|
.IRON, TOTAL
|
Facility
IP
|
$9.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: BCBS HMK CHIP |
$8.10
|
| Rate for Payer: AETNA Commercial |
$8.55
|
| Rate for Payer: AETNA Medicare |
$8.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$8.55
|
| Rate for Payer: BCBS Healthlink |
$8.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$8.10
|
| Rate for Payer: BCBS POS |
$8.55
|
| Rate for Payer: BCBS Traditional |
$9.00
|
| Rate for Payer: CASH_PRICE |
$7.20
|
| Rate for Payer: CIGNA Commercial |
$8.55
|
| Rate for Payer: CIGNA Medicare |
$8.10
|
| Rate for Payer: HUMANA Commercial |
$8.10
|
| Rate for Payer: MEDICAID Medicaid |
$8.28
|
| Rate for Payer: MEDICARE Medicare |
$6.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$8.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$8.73
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$8.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$8.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$7.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$7.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$7.20
|
|
|
IRON, TOTAL (001339)
|
Facility
IP
|
$9.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
IRON, TOTAL (001339)
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
CPT 83540
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
300
|
| 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
|
|
|
IRRIGATION OF IMPLANTED VENOUS ACCESS TR
|
Facility
IP
|
$135.00
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: BCBS HMK CHIP |
$121.50
|
| Rate for Payer: AETNA Commercial |
$128.25
|
| Rate for Payer: AETNA Medicare |
$121.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$128.25
|
| Rate for Payer: BCBS Healthlink |
$121.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$121.50
|
| Rate for Payer: BCBS POS |
$128.25
|
| Rate for Payer: BCBS Traditional |
$135.00
|
| Rate for Payer: CASH_PRICE |
$108.00
|
| Rate for Payer: CIGNA Commercial |
$128.25
|
| Rate for Payer: CIGNA Medicare |
$121.50
|
| Rate for Payer: HUMANA Commercial |
$121.50
|
| Rate for Payer: MEDICAID Medicaid |
$124.20
|
| Rate for Payer: MEDICARE Medicare |
$94.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$128.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$130.95
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$128.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$128.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$114.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$108.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$108.00
|
|
|
IRRIGATION OF IMPLANTED VENOUS ACCESS TR
|
Facility
OP
|
$135.00
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: AETNA Commercial |
$128.25
|
| Rate for Payer: AETNA Medicare |
$121.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$128.25
|
| Rate for Payer: BCBS Healthlink |
$121.50
|
| Rate for Payer: BCBS HMK CHIP |
$121.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$121.50
|
| Rate for Payer: BCBS POS |
$128.25
|
| Rate for Payer: BCBS Traditional |
$135.00
|
| Rate for Payer: CASH_PRICE |
$108.00
|
| Rate for Payer: CIGNA Commercial |
$128.25
|
| Rate for Payer: CIGNA Medicare |
$121.50
|
| Rate for Payer: HUMANA Commercial |
$121.50
|
| Rate for Payer: MEDICAID Medicaid |
$124.20
|
| Rate for Payer: MEDICARE Medicare |
$94.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$128.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$130.95
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$128.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$128.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$114.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$108.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$108.00
|
|
|
ISOSORBIDE DINITRATE TAB [10 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
|
|
|
ISOSORBIDE DINITRATE TAB [10 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: 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
|
|
|
ISOSORBIDE MONO ER TAB [30 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
|
|
|
ISOSORBIDE MONO ER TAB [30 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
|
|
|
IV - D5 1/2 NACL [1000 ML]
|
Facility
OP
|
$28.00
|
|
|
Service Code
|
CPT J7799
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: AETNA Commercial |
$26.60
|
| Rate for Payer: AETNA Medicare |
$25.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$26.60
|
| Rate for Payer: BCBS Healthlink |
$25.20
|
| Rate for Payer: BCBS HMK CHIP |
$25.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$25.20
|
| Rate for Payer: BCBS POS |
$26.60
|
| Rate for Payer: BCBS Traditional |
$28.00
|
| Rate for Payer: CASH_PRICE |
$22.40
|
| Rate for Payer: CIGNA Commercial |
$26.60
|
| Rate for Payer: CIGNA Medicare |
$25.20
|
| Rate for Payer: HUMANA Commercial |
$25.20
|
| Rate for Payer: MEDICAID Medicaid |
$25.76
|
| Rate for Payer: MEDICARE Medicare |
$19.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$26.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$27.16
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$26.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$26.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$23.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$22.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$22.40
|
|
|
IV - D5 1/2 NACL [1000 ML]
|
Facility
IP
|
$28.00
|
|
|
Service Code
|
CPT J7799
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$19.60 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: AETNA Commercial |
$26.60
|
| Rate for Payer: AETNA Medicare |
$25.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$26.60
|
| Rate for Payer: BCBS Healthlink |
$25.20
|
| Rate for Payer: BCBS HMK CHIP |
$25.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$25.20
|
| Rate for Payer: BCBS POS |
$26.60
|
| Rate for Payer: BCBS Traditional |
$28.00
|
| Rate for Payer: CASH_PRICE |
$22.40
|
| Rate for Payer: CIGNA Commercial |
$26.60
|
| Rate for Payer: CIGNA Medicare |
$25.20
|
| Rate for Payer: HUMANA Commercial |
$25.20
|
| Rate for Payer: MEDICAID Medicaid |
$25.76
|
| Rate for Payer: MEDICARE Medicare |
$19.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$26.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$27.16
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$26.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$26.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$23.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$22.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$22.40
|
|
|
IV - D5 NACL [1000 ML]
|
Facility
IP
|
$22.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: BCBS HMK CHIP |
$19.80
|
| Rate for Payer: AETNA Commercial |
$20.90
|
| Rate for Payer: AETNA Medicare |
$19.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$20.90
|
| Rate for Payer: BCBS Healthlink |
$19.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$19.80
|
| Rate for Payer: BCBS POS |
$20.90
|
| Rate for Payer: BCBS Traditional |
$22.00
|
| Rate for Payer: CASH_PRICE |
$17.60
|
| Rate for Payer: CIGNA Commercial |
$20.90
|
| Rate for Payer: CIGNA Medicare |
$19.80
|
| Rate for Payer: HUMANA Commercial |
$19.80
|
| Rate for Payer: MEDICAID Medicaid |
$20.24
|
| Rate for Payer: MEDICARE Medicare |
$15.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$20.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$21.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$20.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$20.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$18.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$17.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$17.60
|
|
|
IV - D5 NACL [1000 ML]
|
Facility
OP
|
$22.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: AETNA Commercial |
$20.90
|
| Rate for Payer: AETNA Medicare |
$19.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$20.90
|
| Rate for Payer: BCBS Healthlink |
$19.80
|
| Rate for Payer: BCBS HMK CHIP |
$19.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$19.80
|
| Rate for Payer: BCBS POS |
$20.90
|
| Rate for Payer: BCBS Traditional |
$22.00
|
| Rate for Payer: CASH_PRICE |
$17.60
|
| Rate for Payer: CIGNA Commercial |
$20.90
|
| Rate for Payer: CIGNA Medicare |
$19.80
|
| Rate for Payer: HUMANA Commercial |
$19.80
|
| Rate for Payer: MEDICAID Medicaid |
$20.24
|
| Rate for Payer: MEDICARE Medicare |
$15.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$20.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$21.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$20.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$20.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$18.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$17.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$17.60
|
|
|
IV - D5W [1000 ML]
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT J7060
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: AETNA Commercial |
$20.90
|
| Rate for Payer: AETNA Medicare |
$19.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$20.90
|
| Rate for Payer: BCBS Healthlink |
$19.80
|
| Rate for Payer: BCBS HMK CHIP |
$19.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$19.80
|
| Rate for Payer: BCBS POS |
$20.90
|
| Rate for Payer: BCBS Traditional |
$22.00
|
| Rate for Payer: CASH_PRICE |
$17.60
|
| Rate for Payer: CIGNA Commercial |
$20.90
|
| Rate for Payer: CIGNA Medicare |
$19.80
|
| Rate for Payer: HUMANA Commercial |
$19.80
|
| Rate for Payer: MEDICAID Medicaid |
$20.24
|
| Rate for Payer: MEDICARE Medicare |
$15.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$20.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$21.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$20.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$20.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$18.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$17.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$17.60
|
|
|
IV - D5W [1000 ML]
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT J7060
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.40 |
| Max. Negotiated Rate |
$22.00 |
| Rate for Payer: AETNA Commercial |
$20.90
|
| Rate for Payer: AETNA Medicare |
$19.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$20.90
|
| Rate for Payer: BCBS Healthlink |
$19.80
|
| Rate for Payer: BCBS HMK CHIP |
$19.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$19.80
|
| Rate for Payer: BCBS POS |
$20.90
|
| Rate for Payer: BCBS Traditional |
$22.00
|
| Rate for Payer: CASH_PRICE |
$17.60
|
| Rate for Payer: CIGNA Commercial |
$20.90
|
| Rate for Payer: CIGNA Medicare |
$19.80
|
| Rate for Payer: HUMANA Commercial |
$19.80
|
| Rate for Payer: MEDICAID Medicaid |
$20.24
|
| Rate for Payer: MEDICARE Medicare |
$15.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$20.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$21.34
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$20.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$20.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$18.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$17.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$17.60
|
|
|
IV - D5W [500 ML]
|
Facility
IP
|
$17.00
|
|
|
Service Code
|
CPT J7060
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: BCBS HMK CHIP |
$15.30
|
| Rate for Payer: AETNA Commercial |
$16.15
|
| Rate for Payer: AETNA Medicare |
$15.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$16.15
|
| Rate for Payer: BCBS Healthlink |
$15.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$15.30
|
| Rate for Payer: BCBS POS |
$16.15
|
| Rate for Payer: BCBS Traditional |
$17.00
|
| Rate for Payer: CASH_PRICE |
$13.60
|
| Rate for Payer: CIGNA Commercial |
$16.15
|
| Rate for Payer: CIGNA Medicare |
$15.30
|
| Rate for Payer: HUMANA Commercial |
$15.30
|
| Rate for Payer: MEDICAID Medicaid |
$15.64
|
| Rate for Payer: MEDICARE Medicare |
$11.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$16.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$16.49
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$16.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$14.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$13.60
|
|
|
IV - D5W [500 ML]
|
Facility
OP
|
$17.00
|
|
|
Service Code
|
CPT J7060
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: AETNA Commercial |
$16.15
|
| Rate for Payer: AETNA Medicare |
$15.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$16.15
|
| Rate for Payer: BCBS Healthlink |
$15.30
|
| Rate for Payer: BCBS HMK CHIP |
$15.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$15.30
|
| Rate for Payer: BCBS POS |
$16.15
|
| Rate for Payer: BCBS Traditional |
$17.00
|
| Rate for Payer: CASH_PRICE |
$13.60
|
| Rate for Payer: CIGNA Commercial |
$16.15
|
| Rate for Payer: CIGNA Medicare |
$15.30
|
| Rate for Payer: HUMANA Commercial |
$15.30
|
| Rate for Payer: MEDICAID Medicaid |
$15.64
|
| Rate for Payer: MEDICARE Medicare |
$11.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$16.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$16.49
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$16.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$14.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$13.60
|
|
|
IVERMECTIN TAB [3 MG]
|
Facility
OP
|
$17.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: AETNA Commercial |
$16.15
|
| Rate for Payer: AETNA Medicare |
$15.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$16.15
|
| Rate for Payer: BCBS Healthlink |
$15.30
|
| Rate for Payer: BCBS HMK CHIP |
$15.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$15.30
|
| Rate for Payer: BCBS POS |
$16.15
|
| Rate for Payer: BCBS Traditional |
$17.00
|
| Rate for Payer: CASH_PRICE |
$13.60
|
| Rate for Payer: CIGNA Commercial |
$16.15
|
| Rate for Payer: CIGNA Medicare |
$15.30
|
| Rate for Payer: HUMANA Commercial |
$15.30
|
| Rate for Payer: MEDICAID Medicaid |
$15.64
|
| Rate for Payer: MEDICARE Medicare |
$11.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$16.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$16.49
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$16.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$14.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$13.60
|
|
|
IVERMECTIN TAB [3 MG]
|
Facility
IP
|
$17.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.90 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: BCBS HMK CHIP |
$15.30
|
| Rate for Payer: AETNA Commercial |
$16.15
|
| Rate for Payer: AETNA Medicare |
$15.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$16.15
|
| Rate for Payer: BCBS Healthlink |
$15.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$15.30
|
| Rate for Payer: BCBS POS |
$16.15
|
| Rate for Payer: BCBS Traditional |
$17.00
|
| Rate for Payer: CASH_PRICE |
$13.60
|
| Rate for Payer: CIGNA Commercial |
$16.15
|
| Rate for Payer: CIGNA Medicare |
$15.30
|
| Rate for Payer: HUMANA Commercial |
$15.30
|
| Rate for Payer: MEDICAID Medicaid |
$15.64
|
| Rate for Payer: MEDICARE Medicare |
$11.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$16.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$16.49
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$16.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$16.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$14.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$13.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$13.60
|
|
|
IV HEP LOCK
|
Facility
IP
|
$109.00
|
|
|
Service Code
|
CPT 36000
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$109.00 |
| Rate for Payer: BCBS HMK CHIP |
$98.10
|
| Rate for Payer: AETNA Commercial |
$103.55
|
| Rate for Payer: AETNA Medicare |
$98.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$103.55
|
| Rate for Payer: BCBS Healthlink |
$98.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$98.10
|
| Rate for Payer: BCBS POS |
$103.55
|
| Rate for Payer: BCBS Traditional |
$109.00
|
| Rate for Payer: CASH_PRICE |
$87.20
|
| Rate for Payer: CIGNA Commercial |
$103.55
|
| Rate for Payer: CIGNA Medicare |
$98.10
|
| Rate for Payer: HUMANA Commercial |
$98.10
|
| Rate for Payer: MEDICAID Medicaid |
$100.28
|
| Rate for Payer: MEDICARE Medicare |
$76.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$103.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$105.73
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$103.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$103.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$92.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$87.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$87.20
|
|
|
IV HEP LOCK
|
Facility
OP
|
$109.00
|
|
|
Service Code
|
CPT 36000
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$109.00 |
| Rate for Payer: AETNA Commercial |
$103.55
|
| Rate for Payer: AETNA Medicare |
$98.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$103.55
|
| Rate for Payer: BCBS Healthlink |
$98.10
|
| Rate for Payer: BCBS HMK CHIP |
$98.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$98.10
|
| Rate for Payer: BCBS POS |
$103.55
|
| Rate for Payer: BCBS Traditional |
$109.00
|
| Rate for Payer: CASH_PRICE |
$87.20
|
| Rate for Payer: CIGNA Commercial |
$103.55
|
| Rate for Payer: CIGNA Medicare |
$98.10
|
| Rate for Payer: HUMANA Commercial |
$98.10
|
| Rate for Payer: MEDICAID Medicaid |
$100.28
|
| Rate for Payer: MEDICARE Medicare |
$76.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$103.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$105.73
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$103.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$103.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$92.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$87.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$87.20
|
|
|
IV INFUSION ADDON EA HR
|
Facility
IP
|
$126.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: AETNA Commercial |
$119.70
|
| Rate for Payer: AETNA Medicare |
$113.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$119.70
|
| Rate for Payer: BCBS Healthlink |
$113.40
|
| Rate for Payer: BCBS HMK CHIP |
$113.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$113.40
|
| Rate for Payer: BCBS POS |
$119.70
|
| Rate for Payer: BCBS Traditional |
$126.00
|
| Rate for Payer: CASH_PRICE |
$100.80
|
| Rate for Payer: CIGNA Commercial |
$119.70
|
| Rate for Payer: CIGNA Medicare |
$113.40
|
| Rate for Payer: HUMANA Commercial |
$113.40
|
| Rate for Payer: MEDICAID Medicaid |
$115.92
|
| Rate for Payer: MEDICARE Medicare |
$88.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$119.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$122.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$119.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$119.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$107.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$100.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$100.80
|
|
|
IV INFUSION ADDON EA HR
|
Facility
OP
|
$126.00
|
|
|
Service Code
|
CPT 96366
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$88.20 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: AETNA Commercial |
$119.70
|
| Rate for Payer: AETNA Medicare |
$113.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$119.70
|
| Rate for Payer: BCBS Healthlink |
$113.40
|
| Rate for Payer: BCBS HMK CHIP |
$113.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$113.40
|
| Rate for Payer: BCBS POS |
$119.70
|
| Rate for Payer: BCBS Traditional |
$126.00
|
| Rate for Payer: CASH_PRICE |
$100.80
|
| Rate for Payer: CIGNA Commercial |
$119.70
|
| Rate for Payer: CIGNA Medicare |
$113.40
|
| Rate for Payer: HUMANA Commercial |
$113.40
|
| Rate for Payer: MEDICAID Medicaid |
$115.92
|
| Rate for Payer: MEDICARE Medicare |
$88.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$119.70
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$122.22
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$119.70
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$119.70
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$107.10
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$100.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$100.80
|
|
|
IV INFUSION ADDTL DRUG
|
Facility
OP
|
$153.00
|
|
|
Service Code
|
CPT 96367
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: AETNA Commercial |
$145.35
|
| Rate for Payer: AETNA Medicare |
$137.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$145.35
|
| Rate for Payer: BCBS Healthlink |
$137.70
|
| Rate for Payer: BCBS HMK CHIP |
$137.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$137.70
|
| Rate for Payer: BCBS POS |
$145.35
|
| Rate for Payer: BCBS Traditional |
$153.00
|
| Rate for Payer: CASH_PRICE |
$122.40
|
| Rate for Payer: CIGNA Commercial |
$145.35
|
| Rate for Payer: CIGNA Medicare |
$137.70
|
| Rate for Payer: HUMANA Commercial |
$137.70
|
| Rate for Payer: MEDICAID Medicaid |
$140.76
|
| Rate for Payer: MEDICARE Medicare |
$107.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$145.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$148.41
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$145.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$145.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$130.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$122.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$122.40
|
|
|
IV INFUSION ADDTL DRUG
|
Facility
IP
|
$153.00
|
|
|
Service Code
|
CPT 96367
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: BCBS HMK CHIP |
$137.70
|
| Rate for Payer: AETNA Commercial |
$145.35
|
| Rate for Payer: AETNA Medicare |
$137.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$145.35
|
| Rate for Payer: BCBS Healthlink |
$137.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$137.70
|
| Rate for Payer: BCBS POS |
$145.35
|
| Rate for Payer: BCBS Traditional |
$153.00
|
| Rate for Payer: CASH_PRICE |
$122.40
|
| Rate for Payer: CIGNA Commercial |
$145.35
|
| Rate for Payer: CIGNA Medicare |
$137.70
|
| Rate for Payer: HUMANA Commercial |
$137.70
|
| Rate for Payer: MEDICAID Medicaid |
$140.76
|
| Rate for Payer: MEDICARE Medicare |
$107.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$145.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$148.41
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$145.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$145.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$130.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$122.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$122.40
|
|
