|
LAB BLOOD X-MATCH
|
Facility
OP
|
$158.00
|
|
|
Service Code
|
CPT 86920
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$110.60 |
| Max. Negotiated Rate |
$158.00 |
| Rate for Payer: AETNA Commercial |
$150.10
|
| Rate for Payer: AETNA Medicare |
$142.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$150.10
|
| Rate for Payer: BCBS Healthlink |
$142.20
|
| Rate for Payer: BCBS HMK CHIP |
$142.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$142.20
|
| Rate for Payer: BCBS POS |
$150.10
|
| Rate for Payer: BCBS Traditional |
$158.00
|
| Rate for Payer: CASH_PRICE |
$126.40
|
| Rate for Payer: CIGNA Commercial |
$150.10
|
| Rate for Payer: CIGNA Medicare |
$142.20
|
| Rate for Payer: HUMANA Commercial |
$142.20
|
| Rate for Payer: MEDICAID Medicaid |
$145.36
|
| Rate for Payer: MEDICARE Medicare |
$110.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$150.10
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$153.26
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$150.10
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$150.10
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$134.30
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$126.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$126.40
|
|
|
LAB BORDETELLA PERTUSSIS
|
Facility
OP
|
$70.00
|
|
|
Service Code
|
CPT 87265
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: AETNA Commercial |
$66.50
|
| Rate for Payer: AETNA Medicare |
$63.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$66.50
|
| Rate for Payer: BCBS Healthlink |
$63.00
|
| Rate for Payer: BCBS HMK CHIP |
$63.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$63.00
|
| Rate for Payer: BCBS POS |
$66.50
|
| Rate for Payer: BCBS Traditional |
$70.00
|
| Rate for Payer: CASH_PRICE |
$56.00
|
| Rate for Payer: CIGNA Commercial |
$66.50
|
| Rate for Payer: CIGNA Medicare |
$63.00
|
| Rate for Payer: HUMANA Commercial |
$63.00
|
| Rate for Payer: MEDICAID Medicaid |
$64.40
|
| Rate for Payer: MEDICARE Medicare |
$49.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$66.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$67.90
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$66.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$66.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$59.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$56.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$56.00
|
|
|
LAB BORDETELLA PERTUSSIS
|
Facility
IP
|
$70.00
|
|
|
Service Code
|
CPT 87265
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.00 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: AETNA Commercial |
$66.50
|
| Rate for Payer: AETNA Medicare |
$63.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$66.50
|
| Rate for Payer: BCBS Healthlink |
$63.00
|
| Rate for Payer: BCBS HMK CHIP |
$63.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$63.00
|
| Rate for Payer: BCBS POS |
$66.50
|
| Rate for Payer: BCBS Traditional |
$70.00
|
| Rate for Payer: CASH_PRICE |
$56.00
|
| Rate for Payer: CIGNA Commercial |
$66.50
|
| Rate for Payer: CIGNA Medicare |
$63.00
|
| Rate for Payer: HUMANA Commercial |
$63.00
|
| Rate for Payer: MEDICAID Medicaid |
$64.40
|
| Rate for Payer: MEDICARE Medicare |
$49.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$66.50
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$67.90
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$66.50
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$66.50
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$59.50
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$56.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$56.00
|
|
|
LAB BORRELIA HERMSII TITER
|
Facility
OP
|
$113.00
|
|
|
Service Code
|
CPT 86619
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.10 |
| Max. Negotiated Rate |
$113.00 |
| Rate for Payer: AETNA Commercial |
$107.35
|
| Rate for Payer: AETNA Medicare |
$101.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$107.35
|
| Rate for Payer: BCBS Healthlink |
$101.70
|
| Rate for Payer: BCBS HMK CHIP |
$101.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$101.70
|
| Rate for Payer: BCBS POS |
$107.35
|
| Rate for Payer: BCBS Traditional |
$113.00
|
| Rate for Payer: CASH_PRICE |
$90.40
|
| Rate for Payer: CIGNA Commercial |
$107.35
|
| Rate for Payer: CIGNA Medicare |
$101.70
|
| Rate for Payer: HUMANA Commercial |
$101.70
|
| Rate for Payer: MEDICAID Medicaid |
$103.96
|
| Rate for Payer: MEDICARE Medicare |
$79.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$107.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$109.61
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$107.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$107.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$96.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$90.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$90.40
|
|
|
LAB BORRELIA HERMSII TITER
|
Facility
IP
|
$113.00
|
|
|
Service Code
|
CPT 86619
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$79.10 |
| Max. Negotiated Rate |
$113.00 |
| Rate for Payer: BCBS HMK CHIP |
$101.70
|
| Rate for Payer: AETNA Commercial |
$107.35
|
| Rate for Payer: AETNA Medicare |
$101.70
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$107.35
|
| Rate for Payer: BCBS Healthlink |
$101.70
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$101.70
|
| Rate for Payer: BCBS POS |
$107.35
|
| Rate for Payer: BCBS Traditional |
$113.00
|
| Rate for Payer: CASH_PRICE |
$90.40
|
| Rate for Payer: CIGNA Commercial |
$107.35
|
| Rate for Payer: CIGNA Medicare |
$101.70
|
| Rate for Payer: HUMANA Commercial |
$101.70
|
| Rate for Payer: MEDICAID Medicaid |
$103.96
|
| Rate for Payer: MEDICARE Medicare |
$79.10
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$107.35
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$109.61
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$107.35
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$107.35
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$96.05
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$90.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$90.40
|
|
|
LAB BRUCELLA
|
Facility
OP
|
$211.00
|
|
|
Service Code
|
CPT 86622
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$147.70 |
| Max. Negotiated Rate |
$211.00 |
| Rate for Payer: AETNA Commercial |
$200.45
|
| Rate for Payer: AETNA Medicare |
$189.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$200.45
|
| Rate for Payer: BCBS Healthlink |
$189.90
|
| Rate for Payer: BCBS HMK CHIP |
$189.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$189.90
|
| Rate for Payer: BCBS POS |
$200.45
|
| Rate for Payer: BCBS Traditional |
$211.00
|
| Rate for Payer: CASH_PRICE |
$168.80
|
| Rate for Payer: CIGNA Commercial |
$200.45
|
| Rate for Payer: CIGNA Medicare |
$189.90
|
| Rate for Payer: HUMANA Commercial |
$189.90
|
| Rate for Payer: MEDICAID Medicaid |
$194.12
|
| Rate for Payer: MEDICARE Medicare |
$147.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$200.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$204.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$200.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$200.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$179.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$168.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$168.80
|
|
|
LAB BRUCELLA
|
Facility
IP
|
$211.00
|
|
|
Service Code
|
CPT 86622
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$147.70 |
| Max. Negotiated Rate |
$211.00 |
| Rate for Payer: AETNA Commercial |
$200.45
|
| Rate for Payer: AETNA Medicare |
$189.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$200.45
|
| Rate for Payer: BCBS Healthlink |
$189.90
|
| Rate for Payer: BCBS HMK CHIP |
$189.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$189.90
|
| Rate for Payer: BCBS POS |
$200.45
|
| Rate for Payer: BCBS Traditional |
$211.00
|
| Rate for Payer: CASH_PRICE |
$168.80
|
| Rate for Payer: CIGNA Commercial |
$200.45
|
| Rate for Payer: CIGNA Medicare |
$189.90
|
| Rate for Payer: HUMANA Commercial |
$189.90
|
| Rate for Payer: MEDICAID Medicaid |
$194.12
|
| Rate for Payer: MEDICARE Medicare |
$147.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$200.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$204.67
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$200.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$200.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$179.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$168.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$168.80
|
|
|
LAB CADMIUM
|
Facility
OP
|
$68.00
|
|
|
Service Code
|
CPT 82300
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: AETNA Commercial |
$64.60
|
| Rate for Payer: AETNA Medicare |
$61.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$64.60
|
| Rate for Payer: BCBS Healthlink |
$61.20
|
| Rate for Payer: BCBS HMK CHIP |
$61.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$61.20
|
| Rate for Payer: BCBS POS |
$64.60
|
| Rate for Payer: BCBS Traditional |
$68.00
|
| Rate for Payer: CASH_PRICE |
$54.40
|
| Rate for Payer: CIGNA Commercial |
$64.60
|
| Rate for Payer: CIGNA Medicare |
$61.20
|
| Rate for Payer: HUMANA Commercial |
$61.20
|
| Rate for Payer: MEDICAID Medicaid |
$62.56
|
| Rate for Payer: MEDICARE Medicare |
$47.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$64.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$65.96
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$64.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$64.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$57.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$54.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$54.40
|
|
|
LAB CADMIUM
|
Facility
IP
|
$68.00
|
|
|
Service Code
|
CPT 82300
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.60 |
| Max. Negotiated Rate |
$68.00 |
| Rate for Payer: BCBS HMK CHIP |
$61.20
|
| Rate for Payer: AETNA Commercial |
$64.60
|
| Rate for Payer: AETNA Medicare |
$61.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$64.60
|
| Rate for Payer: BCBS Healthlink |
$61.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$61.20
|
| Rate for Payer: BCBS POS |
$64.60
|
| Rate for Payer: BCBS Traditional |
$68.00
|
| Rate for Payer: CASH_PRICE |
$54.40
|
| Rate for Payer: CIGNA Commercial |
$64.60
|
| Rate for Payer: CIGNA Medicare |
$61.20
|
| Rate for Payer: HUMANA Commercial |
$61.20
|
| Rate for Payer: MEDICAID Medicaid |
$62.56
|
| Rate for Payer: MEDICARE Medicare |
$47.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$64.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$65.96
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$64.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$64.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$57.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$54.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$54.40
|
|
|
LAB CANDIDA ALBICANS IGE
|
Facility
IP
|
$36.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: AETNA Commercial |
$34.20
|
| Rate for Payer: AETNA Medicare |
$32.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$34.20
|
| Rate for Payer: BCBS Healthlink |
$32.40
|
| Rate for Payer: BCBS HMK CHIP |
$32.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$32.40
|
| Rate for Payer: BCBS POS |
$34.20
|
| Rate for Payer: BCBS Traditional |
$36.00
|
| Rate for Payer: CASH_PRICE |
$28.80
|
| Rate for Payer: CIGNA Commercial |
$34.20
|
| Rate for Payer: CIGNA Medicare |
$32.40
|
| Rate for Payer: HUMANA Commercial |
$32.40
|
| Rate for Payer: MEDICAID Medicaid |
$33.12
|
| Rate for Payer: MEDICARE Medicare |
$25.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$34.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$34.92
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$34.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$34.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$30.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$28.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$28.80
|
|
|
LAB CANDIDA ALBICANS IGE
|
Facility
OP
|
$36.00
|
|
|
Service Code
|
CPT 86003
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: AETNA Commercial |
$34.20
|
| Rate for Payer: AETNA Medicare |
$32.40
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$34.20
|
| Rate for Payer: BCBS Healthlink |
$32.40
|
| Rate for Payer: BCBS HMK CHIP |
$32.40
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$32.40
|
| Rate for Payer: BCBS POS |
$34.20
|
| Rate for Payer: BCBS Traditional |
$36.00
|
| Rate for Payer: CASH_PRICE |
$28.80
|
| Rate for Payer: CIGNA Commercial |
$34.20
|
| Rate for Payer: CIGNA Medicare |
$32.40
|
| Rate for Payer: HUMANA Commercial |
$32.40
|
| Rate for Payer: MEDICAID Medicaid |
$33.12
|
| Rate for Payer: MEDICARE Medicare |
$25.20
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$34.20
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$34.92
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$34.20
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$34.20
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$30.60
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$28.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$28.80
|
|
|
LAB CANDIDA SPECIES DIR 1
|
Facility
IP
|
$69.00
|
|
|
Service Code
|
CPT 87480
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: BCBS HMK CHIP |
$62.10
|
| Rate for Payer: AETNA Commercial |
$65.55
|
| Rate for Payer: AETNA Medicare |
$62.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$65.55
|
| Rate for Payer: BCBS Healthlink |
$62.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$62.10
|
| Rate for Payer: BCBS POS |
$65.55
|
| Rate for Payer: BCBS Traditional |
$69.00
|
| Rate for Payer: CASH_PRICE |
$55.20
|
| Rate for Payer: CIGNA Commercial |
$65.55
|
| Rate for Payer: CIGNA Medicare |
$62.10
|
| Rate for Payer: HUMANA Commercial |
$62.10
|
| Rate for Payer: MEDICAID Medicaid |
$63.48
|
| Rate for Payer: MEDICARE Medicare |
$48.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$65.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$66.93
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$65.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$65.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$58.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$55.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$55.20
|
|
|
LAB CANDIDA SPECIES DIR 1
|
Facility
OP
|
$69.00
|
|
|
Service Code
|
CPT 87480
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: AETNA Commercial |
$65.55
|
| Rate for Payer: AETNA Medicare |
$62.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$65.55
|
| Rate for Payer: BCBS Healthlink |
$62.10
|
| Rate for Payer: BCBS HMK CHIP |
$62.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$62.10
|
| Rate for Payer: BCBS POS |
$65.55
|
| Rate for Payer: BCBS Traditional |
$69.00
|
| Rate for Payer: CASH_PRICE |
$55.20
|
| Rate for Payer: CIGNA Commercial |
$65.55
|
| Rate for Payer: CIGNA Medicare |
$62.10
|
| Rate for Payer: HUMANA Commercial |
$62.10
|
| Rate for Payer: MEDICAID Medicaid |
$63.48
|
| Rate for Payer: MEDICARE Medicare |
$48.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$65.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$66.93
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$65.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$65.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$58.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$55.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$55.20
|
|
|
LAB CARBON MONOXIDE
|
Facility
OP
|
$81.00
|
|
|
Service Code
|
CPT 82375
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: AETNA Commercial |
$76.95
|
| Rate for Payer: AETNA Medicare |
$72.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$76.95
|
| Rate for Payer: BCBS Healthlink |
$72.90
|
| Rate for Payer: BCBS HMK CHIP |
$72.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$72.90
|
| Rate for Payer: BCBS POS |
$76.95
|
| Rate for Payer: BCBS Traditional |
$81.00
|
| Rate for Payer: CASH_PRICE |
$64.80
|
| Rate for Payer: CIGNA Commercial |
$76.95
|
| Rate for Payer: CIGNA Medicare |
$72.90
|
| Rate for Payer: HUMANA Commercial |
$72.90
|
| Rate for Payer: MEDICAID Medicaid |
$74.52
|
| Rate for Payer: MEDICARE Medicare |
$56.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$76.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$78.57
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$76.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$76.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$68.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$64.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$64.80
|
|
|
LAB CARBON MONOXIDE
|
Facility
IP
|
$81.00
|
|
|
Service Code
|
CPT 82375
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$56.70 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: AETNA Commercial |
$76.95
|
| Rate for Payer: AETNA Medicare |
$72.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$76.95
|
| Rate for Payer: BCBS Healthlink |
$72.90
|
| Rate for Payer: BCBS HMK CHIP |
$72.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$72.90
|
| Rate for Payer: BCBS POS |
$76.95
|
| Rate for Payer: BCBS Traditional |
$81.00
|
| Rate for Payer: CASH_PRICE |
$64.80
|
| Rate for Payer: CIGNA Commercial |
$76.95
|
| Rate for Payer: CIGNA Medicare |
$72.90
|
| Rate for Payer: HUMANA Commercial |
$72.90
|
| Rate for Payer: MEDICAID Medicaid |
$74.52
|
| Rate for Payer: MEDICARE Medicare |
$56.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$76.95
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$78.57
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$76.95
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$76.95
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$68.85
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$64.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$64.80
|
|
|
LAB CARNERELLA VAG DIR 1
|
Facility
OP
|
$69.00
|
|
|
Service Code
|
CPT 87510
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: AETNA Commercial |
$65.55
|
| Rate for Payer: AETNA Medicare |
$62.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$65.55
|
| Rate for Payer: BCBS Healthlink |
$62.10
|
| Rate for Payer: BCBS HMK CHIP |
$62.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$62.10
|
| Rate for Payer: BCBS POS |
$65.55
|
| Rate for Payer: BCBS Traditional |
$69.00
|
| Rate for Payer: CASH_PRICE |
$55.20
|
| Rate for Payer: CIGNA Commercial |
$65.55
|
| Rate for Payer: CIGNA Medicare |
$62.10
|
| Rate for Payer: HUMANA Commercial |
$62.10
|
| Rate for Payer: MEDICAID Medicaid |
$63.48
|
| Rate for Payer: MEDICARE Medicare |
$48.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$65.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$66.93
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$65.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$65.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$58.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$55.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$55.20
|
|
|
LAB CARNERELLA VAG DIR 1
|
Facility
IP
|
$69.00
|
|
|
Service Code
|
CPT 87510
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: BCBS HMK CHIP |
$62.10
|
| Rate for Payer: AETNA Commercial |
$65.55
|
| Rate for Payer: AETNA Medicare |
$62.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$65.55
|
| Rate for Payer: BCBS Healthlink |
$62.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$62.10
|
| Rate for Payer: BCBS POS |
$65.55
|
| Rate for Payer: BCBS Traditional |
$69.00
|
| Rate for Payer: CASH_PRICE |
$55.20
|
| Rate for Payer: CIGNA Commercial |
$65.55
|
| Rate for Payer: CIGNA Medicare |
$62.10
|
| Rate for Payer: HUMANA Commercial |
$62.10
|
| Rate for Payer: MEDICAID Medicaid |
$63.48
|
| Rate for Payer: MEDICARE Medicare |
$48.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$65.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$66.93
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$65.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$65.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$58.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$55.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$55.20
|
|
|
LAB CATACHOLAMINES
|
Facility
OP
|
$148.00
|
|
|
Service Code
|
CPT 82384
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: AETNA Commercial |
$140.60
|
| Rate for Payer: AETNA Medicare |
$133.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$140.60
|
| Rate for Payer: BCBS Healthlink |
$133.20
|
| Rate for Payer: BCBS HMK CHIP |
$133.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$133.20
|
| Rate for Payer: BCBS POS |
$140.60
|
| Rate for Payer: BCBS Traditional |
$148.00
|
| Rate for Payer: CASH_PRICE |
$118.40
|
| Rate for Payer: CIGNA Commercial |
$140.60
|
| Rate for Payer: CIGNA Medicare |
$133.20
|
| Rate for Payer: HUMANA Commercial |
$133.20
|
| Rate for Payer: MEDICAID Medicaid |
$136.16
|
| Rate for Payer: MEDICARE Medicare |
$103.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$140.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$143.56
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$140.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$140.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$125.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$118.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$118.40
|
|
|
LAB CATACHOLAMINES
|
Facility
IP
|
$148.00
|
|
|
Service Code
|
CPT 82384
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$103.60 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: AETNA Commercial |
$140.60
|
| Rate for Payer: AETNA Medicare |
$133.20
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$140.60
|
| Rate for Payer: BCBS Healthlink |
$133.20
|
| Rate for Payer: BCBS HMK CHIP |
$133.20
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$133.20
|
| Rate for Payer: BCBS POS |
$140.60
|
| Rate for Payer: BCBS Traditional |
$148.00
|
| Rate for Payer: CASH_PRICE |
$118.40
|
| Rate for Payer: CIGNA Commercial |
$140.60
|
| Rate for Payer: CIGNA Medicare |
$133.20
|
| Rate for Payer: HUMANA Commercial |
$133.20
|
| Rate for Payer: MEDICAID Medicaid |
$136.16
|
| Rate for Payer: MEDICARE Medicare |
$103.60
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$140.60
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$143.56
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$140.60
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$140.60
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$125.80
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$118.40
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$118.40
|
|
|
LAB CEA
|
Facility
IP
|
$135.00
|
|
|
Service Code
|
CPT 82378
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
LAB CEA
|
Facility
OP
|
$135.00
|
|
|
Service Code
|
CPT 82378
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| 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
|
|
|
LAB CFTR GENE COM VARIANTS
|
Facility
IP
|
$649.00
|
|
|
Service Code
|
CPT 81220
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$454.30 |
| Max. Negotiated Rate |
$649.00 |
| Rate for Payer: AETNA Commercial |
$616.55
|
| Rate for Payer: AETNA Medicare |
$584.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$616.55
|
| Rate for Payer: BCBS Healthlink |
$584.10
|
| Rate for Payer: BCBS HMK CHIP |
$584.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$584.10
|
| Rate for Payer: BCBS POS |
$616.55
|
| Rate for Payer: BCBS Traditional |
$649.00
|
| Rate for Payer: CASH_PRICE |
$519.20
|
| Rate for Payer: CIGNA Commercial |
$616.55
|
| Rate for Payer: CIGNA Medicare |
$584.10
|
| Rate for Payer: HUMANA Commercial |
$584.10
|
| Rate for Payer: MEDICAID Medicaid |
$597.08
|
| Rate for Payer: MEDICARE Medicare |
$454.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$616.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$629.53
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$616.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$616.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$551.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$519.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$519.20
|
|
|
LAB CFTR GENE COM VARIANTS
|
Facility
OP
|
$649.00
|
|
|
Service Code
|
CPT 81220
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$454.30 |
| Max. Negotiated Rate |
$649.00 |
| Rate for Payer: AETNA Commercial |
$616.55
|
| Rate for Payer: AETNA Medicare |
$584.10
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$616.55
|
| Rate for Payer: BCBS Healthlink |
$584.10
|
| Rate for Payer: BCBS HMK CHIP |
$584.10
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$584.10
|
| Rate for Payer: BCBS POS |
$616.55
|
| Rate for Payer: BCBS Traditional |
$649.00
|
| Rate for Payer: CASH_PRICE |
$519.20
|
| Rate for Payer: CIGNA Commercial |
$616.55
|
| Rate for Payer: CIGNA Medicare |
$584.10
|
| Rate for Payer: HUMANA Commercial |
$584.10
|
| Rate for Payer: MEDICAID Medicaid |
$597.08
|
| Rate for Payer: MEDICARE Medicare |
$454.30
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$616.55
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$629.53
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$616.55
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$616.55
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$551.65
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$519.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$519.20
|
|
|
LAB CHLAMYDIA PNEUMONIA
|
Facility
IP
|
$87.00
|
|
|
Service Code
|
CPT 87486
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$60.90 |
| Max. Negotiated Rate |
$87.00 |
| Rate for Payer: BCBS HMK CHIP |
$78.30
|
| Rate for Payer: AETNA Commercial |
$82.65
|
| Rate for Payer: AETNA Medicare |
$78.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$82.65
|
| Rate for Payer: BCBS Healthlink |
$78.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$78.30
|
| Rate for Payer: BCBS POS |
$82.65
|
| Rate for Payer: BCBS Traditional |
$87.00
|
| Rate for Payer: CASH_PRICE |
$69.60
|
| Rate for Payer: CIGNA Commercial |
$82.65
|
| Rate for Payer: CIGNA Medicare |
$78.30
|
| Rate for Payer: HUMANA Commercial |
$78.30
|
| Rate for Payer: MEDICAID Medicaid |
$80.04
|
| Rate for Payer: MEDICARE Medicare |
$60.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$82.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$84.39
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$82.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$82.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$73.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$69.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$69.60
|
|
|
LAB CHLAMYDIA PNEUMONIA
|
Facility
OP
|
$87.00
|
|
|
Service Code
|
CPT 87486
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$60.90 |
| Max. Negotiated Rate |
$87.00 |
| Rate for Payer: AETNA Commercial |
$82.65
|
| Rate for Payer: AETNA Medicare |
$78.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$82.65
|
| Rate for Payer: BCBS Healthlink |
$78.30
|
| Rate for Payer: BCBS HMK CHIP |
$78.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$78.30
|
| Rate for Payer: BCBS POS |
$82.65
|
| Rate for Payer: BCBS Traditional |
$87.00
|
| Rate for Payer: CASH_PRICE |
$69.60
|
| Rate for Payer: CIGNA Commercial |
$82.65
|
| Rate for Payer: CIGNA Medicare |
$78.30
|
| Rate for Payer: HUMANA Commercial |
$78.30
|
| Rate for Payer: MEDICAID Medicaid |
$80.04
|
| Rate for Payer: MEDICARE Medicare |
$60.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$82.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$84.39
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$82.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$82.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$73.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$69.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$69.60
|
|
