|
BIOPSY-PUNCH SINGLE LESION-11104
|
Facility
OP
|
$196.00
|
|
|
Service Code
|
CPT 11104
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: AETNA Commercial |
$186.20
|
| Rate for Payer: AETNA Medicare |
$176.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$186.20
|
| Rate for Payer: BCBS Healthlink |
$176.40
|
| Rate for Payer: BCBS HMK CHIP |
$176.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$176.40
|
| Rate for Payer: BCBS POS |
$186.20
|
| Rate for Payer: BCBS Traditional |
$196.00
|
| Rate for Payer: CASH_PRICE |
$156.80
|
| Rate for Payer: CIGNA Commercial |
$186.20
|
| Rate for Payer: CIGNA Medicare |
$176.40
|
| Rate for Payer: HUMANA Commercial |
$176.40
|
| Rate for Payer: MEDICAID Medicaid |
$180.32
|
| Rate for Payer: MEDICARE Medicare |
$137.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$186.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$190.12
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$186.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$186.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$166.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$156.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$156.80
|
|
|
BIOPSY-PUNCH SINGLE LESION-11104
|
Facility
IP
|
$196.00
|
|
|
Service Code
|
CPT 11104
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$137.20 |
| Max. Negotiated Rate |
$196.00 |
| Rate for Payer: AETNA Commercial |
$186.20
|
| Rate for Payer: AETNA Medicare |
$176.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$186.20
|
| Rate for Payer: BCBS Healthlink |
$176.40
|
| Rate for Payer: BCBS HMK CHIP |
$176.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$176.40
|
| Rate for Payer: BCBS POS |
$186.20
|
| Rate for Payer: BCBS Traditional |
$196.00
|
| Rate for Payer: CASH_PRICE |
$156.80
|
| Rate for Payer: CIGNA Commercial |
$186.20
|
| Rate for Payer: CIGNA Medicare |
$176.40
|
| Rate for Payer: HUMANA Commercial |
$176.40
|
| Rate for Payer: MEDICAID Medicaid |
$180.32
|
| Rate for Payer: MEDICARE Medicare |
$137.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$186.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$190.12
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$186.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$186.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$166.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$156.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$156.80
|
|
|
BIOPSY-SHAVE/SCOOP SNGL LESION-11102
|
Facility
IP
|
$175.00
|
|
|
Service Code
|
CPT 11102
|
| Hospital Charge Code |
20230324
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: BCBS HMK CHIP |
$157.50
|
| Rate for Payer: AETNA Commercial |
$166.25
|
| Rate for Payer: AETNA Medicare |
$157.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$166.25
|
| Rate for Payer: BCBS Healthlink |
$157.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$157.50
|
| Rate for Payer: BCBS POS |
$166.25
|
| Rate for Payer: BCBS Traditional |
$175.00
|
| Rate for Payer: CASH_PRICE |
$140.00
|
| Rate for Payer: CIGNA Commercial |
$166.25
|
| Rate for Payer: CIGNA Medicare |
$157.50
|
| Rate for Payer: HUMANA Commercial |
$157.50
|
| Rate for Payer: MEDICAID Medicaid |
$161.00
|
| Rate for Payer: MEDICARE Medicare |
$122.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$166.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$169.75
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$166.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$166.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$148.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$140.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$140.00
|
|
|
BIOPSY-SHAVE/SCOOP SNGL LESION-11102
|
Facility
OP
|
$175.00
|
|
|
Service Code
|
CPT 11102
|
| Hospital Charge Code |
20230324
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: AETNA Commercial |
$166.25
|
| Rate for Payer: AETNA Medicare |
$157.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$166.25
|
| Rate for Payer: BCBS Healthlink |
$157.50
|
| Rate for Payer: BCBS HMK CHIP |
$157.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$157.50
|
| Rate for Payer: BCBS POS |
$166.25
|
| Rate for Payer: BCBS Traditional |
$175.00
|
| Rate for Payer: CASH_PRICE |
$140.00
|
| Rate for Payer: CIGNA Commercial |
$166.25
|
| Rate for Payer: CIGNA Medicare |
$157.50
|
| Rate for Payer: HUMANA Commercial |
$157.50
|
| Rate for Payer: MEDICAID Medicaid |
$161.00
|
| Rate for Payer: MEDICARE Medicare |
$122.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$166.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$169.75
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$166.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$166.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$148.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$140.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$140.00
|
|
|
BIOPSY-SKIN SINGLE LESION- ER
|
Facility
OP
|
$175.00
|
|
|
Service Code
|
CPT 11102
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: AETNA Commercial |
$166.25
|
| Rate for Payer: AETNA Medicare |
$157.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$166.25
|
| Rate for Payer: BCBS Healthlink |
$157.50
|
| Rate for Payer: BCBS HMK CHIP |
$157.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$157.50
|
| Rate for Payer: BCBS POS |
$166.25
|
| Rate for Payer: BCBS Traditional |
$175.00
|
| Rate for Payer: CASH_PRICE |
$140.00
|
| Rate for Payer: CIGNA Commercial |
$166.25
|
| Rate for Payer: CIGNA Medicare |
$157.50
|
| Rate for Payer: HUMANA Commercial |
$157.50
|
| Rate for Payer: MEDICAID Medicaid |
$161.00
|
| Rate for Payer: MEDICARE Medicare |
$122.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$166.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$169.75
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$166.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$166.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$148.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$140.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$140.00
|
|
|
BIOPSY-SKIN SINGLE LESION- ER
|
Facility
IP
|
$175.00
|
|
|
Service Code
|
CPT 11102
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: AETNA Commercial |
$166.25
|
| Rate for Payer: AETNA Medicare |
$157.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$166.25
|
| Rate for Payer: BCBS Healthlink |
$157.50
|
| Rate for Payer: BCBS HMK CHIP |
$157.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$157.50
|
| Rate for Payer: BCBS POS |
$166.25
|
| Rate for Payer: BCBS Traditional |
$175.00
|
| Rate for Payer: CASH_PRICE |
$140.00
|
| Rate for Payer: CIGNA Commercial |
$166.25
|
| Rate for Payer: CIGNA Medicare |
$157.50
|
| Rate for Payer: HUMANA Commercial |
$157.50
|
| Rate for Payer: MEDICAID Medicaid |
$161.00
|
| Rate for Payer: MEDICARE Medicare |
$122.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$166.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$169.75
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$166.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$166.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$148.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$140.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$140.00
|
|
|
BIOPSY SUPERFICIAL FOREARM/WRIST
|
Facility
IP
|
$611.00
|
|
|
Service Code
|
CPT 25065
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$427.70 |
| Max. Negotiated Rate |
$611.00 |
| Rate for Payer: AETNA Commercial |
$580.45
|
| Rate for Payer: AETNA Medicare |
$549.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$580.45
|
| Rate for Payer: BCBS Healthlink |
$549.90
|
| Rate for Payer: BCBS HMK CHIP |
$549.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$549.90
|
| Rate for Payer: BCBS POS |
$580.45
|
| Rate for Payer: BCBS Traditional |
$611.00
|
| Rate for Payer: CASH_PRICE |
$488.80
|
| Rate for Payer: CIGNA Commercial |
$580.45
|
| Rate for Payer: CIGNA Medicare |
$549.90
|
| Rate for Payer: HUMANA Commercial |
$549.90
|
| Rate for Payer: MEDICAID Medicaid |
$562.12
|
| Rate for Payer: MEDICARE Medicare |
$427.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$580.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$592.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$580.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$580.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$519.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$488.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$488.80
|
|
|
BIOPSY SUPERFICIAL FOREARM/WRIST
|
Facility
OP
|
$611.00
|
|
|
Service Code
|
CPT 25065
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$427.70 |
| Max. Negotiated Rate |
$611.00 |
| Rate for Payer: AETNA Commercial |
$580.45
|
| Rate for Payer: AETNA Medicare |
$549.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$580.45
|
| Rate for Payer: BCBS Healthlink |
$549.90
|
| Rate for Payer: BCBS HMK CHIP |
$549.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$549.90
|
| Rate for Payer: BCBS POS |
$580.45
|
| Rate for Payer: BCBS Traditional |
$611.00
|
| Rate for Payer: CASH_PRICE |
$488.80
|
| Rate for Payer: CIGNA Commercial |
$580.45
|
| Rate for Payer: CIGNA Medicare |
$549.90
|
| Rate for Payer: HUMANA Commercial |
$549.90
|
| Rate for Payer: MEDICAID Medicaid |
$562.12
|
| Rate for Payer: MEDICARE Medicare |
$427.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$580.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$592.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$580.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$580.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$519.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$488.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$488.80
|
|
|
Biotene Moisturizing Mouth Oral Spray-NF
|
Facility
IP
|
$35.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.50 |
| Max. Negotiated Rate |
$35.00 |
| Rate for Payer: BCBS HMK CHIP |
$31.50
|
| 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 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
|
|
|
Biotene Moisturizing Mouth Oral Spray-NF
|
Facility
OP
|
$35.00
|
|
| 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
|
|
|
BISACODYL SUPP [10 MG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
BISACODYL SUPP [10 MG]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| 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
|
|
|
BISACODYL TAB [5 MG]
|
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: BCBS HMK CHIP |
$7.20
|
| 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 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
|
|
|
BISACODYL TAB [5 MG]
|
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
|
|
|
BLADDER SCAN
|
Facility
IP
|
$142.00
|
|
|
Service Code
|
CPT 51798
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$99.40 |
| Max. Negotiated Rate |
$142.00 |
| Rate for Payer: AETNA Commercial |
$134.90
|
| Rate for Payer: AETNA Medicare |
$127.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$134.90
|
| Rate for Payer: BCBS Healthlink |
$127.80
|
| Rate for Payer: BCBS HMK CHIP |
$127.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$127.80
|
| Rate for Payer: BCBS POS |
$134.90
|
| Rate for Payer: BCBS Traditional |
$142.00
|
| Rate for Payer: CASH_PRICE |
$113.60
|
| Rate for Payer: CIGNA Commercial |
$134.90
|
| Rate for Payer: CIGNA Medicare |
$127.80
|
| Rate for Payer: HUMANA Commercial |
$127.80
|
| Rate for Payer: MEDICAID Medicaid |
$130.64
|
| Rate for Payer: MEDICARE Medicare |
$99.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$134.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$137.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$134.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$134.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$120.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$113.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$113.60
|
|
|
BLADDER SCAN
|
Facility
OP
|
$142.00
|
|
|
Service Code
|
CPT 51798
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$99.40 |
| Max. Negotiated Rate |
$142.00 |
| Rate for Payer: AETNA Commercial |
$134.90
|
| Rate for Payer: AETNA Medicare |
$127.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$134.90
|
| Rate for Payer: BCBS Healthlink |
$127.80
|
| Rate for Payer: BCBS HMK CHIP |
$127.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$127.80
|
| Rate for Payer: BCBS POS |
$134.90
|
| Rate for Payer: BCBS Traditional |
$142.00
|
| Rate for Payer: CASH_PRICE |
$113.60
|
| Rate for Payer: CIGNA Commercial |
$134.90
|
| Rate for Payer: CIGNA Medicare |
$127.80
|
| Rate for Payer: HUMANA Commercial |
$127.80
|
| Rate for Payer: MEDICAID Medicaid |
$130.64
|
| Rate for Payer: MEDICARE Medicare |
$99.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$134.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$137.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$134.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$134.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$120.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$113.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$113.60
|
|
|
BLADDER SCANNER VITASCAN
|
Facility
OP
|
$142.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$99.40 |
| Max. Negotiated Rate |
$142.00 |
| Rate for Payer: AETNA Commercial |
$134.90
|
| Rate for Payer: AETNA Medicare |
$127.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$134.90
|
| Rate for Payer: BCBS Healthlink |
$127.80
|
| Rate for Payer: BCBS HMK CHIP |
$127.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$127.80
|
| Rate for Payer: BCBS POS |
$134.90
|
| Rate for Payer: BCBS Traditional |
$142.00
|
| Rate for Payer: CASH_PRICE |
$113.60
|
| Rate for Payer: CIGNA Commercial |
$134.90
|
| Rate for Payer: CIGNA Medicare |
$127.80
|
| Rate for Payer: HUMANA Commercial |
$127.80
|
| Rate for Payer: MEDICAID Medicaid |
$130.64
|
| Rate for Payer: MEDICARE Medicare |
$99.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$134.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$137.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$134.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$134.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$120.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$113.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$113.60
|
|
|
BLADDER SCANNER VITASCAN
|
Facility
IP
|
$142.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$99.40 |
| Max. Negotiated Rate |
$142.00 |
| Rate for Payer: BCBS HMK CHIP |
$127.80
|
| Rate for Payer: AETNA Commercial |
$134.90
|
| Rate for Payer: AETNA Medicare |
$127.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$134.90
|
| Rate for Payer: BCBS Healthlink |
$127.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$127.80
|
| Rate for Payer: BCBS POS |
$134.90
|
| Rate for Payer: BCBS Traditional |
$142.00
|
| Rate for Payer: CASH_PRICE |
$113.60
|
| Rate for Payer: CIGNA Commercial |
$134.90
|
| Rate for Payer: CIGNA Medicare |
$127.80
|
| Rate for Payer: HUMANA Commercial |
$127.80
|
| Rate for Payer: MEDICAID Medicaid |
$130.64
|
| Rate for Payer: MEDICARE Medicare |
$99.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$134.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$137.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$134.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$134.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$120.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$113.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$113.60
|
|
|
BLOOD CULTURE
|
Facility
IP
|
$114.00
|
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: AETNA Commercial |
$108.30
|
| Rate for Payer: AETNA Medicare |
$102.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$108.30
|
| Rate for Payer: BCBS Healthlink |
$102.60
|
| Rate for Payer: BCBS HMK CHIP |
$102.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$102.60
|
| Rate for Payer: BCBS POS |
$108.30
|
| Rate for Payer: BCBS Traditional |
$114.00
|
| Rate for Payer: CASH_PRICE |
$91.20
|
| Rate for Payer: CIGNA Commercial |
$108.30
|
| Rate for Payer: CIGNA Medicare |
$102.60
|
| Rate for Payer: HUMANA Commercial |
$102.60
|
| Rate for Payer: MEDICAID Medicaid |
$104.88
|
| Rate for Payer: MEDICARE Medicare |
$79.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$108.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$110.58
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$108.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$108.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$96.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$91.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$91.20
|
|
|
BLOOD CULTURE
|
Facility
OP
|
$114.00
|
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: AETNA Commercial |
$108.30
|
| Rate for Payer: AETNA Medicare |
$102.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$108.30
|
| Rate for Payer: BCBS Healthlink |
$102.60
|
| Rate for Payer: BCBS HMK CHIP |
$102.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$102.60
|
| Rate for Payer: BCBS POS |
$108.30
|
| Rate for Payer: BCBS Traditional |
$114.00
|
| Rate for Payer: CASH_PRICE |
$91.20
|
| Rate for Payer: CIGNA Commercial |
$108.30
|
| Rate for Payer: CIGNA Medicare |
$102.60
|
| Rate for Payer: HUMANA Commercial |
$102.60
|
| Rate for Payer: MEDICAID Medicaid |
$104.88
|
| Rate for Payer: MEDICARE Medicare |
$79.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$108.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$110.58
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$108.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$108.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$96.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$91.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$91.20
|
|
|
BLOOD CULTURE, PEDIATRIC (008300)
|
Facility
IP
|
$29.00
|
|
|
Service Code
|
CPT 87040
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: BCBS HMK CHIP |
$26.10
|
| Rate for Payer: AETNA Commercial |
$27.55
|
| Rate for Payer: AETNA Medicare |
$26.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$27.55
|
| Rate for Payer: BCBS Healthlink |
$26.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$26.10
|
| Rate for Payer: BCBS POS |
$27.55
|
| Rate for Payer: BCBS Traditional |
$29.00
|
| Rate for Payer: CASH_PRICE |
$23.20
|
| Rate for Payer: CIGNA Commercial |
$27.55
|
| Rate for Payer: CIGNA Medicare |
$26.10
|
| Rate for Payer: HUMANA Commercial |
$26.10
|
| Rate for Payer: MEDICAID Medicaid |
$26.68
|
| Rate for Payer: MEDICARE Medicare |
$20.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$27.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$28.13
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$27.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$27.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$24.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$23.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$23.20
|
|
|
BLOOD CULTURE, PEDIATRIC (008300)
|
Facility
OP
|
$29.00
|
|
|
Service Code
|
CPT 87040
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: AETNA Commercial |
$27.55
|
| Rate for Payer: AETNA Medicare |
$26.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$27.55
|
| Rate for Payer: BCBS Healthlink |
$26.10
|
| Rate for Payer: BCBS HMK CHIP |
$26.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$26.10
|
| Rate for Payer: BCBS POS |
$27.55
|
| Rate for Payer: BCBS Traditional |
$29.00
|
| Rate for Payer: CASH_PRICE |
$23.20
|
| Rate for Payer: CIGNA Commercial |
$27.55
|
| Rate for Payer: CIGNA Medicare |
$26.10
|
| Rate for Payer: HUMANA Commercial |
$26.10
|
| Rate for Payer: MEDICAID Medicaid |
$26.68
|
| Rate for Payer: MEDICARE Medicare |
$20.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$27.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$28.13
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$27.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$27.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$24.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$23.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$23.20
|
|
|
BLOOD CULTURE, SET 1 (008300)
|
Facility
IP
|
$29.00
|
|
|
Service Code
|
CPT 87040
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: AETNA Commercial |
$27.55
|
| Rate for Payer: AETNA Medicare |
$26.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$27.55
|
| Rate for Payer: BCBS Healthlink |
$26.10
|
| Rate for Payer: BCBS HMK CHIP |
$26.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$26.10
|
| Rate for Payer: BCBS POS |
$27.55
|
| Rate for Payer: BCBS Traditional |
$29.00
|
| Rate for Payer: CASH_PRICE |
$23.20
|
| Rate for Payer: CIGNA Commercial |
$27.55
|
| Rate for Payer: CIGNA Medicare |
$26.10
|
| Rate for Payer: HUMANA Commercial |
$26.10
|
| Rate for Payer: MEDICAID Medicaid |
$26.68
|
| Rate for Payer: MEDICARE Medicare |
$20.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$27.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$28.13
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$27.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$27.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$24.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$23.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$23.20
|
|
|
BLOOD CULTURE, SET 1 (008300)
|
Facility
OP
|
$29.00
|
|
|
Service Code
|
CPT 87040
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: AETNA Commercial |
$27.55
|
| Rate for Payer: AETNA Medicare |
$26.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$27.55
|
| Rate for Payer: BCBS Healthlink |
$26.10
|
| Rate for Payer: BCBS HMK CHIP |
$26.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$26.10
|
| Rate for Payer: BCBS POS |
$27.55
|
| Rate for Payer: BCBS Traditional |
$29.00
|
| Rate for Payer: CASH_PRICE |
$23.20
|
| Rate for Payer: CIGNA Commercial |
$27.55
|
| Rate for Payer: CIGNA Medicare |
$26.10
|
| Rate for Payer: HUMANA Commercial |
$26.10
|
| Rate for Payer: MEDICAID Medicaid |
$26.68
|
| Rate for Payer: MEDICARE Medicare |
$20.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$27.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$28.13
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$27.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$27.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$24.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$23.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$23.20
|
|
|
BLOOD CULTURE, SET 2 (008300)
|
Facility
OP
|
$29.00
|
|
|
Service Code
|
CPT 87040 91
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: AETNA Commercial |
$27.55
|
| Rate for Payer: AETNA Medicare |
$26.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$27.55
|
| Rate for Payer: BCBS Healthlink |
$26.10
|
| Rate for Payer: BCBS HMK CHIP |
$26.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$26.10
|
| Rate for Payer: BCBS POS |
$27.55
|
| Rate for Payer: BCBS Traditional |
$29.00
|
| Rate for Payer: CASH_PRICE |
$23.20
|
| Rate for Payer: CIGNA Commercial |
$27.55
|
| Rate for Payer: CIGNA Medicare |
$26.10
|
| Rate for Payer: HUMANA Commercial |
$26.10
|
| Rate for Payer: MEDICAID Medicaid |
$26.68
|
| Rate for Payer: MEDICARE Medicare |
$20.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$27.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$28.13
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$27.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$27.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$24.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$23.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$23.20
|
|
