicaid |
$11.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$11.70
|
| Rate for Payer: Priority Health Choice Medicaid |
$11.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,038.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$778.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,627.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$68.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$68.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$68.39
|
| Rate for Payer: Priority Health Medicare |
$21.38
|
| Rate for Payer: Priority Health Medicare |
$21.38
|
| Rate for Payer: Priority Health Medicare |
$21.38
|
| Rate for Payer: Priority Health Narrow Network |
$54.71
|
| Rate for Payer: Priority Health Narrow Network |
$54.71
|
| Rate for Payer: Priority Health Narrow Network |
$54.71
|
| Rate for Payer: Priority Health SBD |
$700.56
|
| Rate for Payer: Priority Health SBD |
$934.42
|
| Rate for Payer: Priority Health SBD |
$1,464.54
|
| Rate for Payer: Railroad Medicare Medicare |
$21.38
|
| Rate for Payer: Railroad Medicare Medicare |
$21.38
|
| Rate for Payer: Railroad Medicare Medicare |
$21.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$21.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$21.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$21.38
|
| Rate for Payer: UHC Medicare Advantage |
$22.03
|
| Rate for Payer: UHC Medicare Advantage |
$22.03
|
| Rate for Payer: UHC Medicare Advantage |
$22.03
|
| Rate for Payer: UMR Bronson Commercial |
$860.12
|
| Rate for Payer: UMR Bronson Commercial |
$548.78
|
| Rate for Payer: UMR Bronson Commercial |
$411.44
|
| Rate for Payer: VA VA |
$21.38
|
| Rate for Payer: VA VA |
$21.38
|
| Rate for Payer: VA VA |
$21.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,112.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$834.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,743.50
|
|
|
CLOFARABINE 1 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$2,324.66
|
|
|
Service Code
|
HCPCS J9027
|
| Hospital Charge Code |
40404
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,022.85 |
| Max. Negotiated Rate |
$2,092.19 |
| Rate for Payer: Aetna American Axle |
$1,511.03
|
| Rate for Payer: Aetna American Axle |
$964.08
|
| Rate for Payer: Aetna American Axle |
$722.80
|
| Rate for Payer: Aetna Commercial |
$945.20
|
| Rate for Payer: Aetna Commercial |
$1,975.96
|
| Rate for Payer: Aetna Commercial |
$1,260.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$964.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$722.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,511.03
|
| Rate for Payer: Cash Price |
$1,859.73
|
| Rate for Payer: Cash Price |
$889.60
|
| Rate for Payer: Cash Price |
$1,186.56
|
| Rate for Payer: Cofinity Commercial |
$1,627.26
|
| Rate for Payer: Cofinity Commercial |
$778.40
|
| Rate for Payer: Cofinity Commercial |
$956.32
|
| Rate for Payer: Cofinity Commercial |
$1,038.24
|
| Rate for Payer: Cofinity Commercial |
$1,275.55
|
| Rate for Payer: Cofinity Commercial |
$1,999.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,186.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,859.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$889.60
|
| Rate for Payer: Healthscope Commercial |
$2,092.19
|
| Rate for Payer: Healthscope Commercial |
$1,334.88
|
| Rate for Payer: Healthscope Commercial |
$1,000.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,627.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$778.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,038.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,743.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,112.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$834.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,260.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,975.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$945.20
|
| Rate for Payer: PHP Commercial |
$1,975.96
|
| Rate for Payer: PHP Commercial |
$1,260.72
|
| Rate for Payer: PHP Commercial |
$945.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$778.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,038.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,627.26
|
| Rate for Payer: Priority Health SBD |
$700.56
|
| Rate for Payer: Priority Health SBD |
$934.42
|
| Rate for Payer: Priority Health SBD |
$1,464.54
|
| Rate for Payer: UMR Bronson Commercial |
$652.61
|
| Rate for Payer: UMR Bronson Commercial |
$489.28
|
| Rate for Payer: UMR Bronson Commercial |
$1,022.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$834.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,112.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,743.50
|
|
|
CLOMIPRAMINE 25 MG CAPSULE
|
Facility
|
IP
|
$265.05
|
|
|
Service Code
|
NDC 51672-4011-5
|
| Hospital Charge Code |
9635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$238.54 |
| Rate for Payer: Aetna American Axle |
$172.28
|
| Rate for Payer: Aetna Commercial |
$225.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.28
|
| Rate for Payer: Cash Price |
$212.04
|
| Rate for Payer: Cofinity Commercial |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$227.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.04
|
| Rate for Payer: Healthscope Commercial |
$238.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$185.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$198.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$225.29
|
| Rate for Payer: PHP Commercial |
$225.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.54
|
| Rate for Payer: Priority Health SBD |
$166.98
|
| Rate for Payer: UMR Bronson Commercial |
$116.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$198.79
|
|
|
CLOMIPRAMINE 25 MG CAPSULE
|
Facility
|
IP
|
$132.53
|
|
|
Service Code
|
NDC 51672-4011-6
|
| Hospital Charge Code |
9635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.31 |
| Max. Negotiated Rate |
$119.28 |
| Rate for Payer: Aetna American Axle |
$86.14
|
| Rate for Payer: Aetna Commercial |
$112.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.14
|
| Rate for Payer: Cash Price |
$106.02
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| Rate for Payer: Cofinity Commercial |
$92.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.02
|
| Rate for Payer: Healthscope Commercial |
$119.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.65
|
| Rate for Payer: PHP Commercial |
$112.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.77
|
| Rate for Payer: Priority Health SBD |
$83.49
|
| Rate for Payer: UMR Bronson Commercial |
$58.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.40
|
|
|
CLOMIPRAMINE 25 MG CAPSULE
|
Facility
|
IP
|
$88.35
|
|
|
Service Code
|
NDC 16571-683-03
|
| Hospital Charge Code |
9635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.87 |
| Max. Negotiated Rate |
$79.52 |
| Rate for Payer: Aetna American Axle |
$57.43
|
| Rate for Payer: Aetna Commercial |
$75.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.43
|
| Rate for Payer: Cash Price |
$70.68
|
| Rate for Payer: Cofinity Commercial |
$61.84
|
| Rate for Payer: Cofinity Commercial |
$75.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.68
|
| Rate for Payer: Healthscope Commercial |
$79.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.10
|
| Rate for Payer: PHP Commercial |
$75.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.84
|
| Rate for Payer: Priority Health SBD |
$55.66
|
| Rate for Payer: UMR Bronson Commercial |
$38.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.26
|
|
|
CLOMIPRAMINE 25 MG CAPSULE
|
Facility
|
IP
|
$120.56
|
|
|
Service Code
|
NDC 42571-342-30
|
| Hospital Charge Code |
9635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.05 |
| Max. Negotiated Rate |
$108.50 |
| Rate for Payer: Aetna American Axle |
$78.36
|
| Rate for Payer: Aetna Commercial |
$102.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$78.36
|
| Rate for Payer: Cash Price |
$96.45
|
| Rate for Payer: Cofinity Commercial |
$103.68
|
| Rate for Payer: Cofinity Commercial |
$84.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.45
|
| Rate for Payer: Healthscope Commercial |
$108.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$84.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$90.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$102.48
|
| Rate for Payer: PHP Commercial |
$102.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.39
|
| Rate for Payer: Priority Health SBD |
$75.95
|
| Rate for Payer: UMR Bronson Commercial |
$53.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$90.42
|
|
|
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 49884-306-52
|
| Hospital Charge Code |
35625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Aetna American Axle |
$2.91
|
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.91
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Cofinity Commercial |
$3.13
|
| Rate for Payer: Cofinity Commercial |
$3.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.58
|
| Rate for Payer: Healthscope Commercial |
$4.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.80
|
| Rate for Payer: PHP Commercial |
$3.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.13
|
| Rate for Payer: Priority Health SBD |
$2.82
|
| Rate for Payer: UMR Bronson Commercial |
$1.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.35
|
|
|
CLONAZEPAM 0.125 MG DISINTEGRATING TABLET
|
Facility
|
IP
|
$267.90
|
|
|
Service Code
|
NDC 49884-306-02
|
| Hospital Charge Code |
35625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.88 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna American Axle |
$174.14
|
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.14
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Commercial |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$187.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$227.72
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.53
|
| Rate for Payer: Priority Health SBD |
$168.78
|
| Rate for Payer: UMR Bronson Commercial |
$117.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.92
|
|
