|
ST TREATMENT OF SPEECH/LANG (INDIV)
|
Facility
OP
|
$285.00
|
|
|
Service Code
|
CPT 92507 GN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$199.50 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: AETNA Commercial |
$270.75
|
| Rate for Payer: AETNA Medicare |
$256.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$270.75
|
| Rate for Payer: BCBS Healthlink |
$256.50
|
| Rate for Payer: BCBS HMK CHIP |
$256.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$256.50
|
| Rate for Payer: BCBS POS |
$270.75
|
| Rate for Payer: BCBS Traditional |
$285.00
|
| Rate for Payer: CASH_PRICE |
$228.00
|
| Rate for Payer: CIGNA Commercial |
$270.75
|
| Rate for Payer: CIGNA Medicare |
$256.50
|
| Rate for Payer: HUMANA Commercial |
$256.50
|
| Rate for Payer: MEDICAID Medicaid |
$262.20
|
| Rate for Payer: MEDICARE Medicare |
$199.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$270.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$276.45
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$270.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$270.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$242.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$228.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$228.00
|
|
|
ST TREATMENT OF SPEECH/LANG (INDIV)
|
Facility
IP
|
$285.00
|
|
|
Service Code
|
CPT 92507 GN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$199.50 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: AETNA Commercial |
$270.75
|
| Rate for Payer: AETNA Medicare |
$256.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$270.75
|
| Rate for Payer: BCBS Healthlink |
$256.50
|
| Rate for Payer: BCBS HMK CHIP |
$256.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$256.50
|
| Rate for Payer: BCBS POS |
$270.75
|
| Rate for Payer: BCBS Traditional |
$285.00
|
| Rate for Payer: CASH_PRICE |
$228.00
|
| Rate for Payer: CIGNA Commercial |
$270.75
|
| Rate for Payer: CIGNA Medicare |
$256.50
|
| Rate for Payer: HUMANA Commercial |
$256.50
|
| Rate for Payer: MEDICAID Medicaid |
$262.20
|
| Rate for Payer: MEDICARE Medicare |
$199.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$270.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$276.45
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$270.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$270.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$242.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$228.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$228.00
|
|
|
ST TREATMENT OF SWALLOWING DYSF
|
Facility
IP
|
$286.00
|
|
|
Service Code
|
CPT 92526 GN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$200.20 |
| Max. Negotiated Rate |
$286.00 |
| Rate for Payer: AETNA Commercial |
$271.70
|
| Rate for Payer: AETNA Medicare |
$257.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$271.70
|
| Rate for Payer: BCBS Healthlink |
$257.40
|
| Rate for Payer: BCBS HMK CHIP |
$257.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$257.40
|
| Rate for Payer: BCBS POS |
$271.70
|
| Rate for Payer: BCBS Traditional |
$286.00
|
| Rate for Payer: CASH_PRICE |
$228.80
|
| Rate for Payer: CIGNA Commercial |
$271.70
|
| Rate for Payer: CIGNA Medicare |
$257.40
|
| Rate for Payer: HUMANA Commercial |
$257.40
|
| Rate for Payer: MEDICAID Medicaid |
$263.12
|
| Rate for Payer: MEDICARE Medicare |
$200.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$271.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$277.42
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$271.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$271.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$243.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$228.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$228.80
|
|
|
ST TREATMENT OF SWALLOWING DYSF
|
Facility
OP
|
$286.00
|
|
|
Service Code
|
CPT 92526 GN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$200.20 |
| Max. Negotiated Rate |
$286.00 |
| Rate for Payer: AETNA Commercial |
$271.70
|
| Rate for Payer: AETNA Medicare |
$257.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$271.70
|
| Rate for Payer: BCBS Healthlink |
$257.40
|
| Rate for Payer: BCBS HMK CHIP |
$257.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$257.40
|
| Rate for Payer: BCBS POS |
$271.70
|
| Rate for Payer: BCBS Traditional |
$286.00
|
| Rate for Payer: CASH_PRICE |
$228.80
|
| Rate for Payer: CIGNA Commercial |
$271.70
|
| Rate for Payer: CIGNA Medicare |
$257.40
|
| Rate for Payer: HUMANA Commercial |
$257.40
|
| Rate for Payer: MEDICAID Medicaid |
$263.12
|
| Rate for Payer: MEDICARE Medicare |
$200.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$271.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$277.42
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$271.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$271.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$243.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$228.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$228.80
|
|
|
ST VIDEO STUDY MOTION FLUOROSCOPIC EVAL
|
Facility
OP
|
$796.00
|
|
|
Service Code
|
CPT 92611 GN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$557.20 |
| Max. Negotiated Rate |
$796.00 |
| Rate for Payer: AETNA Commercial |
$756.20
|
| Rate for Payer: AETNA Medicare |
$716.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$756.20
|
| Rate for Payer: BCBS Healthlink |
$716.40
|
| Rate for Payer: BCBS HMK CHIP |
$716.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$716.40
|
| Rate for Payer: BCBS POS |
$756.20
|
| Rate for Payer: BCBS Traditional |
$796.00
|
| Rate for Payer: CASH_PRICE |
$636.80
|
| Rate for Payer: CIGNA Commercial |
$756.20
|
| Rate for Payer: CIGNA Medicare |
$716.40
|
| Rate for Payer: HUMANA Commercial |
$716.40
|
| Rate for Payer: MEDICAID Medicaid |
$732.32
|
| Rate for Payer: MEDICARE Medicare |
$557.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$756.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$772.12
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$756.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$756.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$676.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$636.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$636.80
|
|
|
ST VIDEO STUDY MOTION FLUOROSCOPIC EVAL
|
Facility
IP
|
$796.00
|
|
|
Service Code
|
CPT 92611 GN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$557.20 |
| Max. Negotiated Rate |
$796.00 |
| Rate for Payer: AETNA Commercial |
$756.20
|
| Rate for Payer: AETNA Medicare |
$716.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$756.20
|
| Rate for Payer: BCBS Healthlink |
$716.40
|
| Rate for Payer: BCBS HMK CHIP |
$716.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$716.40
|
| Rate for Payer: BCBS POS |
$756.20
|
| Rate for Payer: BCBS Traditional |
$796.00
|
| Rate for Payer: CASH_PRICE |
$636.80
|
| Rate for Payer: CIGNA Commercial |
$756.20
|
| Rate for Payer: CIGNA Medicare |
$716.40
|
| Rate for Payer: HUMANA Commercial |
$716.40
|
| Rate for Payer: MEDICAID Medicaid |
$732.32
|
| Rate for Payer: MEDICARE Medicare |
$557.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$756.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$772.12
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$756.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$756.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$676.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$636.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$636.80
|
|
|
SUCRALFATE TAB [1 GM]
|
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
|
|
|
SUCRALFATE TAB [1 GM]
|
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
|
|
|
SUCTION CATHETER 6FR
|
Facility
OP
|
$18.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: AETNA Commercial |
$17.10
|
| Rate for Payer: AETNA Medicare |
$16.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$17.10
|
| Rate for Payer: BCBS Healthlink |
$16.20
|
| Rate for Payer: BCBS HMK CHIP |
$16.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$16.20
|
| Rate for Payer: BCBS POS |
$17.10
|
| Rate for Payer: BCBS Traditional |
$18.00
|
| Rate for Payer: CASH_PRICE |
$14.40
|
| Rate for Payer: CIGNA Commercial |
$17.10
|
| Rate for Payer: CIGNA Medicare |
$16.20
|
| Rate for Payer: HUMANA Commercial |
$16.20
|
| Rate for Payer: MEDICAID Medicaid |
$16.56
|
| Rate for Payer: MEDICARE Medicare |
$12.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$17.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$17.46
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$17.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$17.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$15.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$14.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$14.40
|
|
|
SUCTION CATHETER 6FR
|
Facility
IP
|
$18.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.60 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: AETNA Commercial |
$17.10
|
| Rate for Payer: AETNA Medicare |
$16.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$17.10
|
| Rate for Payer: BCBS Healthlink |
$16.20
|
| Rate for Payer: BCBS HMK CHIP |
$16.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$16.20
|
| Rate for Payer: BCBS POS |
$17.10
|
| Rate for Payer: BCBS Traditional |
$18.00
|
| Rate for Payer: CASH_PRICE |
$14.40
|
| Rate for Payer: CIGNA Commercial |
$17.10
|
| Rate for Payer: CIGNA Medicare |
$16.20
|
| Rate for Payer: HUMANA Commercial |
$16.20
|
| Rate for Payer: MEDICAID Medicaid |
$16.56
|
| Rate for Payer: MEDICARE Medicare |
$12.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$17.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$17.46
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$17.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$17.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$15.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$14.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$14.40
|
|
|
SUCTION TIP
|
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: UNITED HEALTHCARE Commercial |
$10.20
|
| 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 MCD ADVANTAGE Medicaid |
$9.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$9.60
|
|
|
SUCTION TIP
|
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
|
|
|
SUCTION TUBING (BLUE TIPS)
|
Facility
IP
|
$27.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: AETNA Commercial |
$25.65
|
| Rate for Payer: AETNA Medicare |
$24.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$25.65
|
| Rate for Payer: BCBS Healthlink |
$24.30
|
| Rate for Payer: BCBS HMK CHIP |
$24.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$24.30
|
| Rate for Payer: BCBS POS |
$25.65
|
| Rate for Payer: BCBS Traditional |
$27.00
|
| Rate for Payer: CASH_PRICE |
$21.60
|
| Rate for Payer: CIGNA Commercial |
$25.65
|
| Rate for Payer: CIGNA Medicare |
$24.30
|
| Rate for Payer: HUMANA Commercial |
$24.30
|
| Rate for Payer: MEDICAID Medicaid |
$24.84
|
| Rate for Payer: MEDICARE Medicare |
$18.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$25.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$26.19
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$25.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$25.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$21.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$21.60
|
|
|
SUCTION TUBING (BLUE TIPS)
|
Facility
OP
|
$27.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: AETNA Commercial |
$25.65
|
| Rate for Payer: AETNA Medicare |
$24.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$25.65
|
| Rate for Payer: BCBS Healthlink |
$24.30
|
| Rate for Payer: BCBS HMK CHIP |
$24.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$24.30
|
| Rate for Payer: BCBS POS |
$25.65
|
| Rate for Payer: BCBS Traditional |
$27.00
|
| Rate for Payer: CASH_PRICE |
$21.60
|
| Rate for Payer: CIGNA Commercial |
$25.65
|
| Rate for Payer: CIGNA Medicare |
$24.30
|
| Rate for Payer: HUMANA Commercial |
$24.30
|
| Rate for Payer: MEDICAID Medicaid |
$24.84
|
| Rate for Payer: MEDICARE Medicare |
$18.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$25.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$26.19
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$25.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$25.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$21.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$21.60
|
|
|
SUGAMMADEX INJ [500 MG/5 ML] VL
|
Facility
OP
|
$706.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$494.20 |
| Max. Negotiated Rate |
$706.00 |
| Rate for Payer: AETNA Commercial |
$670.70
|
| Rate for Payer: AETNA Medicare |
$635.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$670.70
|
| Rate for Payer: BCBS Healthlink |
$635.40
|
| Rate for Payer: BCBS HMK CHIP |
$635.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$635.40
|
| Rate for Payer: BCBS POS |
$670.70
|
| Rate for Payer: BCBS Traditional |
$706.00
|
| Rate for Payer: CASH_PRICE |
$564.80
|
| Rate for Payer: CIGNA Commercial |
$670.70
|
| Rate for Payer: CIGNA Medicare |
$635.40
|
| Rate for Payer: HUMANA Commercial |
$635.40
|
| Rate for Payer: MEDICAID Medicaid |
$649.52
|
| Rate for Payer: MEDICARE Medicare |
$494.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$670.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$684.82
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$670.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$670.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$600.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$564.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$564.80
|
|
|
SUGAMMADEX INJ [500 MG/5 ML] VL
|
Facility
IP
|
$706.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$494.20 |
| Max. Negotiated Rate |
$706.00 |
| Rate for Payer: UNITED HEALTHCARE Commercial |
$600.10
|
| Rate for Payer: AETNA Commercial |
$670.70
|
| Rate for Payer: AETNA Medicare |
$635.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$670.70
|
| Rate for Payer: BCBS Healthlink |
$635.40
|
| Rate for Payer: BCBS HMK CHIP |
$635.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$635.40
|
| Rate for Payer: BCBS POS |
$670.70
|
| Rate for Payer: BCBS Traditional |
$706.00
|
| Rate for Payer: CASH_PRICE |
$564.80
|
| Rate for Payer: CIGNA Commercial |
$670.70
|
| Rate for Payer: CIGNA Medicare |
$635.40
|
| Rate for Payer: HUMANA Commercial |
$635.40
|
| Rate for Payer: MEDICAID Medicaid |
$649.52
|
| Rate for Payer: MEDICARE Medicare |
$494.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$670.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$684.82
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$670.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$670.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$564.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$564.80
|
|
|
SULFAMETH/ TMP DS TAB [800-160 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
|
|
|
SULFAMETH/ TMP DS TAB [800-160 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
|
|
|
SULFASASALAZINE TAB [500 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
|
|
|
SULFASASALAZINE TAB [500 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
|
|
|
SUMATRIPTAN INJ [6 MG/0.5 ML]
|
Facility
IP
|
$286.00
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$200.20 |
| Max. Negotiated Rate |
$286.00 |
| Rate for Payer: AETNA Commercial |
$271.70
|
| Rate for Payer: AETNA Medicare |
$257.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$271.70
|
| Rate for Payer: BCBS Healthlink |
$257.40
|
| Rate for Payer: BCBS HMK CHIP |
$257.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$257.40
|
| Rate for Payer: BCBS POS |
$271.70
|
| Rate for Payer: BCBS Traditional |
$286.00
|
| Rate for Payer: CASH_PRICE |
$228.80
|
| Rate for Payer: CIGNA Commercial |
$271.70
|
| Rate for Payer: CIGNA Medicare |
$257.40
|
| Rate for Payer: HUMANA Commercial |
$257.40
|
| Rate for Payer: MEDICAID Medicaid |
$263.12
|
| Rate for Payer: MEDICARE Medicare |
$200.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$271.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$277.42
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$271.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$271.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$243.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$228.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$228.80
|
|
|
SUMATRIPTAN INJ [6 MG/0.5 ML]
|
Facility
OP
|
$286.00
|
|
|
Service Code
|
CPT J3030
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$200.20 |
| Max. Negotiated Rate |
$286.00 |
| Rate for Payer: AETNA Commercial |
$271.70
|
| Rate for Payer: AETNA Medicare |
$257.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$271.70
|
| Rate for Payer: BCBS Healthlink |
$257.40
|
| Rate for Payer: BCBS HMK CHIP |
$257.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$257.40
|
| Rate for Payer: BCBS POS |
$271.70
|
| Rate for Payer: BCBS Traditional |
$286.00
|
| Rate for Payer: CASH_PRICE |
$228.80
|
| Rate for Payer: CIGNA Commercial |
$271.70
|
| Rate for Payer: CIGNA Medicare |
$257.40
|
| Rate for Payer: HUMANA Commercial |
$257.40
|
| Rate for Payer: MEDICAID Medicaid |
$263.12
|
| Rate for Payer: MEDICARE Medicare |
$200.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$271.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$277.42
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$271.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$271.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$243.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$228.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$228.80
|
|
|
SUPPLIES
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
SUPPLIES
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT 99070
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| 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
|
|
|
SUPPLIES AIRCAST ANKLE
|
Facility
IP
|
$176.00
|
|
|
Service Code
|
CPT L4350
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$123.20 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: AETNA Commercial |
$167.20
|
| Rate for Payer: AETNA Medicare |
$158.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$167.20
|
| Rate for Payer: BCBS Healthlink |
$158.40
|
| Rate for Payer: BCBS HMK CHIP |
$158.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$158.40
|
| Rate for Payer: BCBS POS |
$167.20
|
| Rate for Payer: BCBS Traditional |
$176.00
|
| Rate for Payer: CASH_PRICE |
$140.80
|
| Rate for Payer: CIGNA Commercial |
$167.20
|
| Rate for Payer: CIGNA Medicare |
$158.40
|
| Rate for Payer: HUMANA Commercial |
$158.40
|
| Rate for Payer: MEDICAID Medicaid |
$161.92
|
| Rate for Payer: MEDICARE Medicare |
$123.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$167.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$170.72
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$167.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$167.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$149.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$140.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$140.80
|
|
