|
THIAMINE (121186)
|
Facility
OP
|
$45.00
|
|
|
Service Code
|
CPT 84425
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: AETNA Commercial |
$42.75
|
| Rate for Payer: AETNA Medicare |
$40.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$42.75
|
| Rate for Payer: BCBS Healthlink |
$40.50
|
| Rate for Payer: BCBS HMK CHIP |
$40.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$40.50
|
| Rate for Payer: BCBS POS |
$42.75
|
| Rate for Payer: BCBS Traditional |
$45.00
|
| Rate for Payer: CASH_PRICE |
$36.00
|
| Rate for Payer: CIGNA Commercial |
$42.75
|
| Rate for Payer: CIGNA Medicare |
$40.50
|
| Rate for Payer: HUMANA Commercial |
$40.50
|
| Rate for Payer: MEDICAID Medicaid |
$41.40
|
| Rate for Payer: MEDICARE Medicare |
$31.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$42.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$43.65
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$42.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$42.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$38.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$36.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$36.00
|
|
|
THIAMINE INJ [100 MG/ML] 2 ML
|
Facility
IP
|
$40.00
|
|
|
Service Code
|
CPT J3411
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: AETNA Commercial |
$38.00
|
| Rate for Payer: AETNA Medicare |
$36.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$38.00
|
| Rate for Payer: BCBS Healthlink |
$36.00
|
| Rate for Payer: BCBS HMK CHIP |
$36.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$36.00
|
| Rate for Payer: BCBS POS |
$38.00
|
| Rate for Payer: BCBS Traditional |
$40.00
|
| Rate for Payer: CASH_PRICE |
$32.00
|
| Rate for Payer: CIGNA Commercial |
$38.00
|
| Rate for Payer: CIGNA Medicare |
$36.00
|
| Rate for Payer: HUMANA Commercial |
$36.00
|
| Rate for Payer: MEDICAID Medicaid |
$36.80
|
| Rate for Payer: MEDICARE Medicare |
$28.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$38.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$38.80
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$38.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$38.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$34.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$32.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$32.00
|
|
|
THIAMINE INJ [100 MG/ML] 2 ML
|
Facility
OP
|
$40.00
|
|
|
Service Code
|
CPT J3411
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$28.00 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: AETNA Commercial |
$38.00
|
| Rate for Payer: AETNA Medicare |
$36.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$38.00
|
| Rate for Payer: BCBS Healthlink |
$36.00
|
| Rate for Payer: BCBS HMK CHIP |
$36.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$36.00
|
| Rate for Payer: BCBS POS |
$38.00
|
| Rate for Payer: BCBS Traditional |
$40.00
|
| Rate for Payer: CASH_PRICE |
$32.00
|
| Rate for Payer: CIGNA Commercial |
$38.00
|
| Rate for Payer: CIGNA Medicare |
$36.00
|
| Rate for Payer: HUMANA Commercial |
$36.00
|
| Rate for Payer: MEDICAID Medicaid |
$36.80
|
| Rate for Payer: MEDICARE Medicare |
$28.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$38.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$38.80
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$38.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$38.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$34.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$32.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$32.00
|
|
|
THROMBIN-JMI DILUENT 5000U
|
Facility
OP
|
$291.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$203.70 |
| Max. Negotiated Rate |
$291.00 |
| Rate for Payer: AETNA Commercial |
$276.45
|
| Rate for Payer: AETNA Medicare |
$261.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$276.45
|
| Rate for Payer: BCBS Healthlink |
$261.90
|
| Rate for Payer: BCBS HMK CHIP |
$261.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$261.90
|
| Rate for Payer: BCBS POS |
$276.45
|
| Rate for Payer: BCBS Traditional |
$291.00
|
| Rate for Payer: CASH_PRICE |
$232.80
|
| Rate for Payer: CIGNA Commercial |
$276.45
|
| Rate for Payer: CIGNA Medicare |
$261.90
|
| Rate for Payer: HUMANA Commercial |
$261.90
|
| Rate for Payer: MEDICAID Medicaid |
$267.72
|
| Rate for Payer: MEDICARE Medicare |
$203.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$276.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$282.27
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$276.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$276.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$247.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$232.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$232.80
|
|
|
THROMBIN-JMI DILUENT 5000U
|
Facility
IP
|
$291.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$203.70 |
| Max. Negotiated Rate |
$291.00 |
| Rate for Payer: AETNA Commercial |
$276.45
|
| Rate for Payer: AETNA Medicare |
$261.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$276.45
|
| Rate for Payer: BCBS Healthlink |
$261.90
|
| Rate for Payer: BCBS HMK CHIP |
$261.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$261.90
|
| Rate for Payer: BCBS POS |
$276.45
|
| Rate for Payer: BCBS Traditional |
$291.00
|
| Rate for Payer: CASH_PRICE |
$232.80
|
| Rate for Payer: CIGNA Commercial |
$276.45
|
| Rate for Payer: CIGNA Medicare |
$261.90
|
| Rate for Payer: HUMANA Commercial |
$261.90
|
| Rate for Payer: MEDICAID Medicaid |
$267.72
|
| Rate for Payer: MEDICARE Medicare |
$203.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$276.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$282.27
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$276.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$276.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$247.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$232.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$232.80
|
|
|
THROMBIN TIME (015230)
|
Facility
IP
|
$53.00
|
|
|
Service Code
|
CPT 85670
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: AETNA Commercial |
$50.35
|
| Rate for Payer: AETNA Medicare |
$47.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$50.35
|
| Rate for Payer: BCBS Healthlink |
$47.70
|
| Rate for Payer: BCBS HMK CHIP |
$47.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$47.70
|
| Rate for Payer: BCBS POS |
$50.35
|
| Rate for Payer: BCBS Traditional |
$53.00
|
| Rate for Payer: CASH_PRICE |
$42.40
|
| Rate for Payer: CIGNA Commercial |
$50.35
|
| Rate for Payer: CIGNA Medicare |
$47.70
|
| Rate for Payer: HUMANA Commercial |
$47.70
|
| Rate for Payer: MEDICAID Medicaid |
$48.76
|
| Rate for Payer: MEDICARE Medicare |
$37.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$50.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$51.41
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$50.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$50.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$45.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$42.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$42.40
|
|
|
THROMBIN TIME (015230)
|
Facility
OP
|
$53.00
|
|
|
Service Code
|
CPT 85670
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$37.10 |
| Max. Negotiated Rate |
$53.00 |
| Rate for Payer: AETNA Commercial |
$50.35
|
| Rate for Payer: AETNA Medicare |
$47.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$50.35
|
| Rate for Payer: BCBS Healthlink |
$47.70
|
| Rate for Payer: BCBS HMK CHIP |
$47.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$47.70
|
| Rate for Payer: BCBS POS |
$50.35
|
| Rate for Payer: BCBS Traditional |
$53.00
|
| Rate for Payer: CASH_PRICE |
$42.40
|
| Rate for Payer: CIGNA Commercial |
$50.35
|
| Rate for Payer: CIGNA Medicare |
$47.70
|
| Rate for Payer: HUMANA Commercial |
$47.70
|
| Rate for Payer: MEDICAID Medicaid |
$48.76
|
| Rate for Payer: MEDICARE Medicare |
$37.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$50.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$51.41
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$50.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$50.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$45.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$42.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$42.40
|
|
|
.THROMBOPLASTIN INHIBITION, TISSUE
|
Facility
OP
|
$100.00
|
|
|
Service Code
|
CPT 85705
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: AETNA Commercial |
$95.00
|
| Rate for Payer: AETNA Medicare |
$90.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$95.00
|
| Rate for Payer: BCBS Healthlink |
$90.00
|
| Rate for Payer: BCBS HMK CHIP |
$90.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$90.00
|
| Rate for Payer: BCBS POS |
$95.00
|
| Rate for Payer: BCBS Traditional |
$100.00
|
| Rate for Payer: CASH_PRICE |
$80.00
|
| Rate for Payer: CIGNA Commercial |
$95.00
|
| Rate for Payer: CIGNA Medicare |
$90.00
|
| Rate for Payer: HUMANA Commercial |
$90.00
|
| Rate for Payer: MEDICAID Medicaid |
$92.00
|
| Rate for Payer: MEDICARE Medicare |
$70.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$95.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$97.00
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$95.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$95.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$85.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$80.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$80.00
|
|
|
.THROMBOPLASTIN INHIBITION, TISSUE
|
Facility
IP
|
$100.00
|
|
|
Service Code
|
CPT 85705
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: BCBS HMK CHIP |
$90.00
|
| Rate for Payer: AETNA Commercial |
$95.00
|
| Rate for Payer: AETNA Medicare |
$90.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$95.00
|
| Rate for Payer: BCBS Healthlink |
$90.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$90.00
|
| Rate for Payer: BCBS POS |
$95.00
|
| Rate for Payer: BCBS Traditional |
$100.00
|
| Rate for Payer: CASH_PRICE |
$80.00
|
| Rate for Payer: CIGNA Commercial |
$95.00
|
| Rate for Payer: CIGNA Medicare |
$90.00
|
| Rate for Payer: HUMANA Commercial |
$90.00
|
| Rate for Payer: MEDICAID Medicaid |
$92.00
|
| Rate for Payer: MEDICARE Medicare |
$70.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$95.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$97.00
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$95.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$95.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$85.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$80.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$80.00
|
|
|
.THROMBOPLASTIN TIME PARTIAL, MIXING
|
Facility
IP
|
$104.00
|
|
|
Service Code
|
CPT 85732
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: AETNA Commercial |
$98.80
|
| Rate for Payer: AETNA Medicare |
$93.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$98.80
|
| Rate for Payer: BCBS Healthlink |
$93.60
|
| Rate for Payer: BCBS HMK CHIP |
$93.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$93.60
|
| Rate for Payer: BCBS POS |
$98.80
|
| Rate for Payer: BCBS Traditional |
$104.00
|
| Rate for Payer: CASH_PRICE |
$83.20
|
| Rate for Payer: CIGNA Commercial |
$98.80
|
| Rate for Payer: CIGNA Medicare |
$93.60
|
| Rate for Payer: HUMANA Commercial |
$93.60
|
| Rate for Payer: MEDICAID Medicaid |
$95.68
|
| Rate for Payer: MEDICARE Medicare |
$72.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$98.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$100.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$98.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$98.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$88.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$83.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$83.20
|
|
|
.THROMBOPLASTIN TIME PARTIAL, MIXING
|
Facility
OP
|
$104.00
|
|
|
Service Code
|
CPT 85732
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$72.80 |
| Max. Negotiated Rate |
$104.00 |
| Rate for Payer: AETNA Commercial |
$98.80
|
| Rate for Payer: AETNA Medicare |
$93.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$98.80
|
| Rate for Payer: BCBS Healthlink |
$93.60
|
| Rate for Payer: BCBS HMK CHIP |
$93.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$93.60
|
| Rate for Payer: BCBS POS |
$98.80
|
| Rate for Payer: BCBS Traditional |
$104.00
|
| Rate for Payer: CASH_PRICE |
$83.20
|
| Rate for Payer: CIGNA Commercial |
$98.80
|
| Rate for Payer: CIGNA Medicare |
$93.60
|
| Rate for Payer: HUMANA Commercial |
$93.60
|
| Rate for Payer: MEDICAID Medicaid |
$95.68
|
| Rate for Payer: MEDICARE Medicare |
$72.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$98.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$100.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$98.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$98.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$88.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$83.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$83.20
|
|
|
THUMBOPRENE UNIVERSAL
|
Facility
IP
|
$28.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: AETNA Commercial |
$26.60
|
| Rate for Payer: AETNA Medicare |
$25.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$26.60
|
| Rate for Payer: BCBS Healthlink |
$25.20
|
| Rate for Payer: BCBS HMK CHIP |
$25.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$25.20
|
| Rate for Payer: BCBS POS |
$26.60
|
| Rate for Payer: BCBS Traditional |
$28.00
|
| Rate for Payer: CASH_PRICE |
$22.40
|
| Rate for Payer: CIGNA Commercial |
$26.60
|
| Rate for Payer: CIGNA Medicare |
$25.20
|
| Rate for Payer: HUMANA Commercial |
$25.20
|
| Rate for Payer: MEDICAID Medicaid |
$25.76
|
| Rate for Payer: MEDICARE Medicare |
$19.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$26.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$27.16
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$26.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$26.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$23.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$22.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$22.40
|
|
|
THUMBOPRENE UNIVERSAL
|
Facility
OP
|
$28.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: AETNA Commercial |
$26.60
|
| Rate for Payer: AETNA Medicare |
$25.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$26.60
|
| Rate for Payer: BCBS Healthlink |
$25.20
|
| Rate for Payer: BCBS HMK CHIP |
$25.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$25.20
|
| Rate for Payer: BCBS POS |
$26.60
|
| Rate for Payer: BCBS Traditional |
$28.00
|
| Rate for Payer: CASH_PRICE |
$22.40
|
| Rate for Payer: CIGNA Commercial |
$26.60
|
| Rate for Payer: CIGNA Medicare |
$25.20
|
| Rate for Payer: HUMANA Commercial |
$25.20
|
| Rate for Payer: MEDICAID Medicaid |
$25.76
|
| Rate for Payer: MEDICARE Medicare |
$19.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$26.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$27.16
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$26.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$26.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$23.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$22.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$22.40
|
|
|
THUMB SPICA SPLINT LEFT LG/XL
|
Facility
OP
|
$50.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: AETNA Commercial |
$47.50
|
| Rate for Payer: AETNA Medicare |
$45.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$47.50
|
| Rate for Payer: BCBS Healthlink |
$45.00
|
| Rate for Payer: BCBS HMK CHIP |
$45.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$45.00
|
| Rate for Payer: BCBS POS |
$47.50
|
| Rate for Payer: BCBS Traditional |
$50.00
|
| Rate for Payer: CASH_PRICE |
$40.00
|
| Rate for Payer: CIGNA Commercial |
$47.50
|
| Rate for Payer: CIGNA Medicare |
$45.00
|
| Rate for Payer: HUMANA Commercial |
$45.00
|
| Rate for Payer: MEDICAID Medicaid |
$46.00
|
| Rate for Payer: MEDICARE Medicare |
$35.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$47.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$48.50
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$47.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$47.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$42.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$40.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$40.00
|
|
|
THUMB SPICA SPLINT LEFT LG/XL
|
Facility
IP
|
$50.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: AETNA Commercial |
$47.50
|
| Rate for Payer: AETNA Medicare |
$45.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$47.50
|
| Rate for Payer: BCBS Healthlink |
$45.00
|
| Rate for Payer: BCBS HMK CHIP |
$45.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$45.00
|
| Rate for Payer: BCBS POS |
$47.50
|
| Rate for Payer: BCBS Traditional |
$50.00
|
| Rate for Payer: CASH_PRICE |
$40.00
|
| Rate for Payer: CIGNA Commercial |
$47.50
|
| Rate for Payer: CIGNA Medicare |
$45.00
|
| Rate for Payer: HUMANA Commercial |
$45.00
|
| Rate for Payer: MEDICAID Medicaid |
$46.00
|
| Rate for Payer: MEDICARE Medicare |
$35.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$47.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$48.50
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$47.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$47.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$42.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$40.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$40.00
|
|
|
THUMB SPICA SPLINT LEFT SM/MD
|
Facility
OP
|
$63.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: AETNA Commercial |
$59.85
|
| Rate for Payer: AETNA Medicare |
$56.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$59.85
|
| Rate for Payer: BCBS Healthlink |
$56.70
|
| Rate for Payer: BCBS HMK CHIP |
$56.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$56.70
|
| Rate for Payer: BCBS POS |
$59.85
|
| Rate for Payer: BCBS Traditional |
$63.00
|
| Rate for Payer: CASH_PRICE |
$50.40
|
| Rate for Payer: CIGNA Commercial |
$59.85
|
| Rate for Payer: CIGNA Medicare |
$56.70
|
| Rate for Payer: HUMANA Commercial |
$56.70
|
| Rate for Payer: MEDICAID Medicaid |
$57.96
|
| Rate for Payer: MEDICARE Medicare |
$44.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$59.85
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$61.11
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$59.85
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$59.85
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$53.55
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$50.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$50.40
|
|
|
THUMB SPICA SPLINT LEFT SM/MD
|
Facility
IP
|
$63.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: AETNA Commercial |
$59.85
|
| Rate for Payer: AETNA Medicare |
$56.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$59.85
|
| Rate for Payer: BCBS Healthlink |
$56.70
|
| Rate for Payer: BCBS HMK CHIP |
$56.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$56.70
|
| Rate for Payer: BCBS POS |
$59.85
|
| Rate for Payer: BCBS Traditional |
$63.00
|
| Rate for Payer: CASH_PRICE |
$50.40
|
| Rate for Payer: CIGNA Commercial |
$59.85
|
| Rate for Payer: CIGNA Medicare |
$56.70
|
| Rate for Payer: HUMANA Commercial |
$56.70
|
| Rate for Payer: MEDICAID Medicaid |
$57.96
|
| Rate for Payer: MEDICARE Medicare |
$44.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$59.85
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$61.11
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$59.85
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$59.85
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$53.55
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$50.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$50.40
|
|
|
THUMB SPICA SPLINT RIGHT LG/X
|
Facility
OP
|
$50.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: AETNA Commercial |
$47.50
|
| Rate for Payer: AETNA Medicare |
$45.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$47.50
|
| Rate for Payer: BCBS Healthlink |
$45.00
|
| Rate for Payer: BCBS HMK CHIP |
$45.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$45.00
|
| Rate for Payer: BCBS POS |
$47.50
|
| Rate for Payer: BCBS Traditional |
$50.00
|
| Rate for Payer: CASH_PRICE |
$40.00
|
| Rate for Payer: CIGNA Commercial |
$47.50
|
| Rate for Payer: CIGNA Medicare |
$45.00
|
| Rate for Payer: HUMANA Commercial |
$45.00
|
| Rate for Payer: MEDICAID Medicaid |
$46.00
|
| Rate for Payer: MEDICARE Medicare |
$35.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$47.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$48.50
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$47.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$47.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$42.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$40.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$40.00
|
|
|
THUMB SPICA SPLINT RIGHT LG/X
|
Facility
IP
|
$50.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: AETNA Commercial |
$47.50
|
| Rate for Payer: AETNA Medicare |
$45.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$47.50
|
| Rate for Payer: BCBS Healthlink |
$45.00
|
| Rate for Payer: BCBS HMK CHIP |
$45.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$45.00
|
| Rate for Payer: BCBS POS |
$47.50
|
| Rate for Payer: BCBS Traditional |
$50.00
|
| Rate for Payer: CASH_PRICE |
$40.00
|
| Rate for Payer: CIGNA Commercial |
$47.50
|
| Rate for Payer: CIGNA Medicare |
$45.00
|
| Rate for Payer: HUMANA Commercial |
$45.00
|
| Rate for Payer: MEDICAID Medicaid |
$46.00
|
| Rate for Payer: MEDICARE Medicare |
$35.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$47.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$48.50
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$47.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$47.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$42.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$40.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$40.00
|
|
|
THUMB SPICA SPLINT RIGHT SM/ME
|
Facility
IP
|
$50.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: AETNA Commercial |
$47.50
|
| Rate for Payer: AETNA Medicare |
$45.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$47.50
|
| Rate for Payer: BCBS Healthlink |
$45.00
|
| Rate for Payer: BCBS HMK CHIP |
$45.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$45.00
|
| Rate for Payer: BCBS POS |
$47.50
|
| Rate for Payer: BCBS Traditional |
$50.00
|
| Rate for Payer: CASH_PRICE |
$40.00
|
| Rate for Payer: CIGNA Commercial |
$47.50
|
| Rate for Payer: CIGNA Medicare |
$45.00
|
| Rate for Payer: HUMANA Commercial |
$45.00
|
| Rate for Payer: MEDICAID Medicaid |
$46.00
|
| Rate for Payer: MEDICARE Medicare |
$35.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$47.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$48.50
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$47.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$47.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$42.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$40.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$40.00
|
|
|
THUMB SPICA SPLINT RIGHT SM/ME
|
Facility
OP
|
$50.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$50.00 |
| Rate for Payer: AETNA Commercial |
$47.50
|
| Rate for Payer: AETNA Medicare |
$45.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$47.50
|
| Rate for Payer: BCBS Healthlink |
$45.00
|
| Rate for Payer: BCBS HMK CHIP |
$45.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$45.00
|
| Rate for Payer: BCBS POS |
$47.50
|
| Rate for Payer: BCBS Traditional |
$50.00
|
| Rate for Payer: CASH_PRICE |
$40.00
|
| Rate for Payer: CIGNA Commercial |
$47.50
|
| Rate for Payer: CIGNA Medicare |
$45.00
|
| Rate for Payer: HUMANA Commercial |
$45.00
|
| Rate for Payer: MEDICAID Medicaid |
$46.00
|
| Rate for Payer: MEDICARE Medicare |
$35.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$47.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$48.50
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$47.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$47.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$42.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$40.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$40.00
|
|
|
THYROGLOBULIN ANTIBODY (006685)
|
Facility
OP
|
$26.00
|
|
|
Service Code
|
CPT 86800
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: BCBS HMK CHIP |
$23.40
|
| Rate for Payer: AETNA Commercial |
$24.70
|
| Rate for Payer: AETNA Medicare |
$23.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$24.70
|
| Rate for Payer: BCBS Healthlink |
$23.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$23.40
|
| Rate for Payer: BCBS POS |
$24.70
|
| Rate for Payer: BCBS Traditional |
$26.00
|
| Rate for Payer: CASH_PRICE |
$20.80
|
| Rate for Payer: CIGNA Commercial |
$24.70
|
| Rate for Payer: CIGNA Medicare |
$23.40
|
| Rate for Payer: HUMANA Commercial |
$23.40
|
| Rate for Payer: MEDICAID Medicaid |
$23.92
|
| Rate for Payer: MEDICARE Medicare |
$18.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$24.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$25.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$24.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$24.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.80
|
|
|
THYROGLOBULIN ANTIBODY (006685)
|
Facility
IP
|
$26.00
|
|
|
Service Code
|
CPT 86800
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: AETNA Commercial |
$24.70
|
| Rate for Payer: AETNA Medicare |
$23.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$24.70
|
| Rate for Payer: BCBS Healthlink |
$23.40
|
| Rate for Payer: BCBS HMK CHIP |
$23.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$23.40
|
| Rate for Payer: BCBS POS |
$24.70
|
| Rate for Payer: BCBS Traditional |
$26.00
|
| Rate for Payer: CASH_PRICE |
$20.80
|
| Rate for Payer: CIGNA Commercial |
$24.70
|
| Rate for Payer: CIGNA Medicare |
$23.40
|
| Rate for Payer: HUMANA Commercial |
$23.40
|
| Rate for Payer: MEDICAID Medicaid |
$23.92
|
| Rate for Payer: MEDICARE Medicare |
$18.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$24.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$25.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$24.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$24.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$22.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.80
|
|
|
THYROGLOBULIN ANTIBODY, REFLEX (042045)
|
Facility
IP
|
$68.00
|
|
|
Service Code
|
CPT 86800
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
THYROGLOBULIN ANTIBODY, REFLEX (042045)
|
Facility
OP
|
$68.00
|
|
|
Service Code
|
CPT 86800
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
