|
CA 19-9 (002261)
|
Facility
IP
|
$39.00
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: AETNA Commercial |
$37.05
|
| Rate for Payer: AETNA Medicare |
$35.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$37.05
|
| Rate for Payer: BCBS Healthlink |
$35.10
|
| Rate for Payer: BCBS HMK CHIP |
$35.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$35.10
|
| Rate for Payer: BCBS POS |
$37.05
|
| Rate for Payer: BCBS Traditional |
$39.00
|
| Rate for Payer: CASH_PRICE |
$31.20
|
| Rate for Payer: CIGNA Commercial |
$37.05
|
| Rate for Payer: CIGNA Medicare |
$35.10
|
| Rate for Payer: HUMANA Commercial |
$35.10
|
| Rate for Payer: MEDICAID Medicaid |
$35.88
|
| Rate for Payer: MEDICARE Medicare |
$27.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$37.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$37.83
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$37.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$37.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$33.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$31.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$31.20
|
|
|
CA 27.29 (140293)
|
Facility
IP
|
$32.00
|
|
|
Service Code
|
CPT 86300
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: BCBS HMK CHIP |
$28.80
|
| Rate for Payer: AETNA Commercial |
$30.40
|
| Rate for Payer: AETNA Medicare |
$28.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$30.40
|
| Rate for Payer: BCBS Healthlink |
$28.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$28.80
|
| Rate for Payer: BCBS POS |
$30.40
|
| Rate for Payer: BCBS Traditional |
$32.00
|
| Rate for Payer: CASH_PRICE |
$25.60
|
| Rate for Payer: CIGNA Commercial |
$30.40
|
| Rate for Payer: CIGNA Medicare |
$28.80
|
| Rate for Payer: HUMANA Commercial |
$28.80
|
| Rate for Payer: MEDICAID Medicaid |
$29.44
|
| Rate for Payer: MEDICARE Medicare |
$22.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$30.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$31.04
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$30.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$30.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$27.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$25.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$25.60
|
|
|
CA 27.29 (140293)
|
Facility
OP
|
$32.00
|
|
|
Service Code
|
CPT 86300
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: AETNA Commercial |
$30.40
|
| Rate for Payer: AETNA Medicare |
$28.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$30.40
|
| Rate for Payer: BCBS Healthlink |
$28.80
|
| Rate for Payer: BCBS HMK CHIP |
$28.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$28.80
|
| Rate for Payer: BCBS POS |
$30.40
|
| Rate for Payer: BCBS Traditional |
$32.00
|
| Rate for Payer: CASH_PRICE |
$25.60
|
| Rate for Payer: CIGNA Commercial |
$30.40
|
| Rate for Payer: CIGNA Medicare |
$28.80
|
| Rate for Payer: HUMANA Commercial |
$28.80
|
| Rate for Payer: MEDICAID Medicaid |
$29.44
|
| Rate for Payer: MEDICARE Medicare |
$22.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$30.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$31.04
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$30.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$30.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$27.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$25.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$25.60
|
|
|
CADEXOMER IODINE GEL [40 G]
|
Facility
OP
|
$219.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$153.30 |
| Max. Negotiated Rate |
$219.00 |
| Rate for Payer: AETNA Commercial |
$208.05
|
| Rate for Payer: AETNA Medicare |
$197.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$208.05
|
| Rate for Payer: BCBS Healthlink |
$197.10
|
| Rate for Payer: BCBS HMK CHIP |
$197.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$197.10
|
| Rate for Payer: BCBS POS |
$208.05
|
| Rate for Payer: BCBS Traditional |
$219.00
|
| Rate for Payer: CASH_PRICE |
$175.20
|
| Rate for Payer: CIGNA Commercial |
$208.05
|
| Rate for Payer: CIGNA Medicare |
$197.10
|
| Rate for Payer: HUMANA Commercial |
$197.10
|
| Rate for Payer: MEDICAID Medicaid |
$201.48
|
| Rate for Payer: MEDICARE Medicare |
$153.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$208.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$212.43
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$208.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$208.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$186.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$175.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$175.20
|
|
|
CADEXOMER IODINE GEL [40 G]
|
Facility
IP
|
$219.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$153.30 |
| Max. Negotiated Rate |
$219.00 |
| Rate for Payer: BCBS HMK CHIP |
$197.10
|
| Rate for Payer: AETNA Commercial |
$208.05
|
| Rate for Payer: AETNA Medicare |
$197.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$208.05
|
| Rate for Payer: BCBS Healthlink |
$197.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$197.10
|
| Rate for Payer: BCBS POS |
$208.05
|
| Rate for Payer: BCBS Traditional |
$219.00
|
| Rate for Payer: CASH_PRICE |
$175.20
|
| Rate for Payer: CIGNA Commercial |
$208.05
|
| Rate for Payer: CIGNA Medicare |
$197.10
|
| Rate for Payer: HUMANA Commercial |
$197.10
|
| Rate for Payer: MEDICAID Medicaid |
$201.48
|
| Rate for Payer: MEDICARE Medicare |
$153.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$208.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$212.43
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$208.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$208.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$186.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$175.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$175.20
|
|
|
CALAZIME
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: AETNA Commercial |
$3.80
|
| Rate for Payer: AETNA Medicare |
$3.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$3.80
|
| Rate for Payer: BCBS Healthlink |
$3.60
|
| Rate for Payer: BCBS HMK CHIP |
$3.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$3.60
|
| Rate for Payer: BCBS POS |
$3.80
|
| Rate for Payer: BCBS Traditional |
$4.00
|
| Rate for Payer: CASH_PRICE |
$3.20
|
| Rate for Payer: CIGNA Commercial |
$3.80
|
| Rate for Payer: CIGNA Medicare |
$3.60
|
| Rate for Payer: HUMANA Commercial |
$3.60
|
| Rate for Payer: MEDICAID Medicaid |
$3.68
|
| Rate for Payer: MEDICARE Medicare |
$2.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$3.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$3.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$3.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$3.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$3.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$3.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$3.20
|
|
|
CALAZIME
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: AETNA Commercial |
$3.80
|
| Rate for Payer: AETNA Medicare |
$3.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$3.80
|
| Rate for Payer: BCBS Healthlink |
$3.60
|
| Rate for Payer: BCBS HMK CHIP |
$3.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$3.60
|
| Rate for Payer: BCBS POS |
$3.80
|
| Rate for Payer: BCBS Traditional |
$4.00
|
| Rate for Payer: CASH_PRICE |
$3.20
|
| Rate for Payer: CIGNA Commercial |
$3.80
|
| Rate for Payer: CIGNA Medicare |
$3.60
|
| Rate for Payer: HUMANA Commercial |
$3.60
|
| Rate for Payer: MEDICAID Medicaid |
$3.68
|
| Rate for Payer: MEDICARE Medicare |
$2.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$3.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$3.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$3.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$3.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$3.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$3.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$3.20
|
|
|
CALCITONIN (004895)
|
Facility
IP
|
$113.00
|
|
|
Service Code
|
CPT 82308
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$79.10 |
| Max. Negotiated Rate |
$113.00 |
| Rate for Payer: BCBS HMK CHIP |
$101.70
|
| Rate for Payer: AETNA Commercial |
$107.35
|
| Rate for Payer: AETNA Medicare |
$101.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$107.35
|
| Rate for Payer: BCBS Healthlink |
$101.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$101.70
|
| Rate for Payer: BCBS POS |
$107.35
|
| Rate for Payer: BCBS Traditional |
$113.00
|
| Rate for Payer: CASH_PRICE |
$90.40
|
| Rate for Payer: CIGNA Commercial |
$107.35
|
| Rate for Payer: CIGNA Medicare |
$101.70
|
| Rate for Payer: HUMANA Commercial |
$101.70
|
| Rate for Payer: MEDICAID Medicaid |
$103.96
|
| Rate for Payer: MEDICARE Medicare |
$79.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$107.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$109.61
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$107.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$107.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$96.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$90.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$90.40
|
|
|
CALCITONIN (004895)
|
Facility
OP
|
$113.00
|
|
|
Service Code
|
CPT 82308
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$79.10 |
| Max. Negotiated Rate |
$113.00 |
| Rate for Payer: AETNA Commercial |
$107.35
|
| Rate for Payer: AETNA Medicare |
$101.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$107.35
|
| Rate for Payer: BCBS Healthlink |
$101.70
|
| Rate for Payer: BCBS HMK CHIP |
$101.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$101.70
|
| Rate for Payer: BCBS POS |
$107.35
|
| Rate for Payer: BCBS Traditional |
$113.00
|
| Rate for Payer: CASH_PRICE |
$90.40
|
| Rate for Payer: CIGNA Commercial |
$107.35
|
| Rate for Payer: CIGNA Medicare |
$101.70
|
| Rate for Payer: HUMANA Commercial |
$101.70
|
| Rate for Payer: MEDICAID Medicaid |
$103.96
|
| Rate for Payer: MEDICARE Medicare |
$79.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$107.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$109.61
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$107.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$107.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$96.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$90.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$90.40
|
|
|
CALCITONIN-SALMON NASAL SPRAY
|
Facility
IP
|
$398.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$278.60 |
| Max. Negotiated Rate |
$398.00 |
| Rate for Payer: AETNA Commercial |
$378.10
|
| Rate for Payer: AETNA Medicare |
$358.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$378.10
|
| Rate for Payer: BCBS Healthlink |
$358.20
|
| Rate for Payer: BCBS HMK CHIP |
$358.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$358.20
|
| Rate for Payer: BCBS POS |
$378.10
|
| Rate for Payer: BCBS Traditional |
$398.00
|
| Rate for Payer: CASH_PRICE |
$318.40
|
| Rate for Payer: CIGNA Commercial |
$378.10
|
| Rate for Payer: CIGNA Medicare |
$358.20
|
| Rate for Payer: HUMANA Commercial |
$358.20
|
| Rate for Payer: MEDICAID Medicaid |
$366.16
|
| Rate for Payer: MEDICARE Medicare |
$278.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$378.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$386.06
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$378.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$378.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$338.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$318.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$318.40
|
|
|
CALCITONIN-SALMON NASAL SPRAY
|
Facility
OP
|
$398.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$278.60 |
| Max. Negotiated Rate |
$398.00 |
| Rate for Payer: AETNA Commercial |
$378.10
|
| Rate for Payer: AETNA Medicare |
$358.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$378.10
|
| Rate for Payer: BCBS Healthlink |
$358.20
|
| Rate for Payer: BCBS HMK CHIP |
$358.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$358.20
|
| Rate for Payer: BCBS POS |
$378.10
|
| Rate for Payer: BCBS Traditional |
$398.00
|
| Rate for Payer: CASH_PRICE |
$318.40
|
| Rate for Payer: CIGNA Commercial |
$378.10
|
| Rate for Payer: CIGNA Medicare |
$358.20
|
| Rate for Payer: HUMANA Commercial |
$358.20
|
| Rate for Payer: MEDICAID Medicaid |
$366.16
|
| Rate for Payer: MEDICARE Medicare |
$278.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$378.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$386.06
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$378.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$378.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$338.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$318.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$318.40
|
|
|
CALCITRIOL 0.25MCG CAPSULE
|
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
|
|
|
CALCITRIOL 0.25MCG CAPSULE
|
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: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
CALCIUM, 24 HOUR URINE (003269)
|
Facility
IP
|
$16.00
|
|
|
Service Code
|
CPT 82340
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: BCBS HMK CHIP |
$14.40
|
| Rate for Payer: AETNA Commercial |
$15.20
|
| Rate for Payer: AETNA Medicare |
$14.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$15.20
|
| Rate for Payer: BCBS Healthlink |
$14.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$14.40
|
| Rate for Payer: BCBS POS |
$15.20
|
| Rate for Payer: BCBS Traditional |
$16.00
|
| Rate for Payer: CASH_PRICE |
$12.80
|
| Rate for Payer: CIGNA Commercial |
$15.20
|
| Rate for Payer: CIGNA Medicare |
$14.40
|
| Rate for Payer: HUMANA Commercial |
$14.40
|
| Rate for Payer: MEDICAID Medicaid |
$14.72
|
| Rate for Payer: MEDICARE Medicare |
$11.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$15.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$15.52
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$15.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$15.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$12.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$12.80
|
|
|
CALCIUM, 24 HOUR URINE (003269)
|
Facility
OP
|
$16.00
|
|
|
Service Code
|
CPT 82340
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.20 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: AETNA Commercial |
$15.20
|
| Rate for Payer: AETNA Medicare |
$14.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$15.20
|
| Rate for Payer: BCBS Healthlink |
$14.40
|
| Rate for Payer: BCBS HMK CHIP |
$14.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$14.40
|
| Rate for Payer: BCBS POS |
$15.20
|
| Rate for Payer: BCBS Traditional |
$16.00
|
| Rate for Payer: CASH_PRICE |
$12.80
|
| Rate for Payer: CIGNA Commercial |
$15.20
|
| Rate for Payer: CIGNA Medicare |
$14.40
|
| Rate for Payer: HUMANA Commercial |
$14.40
|
| Rate for Payer: MEDICAID Medicaid |
$14.72
|
| Rate for Payer: MEDICARE Medicare |
$11.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$15.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$15.52
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$15.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$15.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$12.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$12.80
|
|
|
CALCIUM CARB CHEW TAB [500 MG]
|
Facility
IP
|
$5.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: AETNA Commercial |
$4.75
|
| Rate for Payer: AETNA Medicare |
$4.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$4.75
|
| Rate for Payer: BCBS Healthlink |
$4.50
|
| Rate for Payer: BCBS HMK CHIP |
$4.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$4.50
|
| Rate for Payer: BCBS POS |
$4.75
|
| Rate for Payer: BCBS Traditional |
$5.00
|
| Rate for Payer: CASH_PRICE |
$4.00
|
| Rate for Payer: CIGNA Commercial |
$4.75
|
| Rate for Payer: CIGNA Medicare |
$4.50
|
| Rate for Payer: HUMANA Commercial |
$4.50
|
| Rate for Payer: MEDICAID Medicaid |
$4.60
|
| Rate for Payer: MEDICARE Medicare |
$3.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$4.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$4.85
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$4.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$4.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$4.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$4.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$4.00
|
|
|
CALCIUM CARB CHEW TAB [500 MG]
|
Facility
OP
|
$5.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: AETNA Commercial |
$4.75
|
| Rate for Payer: AETNA Medicare |
$4.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$4.75
|
| Rate for Payer: BCBS Healthlink |
$4.50
|
| Rate for Payer: BCBS HMK CHIP |
$4.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$4.50
|
| Rate for Payer: BCBS POS |
$4.75
|
| Rate for Payer: BCBS Traditional |
$5.00
|
| Rate for Payer: CASH_PRICE |
$4.00
|
| Rate for Payer: CIGNA Commercial |
$4.75
|
| Rate for Payer: CIGNA Medicare |
$4.50
|
| Rate for Payer: HUMANA Commercial |
$4.50
|
| Rate for Payer: MEDICAID Medicaid |
$4.60
|
| Rate for Payer: MEDICARE Medicare |
$3.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$4.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$4.85
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$4.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$4.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$4.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$4.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$4.00
|
|
|
CALCIUM CHLORIDE 10% INJ [10 ML]
|
Facility
IP
|
$38.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: BCBS HMK CHIP |
$34.20
|
| Rate for Payer: AETNA Commercial |
$36.10
|
| Rate for Payer: AETNA Medicare |
$34.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$36.10
|
| Rate for Payer: BCBS Healthlink |
$34.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$34.20
|
| Rate for Payer: BCBS POS |
$36.10
|
| Rate for Payer: BCBS Traditional |
$38.00
|
| Rate for Payer: CASH_PRICE |
$30.40
|
| Rate for Payer: CIGNA Commercial |
$36.10
|
| Rate for Payer: CIGNA Medicare |
$34.20
|
| Rate for Payer: HUMANA Commercial |
$34.20
|
| Rate for Payer: MEDICAID Medicaid |
$34.96
|
| Rate for Payer: MEDICARE Medicare |
$26.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$36.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$36.86
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$36.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$36.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$32.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$30.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$30.40
|
|
|
CALCIUM CHLORIDE 10% INJ [10 ML]
|
Facility
OP
|
$38.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.60 |
| Max. Negotiated Rate |
$38.00 |
| Rate for Payer: AETNA Commercial |
$36.10
|
| Rate for Payer: AETNA Medicare |
$34.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$36.10
|
| Rate for Payer: BCBS Healthlink |
$34.20
|
| Rate for Payer: BCBS HMK CHIP |
$34.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$34.20
|
| Rate for Payer: BCBS POS |
$36.10
|
| Rate for Payer: BCBS Traditional |
$38.00
|
| Rate for Payer: CASH_PRICE |
$30.40
|
| Rate for Payer: CIGNA Commercial |
$36.10
|
| Rate for Payer: CIGNA Medicare |
$34.20
|
| Rate for Payer: HUMANA Commercial |
$34.20
|
| Rate for Payer: MEDICAID Medicaid |
$34.96
|
| Rate for Payer: MEDICARE Medicare |
$26.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$36.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$36.86
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$36.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$36.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$32.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$30.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$30.40
|
|
|
CALCIUM, IONIZED
|
Facility
IP
|
$131.00
|
|
|
Service Code
|
CPT 82330
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$131.00 |
| Rate for Payer: AETNA Commercial |
$124.45
|
| Rate for Payer: AETNA Medicare |
$117.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$124.45
|
| Rate for Payer: BCBS Healthlink |
$117.90
|
| Rate for Payer: BCBS HMK CHIP |
$117.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$117.90
|
| Rate for Payer: BCBS POS |
$124.45
|
| Rate for Payer: BCBS Traditional |
$131.00
|
| Rate for Payer: CASH_PRICE |
$104.80
|
| Rate for Payer: CIGNA Commercial |
$124.45
|
| Rate for Payer: CIGNA Medicare |
$117.90
|
| Rate for Payer: HUMANA Commercial |
$117.90
|
| Rate for Payer: MEDICAID Medicaid |
$120.52
|
| Rate for Payer: MEDICARE Medicare |
$91.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$124.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$127.07
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$124.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$124.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$111.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$104.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$104.80
|
|
|
CALCIUM, IONIZED
|
Facility
OP
|
$131.00
|
|
|
Service Code
|
CPT 82330
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$91.70 |
| Max. Negotiated Rate |
$131.00 |
| Rate for Payer: AETNA Commercial |
$124.45
|
| Rate for Payer: AETNA Medicare |
$117.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$124.45
|
| Rate for Payer: BCBS Healthlink |
$117.90
|
| Rate for Payer: BCBS HMK CHIP |
$117.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$117.90
|
| Rate for Payer: BCBS POS |
$124.45
|
| Rate for Payer: BCBS Traditional |
$131.00
|
| Rate for Payer: CASH_PRICE |
$104.80
|
| Rate for Payer: CIGNA Commercial |
$124.45
|
| Rate for Payer: CIGNA Medicare |
$117.90
|
| Rate for Payer: HUMANA Commercial |
$117.90
|
| Rate for Payer: MEDICAID Medicaid |
$120.52
|
| Rate for Payer: MEDICARE Medicare |
$91.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$124.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$127.07
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$124.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$124.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$111.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$104.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$104.80
|
|
|
CALCIUM TAB [600 MG + D 400]
|
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
|
|
|
CALCIUM TAB [600 MG + D 400]
|
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
|
|
|
CALCIUM, TOTAL
|
Facility
OP
|
$62.00
|
|
|
Service Code
|
CPT 82310
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$43.40 |
| Max. Negotiated Rate |
$62.00 |
| Rate for Payer: AETNA Commercial |
$58.90
|
| Rate for Payer: AETNA Medicare |
$55.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$58.90
|
| Rate for Payer: BCBS Healthlink |
$55.80
|
| Rate for Payer: BCBS HMK CHIP |
$55.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$55.80
|
| Rate for Payer: BCBS POS |
$58.90
|
| Rate for Payer: BCBS Traditional |
$62.00
|
| Rate for Payer: CASH_PRICE |
$49.60
|
| Rate for Payer: CIGNA Commercial |
$58.90
|
| Rate for Payer: CIGNA Medicare |
$55.80
|
| Rate for Payer: HUMANA Commercial |
$55.80
|
| Rate for Payer: MEDICAID Medicaid |
$57.04
|
| Rate for Payer: MEDICARE Medicare |
$43.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$58.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$60.14
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$58.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$58.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$52.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$49.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$49.60
|
|
|
CALCIUM, TOTAL
|
Facility
IP
|
$62.00
|
|
|
Service Code
|
CPT 82310
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$43.40 |
| Max. Negotiated Rate |
$62.00 |
| Rate for Payer: BCBS HMK CHIP |
$55.80
|
| Rate for Payer: AETNA Commercial |
$58.90
|
| Rate for Payer: AETNA Medicare |
$55.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$58.90
|
| Rate for Payer: BCBS Healthlink |
$55.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$55.80
|
| Rate for Payer: BCBS POS |
$58.90
|
| Rate for Payer: BCBS Traditional |
$62.00
|
| Rate for Payer: CASH_PRICE |
$49.60
|
| Rate for Payer: CIGNA Commercial |
$58.90
|
| Rate for Payer: CIGNA Medicare |
$55.80
|
| Rate for Payer: HUMANA Commercial |
$55.80
|
| Rate for Payer: MEDICAID Medicaid |
$57.04
|
| Rate for Payer: MEDICARE Medicare |
$43.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$58.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$60.14
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$58.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$58.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$52.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$49.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$49.60
|
|
