|
EYE STREAM IRRIGATING RINSE [4 OZ]
|
Facility
OP
|
$117.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$117.00 |
| Rate for Payer: AETNA Commercial |
$111.15
|
| Rate for Payer: AETNA Medicare |
$105.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$111.15
|
| Rate for Payer: BCBS Healthlink |
$105.30
|
| Rate for Payer: BCBS HMK CHIP |
$105.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$105.30
|
| Rate for Payer: BCBS POS |
$111.15
|
| Rate for Payer: BCBS Traditional |
$117.00
|
| Rate for Payer: CASH_PRICE |
$93.60
|
| Rate for Payer: CIGNA Commercial |
$111.15
|
| Rate for Payer: CIGNA Medicare |
$105.30
|
| Rate for Payer: HUMANA Commercial |
$105.30
|
| Rate for Payer: MEDICAID Medicaid |
$107.64
|
| Rate for Payer: MEDICARE Medicare |
$81.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$111.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$113.49
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$111.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$111.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$99.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$93.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$93.60
|
|
|
EZ SCRUB
|
Facility
IP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
EZ SCRUB
|
Facility
OP
|
$4.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
EZ WRAP FOAM TUBES
|
Facility
IP
|
$11.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: BCBS HMK CHIP |
$9.90
|
| Rate for Payer: AETNA Commercial |
$10.45
|
| Rate for Payer: AETNA Medicare |
$9.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$10.45
|
| Rate for Payer: BCBS Healthlink |
$9.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$9.90
|
| Rate for Payer: BCBS POS |
$10.45
|
| Rate for Payer: BCBS Traditional |
$11.00
|
| Rate for Payer: CASH_PRICE |
$8.80
|
| Rate for Payer: CIGNA Commercial |
$10.45
|
| Rate for Payer: CIGNA Medicare |
$9.90
|
| Rate for Payer: HUMANA Commercial |
$9.90
|
| Rate for Payer: MEDICAID Medicaid |
$10.12
|
| Rate for Payer: MEDICARE Medicare |
$7.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$10.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$10.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$10.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$10.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$9.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$8.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$8.80
|
|
|
EZ WRAP FOAM TUBES
|
Facility
OP
|
$11.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: AETNA Commercial |
$10.45
|
| Rate for Payer: AETNA Medicare |
$9.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$10.45
|
| Rate for Payer: BCBS Healthlink |
$9.90
|
| Rate for Payer: BCBS HMK CHIP |
$9.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$9.90
|
| Rate for Payer: BCBS POS |
$10.45
|
| Rate for Payer: BCBS Traditional |
$11.00
|
| Rate for Payer: CASH_PRICE |
$8.80
|
| Rate for Payer: CIGNA Commercial |
$10.45
|
| Rate for Payer: CIGNA Medicare |
$9.90
|
| Rate for Payer: HUMANA Commercial |
$9.90
|
| Rate for Payer: MEDICAID Medicaid |
$10.12
|
| Rate for Payer: MEDICARE Medicare |
$7.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$10.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$10.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$10.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$10.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$9.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$8.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$8.80
|
|
|
FACTOR IX ACTIVITY (086298)
|
Facility
IP
|
$197.00
|
|
|
Service Code
|
CPT 85250
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: AETNA Commercial |
$187.15
|
| Rate for Payer: AETNA Medicare |
$177.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$187.15
|
| Rate for Payer: BCBS Healthlink |
$177.30
|
| Rate for Payer: BCBS HMK CHIP |
$177.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$177.30
|
| Rate for Payer: BCBS POS |
$187.15
|
| Rate for Payer: BCBS Traditional |
$197.00
|
| Rate for Payer: CASH_PRICE |
$157.60
|
| Rate for Payer: CIGNA Commercial |
$187.15
|
| Rate for Payer: CIGNA Medicare |
$177.30
|
| Rate for Payer: HUMANA Commercial |
$177.30
|
| Rate for Payer: MEDICAID Medicaid |
$181.24
|
| Rate for Payer: MEDICARE Medicare |
$137.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$187.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$191.09
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$187.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$187.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$167.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$157.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$157.60
|
|
|
FACTOR IX ACTIVITY (086298)
|
Facility
OP
|
$197.00
|
|
|
Service Code
|
CPT 85250
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: AETNA Commercial |
$187.15
|
| Rate for Payer: AETNA Medicare |
$177.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$187.15
|
| Rate for Payer: BCBS Healthlink |
$177.30
|
| Rate for Payer: BCBS HMK CHIP |
$177.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$177.30
|
| Rate for Payer: BCBS POS |
$187.15
|
| Rate for Payer: BCBS Traditional |
$197.00
|
| Rate for Payer: CASH_PRICE |
$157.60
|
| Rate for Payer: CIGNA Commercial |
$187.15
|
| Rate for Payer: CIGNA Medicare |
$177.30
|
| Rate for Payer: HUMANA Commercial |
$177.30
|
| Rate for Payer: MEDICAID Medicaid |
$181.24
|
| Rate for Payer: MEDICARE Medicare |
$137.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$187.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$191.09
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$187.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$187.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$167.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$157.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$157.60
|
|
|
FACTOR V ACTIVITY (086249)
|
Facility
OP
|
$197.00
|
|
|
Service Code
|
CPT 85220
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: AETNA Commercial |
$187.15
|
| Rate for Payer: AETNA Medicare |
$177.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$187.15
|
| Rate for Payer: BCBS Healthlink |
$177.30
|
| Rate for Payer: BCBS HMK CHIP |
$177.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$177.30
|
| Rate for Payer: BCBS POS |
$187.15
|
| Rate for Payer: BCBS Traditional |
$197.00
|
| Rate for Payer: CASH_PRICE |
$157.60
|
| Rate for Payer: CIGNA Commercial |
$187.15
|
| Rate for Payer: CIGNA Medicare |
$177.30
|
| Rate for Payer: HUMANA Commercial |
$177.30
|
| Rate for Payer: MEDICAID Medicaid |
$181.24
|
| Rate for Payer: MEDICARE Medicare |
$137.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$187.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$191.09
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$187.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$187.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$167.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$157.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$157.60
|
|
|
FACTOR V ACTIVITY (086249)
|
Facility
IP
|
$197.00
|
|
|
Service Code
|
CPT 85220
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: BCBS HMK CHIP |
$177.30
|
| Rate for Payer: AETNA Commercial |
$187.15
|
| Rate for Payer: AETNA Medicare |
$177.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$187.15
|
| Rate for Payer: BCBS Healthlink |
$177.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$177.30
|
| Rate for Payer: BCBS POS |
$187.15
|
| Rate for Payer: BCBS Traditional |
$197.00
|
| Rate for Payer: CASH_PRICE |
$157.60
|
| Rate for Payer: CIGNA Commercial |
$187.15
|
| Rate for Payer: CIGNA Medicare |
$177.30
|
| Rate for Payer: HUMANA Commercial |
$177.30
|
| Rate for Payer: MEDICAID Medicaid |
$181.24
|
| Rate for Payer: MEDICARE Medicare |
$137.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$187.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$191.09
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$187.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$187.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$167.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$157.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$157.60
|
|
|
FACTOR VIII ASSAY (086264)
|
Facility
OP
|
$197.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: AETNA Commercial |
$187.15
|
| Rate for Payer: AETNA Medicare |
$177.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$187.15
|
| Rate for Payer: BCBS Healthlink |
$177.30
|
| Rate for Payer: BCBS HMK CHIP |
$177.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$177.30
|
| Rate for Payer: BCBS POS |
$187.15
|
| Rate for Payer: BCBS Traditional |
$197.00
|
| Rate for Payer: CASH_PRICE |
$157.60
|
| Rate for Payer: CIGNA Commercial |
$187.15
|
| Rate for Payer: CIGNA Medicare |
$177.30
|
| Rate for Payer: HUMANA Commercial |
$177.30
|
| Rate for Payer: MEDICAID Medicaid |
$181.24
|
| Rate for Payer: MEDICARE Medicare |
$137.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$187.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$191.09
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$187.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$187.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$167.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$157.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$157.60
|
|
|
FACTOR VIII ASSAY (086264)
|
Facility
IP
|
$197.00
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$137.90 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: BCBS HMK CHIP |
$177.30
|
| Rate for Payer: AETNA Commercial |
$187.15
|
| Rate for Payer: AETNA Medicare |
$177.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$187.15
|
| Rate for Payer: BCBS Healthlink |
$177.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$177.30
|
| Rate for Payer: BCBS POS |
$187.15
|
| Rate for Payer: BCBS Traditional |
$197.00
|
| Rate for Payer: CASH_PRICE |
$157.60
|
| Rate for Payer: CIGNA Commercial |
$187.15
|
| Rate for Payer: CIGNA Medicare |
$177.30
|
| Rate for Payer: HUMANA Commercial |
$177.30
|
| Rate for Payer: MEDICAID Medicaid |
$181.24
|
| Rate for Payer: MEDICARE Medicare |
$137.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$187.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$191.09
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$187.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$187.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$167.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$157.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$157.60
|
|
|
FACTOR V LEIDEN MUTATION (511154)
|
Facility
IP
|
$259.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$259.00 |
| Rate for Payer: AETNA Commercial |
$246.05
|
| Rate for Payer: AETNA Medicare |
$233.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$246.05
|
| Rate for Payer: BCBS Healthlink |
$233.10
|
| Rate for Payer: BCBS HMK CHIP |
$233.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$233.10
|
| Rate for Payer: BCBS POS |
$246.05
|
| Rate for Payer: BCBS Traditional |
$259.00
|
| Rate for Payer: CASH_PRICE |
$207.20
|
| Rate for Payer: CIGNA Commercial |
$246.05
|
| Rate for Payer: CIGNA Medicare |
$233.10
|
| Rate for Payer: HUMANA Commercial |
$233.10
|
| Rate for Payer: MEDICAID Medicaid |
$238.28
|
| Rate for Payer: MEDICARE Medicare |
$181.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$246.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$251.23
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$246.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$246.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$220.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$207.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$207.20
|
|
|
FACTOR V LEIDEN MUTATION (511154)
|
Facility
OP
|
$259.00
|
|
|
Service Code
|
CPT 81241
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$259.00 |
| Rate for Payer: AETNA Commercial |
$246.05
|
| Rate for Payer: AETNA Medicare |
$233.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$246.05
|
| Rate for Payer: BCBS Healthlink |
$233.10
|
| Rate for Payer: BCBS HMK CHIP |
$233.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$233.10
|
| Rate for Payer: BCBS POS |
$246.05
|
| Rate for Payer: BCBS Traditional |
$259.00
|
| Rate for Payer: CASH_PRICE |
$207.20
|
| Rate for Payer: CIGNA Commercial |
$246.05
|
| Rate for Payer: CIGNA Medicare |
$233.10
|
| Rate for Payer: HUMANA Commercial |
$233.10
|
| Rate for Payer: MEDICAID Medicaid |
$238.28
|
| Rate for Payer: MEDICARE Medicare |
$181.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$246.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$251.23
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$246.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$246.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$220.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$207.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$207.20
|
|
|
FAMILY PSYCHOTHERAPY W/O PATIENT
|
Facility
OP
|
$240.00
|
|
|
Service Code
|
CPT 90846
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$168.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: AETNA Commercial |
$228.00
|
| Rate for Payer: AETNA Medicare |
$216.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$228.00
|
| Rate for Payer: BCBS Healthlink |
$216.00
|
| Rate for Payer: BCBS HMK CHIP |
$216.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$216.00
|
| Rate for Payer: BCBS POS |
$228.00
|
| Rate for Payer: BCBS Traditional |
$240.00
|
| Rate for Payer: CASH_PRICE |
$192.00
|
| Rate for Payer: CIGNA Commercial |
$228.00
|
| Rate for Payer: CIGNA Medicare |
$216.00
|
| Rate for Payer: HUMANA Commercial |
$216.00
|
| Rate for Payer: MEDICAID Medicaid |
$220.80
|
| Rate for Payer: MEDICARE Medicare |
$168.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$228.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$232.80
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$228.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$228.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$204.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$192.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$192.00
|
|
|
FAMILY PSYCHOTHERAPY W/O PATIENT
|
Facility
IP
|
$240.00
|
|
|
Service Code
|
CPT 90846
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$168.00 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: AETNA Commercial |
$228.00
|
| Rate for Payer: AETNA Medicare |
$216.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$228.00
|
| Rate for Payer: BCBS Healthlink |
$216.00
|
| Rate for Payer: BCBS HMK CHIP |
$216.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$216.00
|
| Rate for Payer: BCBS POS |
$228.00
|
| Rate for Payer: BCBS Traditional |
$240.00
|
| Rate for Payer: CASH_PRICE |
$192.00
|
| Rate for Payer: CIGNA Commercial |
$228.00
|
| Rate for Payer: CIGNA Medicare |
$216.00
|
| Rate for Payer: HUMANA Commercial |
$216.00
|
| Rate for Payer: MEDICAID Medicaid |
$220.80
|
| Rate for Payer: MEDICARE Medicare |
$168.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$228.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$232.80
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$228.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$228.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$204.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$192.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$192.00
|
|
|
FAMILY THERAPY W/ PATIENT PRESENT
|
Facility
OP
|
$296.00
|
|
|
Service Code
|
CPT 90847
|
| Hospital Charge Code |
20230101
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$207.20 |
| Max. Negotiated Rate |
$296.00 |
| Rate for Payer: AETNA Commercial |
$281.20
|
| Rate for Payer: AETNA Medicare |
$266.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$281.20
|
| Rate for Payer: BCBS Healthlink |
$266.40
|
| Rate for Payer: BCBS HMK CHIP |
$266.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$266.40
|
| Rate for Payer: BCBS POS |
$281.20
|
| Rate for Payer: BCBS Traditional |
$296.00
|
| Rate for Payer: CASH_PRICE |
$236.80
|
| Rate for Payer: CIGNA Commercial |
$281.20
|
| Rate for Payer: CIGNA Medicare |
$266.40
|
| Rate for Payer: HUMANA Commercial |
$266.40
|
| Rate for Payer: MEDICAID Medicaid |
$272.32
|
| Rate for Payer: MEDICARE Medicare |
$207.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$281.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$287.12
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$281.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$281.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$251.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$236.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$236.80
|
|
|
FAMILY THERAPY W/ PATIENT PRESENT
|
Facility
IP
|
$296.00
|
|
|
Service Code
|
CPT 90847
|
| Hospital Charge Code |
20230101
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$207.20 |
| Max. Negotiated Rate |
$296.00 |
| Rate for Payer: BCBS HMK CHIP |
$266.40
|
| Rate for Payer: AETNA Commercial |
$281.20
|
| Rate for Payer: AETNA Medicare |
$266.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$281.20
|
| Rate for Payer: BCBS Healthlink |
$266.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$266.40
|
| Rate for Payer: BCBS POS |
$281.20
|
| Rate for Payer: BCBS Traditional |
$296.00
|
| Rate for Payer: CASH_PRICE |
$236.80
|
| Rate for Payer: CIGNA Commercial |
$281.20
|
| Rate for Payer: CIGNA Medicare |
$266.40
|
| Rate for Payer: HUMANA Commercial |
$266.40
|
| Rate for Payer: MEDICAID Medicaid |
$272.32
|
| Rate for Payer: MEDICARE Medicare |
$207.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$281.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$287.12
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$281.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$281.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$251.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$236.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$236.80
|
|
|
FAMOTIDINE INJ [20 MG/2 ML]
|
Facility
OP
|
$26.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
FAMOTIDINE INJ [20 MG/2 ML]
|
Facility
IP
|
$26.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
FAMOTIDINE TAB [20 MG]
|
Facility
OP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
FAMOTIDINE TAB [20 MG]
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: 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
|
|
|
FARXIGA 5 MG TABLET
|
Facility
OP
|
$77.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$77.00 |
| Rate for Payer: AETNA Commercial |
$73.15
|
| Rate for Payer: AETNA Medicare |
$69.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$73.15
|
| Rate for Payer: BCBS Healthlink |
$69.30
|
| Rate for Payer: BCBS HMK CHIP |
$69.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$69.30
|
| Rate for Payer: BCBS POS |
$73.15
|
| Rate for Payer: BCBS Traditional |
$77.00
|
| Rate for Payer: CASH_PRICE |
$61.60
|
| Rate for Payer: CIGNA Commercial |
$73.15
|
| Rate for Payer: CIGNA Medicare |
$69.30
|
| Rate for Payer: HUMANA Commercial |
$69.30
|
| Rate for Payer: MEDICAID Medicaid |
$70.84
|
| Rate for Payer: MEDICARE Medicare |
$53.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$73.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$74.69
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$73.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$73.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$65.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$61.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$61.60
|
|
|
FARXIGA 5 MG TABLET
|
Facility
IP
|
$77.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$53.90 |
| Max. Negotiated Rate |
$77.00 |
| Rate for Payer: AETNA Commercial |
$73.15
|
| Rate for Payer: AETNA Medicare |
$69.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$73.15
|
| Rate for Payer: BCBS Healthlink |
$69.30
|
| Rate for Payer: BCBS HMK CHIP |
$69.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$69.30
|
| Rate for Payer: BCBS POS |
$73.15
|
| Rate for Payer: BCBS Traditional |
$77.00
|
| Rate for Payer: CASH_PRICE |
$61.60
|
| Rate for Payer: CIGNA Commercial |
$73.15
|
| Rate for Payer: CIGNA Medicare |
$69.30
|
| Rate for Payer: HUMANA Commercial |
$69.30
|
| Rate for Payer: MEDICAID Medicaid |
$70.84
|
| Rate for Payer: MEDICARE Medicare |
$53.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$73.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$74.69
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$73.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$73.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$65.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$61.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$61.60
|
|
|
FEBUXOSTAT TAB 40MG NON FORMULARY
|
Facility
OP
|
$10.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: AETNA Commercial |
$9.50
|
| Rate for Payer: AETNA Medicare |
$9.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$9.50
|
| Rate for Payer: BCBS Healthlink |
$9.00
|
| Rate for Payer: BCBS HMK CHIP |
$9.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$9.00
|
| Rate for Payer: BCBS POS |
$9.50
|
| Rate for Payer: BCBS Traditional |
$10.00
|
| Rate for Payer: CASH_PRICE |
$8.00
|
| Rate for Payer: CIGNA Commercial |
$9.50
|
| Rate for Payer: CIGNA Medicare |
$9.00
|
| Rate for Payer: HUMANA Commercial |
$9.00
|
| Rate for Payer: MEDICAID Medicaid |
$9.20
|
| Rate for Payer: MEDICARE Medicare |
$7.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$9.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$9.70
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$9.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$9.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$8.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$8.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$8.00
|
|
|
FEBUXOSTAT TAB 40MG NON FORMULARY
|
Facility
IP
|
$10.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$10.00 |
| Rate for Payer: BCBS HMK CHIP |
$9.00
|
| Rate for Payer: AETNA Commercial |
$9.50
|
| Rate for Payer: AETNA Medicare |
$9.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$9.50
|
| Rate for Payer: BCBS Healthlink |
$9.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$9.00
|
| Rate for Payer: BCBS POS |
$9.50
|
| Rate for Payer: BCBS Traditional |
$10.00
|
| Rate for Payer: CASH_PRICE |
$8.00
|
| Rate for Payer: CIGNA Commercial |
$9.50
|
| Rate for Payer: CIGNA Medicare |
$9.00
|
| Rate for Payer: HUMANA Commercial |
$9.00
|
| Rate for Payer: MEDICAID Medicaid |
$9.20
|
| Rate for Payer: MEDICARE Medicare |
$7.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$9.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$9.70
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$9.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$9.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$8.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$8.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$8.00
|
|
