|
VAGINAL SPECULUMS SM
|
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
|
|
|
VAGINAL SPECULUMS SM
|
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
|
|
|
VALACYCLOVIR TAB [500 MG]
|
Facility
OP
|
$25.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: AETNA Commercial |
$23.75
|
| Rate for Payer: AETNA Medicare |
$22.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$23.75
|
| Rate for Payer: BCBS Healthlink |
$22.50
|
| Rate for Payer: BCBS HMK CHIP |
$22.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$22.50
|
| Rate for Payer: BCBS POS |
$23.75
|
| Rate for Payer: BCBS Traditional |
$25.00
|
| Rate for Payer: CASH_PRICE |
$20.00
|
| Rate for Payer: CIGNA Commercial |
$23.75
|
| Rate for Payer: CIGNA Medicare |
$22.50
|
| Rate for Payer: HUMANA Commercial |
$22.50
|
| Rate for Payer: MEDICAID Medicaid |
$23.00
|
| Rate for Payer: MEDICARE Medicare |
$17.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$23.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$24.25
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$23.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$23.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$21.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.00
|
|
|
VALACYCLOVIR TAB [500 MG]
|
Facility
IP
|
$25.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.50 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: AETNA Commercial |
$23.75
|
| Rate for Payer: AETNA Medicare |
$22.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$23.75
|
| Rate for Payer: BCBS Healthlink |
$22.50
|
| Rate for Payer: BCBS HMK CHIP |
$22.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$22.50
|
| Rate for Payer: BCBS POS |
$23.75
|
| Rate for Payer: BCBS Traditional |
$25.00
|
| Rate for Payer: CASH_PRICE |
$20.00
|
| Rate for Payer: CIGNA Commercial |
$23.75
|
| Rate for Payer: CIGNA Medicare |
$22.50
|
| Rate for Payer: HUMANA Commercial |
$22.50
|
| Rate for Payer: MEDICAID Medicaid |
$23.00
|
| Rate for Payer: MEDICARE Medicare |
$17.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$23.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$24.25
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$23.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$23.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$21.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$20.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$20.00
|
|
|
VALIUM 5MG/ML IM
|
Facility
IP
|
$26.00
|
|
|
Service Code
|
CPT J3360 QN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
VALIUM 5MG/ML IM
|
Facility
OP
|
$26.00
|
|
|
Service Code
|
CPT J3360 QN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
VALPROIC ACID (007260)
|
Facility
OP
|
$32.00
|
|
|
Service Code
|
CPT 80164
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.40 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: UNITED HEALTHCARE Commercial |
$27.20
|
| 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 MCD ADVANTAGE Medicaid |
$25.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$25.60
|
|
|
VALPROIC ACID (007260)
|
Facility
IP
|
$32.00
|
|
|
Service Code
|
CPT 80164
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
VALPROIC ACID PO SLN [250 MG/5 ML] UD
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20220525
|
|
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
|
|
|
VALPROIC ACID PO SLN [250 MG/5 ML] UD
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20220525
|
|
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
|
|
|
VANCOMYCIN 1.25 GM VIAL
|
Facility
IP
|
$77.20
|
|
| Hospital Charge Code |
20230117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.04 |
| Max. Negotiated Rate |
$77.20 |
| Rate for Payer: AETNA Commercial |
$73.34
|
| Rate for Payer: AETNA Medicare |
$69.48
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$73.34
|
| Rate for Payer: BCBS Healthlink |
$69.48
|
| Rate for Payer: BCBS HMK CHIP |
$69.48
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$69.48
|
| Rate for Payer: BCBS POS |
$73.34
|
| Rate for Payer: BCBS Traditional |
$77.20
|
| Rate for Payer: CASH_PRICE |
$61.76
|
| Rate for Payer: CIGNA Commercial |
$73.34
|
| Rate for Payer: CIGNA Medicare |
$69.48
|
| Rate for Payer: HUMANA Commercial |
$69.48
|
| Rate for Payer: MEDICAID Medicaid |
$71.02
|
| Rate for Payer: MEDICARE Medicare |
$54.04
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$73.34
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$74.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$73.34
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$73.34
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$65.62
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$61.76
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$61.76
|
|
|
VANCOMYCIN 1.25 GM VIAL
|
Facility
OP
|
$77.20
|
|
| Hospital Charge Code |
20230117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$54.04 |
| Max. Negotiated Rate |
$77.20 |
| Rate for Payer: UNITED HEALTHCARE Commercial |
$65.62
|
| Rate for Payer: AETNA Commercial |
$73.34
|
| Rate for Payer: AETNA Medicare |
$69.48
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$73.34
|
| Rate for Payer: BCBS Healthlink |
$69.48
|
| Rate for Payer: BCBS HMK CHIP |
$69.48
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$69.48
|
| Rate for Payer: BCBS POS |
$73.34
|
| Rate for Payer: BCBS Traditional |
$77.20
|
| Rate for Payer: CASH_PRICE |
$61.76
|
| Rate for Payer: CIGNA Commercial |
$73.34
|
| Rate for Payer: CIGNA Medicare |
$69.48
|
| Rate for Payer: HUMANA Commercial |
$69.48
|
| Rate for Payer: MEDICAID Medicaid |
$71.02
|
| Rate for Payer: MEDICARE Medicare |
$54.04
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$73.34
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$74.88
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$73.34
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$73.34
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$61.76
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$61.76
|
|
|
VANCOMYCIN 125MG CAPSULE
|
Facility
OP
|
$920.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$644.00 |
| Max. Negotiated Rate |
$920.00 |
| Rate for Payer: AETNA Commercial |
$874.00
|
| Rate for Payer: AETNA Medicare |
$828.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$874.00
|
| Rate for Payer: BCBS Healthlink |
$828.00
|
| Rate for Payer: BCBS HMK CHIP |
$828.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$828.00
|
| Rate for Payer: BCBS POS |
$874.00
|
| Rate for Payer: BCBS Traditional |
$920.00
|
| Rate for Payer: CASH_PRICE |
$736.00
|
| Rate for Payer: CIGNA Commercial |
$874.00
|
| Rate for Payer: CIGNA Medicare |
$828.00
|
| Rate for Payer: HUMANA Commercial |
$828.00
|
| Rate for Payer: MEDICAID Medicaid |
$846.40
|
| Rate for Payer: MEDICARE Medicare |
$644.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$874.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$892.40
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$874.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$874.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$782.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$736.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$736.00
|
|
|
VANCOMYCIN 125MG CAPSULE
|
Facility
IP
|
$920.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$644.00 |
| Max. Negotiated Rate |
$920.00 |
| Rate for Payer: AETNA Commercial |
$874.00
|
| Rate for Payer: AETNA Medicare |
$828.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$874.00
|
| Rate for Payer: BCBS Healthlink |
$828.00
|
| Rate for Payer: BCBS HMK CHIP |
$828.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$828.00
|
| Rate for Payer: BCBS POS |
$874.00
|
| Rate for Payer: BCBS Traditional |
$920.00
|
| Rate for Payer: CASH_PRICE |
$736.00
|
| Rate for Payer: CIGNA Commercial |
$874.00
|
| Rate for Payer: CIGNA Medicare |
$828.00
|
| Rate for Payer: HUMANA Commercial |
$828.00
|
| Rate for Payer: MEDICAID Medicaid |
$846.40
|
| Rate for Payer: MEDICARE Medicare |
$644.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$874.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$892.40
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$874.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$874.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$782.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$736.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$736.00
|
|
|
VANCOMYCIN 1GM VIAL
|
Facility
IP
|
$65.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: AETNA Commercial |
$61.75
|
| Rate for Payer: AETNA Medicare |
$58.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$61.75
|
| Rate for Payer: BCBS Healthlink |
$58.50
|
| Rate for Payer: BCBS HMK CHIP |
$58.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$58.50
|
| Rate for Payer: BCBS POS |
$61.75
|
| Rate for Payer: BCBS Traditional |
$65.00
|
| Rate for Payer: CASH_PRICE |
$52.00
|
| Rate for Payer: CIGNA Commercial |
$61.75
|
| Rate for Payer: CIGNA Medicare |
$58.50
|
| Rate for Payer: HUMANA Commercial |
$58.50
|
| Rate for Payer: MEDICAID Medicaid |
$59.80
|
| Rate for Payer: MEDICARE Medicare |
$45.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$61.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$63.05
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$61.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$61.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$55.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$52.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$52.00
|
|
|
VANCOMYCIN 1GM VIAL
|
Facility
OP
|
$65.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: AETNA Commercial |
$61.75
|
| Rate for Payer: AETNA Medicare |
$58.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$61.75
|
| Rate for Payer: BCBS Healthlink |
$58.50
|
| Rate for Payer: BCBS HMK CHIP |
$58.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$58.50
|
| Rate for Payer: BCBS POS |
$61.75
|
| Rate for Payer: BCBS Traditional |
$65.00
|
| Rate for Payer: CASH_PRICE |
$52.00
|
| Rate for Payer: CIGNA Commercial |
$61.75
|
| Rate for Payer: CIGNA Medicare |
$58.50
|
| Rate for Payer: HUMANA Commercial |
$58.50
|
| Rate for Payer: MEDICAID Medicaid |
$59.80
|
| Rate for Payer: MEDICARE Medicare |
$45.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$61.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$63.05
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$61.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$61.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$55.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$52.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$52.00
|
|
|
VANCOMYCIN 500MG VIAL
|
Facility
OP
|
$29.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: AETNA Commercial |
$27.55
|
| Rate for Payer: AETNA Medicare |
$26.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$27.55
|
| Rate for Payer: BCBS Healthlink |
$26.10
|
| Rate for Payer: BCBS HMK CHIP |
$26.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$26.10
|
| Rate for Payer: BCBS POS |
$27.55
|
| Rate for Payer: BCBS Traditional |
$29.00
|
| Rate for Payer: CASH_PRICE |
$23.20
|
| Rate for Payer: CIGNA Commercial |
$27.55
|
| Rate for Payer: CIGNA Medicare |
$26.10
|
| Rate for Payer: HUMANA Commercial |
$26.10
|
| Rate for Payer: MEDICAID Medicaid |
$26.68
|
| Rate for Payer: MEDICARE Medicare |
$20.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$27.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$28.13
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$27.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$27.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$24.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$23.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$23.20
|
|
|
VANCOMYCIN 500MG VIAL
|
Facility
IP
|
$29.00
|
|
|
Service Code
|
CPT J3370
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.30 |
| Max. Negotiated Rate |
$29.00 |
| Rate for Payer: AETNA Commercial |
$27.55
|
| Rate for Payer: AETNA Medicare |
$26.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$27.55
|
| Rate for Payer: BCBS Healthlink |
$26.10
|
| Rate for Payer: BCBS HMK CHIP |
$26.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$26.10
|
| Rate for Payer: BCBS POS |
$27.55
|
| Rate for Payer: BCBS Traditional |
$29.00
|
| Rate for Payer: CASH_PRICE |
$23.20
|
| Rate for Payer: CIGNA Commercial |
$27.55
|
| Rate for Payer: CIGNA Medicare |
$26.10
|
| Rate for Payer: HUMANA Commercial |
$26.10
|
| Rate for Payer: MEDICAID Medicaid |
$26.68
|
| Rate for Payer: MEDICARE Medicare |
$20.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$27.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$28.13
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$27.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$27.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$24.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$23.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$23.20
|
|
|
VANCOMYCIN CAPS [250MG] NON FORMULARY
|
Facility
IP
|
$194.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$135.80 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: AETNA Commercial |
$184.30
|
| Rate for Payer: AETNA Medicare |
$174.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$184.30
|
| Rate for Payer: BCBS Healthlink |
$174.60
|
| Rate for Payer: BCBS HMK CHIP |
$174.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$174.60
|
| Rate for Payer: BCBS POS |
$184.30
|
| Rate for Payer: BCBS Traditional |
$194.00
|
| Rate for Payer: CASH_PRICE |
$155.20
|
| Rate for Payer: CIGNA Commercial |
$184.30
|
| Rate for Payer: CIGNA Medicare |
$174.60
|
| Rate for Payer: HUMANA Commercial |
$174.60
|
| Rate for Payer: MEDICAID Medicaid |
$178.48
|
| Rate for Payer: MEDICARE Medicare |
$135.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$184.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$188.18
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$184.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$184.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$164.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$155.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$155.20
|
|
|
VANCOMYCIN CAPS [250MG] NON FORMULARY
|
Facility
OP
|
$194.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$135.80 |
| Max. Negotiated Rate |
$194.00 |
| Rate for Payer: AETNA Commercial |
$184.30
|
| Rate for Payer: AETNA Medicare |
$174.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$184.30
|
| Rate for Payer: BCBS Healthlink |
$174.60
|
| Rate for Payer: BCBS HMK CHIP |
$174.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$174.60
|
| Rate for Payer: BCBS POS |
$184.30
|
| Rate for Payer: BCBS Traditional |
$194.00
|
| Rate for Payer: CASH_PRICE |
$155.20
|
| Rate for Payer: CIGNA Commercial |
$184.30
|
| Rate for Payer: CIGNA Medicare |
$174.60
|
| Rate for Payer: HUMANA Commercial |
$174.60
|
| Rate for Payer: MEDICAID Medicaid |
$178.48
|
| Rate for Payer: MEDICARE Medicare |
$135.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$184.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$188.18
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$184.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$184.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$164.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$155.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$155.20
|
|
|
VANCOMYCIN, PEAK
|
Facility
IP
|
$182.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: AETNA Commercial |
$172.90
|
| Rate for Payer: AETNA Medicare |
$163.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$172.90
|
| Rate for Payer: BCBS Healthlink |
$163.80
|
| Rate for Payer: BCBS HMK CHIP |
$163.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$163.80
|
| Rate for Payer: BCBS POS |
$172.90
|
| Rate for Payer: BCBS Traditional |
$182.00
|
| Rate for Payer: CASH_PRICE |
$145.60
|
| Rate for Payer: CIGNA Commercial |
$172.90
|
| Rate for Payer: CIGNA Medicare |
$163.80
|
| Rate for Payer: HUMANA Commercial |
$163.80
|
| Rate for Payer: MEDICAID Medicaid |
$167.44
|
| Rate for Payer: MEDICARE Medicare |
$127.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$172.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$176.54
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$172.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$172.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$154.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$145.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$145.60
|
|
|
VANCOMYCIN, PEAK
|
Facility
OP
|
$182.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: AETNA Commercial |
$172.90
|
| Rate for Payer: AETNA Medicare |
$163.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$172.90
|
| Rate for Payer: BCBS Healthlink |
$163.80
|
| Rate for Payer: BCBS HMK CHIP |
$163.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$163.80
|
| Rate for Payer: BCBS POS |
$172.90
|
| Rate for Payer: BCBS Traditional |
$182.00
|
| Rate for Payer: CASH_PRICE |
$145.60
|
| Rate for Payer: CIGNA Commercial |
$172.90
|
| Rate for Payer: CIGNA Medicare |
$163.80
|
| Rate for Payer: HUMANA Commercial |
$163.80
|
| Rate for Payer: MEDICAID Medicaid |
$167.44
|
| Rate for Payer: MEDICARE Medicare |
$127.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$172.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$176.54
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$172.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$172.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$154.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$145.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$145.60
|
|
|
VANCOMYCIN, RANDOM
|
Facility
OP
|
$146.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$146.00 |
| Rate for Payer: AETNA Commercial |
$138.70
|
| Rate for Payer: AETNA Medicare |
$131.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$138.70
|
| Rate for Payer: BCBS Healthlink |
$131.40
|
| Rate for Payer: BCBS HMK CHIP |
$131.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$131.40
|
| Rate for Payer: BCBS POS |
$138.70
|
| Rate for Payer: BCBS Traditional |
$146.00
|
| Rate for Payer: CASH_PRICE |
$116.80
|
| Rate for Payer: CIGNA Commercial |
$138.70
|
| Rate for Payer: CIGNA Medicare |
$131.40
|
| Rate for Payer: HUMANA Commercial |
$131.40
|
| Rate for Payer: MEDICAID Medicaid |
$134.32
|
| Rate for Payer: MEDICARE Medicare |
$102.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$138.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$141.62
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$138.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$138.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$124.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$116.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$116.80
|
|
|
VANCOMYCIN, RANDOM
|
Facility
IP
|
$146.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$102.20 |
| Max. Negotiated Rate |
$146.00 |
| Rate for Payer: AETNA Commercial |
$138.70
|
| Rate for Payer: AETNA Medicare |
$131.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$138.70
|
| Rate for Payer: BCBS Healthlink |
$131.40
|
| Rate for Payer: BCBS HMK CHIP |
$131.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$131.40
|
| Rate for Payer: BCBS POS |
$138.70
|
| Rate for Payer: BCBS Traditional |
$146.00
|
| Rate for Payer: CASH_PRICE |
$116.80
|
| Rate for Payer: CIGNA Commercial |
$138.70
|
| Rate for Payer: CIGNA Medicare |
$131.40
|
| Rate for Payer: HUMANA Commercial |
$131.40
|
| Rate for Payer: MEDICAID Medicaid |
$134.32
|
| Rate for Payer: MEDICARE Medicare |
$102.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$138.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$141.62
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$138.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$138.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$124.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$116.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$116.80
|
|
|
VANCOMYCIN, TROUGH
|
Facility
OP
|
$182.00
|
|
|
Service Code
|
CPT 80202
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$127.40 |
| Max. Negotiated Rate |
$182.00 |
| Rate for Payer: AETNA Commercial |
$172.90
|
| Rate for Payer: AETNA Medicare |
$163.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$172.90
|
| Rate for Payer: BCBS Healthlink |
$163.80
|
| Rate for Payer: BCBS HMK CHIP |
$163.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$163.80
|
| Rate for Payer: BCBS POS |
$172.90
|
| Rate for Payer: BCBS Traditional |
$182.00
|
| Rate for Payer: CASH_PRICE |
$145.60
|
| Rate for Payer: CIGNA Commercial |
$172.90
|
| Rate for Payer: CIGNA Medicare |
$163.80
|
| Rate for Payer: HUMANA Commercial |
$163.80
|
| Rate for Payer: MEDICAID Medicaid |
$167.44
|
| Rate for Payer: MEDICARE Medicare |
$127.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$172.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$176.54
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$172.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$172.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$154.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$145.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$145.60
|
|
