|
GENTAMICIN, PEAK (007162)
|
Facility
OP
|
$197.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
GENTAMICIN, PEAK (007162)
|
Facility
IP
|
$197.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
GENTAMICIN, TROUGH (007163)
|
Facility
IP
|
$197.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
GENTAMICIN, TROUGH (007163)
|
Facility
OP
|
$197.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
GENTEAL OPTH GTTS
|
Facility
IP
|
$25.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
GENTEAL OPTH GTTS
|
Facility
OP
|
$25.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| 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
|
|
|
GESTATIONAL DIABETES SCREEN, 1 HR
|
Facility
OP
|
$55.00
|
|
|
Service Code
|
CPT 82950
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: AETNA Commercial |
$52.25
|
| Rate for Payer: AETNA Medicare |
$49.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$52.25
|
| Rate for Payer: BCBS Healthlink |
$49.50
|
| Rate for Payer: BCBS HMK CHIP |
$49.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$49.50
|
| Rate for Payer: BCBS POS |
$52.25
|
| Rate for Payer: BCBS Traditional |
$55.00
|
| Rate for Payer: CASH_PRICE |
$44.00
|
| Rate for Payer: CIGNA Commercial |
$52.25
|
| Rate for Payer: CIGNA Medicare |
$49.50
|
| Rate for Payer: HUMANA Commercial |
$49.50
|
| Rate for Payer: MEDICAID Medicaid |
$50.60
|
| Rate for Payer: MEDICARE Medicare |
$38.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$52.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$53.35
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$52.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$52.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$46.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$44.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$44.00
|
|
|
GESTATIONAL DIABETES SCREEN, 1 HR
|
Facility
IP
|
$55.00
|
|
|
Service Code
|
CPT 82950
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$38.50 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: BCBS HMK CHIP |
$49.50
|
| Rate for Payer: AETNA Commercial |
$52.25
|
| Rate for Payer: AETNA Medicare |
$49.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$52.25
|
| Rate for Payer: BCBS Healthlink |
$49.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$49.50
|
| Rate for Payer: BCBS POS |
$52.25
|
| Rate for Payer: BCBS Traditional |
$55.00
|
| Rate for Payer: CASH_PRICE |
$44.00
|
| Rate for Payer: CIGNA Commercial |
$52.25
|
| Rate for Payer: CIGNA Medicare |
$49.50
|
| Rate for Payer: HUMANA Commercial |
$49.50
|
| Rate for Payer: MEDICAID Medicaid |
$50.60
|
| Rate for Payer: MEDICARE Medicare |
$38.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$52.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$53.35
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$52.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$52.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$46.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$44.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$44.00
|
|
|
GGT (001958)
|
Facility
IP
|
$9.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
GGT (001958)
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
GIARDIA LAMBLIA, EIA (182204)
|
Facility
IP
|
$45.00
|
|
|
Service Code
|
CPT 87329
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: AETNA Commercial |
$42.75
|
| Rate for Payer: AETNA Medicare |
$40.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$42.75
|
| Rate for Payer: BCBS Healthlink |
$40.50
|
| Rate for Payer: BCBS HMK CHIP |
$40.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$40.50
|
| Rate for Payer: BCBS POS |
$42.75
|
| Rate for Payer: BCBS Traditional |
$45.00
|
| Rate for Payer: CASH_PRICE |
$36.00
|
| Rate for Payer: CIGNA Commercial |
$42.75
|
| Rate for Payer: CIGNA Medicare |
$40.50
|
| Rate for Payer: HUMANA Commercial |
$40.50
|
| Rate for Payer: MEDICAID Medicaid |
$41.40
|
| Rate for Payer: MEDICARE Medicare |
$31.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$42.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$43.65
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$42.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$42.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$38.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$36.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$36.00
|
|
|
GIARDIA LAMBLIA, EIA (182204)
|
Facility
OP
|
$45.00
|
|
|
Service Code
|
CPT 87329
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: AETNA Commercial |
$42.75
|
| Rate for Payer: AETNA Medicare |
$40.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$42.75
|
| Rate for Payer: BCBS Healthlink |
$40.50
|
| Rate for Payer: BCBS HMK CHIP |
$40.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$40.50
|
| Rate for Payer: BCBS POS |
$42.75
|
| Rate for Payer: BCBS Traditional |
$45.00
|
| Rate for Payer: CASH_PRICE |
$36.00
|
| Rate for Payer: CIGNA Commercial |
$42.75
|
| Rate for Payer: CIGNA Medicare |
$40.50
|
| Rate for Payer: HUMANA Commercial |
$40.50
|
| Rate for Payer: MEDICAID Medicaid |
$41.40
|
| Rate for Payer: MEDICARE Medicare |
$31.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$42.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$43.65
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$42.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$42.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$38.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$36.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$36.00
|
|
|
GI COCKTAIL
|
Facility
IP
|
$21.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: AETNA Commercial |
$19.95
|
| Rate for Payer: AETNA Medicare |
$18.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
GI COCKTAIL
|
Facility
OP
|
$21.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.70 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: AETNA Commercial |
$19.95
|
| Rate for Payer: AETNA Medicare |
$18.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$19.95
|
| Rate for Payer: BCBS Healthlink |
$18.90
|
| Rate for Payer: BCBS HMK CHIP |
$18.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$18.90
|
| Rate for Payer: BCBS POS |
$19.95
|
| Rate for Payer: BCBS Traditional |
$21.00
|
| Rate for Payer: CASH_PRICE |
$16.80
|
| Rate for Payer: CIGNA Commercial |
$19.95
|
| Rate for Payer: CIGNA Medicare |
$18.90
|
| Rate for Payer: HUMANA Commercial |
$18.90
|
| Rate for Payer: MEDICAID Medicaid |
$19.32
|
| Rate for Payer: MEDICARE Medicare |
$14.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$19.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$20.37
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$19.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$19.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$17.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$16.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$16.80
|
|
|
GLIADIN ANTIBODY IGA (161646)
|
Facility
OP
|
$175.00
|
|
|
Service Code
|
CPT 86258
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: AETNA Commercial |
$166.25
|
| Rate for Payer: AETNA Medicare |
$157.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$166.25
|
| Rate for Payer: BCBS Healthlink |
$157.50
|
| Rate for Payer: BCBS HMK CHIP |
$157.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$157.50
|
| Rate for Payer: BCBS POS |
$166.25
|
| Rate for Payer: BCBS Traditional |
$175.00
|
| Rate for Payer: CASH_PRICE |
$140.00
|
| Rate for Payer: CIGNA Commercial |
$166.25
|
| Rate for Payer: CIGNA Medicare |
$157.50
|
| Rate for Payer: HUMANA Commercial |
$157.50
|
| Rate for Payer: MEDICAID Medicaid |
$161.00
|
| Rate for Payer: MEDICARE Medicare |
$122.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$166.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$169.75
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$166.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$166.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$148.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$140.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$140.00
|
|
|
GLIADIN ANTIBODY IGA (161646)
|
Facility
IP
|
$175.00
|
|
|
Service Code
|
CPT 86258
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: BCBS HMK CHIP |
$157.50
|
| Rate for Payer: AETNA Commercial |
$166.25
|
| Rate for Payer: AETNA Medicare |
$157.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$166.25
|
| Rate for Payer: BCBS Healthlink |
$157.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$157.50
|
| Rate for Payer: BCBS POS |
$166.25
|
| Rate for Payer: BCBS Traditional |
$175.00
|
| Rate for Payer: CASH_PRICE |
$140.00
|
| Rate for Payer: CIGNA Commercial |
$166.25
|
| Rate for Payer: CIGNA Medicare |
$157.50
|
| Rate for Payer: HUMANA Commercial |
$157.50
|
| Rate for Payer: MEDICAID Medicaid |
$161.00
|
| Rate for Payer: MEDICARE Medicare |
$122.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$166.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$169.75
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$166.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$166.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$148.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$140.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$140.00
|
|
|
GLIADIN ANTIBODY IGG (161687)
|
Facility
OP
|
$184.00
|
|
|
Service Code
|
CPT 86258
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: AETNA Commercial |
$174.80
|
| Rate for Payer: AETNA Medicare |
$165.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$174.80
|
| Rate for Payer: BCBS Healthlink |
$165.60
|
| Rate for Payer: BCBS HMK CHIP |
$165.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$165.60
|
| Rate for Payer: BCBS POS |
$174.80
|
| Rate for Payer: BCBS Traditional |
$184.00
|
| Rate for Payer: CASH_PRICE |
$147.20
|
| Rate for Payer: CIGNA Commercial |
$174.80
|
| Rate for Payer: CIGNA Medicare |
$165.60
|
| Rate for Payer: HUMANA Commercial |
$165.60
|
| Rate for Payer: MEDICAID Medicaid |
$169.28
|
| Rate for Payer: MEDICARE Medicare |
$128.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$174.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$178.48
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$174.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$174.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$156.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$147.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$147.20
|
|
|
GLIADIN ANTIBODY IGG (161687)
|
Facility
IP
|
$184.00
|
|
|
Service Code
|
CPT 86258
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: AETNA Commercial |
$174.80
|
| Rate for Payer: AETNA Medicare |
$165.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$174.80
|
| Rate for Payer: BCBS Healthlink |
$165.60
|
| Rate for Payer: BCBS HMK CHIP |
$165.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$165.60
|
| Rate for Payer: BCBS POS |
$174.80
|
| Rate for Payer: BCBS Traditional |
$184.00
|
| Rate for Payer: CASH_PRICE |
$147.20
|
| Rate for Payer: CIGNA Commercial |
$174.80
|
| Rate for Payer: CIGNA Medicare |
$165.60
|
| Rate for Payer: HUMANA Commercial |
$165.60
|
| Rate for Payer: MEDICAID Medicaid |
$169.28
|
| Rate for Payer: MEDICARE Medicare |
$128.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$174.80
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$178.48
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$174.80
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$174.80
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$156.40
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$147.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$147.20
|
|
|
GLIPIZIDE TAB [5 MG] NONFORMULARY
|
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
|
|
|
GLIPIZIDE TAB [5 MG] NONFORMULARY
|
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
|
|
|
GLUCAGON (004622)
|
Facility
IP
|
$92.00
|
|
|
Service Code
|
CPT 82943
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.40 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: AETNA Commercial |
$87.40
|
| Rate for Payer: AETNA Medicare |
$82.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$87.40
|
| Rate for Payer: BCBS Healthlink |
$82.80
|
| Rate for Payer: BCBS HMK CHIP |
$82.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$82.80
|
| Rate for Payer: BCBS POS |
$87.40
|
| Rate for Payer: BCBS Traditional |
$92.00
|
| Rate for Payer: CASH_PRICE |
$73.60
|
| Rate for Payer: CIGNA Commercial |
$87.40
|
| Rate for Payer: CIGNA Medicare |
$82.80
|
| Rate for Payer: HUMANA Commercial |
$82.80
|
| Rate for Payer: MEDICAID Medicaid |
$84.64
|
| Rate for Payer: MEDICARE Medicare |
$64.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$87.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$89.24
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$87.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$87.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$78.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$73.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$73.60
|
|
|
GLUCAGON (004622)
|
Facility
OP
|
$92.00
|
|
|
Service Code
|
CPT 82943
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$64.40 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: AETNA Commercial |
$87.40
|
| Rate for Payer: AETNA Medicare |
$82.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$87.40
|
| Rate for Payer: BCBS Healthlink |
$82.80
|
| Rate for Payer: BCBS HMK CHIP |
$82.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$82.80
|
| Rate for Payer: BCBS POS |
$87.40
|
| Rate for Payer: BCBS Traditional |
$92.00
|
| Rate for Payer: CASH_PRICE |
$73.60
|
| Rate for Payer: CIGNA Commercial |
$87.40
|
| Rate for Payer: CIGNA Medicare |
$82.80
|
| Rate for Payer: HUMANA Commercial |
$82.80
|
| Rate for Payer: MEDICAID Medicaid |
$84.64
|
| Rate for Payer: MEDICARE Medicare |
$64.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$87.40
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$89.24
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$87.40
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$87.40
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$78.20
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$73.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$73.60
|
|
|
GLUCAGON KIT [1 MG]
|
Facility
IP
|
$673.00
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$471.10 |
| Max. Negotiated Rate |
$673.00 |
| Rate for Payer: BCBS HMK CHIP |
$605.70
|
| Rate for Payer: AETNA Commercial |
$639.35
|
| Rate for Payer: AETNA Medicare |
$605.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$639.35
|
| Rate for Payer: BCBS Healthlink |
$605.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$605.70
|
| Rate for Payer: BCBS POS |
$639.35
|
| Rate for Payer: BCBS Traditional |
$673.00
|
| Rate for Payer: CASH_PRICE |
$538.40
|
| Rate for Payer: CIGNA Commercial |
$639.35
|
| Rate for Payer: CIGNA Medicare |
$605.70
|
| Rate for Payer: HUMANA Commercial |
$605.70
|
| Rate for Payer: MEDICAID Medicaid |
$619.16
|
| Rate for Payer: MEDICARE Medicare |
$471.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$639.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$652.81
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$639.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$639.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$572.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$538.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$538.40
|
|
|
GLUCAGON KIT [1 MG]
|
Facility
OP
|
$673.00
|
|
|
Service Code
|
CPT J1610
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$471.10 |
| Max. Negotiated Rate |
$673.00 |
| Rate for Payer: AETNA Commercial |
$639.35
|
| Rate for Payer: AETNA Medicare |
$605.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$639.35
|
| Rate for Payer: BCBS Healthlink |
$605.70
|
| Rate for Payer: BCBS HMK CHIP |
$605.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$605.70
|
| Rate for Payer: BCBS POS |
$639.35
|
| Rate for Payer: BCBS Traditional |
$673.00
|
| Rate for Payer: CASH_PRICE |
$538.40
|
| Rate for Payer: CIGNA Commercial |
$639.35
|
| Rate for Payer: CIGNA Medicare |
$605.70
|
| Rate for Payer: HUMANA Commercial |
$605.70
|
| Rate for Payer: MEDICAID Medicaid |
$619.16
|
| Rate for Payer: MEDICARE Medicare |
$471.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$639.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$652.81
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$639.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$639.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$572.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$538.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$538.40
|
|
|
GLUCOGON HYDROCHLORIDE 1MG RVH
|
Facility
OP
|
$79.00
|
|
|
Service Code
|
CPT J1610 QN
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: AETNA Commercial |
$75.05
|
| Rate for Payer: AETNA Medicare |
$71.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$75.05
|
| Rate for Payer: BCBS Healthlink |
$71.10
|
| Rate for Payer: BCBS HMK CHIP |
$71.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$71.10
|
| Rate for Payer: BCBS POS |
$75.05
|
| Rate for Payer: BCBS Traditional |
$79.00
|
| Rate for Payer: CASH_PRICE |
$63.20
|
| Rate for Payer: CIGNA Commercial |
$75.05
|
| Rate for Payer: CIGNA Medicare |
$71.10
|
| Rate for Payer: HUMANA Commercial |
$71.10
|
| Rate for Payer: MEDICAID Medicaid |
$72.68
|
| Rate for Payer: MEDICARE Medicare |
$55.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$75.05
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$76.63
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$75.05
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$75.05
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$67.15
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$63.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$63.20
|
|
