|
DOPAMINE PREMIX [400 MG/250 ML]
|
Facility
OP
|
$53.00
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
DOPAMINE PREMIX [400 MG/250 ML]
|
Facility
IP
|
$53.00
|
|
|
Service Code
|
CPT J1265
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
636
|
| 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
|
|
|
DORZOLAMIDE-TIMOLOL 22.3 -6.8MG DROPS-NF
|
Facility
OP
|
$390.40
|
|
| Hospital Charge Code |
20221116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$273.28 |
| Max. Negotiated Rate |
$390.40 |
| Rate for Payer: AETNA Commercial |
$370.88
|
| Rate for Payer: AETNA Medicare |
$351.36
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$370.88
|
| Rate for Payer: BCBS Healthlink |
$351.36
|
| Rate for Payer: BCBS HMK CHIP |
$351.36
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$351.36
|
| Rate for Payer: BCBS POS |
$370.88
|
| Rate for Payer: BCBS Traditional |
$390.40
|
| Rate for Payer: CASH_PRICE |
$312.32
|
| Rate for Payer: CIGNA Commercial |
$370.88
|
| Rate for Payer: CIGNA Medicare |
$351.36
|
| Rate for Payer: HUMANA Commercial |
$351.36
|
| Rate for Payer: MEDICAID Medicaid |
$359.17
|
| Rate for Payer: MEDICARE Medicare |
$273.28
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$370.88
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$378.69
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$370.88
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$370.88
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$331.84
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$312.32
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$312.32
|
|
|
DORZOLAMIDE-TIMOLOL 22.3 -6.8MG DROPS-NF
|
Facility
IP
|
$390.40
|
|
| Hospital Charge Code |
20221116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$273.28 |
| Max. Negotiated Rate |
$390.40 |
| Rate for Payer: BCBS HMK CHIP |
$351.36
|
| Rate for Payer: AETNA Commercial |
$370.88
|
| Rate for Payer: AETNA Medicare |
$351.36
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$370.88
|
| Rate for Payer: BCBS Healthlink |
$351.36
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$351.36
|
| Rate for Payer: BCBS POS |
$370.88
|
| Rate for Payer: BCBS Traditional |
$390.40
|
| Rate for Payer: CASH_PRICE |
$312.32
|
| Rate for Payer: CIGNA Commercial |
$370.88
|
| Rate for Payer: CIGNA Medicare |
$351.36
|
| Rate for Payer: HUMANA Commercial |
$351.36
|
| Rate for Payer: MEDICAID Medicaid |
$359.17
|
| Rate for Payer: MEDICARE Medicare |
$273.28
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$370.88
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$378.69
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$370.88
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$370.88
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$331.84
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$312.32
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$312.32
|
|
|
DOXAZOSIN MESYLATE 4MG TAB NON FORMULARY
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20220524
|
|
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
|
|
|
DOXAZOSIN MESYLATE 4MG TAB NON FORMULARY
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20220524
|
|
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
|
|
|
DOXEPIN 50MG CAP NON FORMULARY
|
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: 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
|
|
|
DOXEPIN 50MG CAP NON FORMULARY
|
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
|
|
|
DOXYCYCLINE CAP [100 MG]
|
Facility
OP
|
$19.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: AETNA Commercial |
$18.05
|
| Rate for Payer: AETNA Medicare |
$17.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$18.05
|
| Rate for Payer: BCBS Healthlink |
$17.10
|
| Rate for Payer: BCBS HMK CHIP |
$17.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$17.10
|
| Rate for Payer: BCBS POS |
$18.05
|
| Rate for Payer: BCBS Traditional |
$19.00
|
| Rate for Payer: CASH_PRICE |
$15.20
|
| Rate for Payer: CIGNA Commercial |
$18.05
|
| Rate for Payer: CIGNA Medicare |
$17.10
|
| Rate for Payer: HUMANA Commercial |
$17.10
|
| Rate for Payer: MEDICAID Medicaid |
$17.48
|
| Rate for Payer: MEDICARE Medicare |
$13.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$18.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$18.43
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$18.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$18.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$15.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$15.20
|
|
|
DOXYCYCLINE CAP [100 MG]
|
Facility
IP
|
$19.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.30 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: AETNA Commercial |
$18.05
|
| Rate for Payer: AETNA Medicare |
$17.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$18.05
|
| Rate for Payer: BCBS Healthlink |
$17.10
|
| Rate for Payer: BCBS HMK CHIP |
$17.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$17.10
|
| Rate for Payer: BCBS POS |
$18.05
|
| Rate for Payer: BCBS Traditional |
$19.00
|
| Rate for Payer: CASH_PRICE |
$15.20
|
| Rate for Payer: CIGNA Commercial |
$18.05
|
| Rate for Payer: CIGNA Medicare |
$17.10
|
| Rate for Payer: HUMANA Commercial |
$17.10
|
| Rate for Payer: MEDICAID Medicaid |
$17.48
|
| Rate for Payer: MEDICARE Medicare |
$13.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$18.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$18.43
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$18.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$18.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$15.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$15.20
|
|
|
DRAIN BLOOD FROM UNDER NAIL
|
Facility
OP
|
$165.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: AETNA Commercial |
$156.75
|
| Rate for Payer: AETNA Medicare |
$148.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$156.75
|
| Rate for Payer: BCBS Healthlink |
$148.50
|
| Rate for Payer: BCBS HMK CHIP |
$148.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$148.50
|
| Rate for Payer: BCBS POS |
$156.75
|
| Rate for Payer: BCBS Traditional |
$165.00
|
| Rate for Payer: CASH_PRICE |
$132.00
|
| Rate for Payer: CIGNA Commercial |
$156.75
|
| Rate for Payer: CIGNA Medicare |
$148.50
|
| Rate for Payer: HUMANA Commercial |
$148.50
|
| Rate for Payer: MEDICAID Medicaid |
$151.80
|
| Rate for Payer: MEDICARE Medicare |
$115.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$156.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$160.05
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$156.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$156.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$140.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$132.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$132.00
|
|
|
DRAIN BLOOD FROM UNDER NAIL
|
Facility
IP
|
$165.00
|
|
|
Service Code
|
CPT 11740
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$115.50 |
| Max. Negotiated Rate |
$165.00 |
| Rate for Payer: BCBS HMK CHIP |
$148.50
|
| Rate for Payer: AETNA Commercial |
$156.75
|
| Rate for Payer: AETNA Medicare |
$148.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$156.75
|
| Rate for Payer: BCBS Healthlink |
$148.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$148.50
|
| Rate for Payer: BCBS POS |
$156.75
|
| Rate for Payer: BCBS Traditional |
$165.00
|
| Rate for Payer: CASH_PRICE |
$132.00
|
| Rate for Payer: CIGNA Commercial |
$156.75
|
| Rate for Payer: CIGNA Medicare |
$148.50
|
| Rate for Payer: HUMANA Commercial |
$148.50
|
| Rate for Payer: MEDICAID Medicaid |
$151.80
|
| Rate for Payer: MEDICARE Medicare |
$115.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$156.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$160.05
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$156.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$156.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$140.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$132.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$132.00
|
|
|
DRAIN/INJ JOINT/BURSA W/US 20604
|
Facility
OP
|
$344.00
|
|
|
Service Code
|
CPT 20604
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$240.80 |
| Max. Negotiated Rate |
$344.00 |
| Rate for Payer: AETNA Commercial |
$326.80
|
| Rate for Payer: AETNA Medicare |
$309.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$326.80
|
| Rate for Payer: BCBS Healthlink |
$309.60
|
| Rate for Payer: BCBS HMK CHIP |
$309.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$309.60
|
| Rate for Payer: BCBS POS |
$326.80
|
| Rate for Payer: BCBS Traditional |
$344.00
|
| Rate for Payer: CASH_PRICE |
$275.20
|
| Rate for Payer: CIGNA Commercial |
$326.80
|
| Rate for Payer: CIGNA Medicare |
$309.60
|
| Rate for Payer: HUMANA Commercial |
$309.60
|
| Rate for Payer: MEDICAID Medicaid |
$316.48
|
| Rate for Payer: MEDICARE Medicare |
$240.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$326.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$333.68
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$326.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$326.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$292.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$275.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$275.20
|
|
|
DRAIN/INJ JOINT/BURSA W/US 20604
|
Facility
IP
|
$344.00
|
|
|
Service Code
|
CPT 20604
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$240.80 |
| Max. Negotiated Rate |
$344.00 |
| Rate for Payer: BCBS HMK CHIP |
$309.60
|
| Rate for Payer: AETNA Commercial |
$326.80
|
| Rate for Payer: AETNA Medicare |
$309.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$326.80
|
| Rate for Payer: BCBS Healthlink |
$309.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$309.60
|
| Rate for Payer: BCBS POS |
$326.80
|
| Rate for Payer: BCBS Traditional |
$344.00
|
| Rate for Payer: CASH_PRICE |
$275.20
|
| Rate for Payer: CIGNA Commercial |
$326.80
|
| Rate for Payer: CIGNA Medicare |
$309.60
|
| Rate for Payer: HUMANA Commercial |
$309.60
|
| Rate for Payer: MEDICAID Medicaid |
$316.48
|
| Rate for Payer: MEDICARE Medicare |
$240.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$326.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$333.68
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$326.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$326.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$292.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$275.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$275.20
|
|
|
DRAIN SPONGE
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
DRAIN SPONGE
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
DRONABINOL 2.5MG CAPSULE-NF
|
Facility
OP
|
$17.00
|
|
| Hospital Charge Code |
20221129
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: AETNA Commercial |
$16.15
|
| Rate for Payer: AETNA Medicare |
$15.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$16.15
|
| Rate for Payer: BCBS Healthlink |
$15.30
|
| Rate for Payer: BCBS HMK CHIP |
$15.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$15.30
|
| Rate for Payer: BCBS POS |
$16.15
|
| Rate for Payer: BCBS Traditional |
$17.00
|
| Rate for Payer: CASH_PRICE |
$13.60
|
| Rate for Payer: CIGNA Commercial |
$16.15
|
| Rate for Payer: CIGNA Medicare |
$15.30
|
| Rate for Payer: HUMANA Commercial |
$15.30
|
| Rate for Payer: MEDICAID Medicaid |
$15.64
|
| Rate for Payer: MEDICARE Medicare |
$11.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$16.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$16.49
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$16.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$14.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$13.60
|
|
|
DRONABINOL 2.5MG CAPSULE-NF
|
Facility
IP
|
$17.00
|
|
| Hospital Charge Code |
20221129
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: AETNA Commercial |
$16.15
|
| Rate for Payer: AETNA Medicare |
$15.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$16.15
|
| Rate for Payer: BCBS Healthlink |
$15.30
|
| Rate for Payer: BCBS HMK CHIP |
$15.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$15.30
|
| Rate for Payer: BCBS POS |
$16.15
|
| Rate for Payer: BCBS Traditional |
$17.00
|
| Rate for Payer: CASH_PRICE |
$13.60
|
| Rate for Payer: CIGNA Commercial |
$16.15
|
| Rate for Payer: CIGNA Medicare |
$15.30
|
| Rate for Payer: HUMANA Commercial |
$15.30
|
| Rate for Payer: MEDICAID Medicaid |
$15.64
|
| Rate for Payer: MEDICARE Medicare |
$11.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$16.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$16.49
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$16.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$14.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$13.60
|
|
|
DRUG BUSTER
|
Facility
OP
|
$9.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: AETNA Commercial |
$8.55
|
| Rate for Payer: AETNA Medicare |
$8.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$8.55
|
| Rate for Payer: BCBS Healthlink |
$8.10
|
| Rate for Payer: BCBS HMK CHIP |
$8.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$8.10
|
| Rate for Payer: BCBS POS |
$8.55
|
| Rate for Payer: BCBS Traditional |
$9.00
|
| Rate for Payer: CASH_PRICE |
$7.20
|
| Rate for Payer: CIGNA Commercial |
$8.55
|
| Rate for Payer: CIGNA Medicare |
$8.10
|
| Rate for Payer: HUMANA Commercial |
$8.10
|
| Rate for Payer: MEDICAID Medicaid |
$8.28
|
| Rate for Payer: MEDICARE Medicare |
$6.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$8.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$8.73
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$8.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$8.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$7.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$7.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$7.20
|
|
|
DRUG BUSTER
|
Facility
IP
|
$9.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: BCBS HMK CHIP |
$8.10
|
| Rate for Payer: AETNA Commercial |
$8.55
|
| Rate for Payer: AETNA Medicare |
$8.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$8.55
|
| Rate for Payer: BCBS Healthlink |
$8.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$8.10
|
| Rate for Payer: BCBS POS |
$8.55
|
| Rate for Payer: BCBS Traditional |
$9.00
|
| Rate for Payer: CASH_PRICE |
$7.20
|
| Rate for Payer: CIGNA Commercial |
$8.55
|
| Rate for Payer: CIGNA Medicare |
$8.10
|
| Rate for Payer: HUMANA Commercial |
$8.10
|
| Rate for Payer: MEDICAID Medicaid |
$8.28
|
| Rate for Payer: MEDICARE Medicare |
$6.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$8.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$8.73
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$8.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$8.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$7.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$7.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$7.20
|
|
|
DRUGS OF ABUSE SCREEN, URINE
|
Facility
OP
|
$198.00
|
|
|
Service Code
|
CPT 80306
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$138.60 |
| Max. Negotiated Rate |
$198.00 |
| Rate for Payer: AETNA Commercial |
$188.10
|
| Rate for Payer: AETNA Medicare |
$178.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$188.10
|
| Rate for Payer: BCBS Healthlink |
$178.20
|
| Rate for Payer: BCBS HMK CHIP |
$178.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$178.20
|
| Rate for Payer: BCBS POS |
$188.10
|
| Rate for Payer: BCBS Traditional |
$198.00
|
| Rate for Payer: CASH_PRICE |
$158.40
|
| Rate for Payer: CIGNA Commercial |
$188.10
|
| Rate for Payer: CIGNA Medicare |
$178.20
|
| Rate for Payer: HUMANA Commercial |
$178.20
|
| Rate for Payer: MEDICAID Medicaid |
$182.16
|
| Rate for Payer: MEDICARE Medicare |
$138.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$188.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$192.06
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$188.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$188.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$168.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$158.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$158.40
|
|
|
DRUGS OF ABUSE SCREEN, URINE
|
Facility
IP
|
$198.00
|
|
|
Service Code
|
CPT 80306
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$138.60 |
| Max. Negotiated Rate |
$198.00 |
| Rate for Payer: AETNA Commercial |
$188.10
|
| Rate for Payer: AETNA Medicare |
$178.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$188.10
|
| Rate for Payer: BCBS Healthlink |
$178.20
|
| Rate for Payer: BCBS HMK CHIP |
$178.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$178.20
|
| Rate for Payer: BCBS POS |
$188.10
|
| Rate for Payer: BCBS Traditional |
$198.00
|
| Rate for Payer: CASH_PRICE |
$158.40
|
| Rate for Payer: CIGNA Commercial |
$188.10
|
| Rate for Payer: CIGNA Medicare |
$178.20
|
| Rate for Payer: HUMANA Commercial |
$178.20
|
| Rate for Payer: MEDICAID Medicaid |
$182.16
|
| Rate for Payer: MEDICARE Medicare |
$138.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$188.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$192.06
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$188.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$188.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$168.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$158.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$158.40
|
|
|
DULOXETINE CAP [30 MG]
|
Facility
OP
|
$26.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DULOXETINE CAP [30 MG]
|
Facility
IP
|
$26.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
DULOXETINE ER 60MG CAPS (CYMBALTA)
|
Facility
IP
|
$26.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
