|
LEVONORGESTREL [1.5 MG]
|
Facility
OP
|
$131.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$131.00 |
| Rate for Payer: AETNA Commercial |
$124.45
|
| Rate for Payer: AETNA Medicare |
$117.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$124.45
|
| Rate for Payer: BCBS Healthlink |
$117.90
|
| Rate for Payer: BCBS HMK CHIP |
$117.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$117.90
|
| Rate for Payer: BCBS POS |
$124.45
|
| Rate for Payer: BCBS Traditional |
$131.00
|
| Rate for Payer: CASH_PRICE |
$104.80
|
| Rate for Payer: CIGNA Commercial |
$124.45
|
| Rate for Payer: CIGNA Medicare |
$117.90
|
| Rate for Payer: HUMANA Commercial |
$117.90
|
| Rate for Payer: MEDICAID Medicaid |
$120.52
|
| Rate for Payer: MEDICARE Medicare |
$91.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$124.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$127.07
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$124.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$124.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$111.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$104.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$104.80
|
|
|
LEVOTHYROXINE 88MCG TAB
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE 88MCG TAB
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE TAB [100 MCG]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE TAB [100 MCG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE TAB [112 MCG] 30 TAB PK
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE TAB [112 MCG] 30 TAB PK
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE TAB [50 MCG]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE TAB [50 MCG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE TAB [75 MCG]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE TAB [75 MCG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE TABLET 137MCG
|
Facility
IP
|
$8.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LEVOTHYROXINE TABLET 137MCG
|
Facility
OP
|
$8.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LIDOCAINE 2% INJ SYR [100 MG/5 ML]
|
Facility
OP
|
$26.00
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: AETNA Commercial |
$24.70
|
| Rate for Payer: AETNA Medicare |
$23.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$24.70
|
| Rate for Payer: BCBS Healthlink |
$23.40
|
| Rate for Payer: BCBS HMK CHIP |
$23.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$23.40
|
| Rate for Payer: BCBS POS |
$24.70
|
| Rate for Payer: BCBS Traditional |
$26.00
|
| Rate for Payer: CASH_PRICE |
$20.80
|
| Rate for Payer: CIGNA Commercial |
$24.70
|
| Rate for Payer: CIGNA Medicare |
$23.40
|
| Rate for Payer: HUMANA Commercial |
$23.40
|
| Rate for Payer: MEDICAID Medicaid |
$23.92
|
| Rate for Payer: MEDICARE Medicare |
$18.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$24.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$25.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$24.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$24.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.80
|
|
|
LIDOCAINE 2% INJ SYR [100 MG/5 ML]
|
Facility
IP
|
$26.00
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: AETNA Commercial |
$24.70
|
| Rate for Payer: AETNA Medicare |
$23.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$24.70
|
| Rate for Payer: BCBS Healthlink |
$23.40
|
| Rate for Payer: BCBS HMK CHIP |
$23.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$23.40
|
| Rate for Payer: BCBS POS |
$24.70
|
| Rate for Payer: BCBS Traditional |
$26.00
|
| Rate for Payer: CASH_PRICE |
$20.80
|
| Rate for Payer: CIGNA Commercial |
$24.70
|
| Rate for Payer: CIGNA Medicare |
$23.40
|
| Rate for Payer: HUMANA Commercial |
$23.40
|
| Rate for Payer: MEDICAID Medicaid |
$23.92
|
| Rate for Payer: MEDICARE Medicare |
$18.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$24.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$25.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$24.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$24.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.80
|
|
|
LIDOCAINE 4% PATCH
|
Facility
IP
|
$5.00
|
|
| Hospital Charge Code |
20230119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: AETNA Commercial |
$4.75
|
| Rate for Payer: AETNA Medicare |
$4.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$4.75
|
| Rate for Payer: BCBS Healthlink |
$4.50
|
| Rate for Payer: BCBS HMK CHIP |
$4.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$4.50
|
| Rate for Payer: BCBS POS |
$4.75
|
| Rate for Payer: BCBS Traditional |
$5.00
|
| Rate for Payer: CASH_PRICE |
$4.00
|
| Rate for Payer: CIGNA Commercial |
$4.75
|
| Rate for Payer: CIGNA Medicare |
$4.50
|
| Rate for Payer: HUMANA Commercial |
$4.50
|
| Rate for Payer: MEDICAID Medicaid |
$4.60
|
| Rate for Payer: MEDICARE Medicare |
$3.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$4.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$4.85
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$4.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$4.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$4.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$4.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$4.00
|
|
|
LIDOCAINE 4% PATCH
|
Facility
OP
|
$5.00
|
|
| Hospital Charge Code |
20230119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$4.75
|
| Rate for Payer: AETNA Commercial |
$4.75
|
| Rate for Payer: AETNA Medicare |
$4.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$4.75
|
| Rate for Payer: BCBS Healthlink |
$4.50
|
| Rate for Payer: BCBS HMK CHIP |
$4.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$4.50
|
| Rate for Payer: BCBS POS |
$4.75
|
| Rate for Payer: BCBS Traditional |
$5.00
|
| Rate for Payer: CASH_PRICE |
$4.00
|
| Rate for Payer: CIGNA Commercial |
$4.75
|
| Rate for Payer: CIGNA Medicare |
$4.50
|
| Rate for Payer: HUMANA Commercial |
$4.50
|
| Rate for Payer: MEDICAID Medicaid |
$4.60
|
| Rate for Payer: MEDICARE Medicare |
$3.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$4.85
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$4.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$4.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$4.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$4.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$4.00
|
|
|
LIDOCAINE 4% TOPICAL CREAM
|
Facility
OP
|
$96.00
|
|
| Hospital Charge Code |
20221212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: AETNA Commercial |
$91.20
|
| Rate for Payer: AETNA Medicare |
$86.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$91.20
|
| Rate for Payer: BCBS Healthlink |
$86.40
|
| Rate for Payer: BCBS HMK CHIP |
$86.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$86.40
|
| Rate for Payer: BCBS POS |
$91.20
|
| Rate for Payer: BCBS Traditional |
$96.00
|
| Rate for Payer: CASH_PRICE |
$76.80
|
| Rate for Payer: CIGNA Commercial |
$91.20
|
| Rate for Payer: CIGNA Medicare |
$86.40
|
| Rate for Payer: HUMANA Commercial |
$86.40
|
| Rate for Payer: MEDICAID Medicaid |
$88.32
|
| Rate for Payer: MEDICARE Medicare |
$67.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$91.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$93.12
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$91.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$91.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$81.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$76.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$76.80
|
|
|
LIDOCAINE 4% TOPICAL CREAM
|
Facility
IP
|
$96.00
|
|
| Hospital Charge Code |
20221212
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$67.20 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: AETNA Commercial |
$91.20
|
| Rate for Payer: AETNA Medicare |
$86.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$91.20
|
| Rate for Payer: BCBS Healthlink |
$86.40
|
| Rate for Payer: BCBS HMK CHIP |
$86.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$86.40
|
| Rate for Payer: BCBS POS |
$91.20
|
| Rate for Payer: BCBS Traditional |
$96.00
|
| Rate for Payer: CASH_PRICE |
$76.80
|
| Rate for Payer: CIGNA Commercial |
$91.20
|
| Rate for Payer: CIGNA Medicare |
$86.40
|
| Rate for Payer: HUMANA Commercial |
$86.40
|
| Rate for Payer: MEDICAID Medicaid |
$88.32
|
| Rate for Payer: MEDICARE Medicare |
$67.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$91.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$93.12
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$91.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$91.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$81.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$76.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$76.80
|
|
|
LIDOCAINE EXT SYR 2% GEL [20 MG/1 ML]
|
Facility
OP
|
$35.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20230329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.92 |
| Max. Negotiated Rate |
$35.60 |
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$33.82
|
| Rate for Payer: AETNA Commercial |
$33.82
|
| Rate for Payer: AETNA Medicare |
$32.04
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$33.82
|
| Rate for Payer: BCBS Healthlink |
$32.04
|
| Rate for Payer: BCBS HMK CHIP |
$32.04
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$32.04
|
| Rate for Payer: BCBS POS |
$33.82
|
| Rate for Payer: BCBS Traditional |
$35.60
|
| Rate for Payer: CASH_PRICE |
$28.48
|
| Rate for Payer: CIGNA Commercial |
$33.82
|
| Rate for Payer: CIGNA Medicare |
$32.04
|
| Rate for Payer: HUMANA Commercial |
$32.04
|
| Rate for Payer: MEDICAID Medicaid |
$32.75
|
| Rate for Payer: MEDICARE Medicare |
$24.92
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$34.53
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$33.82
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$33.82
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$30.26
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$28.48
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$28.48
|
|
|
LIDOCAINE EXT SYR 2% GEL [20 MG/1 ML]
|
Facility
IP
|
$35.60
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20230329
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.92 |
| Max. Negotiated Rate |
$35.60 |
| Rate for Payer: AETNA Commercial |
$33.82
|
| Rate for Payer: AETNA Medicare |
$32.04
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$33.82
|
| Rate for Payer: BCBS Healthlink |
$32.04
|
| Rate for Payer: BCBS HMK CHIP |
$32.04
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$32.04
|
| Rate for Payer: BCBS POS |
$33.82
|
| Rate for Payer: BCBS Traditional |
$35.60
|
| Rate for Payer: CASH_PRICE |
$28.48
|
| Rate for Payer: CIGNA Commercial |
$33.82
|
| Rate for Payer: CIGNA Medicare |
$32.04
|
| Rate for Payer: HUMANA Commercial |
$32.04
|
| Rate for Payer: MEDICAID Medicaid |
$32.75
|
| Rate for Payer: MEDICARE Medicare |
$24.92
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$33.82
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$34.53
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$33.82
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$33.82
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$30.26
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$28.48
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$28.48
|
|
|
LIDOCAINE HCL 2% VISCOUS SOL [15 ML]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LIDOCAINE HCL 2% VISCOUS SOL [15 ML]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
LIDOCAINE PATCH 5%
|
Facility
OP
|
$35.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: AETNA Commercial |
$33.25
|
| Rate for Payer: AETNA Medicare |
$31.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$33.25
|
| Rate for Payer: BCBS Healthlink |
$31.50
|
| Rate for Payer: BCBS HMK CHIP |
$31.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$31.50
|
| Rate for Payer: BCBS POS |
$33.25
|
| Rate for Payer: BCBS Traditional |
$35.00
|
| Rate for Payer: CASH_PRICE |
$28.00
|
| Rate for Payer: CIGNA Commercial |
$33.25
|
| Rate for Payer: CIGNA Medicare |
$31.50
|
| Rate for Payer: HUMANA Commercial |
$31.50
|
| Rate for Payer: MEDICAID Medicaid |
$32.20
|
| Rate for Payer: MEDICARE Medicare |
$24.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$33.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$33.95
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$33.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$33.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$29.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$28.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$28.00
|
|
|
LIDOCAINE PATCH 5%
|
Facility
IP
|
$35.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: AETNA Commercial |
$33.25
|
| Rate for Payer: AETNA Medicare |
$31.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$33.25
|
| Rate for Payer: BCBS Healthlink |
$31.50
|
| Rate for Payer: BCBS HMK CHIP |
$31.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$31.50
|
| Rate for Payer: BCBS POS |
$33.25
|
| Rate for Payer: BCBS Traditional |
$35.00
|
| Rate for Payer: CASH_PRICE |
$28.00
|
| Rate for Payer: CIGNA Commercial |
$33.25
|
| Rate for Payer: CIGNA Medicare |
$31.50
|
| Rate for Payer: HUMANA Commercial |
$31.50
|
| Rate for Payer: MEDICAID Medicaid |
$32.20
|
| Rate for Payer: MEDICARE Medicare |
$24.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$33.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$33.95
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$33.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$33.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$29.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$28.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$28.00
|
|
