|
HSV TYPES 1/2, DNA PCR (138651)
|
Facility
OP
|
$433.00
|
|
|
Service Code
|
CPT 87529
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$303.10 |
| Max. Negotiated Rate |
$433.00 |
| Rate for Payer: AETNA Commercial |
$411.35
|
| Rate for Payer: AETNA Medicare |
$389.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$411.35
|
| Rate for Payer: BCBS Healthlink |
$389.70
|
| Rate for Payer: BCBS HMK CHIP |
$389.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$389.70
|
| Rate for Payer: BCBS POS |
$411.35
|
| Rate for Payer: BCBS Traditional |
$433.00
|
| Rate for Payer: CASH_PRICE |
$346.40
|
| Rate for Payer: CIGNA Commercial |
$411.35
|
| Rate for Payer: CIGNA Medicare |
$389.70
|
| Rate for Payer: HUMANA Commercial |
$389.70
|
| Rate for Payer: MEDICAID Medicaid |
$398.36
|
| Rate for Payer: MEDICARE Medicare |
$303.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$411.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$420.01
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$411.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$411.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$368.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$346.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$346.40
|
|
|
HSV TYPES 1/2, DNA PCR (138651)
|
Facility
IP
|
$433.00
|
|
|
Service Code
|
CPT 87529
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$303.10 |
| Max. Negotiated Rate |
$433.00 |
| Rate for Payer: BCBS HMK CHIP |
$389.70
|
| Rate for Payer: AETNA Commercial |
$411.35
|
| Rate for Payer: AETNA Medicare |
$389.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$411.35
|
| Rate for Payer: BCBS Healthlink |
$389.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$389.70
|
| Rate for Payer: BCBS POS |
$411.35
|
| Rate for Payer: BCBS Traditional |
$433.00
|
| Rate for Payer: CASH_PRICE |
$346.40
|
| Rate for Payer: CIGNA Commercial |
$411.35
|
| Rate for Payer: CIGNA Medicare |
$389.70
|
| Rate for Payer: HUMANA Commercial |
$389.70
|
| Rate for Payer: MEDICAID Medicaid |
$398.36
|
| Rate for Payer: MEDICARE Medicare |
$303.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$411.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$420.01
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$411.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$411.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$368.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$346.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$346.40
|
|
|
HYDRALAZINE TAB [10MG]
|
Facility
IP
|
$8.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: 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
|
|
|
HYDRALAZINE TAB [10MG]
|
Facility
OP
|
$8.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
HYDRALAZINE TAB [50 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
|
|
|
HYDRALAZINE TAB [50 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
|
|
|
HYDRATION IV INFUSION, ADD-ON
|
Facility
OP
|
$114.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: AETNA Commercial |
$108.30
|
| Rate for Payer: AETNA Medicare |
$102.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$108.30
|
| Rate for Payer: BCBS Healthlink |
$102.60
|
| Rate for Payer: BCBS HMK CHIP |
$102.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$102.60
|
| Rate for Payer: BCBS POS |
$108.30
|
| Rate for Payer: BCBS Traditional |
$114.00
|
| Rate for Payer: CASH_PRICE |
$91.20
|
| Rate for Payer: CIGNA Commercial |
$108.30
|
| Rate for Payer: CIGNA Medicare |
$102.60
|
| Rate for Payer: HUMANA Commercial |
$102.60
|
| Rate for Payer: MEDICAID Medicaid |
$104.88
|
| Rate for Payer: MEDICARE Medicare |
$79.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$108.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$110.58
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$108.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$108.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$96.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$91.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$91.20
|
|
|
HYDRATION IV INFUSION, ADD-ON
|
Facility
IP
|
$114.00
|
|
|
Service Code
|
CPT 96361
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$79.80 |
| Max. Negotiated Rate |
$114.00 |
| Rate for Payer: BCBS HMK CHIP |
$102.60
|
| Rate for Payer: AETNA Commercial |
$108.30
|
| Rate for Payer: AETNA Medicare |
$102.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$108.30
|
| Rate for Payer: BCBS Healthlink |
$102.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$102.60
|
| Rate for Payer: BCBS POS |
$108.30
|
| Rate for Payer: BCBS Traditional |
$114.00
|
| Rate for Payer: CASH_PRICE |
$91.20
|
| Rate for Payer: CIGNA Commercial |
$108.30
|
| Rate for Payer: CIGNA Medicare |
$102.60
|
| Rate for Payer: HUMANA Commercial |
$102.60
|
| Rate for Payer: MEDICAID Medicaid |
$104.88
|
| Rate for Payer: MEDICARE Medicare |
$79.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$108.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$110.58
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$108.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$108.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$96.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$91.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$91.20
|
|
|
HYDRATION IV INFUSION INIT UP TO 1.5HRS
|
Facility
IP
|
$355.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$248.50 |
| Max. Negotiated Rate |
$355.00 |
| Rate for Payer: AETNA Commercial |
$337.25
|
| Rate for Payer: AETNA Medicare |
$319.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$337.25
|
| Rate for Payer: BCBS Healthlink |
$319.50
|
| Rate for Payer: BCBS HMK CHIP |
$319.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$319.50
|
| Rate for Payer: BCBS POS |
$337.25
|
| Rate for Payer: BCBS Traditional |
$355.00
|
| Rate for Payer: CASH_PRICE |
$284.00
|
| Rate for Payer: CIGNA Commercial |
$337.25
|
| Rate for Payer: CIGNA Medicare |
$319.50
|
| Rate for Payer: HUMANA Commercial |
$319.50
|
| Rate for Payer: MEDICAID Medicaid |
$326.60
|
| Rate for Payer: MEDICARE Medicare |
$248.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$337.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$344.35
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$337.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$337.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$301.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$284.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$284.00
|
|
|
HYDRATION IV INFUSION INIT UP TO 1.5HRS
|
Facility
OP
|
$355.00
|
|
|
Service Code
|
CPT 96360
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$248.50 |
| Max. Negotiated Rate |
$355.00 |
| Rate for Payer: AETNA Commercial |
$337.25
|
| Rate for Payer: AETNA Medicare |
$319.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$337.25
|
| Rate for Payer: BCBS Healthlink |
$319.50
|
| Rate for Payer: BCBS HMK CHIP |
$319.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$319.50
|
| Rate for Payer: BCBS POS |
$337.25
|
| Rate for Payer: BCBS Traditional |
$355.00
|
| Rate for Payer: CASH_PRICE |
$284.00
|
| Rate for Payer: CIGNA Commercial |
$337.25
|
| Rate for Payer: CIGNA Medicare |
$319.50
|
| Rate for Payer: HUMANA Commercial |
$319.50
|
| Rate for Payer: MEDICAID Medicaid |
$326.60
|
| Rate for Payer: MEDICARE Medicare |
$248.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$337.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$344.35
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$337.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$337.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$301.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$284.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$284.00
|
|
|
HYDROCHLOROTHIAZIDE 12.5MG CAP NON FORM
|
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
|
|
|
HYDROCHLOROTHIAZIDE 12.5MG CAP NON FORM
|
Facility
IP
|
$8.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: AETNA Commercial |
$7.60
|
| Rate for Payer: AETNA Medicare |
$7.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$7.60
|
| Rate for Payer: BCBS Healthlink |
$7.20
|
| Rate for Payer: BCBS HMK CHIP |
$7.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$7.20
|
| Rate for Payer: BCBS POS |
$7.60
|
| Rate for Payer: BCBS Traditional |
$8.00
|
| Rate for Payer: CASH_PRICE |
$6.40
|
| Rate for Payer: CIGNA Commercial |
$7.60
|
| Rate for Payer: CIGNA Medicare |
$7.20
|
| Rate for Payer: HUMANA Commercial |
$7.20
|
| Rate for Payer: MEDICAID Medicaid |
$7.36
|
| Rate for Payer: MEDICARE Medicare |
$5.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$7.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$7.76
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$7.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$7.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$6.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$6.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$6.40
|
|
|
HYDROCHLOROTHIAZIDE TAB [25 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
|
|
|
HYDROCHLOROTHIAZIDE TAB [25 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
|
|
|
HYDROCODONE/APAP ORAL SOLN 7.5MG/325MG
|
Facility
OP
|
$8.00
|
|
| Hospital Charge Code |
20230710
|
|
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
|
|
|
HYDROCODONE/APAP ORAL SOLN 7.5MG/325MG
|
Facility
IP
|
$8.00
|
|
| Hospital Charge Code |
20230710
|
|
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
|
|
|
HYDROCODONE/APAP TAB [5-325 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
|
|
|
HYDROCODONE/APAP TAB [5-325 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
|
|
|
HYDROCORTISONE 1% CREAM
|
Facility
IP
|
$14.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: AETNA Commercial |
$13.30
|
| Rate for Payer: AETNA Medicare |
$12.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$13.30
|
| Rate for Payer: BCBS Healthlink |
$12.60
|
| Rate for Payer: BCBS HMK CHIP |
$12.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$12.60
|
| Rate for Payer: BCBS POS |
$13.30
|
| Rate for Payer: BCBS Traditional |
$14.00
|
| Rate for Payer: CASH_PRICE |
$11.20
|
| Rate for Payer: CIGNA Commercial |
$13.30
|
| Rate for Payer: CIGNA Medicare |
$12.60
|
| Rate for Payer: HUMANA Commercial |
$12.60
|
| Rate for Payer: MEDICAID Medicaid |
$12.88
|
| Rate for Payer: MEDICARE Medicare |
$9.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$13.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$13.58
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$13.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$13.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$11.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$11.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$11.20
|
|
|
HYDROCORTISONE 1% CREAM
|
Facility
OP
|
$14.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$14.00 |
| Rate for Payer: AETNA Commercial |
$13.30
|
| Rate for Payer: AETNA Medicare |
$12.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$13.30
|
| Rate for Payer: BCBS Healthlink |
$12.60
|
| Rate for Payer: BCBS HMK CHIP |
$12.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$12.60
|
| Rate for Payer: BCBS POS |
$13.30
|
| Rate for Payer: BCBS Traditional |
$14.00
|
| Rate for Payer: CASH_PRICE |
$11.20
|
| Rate for Payer: CIGNA Commercial |
$13.30
|
| Rate for Payer: CIGNA Medicare |
$12.60
|
| Rate for Payer: HUMANA Commercial |
$12.60
|
| Rate for Payer: MEDICAID Medicaid |
$12.88
|
| Rate for Payer: MEDICARE Medicare |
$9.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$13.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$13.58
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$13.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$13.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$11.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$11.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$11.20
|
|
|
HYDROCORTISONE 2.5% CREAM 30 GRAM
|
Facility
OP
|
$266.15
|
|
| Hospital Charge Code |
20221205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$186.30 |
| Max. Negotiated Rate |
$266.15 |
| Rate for Payer: AETNA Commercial |
$252.84
|
| Rate for Payer: AETNA Medicare |
$239.53
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$252.84
|
| Rate for Payer: BCBS Healthlink |
$239.53
|
| Rate for Payer: BCBS HMK CHIP |
$239.53
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$239.53
|
| Rate for Payer: BCBS POS |
$252.84
|
| Rate for Payer: BCBS Traditional |
$266.15
|
| Rate for Payer: CASH_PRICE |
$212.92
|
| Rate for Payer: CIGNA Commercial |
$252.84
|
| Rate for Payer: CIGNA Medicare |
$239.53
|
| Rate for Payer: HUMANA Commercial |
$239.53
|
| Rate for Payer: MEDICAID Medicaid |
$244.86
|
| Rate for Payer: MEDICARE Medicare |
$186.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$252.84
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$258.17
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$252.84
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$252.84
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$226.23
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$212.92
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$212.92
|
|
|
HYDROCORTISONE 2.5% CREAM 30 GRAM
|
Facility
IP
|
$266.15
|
|
| Hospital Charge Code |
20221205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$186.30 |
| Max. Negotiated Rate |
$266.15 |
| Rate for Payer: BCBS HMK CHIP |
$239.53
|
| Rate for Payer: AETNA Commercial |
$252.84
|
| Rate for Payer: AETNA Medicare |
$239.53
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$252.84
|
| Rate for Payer: BCBS Healthlink |
$239.53
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$239.53
|
| Rate for Payer: BCBS POS |
$252.84
|
| Rate for Payer: BCBS Traditional |
$266.15
|
| Rate for Payer: CASH_PRICE |
$212.92
|
| Rate for Payer: CIGNA Commercial |
$252.84
|
| Rate for Payer: CIGNA Medicare |
$239.53
|
| Rate for Payer: HUMANA Commercial |
$239.53
|
| Rate for Payer: MEDICAID Medicaid |
$244.86
|
| Rate for Payer: MEDICARE Medicare |
$186.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$252.84
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$258.17
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$252.84
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$252.84
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$226.23
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$212.92
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$212.92
|
|
|
HYDROCORTISONE 2.5% OINTMENT
|
Facility
IP
|
$37.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: AETNA Commercial |
$35.15
|
| Rate for Payer: AETNA Medicare |
$33.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$35.15
|
| Rate for Payer: BCBS Healthlink |
$33.30
|
| Rate for Payer: BCBS HMK CHIP |
$33.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$33.30
|
| Rate for Payer: BCBS POS |
$35.15
|
| Rate for Payer: BCBS Traditional |
$37.00
|
| Rate for Payer: CASH_PRICE |
$29.60
|
| Rate for Payer: CIGNA Commercial |
$35.15
|
| Rate for Payer: CIGNA Medicare |
$33.30
|
| Rate for Payer: HUMANA Commercial |
$33.30
|
| Rate for Payer: MEDICAID Medicaid |
$34.04
|
| Rate for Payer: MEDICARE Medicare |
$25.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$35.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$35.89
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$35.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$35.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$31.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$29.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$29.60
|
|
|
HYDROCORTISONE 2.5% OINTMENT
|
Facility
OP
|
$37.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.90 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: AETNA Commercial |
$35.15
|
| Rate for Payer: AETNA Medicare |
$33.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$35.15
|
| Rate for Payer: BCBS Healthlink |
$33.30
|
| Rate for Payer: BCBS HMK CHIP |
$33.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$33.30
|
| Rate for Payer: BCBS POS |
$35.15
|
| Rate for Payer: BCBS Traditional |
$37.00
|
| Rate for Payer: CASH_PRICE |
$29.60
|
| Rate for Payer: CIGNA Commercial |
$35.15
|
| Rate for Payer: CIGNA Medicare |
$33.30
|
| Rate for Payer: HUMANA Commercial |
$33.30
|
| Rate for Payer: MEDICAID Medicaid |
$34.04
|
| Rate for Payer: MEDICARE Medicare |
$25.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$35.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$35.89
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$35.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$35.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$31.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$29.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$29.60
|
|
|
HYDROCORTISONE 2.5% OINTMENT 454 GM
|
Facility
OP
|
$186.65
|
|
| Hospital Charge Code |
20230803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.66 |
| Max. Negotiated Rate |
$186.65 |
| Rate for Payer: AETNA Commercial |
$177.32
|
| Rate for Payer: AETNA Medicare |
$167.99
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$177.32
|
| Rate for Payer: BCBS Healthlink |
$167.99
|
| Rate for Payer: BCBS HMK CHIP |
$167.99
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$167.99
|
| Rate for Payer: BCBS POS |
$177.32
|
| Rate for Payer: BCBS Traditional |
$186.65
|
| Rate for Payer: CASH_PRICE |
$149.32
|
| Rate for Payer: CIGNA Commercial |
$177.32
|
| Rate for Payer: CIGNA Medicare |
$167.99
|
| Rate for Payer: HUMANA Commercial |
$167.99
|
| Rate for Payer: MEDICAID Medicaid |
$171.72
|
| Rate for Payer: MEDICARE Medicare |
$130.66
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$177.32
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$181.05
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$177.32
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$177.32
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$158.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$149.32
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$149.32
|
|
