|
SB/NH SUBSEQUENT CARE 15 MIN (99308)
|
Facility
OP
|
$147.00
|
|
|
Service Code
|
CPT 99308
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$147.00 |
| Rate for Payer: AETNA Commercial |
$139.65
|
| Rate for Payer: AETNA Medicare |
$132.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$139.65
|
| Rate for Payer: BCBS Healthlink |
$132.30
|
| Rate for Payer: BCBS HMK CHIP |
$132.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$132.30
|
| Rate for Payer: BCBS POS |
$139.65
|
| Rate for Payer: BCBS Traditional |
$147.00
|
| Rate for Payer: CASH_PRICE |
$117.60
|
| Rate for Payer: CIGNA Commercial |
$139.65
|
| Rate for Payer: CIGNA Medicare |
$132.30
|
| Rate for Payer: HUMANA Commercial |
$132.30
|
| Rate for Payer: MEDICAID Medicaid |
$135.24
|
| Rate for Payer: MEDICARE Medicare |
$102.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$139.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$142.59
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$139.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$139.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$124.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$117.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$117.60
|
|
|
SB/NH SUBSEQUENT CARE 25 MIN (99309)
|
Facility
OP
|
$194.00
|
|
|
Service Code
|
CPT 99309
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$135.80 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: AETNA Commercial |
$184.30
|
| Rate for Payer: AETNA Medicare |
$174.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$184.30
|
| Rate for Payer: BCBS Healthlink |
$174.60
|
| Rate for Payer: BCBS HMK CHIP |
$174.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$174.60
|
| Rate for Payer: BCBS POS |
$184.30
|
| Rate for Payer: BCBS Traditional |
$194.00
|
| Rate for Payer: CASH_PRICE |
$155.20
|
| Rate for Payer: CIGNA Commercial |
$184.30
|
| Rate for Payer: CIGNA Medicare |
$174.60
|
| Rate for Payer: HUMANA Commercial |
$174.60
|
| Rate for Payer: MEDICAID Medicaid |
$178.48
|
| Rate for Payer: MEDICARE Medicare |
$135.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$184.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$188.18
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$184.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$184.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$164.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$155.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$155.20
|
|
|
SB/NH SUBSEQUENT CARE 25 MIN (99309)
|
Facility
IP
|
$194.00
|
|
|
Service Code
|
CPT 99309
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$135.80 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: AETNA Commercial |
$184.30
|
| Rate for Payer: AETNA Medicare |
$174.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$184.30
|
| Rate for Payer: BCBS Healthlink |
$174.60
|
| Rate for Payer: BCBS HMK CHIP |
$174.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$174.60
|
| Rate for Payer: BCBS POS |
$184.30
|
| Rate for Payer: BCBS Traditional |
$194.00
|
| Rate for Payer: CASH_PRICE |
$155.20
|
| Rate for Payer: CIGNA Commercial |
$184.30
|
| Rate for Payer: CIGNA Medicare |
$174.60
|
| Rate for Payer: HUMANA Commercial |
$174.60
|
| Rate for Payer: MEDICAID Medicaid |
$178.48
|
| Rate for Payer: MEDICARE Medicare |
$135.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$184.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$188.18
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$184.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$184.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$164.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$155.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$155.20
|
|
|
SB/NH SUBSEQUENT CARE 35 MIN (99310)
|
Facility
IP
|
$284.00
|
|
|
Service Code
|
CPT 99310
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$198.80 |
| Max. Negotiated Rate |
$284.00 |
| Rate for Payer: AETNA Commercial |
$269.80
|
| Rate for Payer: AETNA Medicare |
$255.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$269.80
|
| Rate for Payer: BCBS Healthlink |
$255.60
|
| Rate for Payer: BCBS HMK CHIP |
$255.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$255.60
|
| Rate for Payer: BCBS POS |
$269.80
|
| Rate for Payer: BCBS Traditional |
$284.00
|
| Rate for Payer: CASH_PRICE |
$227.20
|
| Rate for Payer: CIGNA Commercial |
$269.80
|
| Rate for Payer: CIGNA Medicare |
$255.60
|
| Rate for Payer: HUMANA Commercial |
$255.60
|
| Rate for Payer: MEDICAID Medicaid |
$261.28
|
| Rate for Payer: MEDICARE Medicare |
$198.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$269.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$275.48
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$269.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$269.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$241.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$227.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$227.20
|
|
|
SB/NH SUBSEQUENT CARE 35 MIN (99310)
|
Facility
OP
|
$284.00
|
|
|
Service Code
|
CPT 99310
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$198.80 |
| Max. Negotiated Rate |
$284.00 |
| Rate for Payer: AETNA Commercial |
$269.80
|
| Rate for Payer: AETNA Medicare |
$255.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$269.80
|
| Rate for Payer: BCBS Healthlink |
$255.60
|
| Rate for Payer: BCBS HMK CHIP |
$255.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$255.60
|
| Rate for Payer: BCBS POS |
$269.80
|
| Rate for Payer: BCBS Traditional |
$284.00
|
| Rate for Payer: CASH_PRICE |
$227.20
|
| Rate for Payer: CIGNA Commercial |
$269.80
|
| Rate for Payer: CIGNA Medicare |
$255.60
|
| Rate for Payer: HUMANA Commercial |
$255.60
|
| Rate for Payer: MEDICAID Medicaid |
$261.28
|
| Rate for Payer: MEDICARE Medicare |
$198.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$269.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$275.48
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$269.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$269.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$241.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$227.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$227.20
|
|
|
SCALPEL #10
|
Facility
OP
|
$11.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: AETNA Commercial |
$10.45
|
| Rate for Payer: AETNA Medicare |
$9.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$10.45
|
| Rate for Payer: BCBS Healthlink |
$9.90
|
| Rate for Payer: BCBS HMK CHIP |
$9.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$9.90
|
| Rate for Payer: BCBS POS |
$10.45
|
| Rate for Payer: BCBS Traditional |
$11.00
|
| Rate for Payer: CASH_PRICE |
$8.80
|
| Rate for Payer: CIGNA Commercial |
$10.45
|
| Rate for Payer: CIGNA Medicare |
$9.90
|
| Rate for Payer: HUMANA Commercial |
$9.90
|
| Rate for Payer: MEDICAID Medicaid |
$10.12
|
| Rate for Payer: MEDICARE Medicare |
$7.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$10.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$10.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$10.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$10.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$9.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$8.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$8.80
|
|
|
SCALPEL #10
|
Facility
IP
|
$11.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: AETNA Commercial |
$10.45
|
| Rate for Payer: AETNA Medicare |
$9.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$10.45
|
| Rate for Payer: BCBS Healthlink |
$9.90
|
| Rate for Payer: BCBS HMK CHIP |
$9.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$9.90
|
| Rate for Payer: BCBS POS |
$10.45
|
| Rate for Payer: BCBS Traditional |
$11.00
|
| Rate for Payer: CASH_PRICE |
$8.80
|
| Rate for Payer: CIGNA Commercial |
$10.45
|
| Rate for Payer: CIGNA Medicare |
$9.90
|
| Rate for Payer: HUMANA Commercial |
$9.90
|
| Rate for Payer: MEDICAID Medicaid |
$10.12
|
| Rate for Payer: MEDICARE Medicare |
$7.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$10.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$10.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$10.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$10.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$9.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$8.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$8.80
|
|
|
SCOPOLAMINE PATCH [1 MG/3 DAYS]]
|
Facility
IP
|
$68.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: AETNA Commercial |
$64.60
|
| Rate for Payer: AETNA Medicare |
$61.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$64.60
|
| Rate for Payer: BCBS Healthlink |
$61.20
|
| Rate for Payer: BCBS HMK CHIP |
$61.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$61.20
|
| Rate for Payer: BCBS POS |
$64.60
|
| Rate for Payer: BCBS Traditional |
$68.00
|
| Rate for Payer: CASH_PRICE |
$54.40
|
| Rate for Payer: CIGNA Commercial |
$64.60
|
| Rate for Payer: CIGNA Medicare |
$61.20
|
| Rate for Payer: HUMANA Commercial |
$61.20
|
| Rate for Payer: MEDICAID Medicaid |
$62.56
|
| Rate for Payer: MEDICARE Medicare |
$47.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$64.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$65.96
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$64.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$64.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$57.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$54.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$54.40
|
|
|
SCOPOLAMINE PATCH [1 MG/3 DAYS]]
|
Facility
OP
|
$68.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: AETNA Commercial |
$64.60
|
| Rate for Payer: AETNA Medicare |
$61.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$64.60
|
| Rate for Payer: BCBS Healthlink |
$61.20
|
| Rate for Payer: BCBS HMK CHIP |
$61.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$61.20
|
| Rate for Payer: BCBS POS |
$64.60
|
| Rate for Payer: BCBS Traditional |
$68.00
|
| Rate for Payer: CASH_PRICE |
$54.40
|
| Rate for Payer: CIGNA Commercial |
$64.60
|
| Rate for Payer: CIGNA Medicare |
$61.20
|
| Rate for Payer: HUMANA Commercial |
$61.20
|
| Rate for Payer: MEDICAID Medicaid |
$62.56
|
| Rate for Payer: MEDICARE Medicare |
$47.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$64.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$65.96
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$64.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$64.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$57.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$54.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$54.40
|
|
|
SCREENING HEARING
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
CPT 92551
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: AETNA Commercial |
$39.90
|
| Rate for Payer: AETNA Medicare |
$37.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$39.90
|
| Rate for Payer: BCBS Healthlink |
$37.80
|
| Rate for Payer: BCBS HMK CHIP |
$37.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$37.80
|
| Rate for Payer: BCBS POS |
$39.90
|
| Rate for Payer: BCBS Traditional |
$42.00
|
| Rate for Payer: CASH_PRICE |
$33.60
|
| Rate for Payer: CIGNA Commercial |
$39.90
|
| Rate for Payer: CIGNA Medicare |
$37.80
|
| Rate for Payer: HUMANA Commercial |
$37.80
|
| Rate for Payer: MEDICAID Medicaid |
$38.64
|
| Rate for Payer: MEDICARE Medicare |
$29.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$39.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$40.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$39.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$39.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$35.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$33.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$33.60
|
|
|
SCREENING HEARING
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
CPT 92551
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$42.00 |
| Rate for Payer: AETNA Commercial |
$39.90
|
| Rate for Payer: AETNA Medicare |
$37.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$39.90
|
| Rate for Payer: BCBS Healthlink |
$37.80
|
| Rate for Payer: BCBS HMK CHIP |
$37.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$37.80
|
| Rate for Payer: BCBS POS |
$39.90
|
| Rate for Payer: BCBS Traditional |
$42.00
|
| Rate for Payer: CASH_PRICE |
$33.60
|
| Rate for Payer: CIGNA Commercial |
$39.90
|
| Rate for Payer: CIGNA Medicare |
$37.80
|
| Rate for Payer: HUMANA Commercial |
$37.80
|
| Rate for Payer: MEDICAID Medicaid |
$38.64
|
| Rate for Payer: MEDICARE Medicare |
$29.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$39.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$40.74
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$39.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$39.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$35.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$33.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$33.60
|
|
|
SCREENING VISUAL
|
Facility
IP
|
$17.00
|
|
|
Service Code
|
CPT 99173
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: UNITED HEALTHCARE Commercial |
$14.45
|
| Rate for Payer: AETNA Commercial |
$16.15
|
| Rate for Payer: AETNA Medicare |
$15.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$16.15
|
| Rate for Payer: BCBS Healthlink |
$15.30
|
| Rate for Payer: BCBS HMK CHIP |
$15.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$15.30
|
| Rate for Payer: BCBS POS |
$16.15
|
| Rate for Payer: BCBS Traditional |
$17.00
|
| Rate for Payer: CASH_PRICE |
$13.60
|
| Rate for Payer: CIGNA Commercial |
$16.15
|
| Rate for Payer: CIGNA Medicare |
$15.30
|
| Rate for Payer: HUMANA Commercial |
$15.30
|
| Rate for Payer: MEDICAID Medicaid |
$15.64
|
| Rate for Payer: MEDICARE Medicare |
$11.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$16.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$16.49
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$16.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$13.60
|
|
|
SCREENING VISUAL
|
Facility
OP
|
$17.00
|
|
|
Service Code
|
CPT 99173
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: AETNA Commercial |
$16.15
|
| Rate for Payer: AETNA Medicare |
$15.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$16.15
|
| Rate for Payer: BCBS Healthlink |
$15.30
|
| Rate for Payer: BCBS HMK CHIP |
$15.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$15.30
|
| Rate for Payer: BCBS POS |
$16.15
|
| Rate for Payer: BCBS Traditional |
$17.00
|
| Rate for Payer: CASH_PRICE |
$13.60
|
| Rate for Payer: CIGNA Commercial |
$16.15
|
| Rate for Payer: CIGNA Medicare |
$15.30
|
| Rate for Payer: HUMANA Commercial |
$15.30
|
| Rate for Payer: MEDICAID Medicaid |
$15.64
|
| Rate for Payer: MEDICARE Medicare |
$11.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$16.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$16.49
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$16.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$14.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$13.60
|
|
|
SELENIUM (716910)
|
Facility
OP
|
$180.00
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: AETNA Commercial |
$171.00
|
| Rate for Payer: AETNA Medicare |
$162.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$171.00
|
| Rate for Payer: BCBS Healthlink |
$162.00
|
| Rate for Payer: BCBS HMK CHIP |
$162.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$162.00
|
| Rate for Payer: BCBS POS |
$171.00
|
| Rate for Payer: BCBS Traditional |
$180.00
|
| Rate for Payer: CASH_PRICE |
$144.00
|
| Rate for Payer: CIGNA Commercial |
$171.00
|
| Rate for Payer: CIGNA Medicare |
$162.00
|
| Rate for Payer: HUMANA Commercial |
$162.00
|
| Rate for Payer: MEDICAID Medicaid |
$165.60
|
| Rate for Payer: MEDICARE Medicare |
$126.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$171.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$174.60
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$171.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$171.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$153.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$144.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$144.00
|
|
|
SELENIUM (716910)
|
Facility
IP
|
$180.00
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$126.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: AETNA Commercial |
$171.00
|
| Rate for Payer: AETNA Medicare |
$162.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$171.00
|
| Rate for Payer: BCBS Healthlink |
$162.00
|
| Rate for Payer: BCBS HMK CHIP |
$162.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$162.00
|
| Rate for Payer: BCBS POS |
$171.00
|
| Rate for Payer: BCBS Traditional |
$180.00
|
| Rate for Payer: CASH_PRICE |
$144.00
|
| Rate for Payer: CIGNA Commercial |
$171.00
|
| Rate for Payer: CIGNA Medicare |
$162.00
|
| Rate for Payer: HUMANA Commercial |
$162.00
|
| Rate for Payer: MEDICAID Medicaid |
$165.60
|
| Rate for Payer: MEDICARE Medicare |
$126.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$171.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$174.60
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$171.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$171.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$153.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$144.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$144.00
|
|
|
.SENSITIVITY, EACH ORGANISM
|
Facility
IP
|
$29.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
.SENSITIVITY, EACH ORGANISM
|
Facility
OP
|
$29.00
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
SERTRALINE TAB [25 MG] NON FORMULARY
|
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: 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
|
|
|
SERTRALINE TAB [25 MG] NON FORMULARY
|
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: UNITED HEALTHCARE Commercial |
$6.80
|
| 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 MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
SERTRALINE TAB [50 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: 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
|
|
|
SERTRALINE TAB [50 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
|
|
|
SEX HORMONE-BINDING GLOBULIN (082016)
|
Facility
IP
|
$79.00
|
|
|
Service Code
|
CPT 84270
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: AETNA Commercial |
$75.05
|
| Rate for Payer: AETNA Medicare |
$71.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$75.05
|
| Rate for Payer: BCBS Healthlink |
$71.10
|
| Rate for Payer: BCBS HMK CHIP |
$71.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$71.10
|
| Rate for Payer: BCBS POS |
$75.05
|
| Rate for Payer: BCBS Traditional |
$79.00
|
| Rate for Payer: CASH_PRICE |
$63.20
|
| Rate for Payer: CIGNA Commercial |
$75.05
|
| Rate for Payer: CIGNA Medicare |
$71.10
|
| Rate for Payer: HUMANA Commercial |
$71.10
|
| Rate for Payer: MEDICAID Medicaid |
$72.68
|
| Rate for Payer: MEDICARE Medicare |
$55.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$75.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$76.63
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$75.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$75.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$67.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$63.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$63.20
|
|
|
SEX HORMONE-BINDING GLOBULIN (082016)
|
Facility
OP
|
$79.00
|
|
|
Service Code
|
CPT 84270
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: AETNA Commercial |
$75.05
|
| Rate for Payer: AETNA Medicare |
$71.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$75.05
|
| Rate for Payer: BCBS Healthlink |
$71.10
|
| Rate for Payer: BCBS HMK CHIP |
$71.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$71.10
|
| Rate for Payer: BCBS POS |
$75.05
|
| Rate for Payer: BCBS Traditional |
$79.00
|
| Rate for Payer: CASH_PRICE |
$63.20
|
| Rate for Payer: CIGNA Commercial |
$75.05
|
| Rate for Payer: CIGNA Medicare |
$71.10
|
| Rate for Payer: HUMANA Commercial |
$71.10
|
| Rate for Payer: MEDICAID Medicaid |
$72.68
|
| Rate for Payer: MEDICARE Medicare |
$55.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$75.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$76.63
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$75.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$75.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$67.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$63.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$63.20
|
|
|
SHAMPOO CAP
|
Facility
IP
|
$12.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: AETNA Commercial |
$11.40
|
| Rate for Payer: AETNA Medicare |
$10.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$11.40
|
| Rate for Payer: BCBS Healthlink |
$10.80
|
| Rate for Payer: BCBS HMK CHIP |
$10.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$10.80
|
| Rate for Payer: BCBS POS |
$11.40
|
| Rate for Payer: BCBS Traditional |
$12.00
|
| Rate for Payer: CASH_PRICE |
$9.60
|
| Rate for Payer: CIGNA Commercial |
$11.40
|
| Rate for Payer: CIGNA Medicare |
$10.80
|
| Rate for Payer: HUMANA Commercial |
$10.80
|
| Rate for Payer: MEDICAID Medicaid |
$11.04
|
| Rate for Payer: MEDICARE Medicare |
$8.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$11.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$11.64
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$11.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$11.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$10.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$9.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$9.60
|
|
|
SHAMPOO CAP
|
Facility
OP
|
$12.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: AETNA Commercial |
$11.40
|
| Rate for Payer: AETNA Medicare |
$10.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$11.40
|
| Rate for Payer: BCBS Healthlink |
$10.80
|
| Rate for Payer: BCBS HMK CHIP |
$10.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$10.80
|
| Rate for Payer: BCBS POS |
$11.40
|
| Rate for Payer: BCBS Traditional |
$12.00
|
| Rate for Payer: CASH_PRICE |
$9.60
|
| Rate for Payer: CIGNA Commercial |
$11.40
|
| Rate for Payer: CIGNA Medicare |
$10.80
|
| Rate for Payer: HUMANA Commercial |
$10.80
|
| Rate for Payer: MEDICAID Medicaid |
$11.04
|
| Rate for Payer: MEDICARE Medicare |
$8.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$11.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$11.64
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$11.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$11.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$10.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$9.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$9.60
|
|
