|
IV INFUSION CONCURRENT
|
Facility
IP
|
$120.00
|
|
|
Service Code
|
CPT 96368
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: AETNA Commercial |
$114.00
|
| Rate for Payer: AETNA Medicare |
$108.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$114.00
|
| Rate for Payer: BCBS Healthlink |
$108.00
|
| Rate for Payer: BCBS HMK CHIP |
$108.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$108.00
|
| Rate for Payer: BCBS POS |
$114.00
|
| Rate for Payer: BCBS Traditional |
$120.00
|
| Rate for Payer: CASH_PRICE |
$96.00
|
| Rate for Payer: CIGNA Commercial |
$114.00
|
| Rate for Payer: CIGNA Medicare |
$108.00
|
| Rate for Payer: HUMANA Commercial |
$108.00
|
| Rate for Payer: MEDICAID Medicaid |
$110.40
|
| Rate for Payer: MEDICARE Medicare |
$84.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$114.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$116.40
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$114.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$114.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$102.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$96.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$96.00
|
|
|
IV INFUSION CONCURRENT
|
Facility
OP
|
$120.00
|
|
|
Service Code
|
CPT 96368
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$84.00 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: AETNA Commercial |
$114.00
|
| Rate for Payer: AETNA Medicare |
$108.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$114.00
|
| Rate for Payer: BCBS Healthlink |
$108.00
|
| Rate for Payer: BCBS HMK CHIP |
$108.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$108.00
|
| Rate for Payer: BCBS POS |
$114.00
|
| Rate for Payer: BCBS Traditional |
$120.00
|
| Rate for Payer: CASH_PRICE |
$96.00
|
| Rate for Payer: CIGNA Commercial |
$114.00
|
| Rate for Payer: CIGNA Medicare |
$108.00
|
| Rate for Payer: HUMANA Commercial |
$108.00
|
| Rate for Payer: MEDICAID Medicaid |
$110.40
|
| Rate for Payer: MEDICARE Medicare |
$84.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$114.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$116.40
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$114.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$114.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$102.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$96.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$96.00
|
|
|
IV INFUSION THERAPY INIT SET UP 1.5 HR
|
Facility
OP
|
$410.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$287.00 |
| Max. Negotiated Rate |
$410.00 |
| Rate for Payer: AETNA Commercial |
$389.50
|
| Rate for Payer: AETNA Medicare |
$369.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$389.50
|
| Rate for Payer: BCBS Healthlink |
$369.00
|
| Rate for Payer: BCBS HMK CHIP |
$369.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$369.00
|
| Rate for Payer: BCBS POS |
$389.50
|
| Rate for Payer: BCBS Traditional |
$410.00
|
| Rate for Payer: CASH_PRICE |
$328.00
|
| Rate for Payer: CIGNA Commercial |
$389.50
|
| Rate for Payer: CIGNA Medicare |
$369.00
|
| Rate for Payer: HUMANA Commercial |
$369.00
|
| Rate for Payer: MEDICAID Medicaid |
$377.20
|
| Rate for Payer: MEDICARE Medicare |
$287.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$389.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$397.70
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$389.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$389.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$348.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$328.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$328.00
|
|
|
IV INFUSION THERAPY INIT SET UP 1.5 HR
|
Facility
IP
|
$410.00
|
|
|
Service Code
|
CPT 96365
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$287.00 |
| Max. Negotiated Rate |
$410.00 |
| Rate for Payer: BCBS HMK CHIP |
$369.00
|
| Rate for Payer: AETNA Commercial |
$389.50
|
| Rate for Payer: AETNA Medicare |
$369.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$389.50
|
| Rate for Payer: BCBS Healthlink |
$369.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$369.00
|
| Rate for Payer: BCBS POS |
$389.50
|
| Rate for Payer: BCBS Traditional |
$410.00
|
| Rate for Payer: CASH_PRICE |
$328.00
|
| Rate for Payer: CIGNA Commercial |
$389.50
|
| Rate for Payer: CIGNA Medicare |
$369.00
|
| Rate for Payer: HUMANA Commercial |
$369.00
|
| Rate for Payer: MEDICAID Medicaid |
$377.20
|
| Rate for Payer: MEDICARE Medicare |
$287.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$389.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$397.70
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$389.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$389.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$348.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$328.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$328.00
|
|
|
IV - LACTATED RINGERS [1000 ML]
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT J7120
|
| 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 - LACTATED RINGERS [1000 ML]
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT J7120
|
| 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 - NACL 0.45% [1000 ML]
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT J7799
|
| 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 - NACL 0.45% [1000 ML]
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT J7799
|
| 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 - NACL 0.45% [250ML]
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT J7799
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| 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 - NACL 0.45% [250ML]
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT J7799
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
250
|
| 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 - NACL 0.45% [500ML]
|
Facility
OP
|
$22.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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 - NACL 0.45% [500ML]
|
Facility
IP
|
$22.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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 - NACL 0.9% [1000 ML]
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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 - NACL 0.9% [1000 ML]
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT J7030
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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 - NACL 0.9% 100 ML
|
Facility
OP
|
$9.00
|
|
|
Service Code
|
CPT J7050
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
IV - NACL 0.9% 100 ML
|
Facility
IP
|
$9.00
|
|
|
Service Code
|
CPT J7050
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
IV - NACL 0.9% [250 ML BAG]
|
Facility
IP
|
$15.00
|
|
|
Service Code
|
CPT J7050
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: BCBS HMK CHIP |
$13.50
|
| Rate for Payer: AETNA Commercial |
$14.25
|
| Rate for Payer: AETNA Medicare |
$13.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$14.25
|
| Rate for Payer: BCBS Healthlink |
$13.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$13.50
|
| Rate for Payer: BCBS POS |
$14.25
|
| Rate for Payer: BCBS Traditional |
$15.00
|
| Rate for Payer: CASH_PRICE |
$12.00
|
| Rate for Payer: CIGNA Commercial |
$14.25
|
| Rate for Payer: CIGNA Medicare |
$13.50
|
| Rate for Payer: HUMANA Commercial |
$13.50
|
| Rate for Payer: MEDICAID Medicaid |
$13.80
|
| Rate for Payer: MEDICARE Medicare |
$10.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$14.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$14.55
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$14.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$14.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$12.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$12.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$12.00
|
|
|
IV - NACL 0.9% [250 ML BAG]
|
Facility
OP
|
$15.00
|
|
|
Service Code
|
CPT J7050
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: AETNA Commercial |
$14.25
|
| Rate for Payer: AETNA Medicare |
$13.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$14.25
|
| Rate for Payer: BCBS Healthlink |
$13.50
|
| Rate for Payer: BCBS HMK CHIP |
$13.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$13.50
|
| Rate for Payer: BCBS POS |
$14.25
|
| Rate for Payer: BCBS Traditional |
$15.00
|
| Rate for Payer: CASH_PRICE |
$12.00
|
| Rate for Payer: CIGNA Commercial |
$14.25
|
| Rate for Payer: CIGNA Medicare |
$13.50
|
| Rate for Payer: HUMANA Commercial |
$13.50
|
| Rate for Payer: MEDICAID Medicaid |
$13.80
|
| Rate for Payer: MEDICARE Medicare |
$10.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$14.25
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$14.55
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$14.25
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$14.25
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$12.75
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$12.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$12.00
|
|
|
IV - NACL 0.9% [500 ML]
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT J7040
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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 - NACL 0.9% [500 ML]
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT J7040
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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 - NACL 0.9% [50 ML]
|
Facility
OP
|
$9.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: AETNA Commercial |
$8.55
|
| Rate for Payer: AETNA Medicare |
$8.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$8.55
|
| Rate for Payer: BCBS Healthlink |
$8.10
|
| Rate for Payer: BCBS HMK CHIP |
$8.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$8.10
|
| Rate for Payer: BCBS POS |
$8.55
|
| Rate for Payer: BCBS Traditional |
$9.00
|
| Rate for Payer: CASH_PRICE |
$7.20
|
| Rate for Payer: CIGNA Commercial |
$8.55
|
| Rate for Payer: CIGNA Medicare |
$8.10
|
| Rate for Payer: HUMANA Commercial |
$8.10
|
| Rate for Payer: MEDICAID Medicaid |
$8.28
|
| Rate for Payer: MEDICARE Medicare |
$6.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$8.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$8.73
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$8.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$8.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$7.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$7.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$7.20
|
|
|
IV - NACL 0.9% [50 ML]
|
Facility
IP
|
$9.00
|
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.30 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: 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
|
|
|
IV - NACL 3% HYPERTONIC [500 ML]
|
Facility
OP
|
$22.00
|
|
|
Service Code
|
CPT J7799
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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 - NACL 3% HYPERTONIC [500 ML]
|
Facility
IP
|
$22.00
|
|
|
Service Code
|
CPT J7799
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
258
|
| 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 - NITROGLYCERIN/D5W [25 MG/250 ML]
|
Facility
IP
|
$91.00
|
|
|
Service Code
|
CPT J3490
|
| Hospital Charge Code |
20221105
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$63.70 |
| Max. Negotiated Rate |
$91.00 |
| Rate for Payer: AETNA Commercial |
$86.45
|
| Rate for Payer: AETNA Medicare |
$81.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$86.45
|
| Rate for Payer: BCBS Healthlink |
$81.90
|
| Rate for Payer: BCBS HMK CHIP |
$81.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$81.90
|
| Rate for Payer: BCBS POS |
$86.45
|
| Rate for Payer: BCBS Traditional |
$91.00
|
| Rate for Payer: CASH_PRICE |
$72.80
|
| Rate for Payer: CIGNA Commercial |
$86.45
|
| Rate for Payer: CIGNA Medicare |
$81.90
|
| Rate for Payer: HUMANA Commercial |
$81.90
|
| Rate for Payer: MEDICAID Medicaid |
$83.72
|
| Rate for Payer: MEDICARE Medicare |
$63.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$86.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$88.27
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$86.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$86.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$77.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$72.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$72.80
|
|
