|
LAB CHROMOGRANIN A
|
Facility
OP
|
$94.00
|
|
|
Service Code
|
CPT 86316
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: AETNA Commercial |
$89.30
|
| Rate for Payer: AETNA Medicare |
$84.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$89.30
|
| Rate for Payer: BCBS Healthlink |
$84.60
|
| Rate for Payer: BCBS HMK CHIP |
$84.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$84.60
|
| Rate for Payer: BCBS POS |
$89.30
|
| Rate for Payer: BCBS Traditional |
$94.00
|
| Rate for Payer: CASH_PRICE |
$75.20
|
| Rate for Payer: CIGNA Commercial |
$89.30
|
| Rate for Payer: CIGNA Medicare |
$84.60
|
| Rate for Payer: HUMANA Commercial |
$84.60
|
| Rate for Payer: MEDICAID Medicaid |
$86.48
|
| Rate for Payer: MEDICARE Medicare |
$65.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$89.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$91.18
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$89.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$89.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$79.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$75.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$75.20
|
|
|
LAB CHROMOGRANIN A
|
Facility
IP
|
$94.00
|
|
|
Service Code
|
CPT 86316
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.80 |
| Max. Negotiated Rate |
$94.00 |
| Rate for Payer: AETNA Commercial |
$89.30
|
| Rate for Payer: AETNA Medicare |
$84.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$89.30
|
| Rate for Payer: BCBS Healthlink |
$84.60
|
| Rate for Payer: BCBS HMK CHIP |
$84.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$84.60
|
| Rate for Payer: BCBS POS |
$89.30
|
| Rate for Payer: BCBS Traditional |
$94.00
|
| Rate for Payer: CASH_PRICE |
$75.20
|
| Rate for Payer: CIGNA Commercial |
$89.30
|
| Rate for Payer: CIGNA Medicare |
$84.60
|
| Rate for Payer: HUMANA Commercial |
$84.60
|
| Rate for Payer: MEDICAID Medicaid |
$86.48
|
| Rate for Payer: MEDICARE Medicare |
$65.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$89.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$91.18
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$89.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$89.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$79.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$75.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$75.20
|
|
|
LAB CHROMOSONE ROUTINE
|
Facility
OP
|
$687.00
|
|
|
Service Code
|
CPT 88262
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$480.90 |
| Max. Negotiated Rate |
$687.00 |
| Rate for Payer: AETNA Commercial |
$652.65
|
| Rate for Payer: AETNA Medicare |
$618.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$652.65
|
| Rate for Payer: BCBS Healthlink |
$618.30
|
| Rate for Payer: BCBS HMK CHIP |
$618.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$618.30
|
| Rate for Payer: BCBS POS |
$652.65
|
| Rate for Payer: BCBS Traditional |
$687.00
|
| Rate for Payer: CASH_PRICE |
$549.60
|
| Rate for Payer: CIGNA Commercial |
$652.65
|
| Rate for Payer: CIGNA Medicare |
$618.30
|
| Rate for Payer: HUMANA Commercial |
$618.30
|
| Rate for Payer: MEDICAID Medicaid |
$632.04
|
| Rate for Payer: MEDICARE Medicare |
$480.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$652.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$666.39
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$652.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$652.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$583.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$549.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$549.60
|
|
|
LAB CHROMOSONE ROUTINE
|
Facility
OP
|
$551.00
|
|
|
Service Code
|
CPT 88230
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$385.70 |
| Max. Negotiated Rate |
$551.00 |
| Rate for Payer: AETNA Commercial |
$523.45
|
| Rate for Payer: AETNA Medicare |
$495.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$523.45
|
| Rate for Payer: BCBS Healthlink |
$495.90
|
| Rate for Payer: BCBS HMK CHIP |
$495.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$495.90
|
| Rate for Payer: BCBS POS |
$523.45
|
| Rate for Payer: BCBS Traditional |
$551.00
|
| Rate for Payer: CASH_PRICE |
$440.80
|
| Rate for Payer: CIGNA Commercial |
$523.45
|
| Rate for Payer: CIGNA Medicare |
$495.90
|
| Rate for Payer: HUMANA Commercial |
$495.90
|
| Rate for Payer: MEDICAID Medicaid |
$506.92
|
| Rate for Payer: MEDICARE Medicare |
$385.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$523.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$534.47
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$523.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$523.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$468.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$440.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$440.80
|
|
|
LAB CHROMOSONE ROUTINE
|
Facility
IP
|
$102.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$71.40 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: BCBS HMK CHIP |
$91.80
|
| Rate for Payer: AETNA Commercial |
$96.90
|
| Rate for Payer: AETNA Medicare |
$91.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$96.90
|
| Rate for Payer: BCBS Healthlink |
$91.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$91.80
|
| Rate for Payer: BCBS POS |
$96.90
|
| Rate for Payer: BCBS Traditional |
$102.00
|
| Rate for Payer: CASH_PRICE |
$81.60
|
| Rate for Payer: CIGNA Commercial |
$96.90
|
| Rate for Payer: CIGNA Medicare |
$91.80
|
| Rate for Payer: HUMANA Commercial |
$91.80
|
| Rate for Payer: MEDICAID Medicaid |
$93.84
|
| Rate for Payer: MEDICARE Medicare |
$71.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$96.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$98.94
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$96.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$96.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$86.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$81.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$81.60
|
|
|
LAB CHROMOSONE ROUTINE
|
Facility
IP
|
$687.00
|
|
|
Service Code
|
CPT 88262
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$480.90 |
| Max. Negotiated Rate |
$687.00 |
| Rate for Payer: AETNA Commercial |
$652.65
|
| Rate for Payer: AETNA Medicare |
$618.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$652.65
|
| Rate for Payer: BCBS Healthlink |
$618.30
|
| Rate for Payer: BCBS HMK CHIP |
$618.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$618.30
|
| Rate for Payer: BCBS POS |
$652.65
|
| Rate for Payer: BCBS Traditional |
$687.00
|
| Rate for Payer: CASH_PRICE |
$549.60
|
| Rate for Payer: CIGNA Commercial |
$652.65
|
| Rate for Payer: CIGNA Medicare |
$618.30
|
| Rate for Payer: HUMANA Commercial |
$618.30
|
| Rate for Payer: MEDICAID Medicaid |
$632.04
|
| Rate for Payer: MEDICARE Medicare |
$480.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$652.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$666.39
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$652.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$652.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$583.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$549.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$549.60
|
|
|
LAB CHROMOSONE ROUTINE
|
Facility
OP
|
$102.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$71.40 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: AETNA Commercial |
$96.90
|
| Rate for Payer: AETNA Medicare |
$91.80
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$96.90
|
| Rate for Payer: BCBS Healthlink |
$91.80
|
| Rate for Payer: BCBS HMK CHIP |
$91.80
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$91.80
|
| Rate for Payer: BCBS POS |
$96.90
|
| Rate for Payer: BCBS Traditional |
$102.00
|
| Rate for Payer: CASH_PRICE |
$81.60
|
| Rate for Payer: CIGNA Commercial |
$96.90
|
| Rate for Payer: CIGNA Medicare |
$91.80
|
| Rate for Payer: HUMANA Commercial |
$91.80
|
| Rate for Payer: MEDICAID Medicaid |
$93.84
|
| Rate for Payer: MEDICARE Medicare |
$71.40
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$96.90
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$98.94
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$96.90
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$96.90
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$86.70
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$81.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$81.60
|
|
|
LAB CHROMOSONE ROUTINE
|
Facility
IP
|
$551.00
|
|
|
Service Code
|
CPT 88230
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$385.70 |
| Max. Negotiated Rate |
$551.00 |
| Rate for Payer: BCBS HMK CHIP |
$495.90
|
| Rate for Payer: AETNA Commercial |
$523.45
|
| Rate for Payer: AETNA Medicare |
$495.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$523.45
|
| Rate for Payer: BCBS Healthlink |
$495.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$495.90
|
| Rate for Payer: BCBS POS |
$523.45
|
| Rate for Payer: BCBS Traditional |
$551.00
|
| Rate for Payer: CASH_PRICE |
$440.80
|
| Rate for Payer: CIGNA Commercial |
$523.45
|
| Rate for Payer: CIGNA Medicare |
$495.90
|
| Rate for Payer: HUMANA Commercial |
$495.90
|
| Rate for Payer: MEDICAID Medicaid |
$506.92
|
| Rate for Payer: MEDICARE Medicare |
$385.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$523.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$534.47
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$523.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$523.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$468.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$440.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$440.80
|
|
|
LAB CITRATE
|
Facility
IP
|
$135.00
|
|
|
Service Code
|
CPT 82507
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| 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 CITRATE
|
Facility
OP
|
$135.00
|
|
|
Service Code
|
CPT 82507
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| 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 CK ISOENZYMES
|
Facility
IP
|
$125.00
|
|
|
Service Code
|
CPT 82552
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: BCBS HMK CHIP |
$112.50
|
| Rate for Payer: AETNA Commercial |
$118.75
|
| Rate for Payer: AETNA Medicare |
$112.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$118.75
|
| Rate for Payer: BCBS Healthlink |
$112.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$112.50
|
| Rate for Payer: BCBS POS |
$118.75
|
| Rate for Payer: BCBS Traditional |
$125.00
|
| Rate for Payer: CASH_PRICE |
$100.00
|
| Rate for Payer: CIGNA Commercial |
$118.75
|
| Rate for Payer: CIGNA Medicare |
$112.50
|
| Rate for Payer: HUMANA Commercial |
$112.50
|
| Rate for Payer: MEDICAID Medicaid |
$115.00
|
| Rate for Payer: MEDICARE Medicare |
$87.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$118.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$121.25
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$118.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$118.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$106.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$100.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$100.00
|
|
|
LAB CK ISOENZYMES
|
Facility
OP
|
$125.00
|
|
|
Service Code
|
CPT 82552
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: AETNA Commercial |
$118.75
|
| Rate for Payer: AETNA Medicare |
$112.50
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$118.75
|
| Rate for Payer: BCBS Healthlink |
$112.50
|
| Rate for Payer: BCBS HMK CHIP |
$112.50
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$112.50
|
| Rate for Payer: BCBS POS |
$118.75
|
| Rate for Payer: BCBS Traditional |
$125.00
|
| Rate for Payer: CASH_PRICE |
$100.00
|
| Rate for Payer: CIGNA Commercial |
$118.75
|
| Rate for Payer: CIGNA Medicare |
$112.50
|
| Rate for Payer: HUMANA Commercial |
$112.50
|
| Rate for Payer: MEDICAID Medicaid |
$115.00
|
| Rate for Payer: MEDICARE Medicare |
$87.50
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$118.75
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$121.25
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$118.75
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$118.75
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$106.25
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$100.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$100.00
|
|
|
LAB CLOMIPRAMINE LEVEL
|
Facility
IP
|
$135.00
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| 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 CLOMIPRAMINE LEVEL
|
Facility
OP
|
$135.00
|
|
|
Service Code
|
CPT 83789
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| 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 COLD AGGLUTININS
|
Facility
OP
|
$54.00
|
|
|
Service Code
|
CPT 86157
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$37.80 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: AETNA Commercial |
$51.30
|
| Rate for Payer: AETNA Medicare |
$48.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$51.30
|
| Rate for Payer: BCBS Healthlink |
$48.60
|
| Rate for Payer: BCBS HMK CHIP |
$48.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$48.60
|
| Rate for Payer: BCBS POS |
$51.30
|
| Rate for Payer: BCBS Traditional |
$54.00
|
| Rate for Payer: CASH_PRICE |
$43.20
|
| Rate for Payer: CIGNA Commercial |
$51.30
|
| Rate for Payer: CIGNA Medicare |
$48.60
|
| Rate for Payer: HUMANA Commercial |
$48.60
|
| Rate for Payer: MEDICAID Medicaid |
$49.68
|
| Rate for Payer: MEDICARE Medicare |
$37.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$51.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$52.38
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$51.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$51.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$45.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$43.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$43.20
|
|
|
LAB COLD AGGLUTININS
|
Facility
IP
|
$54.00
|
|
|
Service Code
|
CPT 86157
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$37.80 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: BCBS HMK CHIP |
$48.60
|
| Rate for Payer: AETNA Commercial |
$51.30
|
| Rate for Payer: AETNA Medicare |
$48.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$51.30
|
| Rate for Payer: BCBS Healthlink |
$48.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$48.60
|
| Rate for Payer: BCBS POS |
$51.30
|
| Rate for Payer: BCBS Traditional |
$54.00
|
| Rate for Payer: CASH_PRICE |
$43.20
|
| Rate for Payer: CIGNA Commercial |
$51.30
|
| Rate for Payer: CIGNA Medicare |
$48.60
|
| Rate for Payer: HUMANA Commercial |
$48.60
|
| Rate for Payer: MEDICAID Medicaid |
$49.68
|
| Rate for Payer: MEDICARE Medicare |
$37.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$51.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$52.38
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$51.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$51.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$45.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$43.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$43.20
|
|
|
LAB COLO CARE (STOOL BLOOD TEST)
|
Facility
IP
|
$7.00
|
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: AETNA Commercial |
$6.65
|
| Rate for Payer: AETNA Medicare |
$6.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$6.65
|
| Rate for Payer: BCBS Healthlink |
$6.30
|
| Rate for Payer: BCBS HMK CHIP |
$6.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$6.30
|
| Rate for Payer: BCBS POS |
$6.65
|
| Rate for Payer: BCBS Traditional |
$7.00
|
| Rate for Payer: CASH_PRICE |
$5.60
|
| Rate for Payer: CIGNA Commercial |
$6.65
|
| Rate for Payer: CIGNA Medicare |
$6.30
|
| Rate for Payer: HUMANA Commercial |
$6.30
|
| Rate for Payer: MEDICAID Medicaid |
$6.44
|
| Rate for Payer: MEDICARE Medicare |
$4.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$6.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$6.79
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$6.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$6.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$5.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$5.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$5.60
|
|
|
LAB COLO CARE (STOOL BLOOD TEST)
|
Facility
OP
|
$7.00
|
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: AETNA Commercial |
$6.65
|
| Rate for Payer: AETNA Medicare |
$6.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$6.65
|
| Rate for Payer: BCBS Healthlink |
$6.30
|
| Rate for Payer: BCBS HMK CHIP |
$6.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$6.30
|
| Rate for Payer: BCBS POS |
$6.65
|
| Rate for Payer: BCBS Traditional |
$7.00
|
| Rate for Payer: CASH_PRICE |
$5.60
|
| Rate for Payer: CIGNA Commercial |
$6.65
|
| Rate for Payer: CIGNA Medicare |
$6.30
|
| Rate for Payer: HUMANA Commercial |
$6.30
|
| Rate for Payer: MEDICAID Medicaid |
$6.44
|
| Rate for Payer: MEDICARE Medicare |
$4.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$6.65
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$6.79
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$6.65
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$6.65
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$5.95
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$5.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$5.60
|
|
|
LAB COMP RESPIRATORY PANEL
|
Facility
IP
|
$697.00
|
|
|
Service Code
|
CPT 87633
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$487.90 |
| Max. Negotiated Rate |
$697.00 |
| Rate for Payer: BCBS HMK CHIP |
$627.30
|
| Rate for Payer: AETNA Commercial |
$662.15
|
| Rate for Payer: AETNA Medicare |
$627.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$662.15
|
| Rate for Payer: BCBS Healthlink |
$627.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$627.30
|
| Rate for Payer: BCBS POS |
$662.15
|
| Rate for Payer: BCBS Traditional |
$697.00
|
| Rate for Payer: CASH_PRICE |
$557.60
|
| Rate for Payer: CIGNA Commercial |
$662.15
|
| Rate for Payer: CIGNA Medicare |
$627.30
|
| Rate for Payer: HUMANA Commercial |
$627.30
|
| Rate for Payer: MEDICAID Medicaid |
$641.24
|
| Rate for Payer: MEDICARE Medicare |
$487.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$662.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$676.09
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$662.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$662.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$592.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$557.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$557.60
|
|
|
LAB COMP RESPIRATORY PANEL
|
Facility
OP
|
$697.00
|
|
|
Service Code
|
CPT 87633
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$487.90 |
| Max. Negotiated Rate |
$697.00 |
| Rate for Payer: AETNA Commercial |
$662.15
|
| Rate for Payer: AETNA Medicare |
$627.30
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$662.15
|
| Rate for Payer: BCBS Healthlink |
$627.30
|
| Rate for Payer: BCBS HMK CHIP |
$627.30
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$627.30
|
| Rate for Payer: BCBS POS |
$662.15
|
| Rate for Payer: BCBS Traditional |
$697.00
|
| Rate for Payer: CASH_PRICE |
$557.60
|
| Rate for Payer: CIGNA Commercial |
$662.15
|
| Rate for Payer: CIGNA Medicare |
$627.30
|
| Rate for Payer: HUMANA Commercial |
$627.30
|
| Rate for Payer: MEDICAID Medicaid |
$641.24
|
| Rate for Payer: MEDICARE Medicare |
$487.90
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$662.15
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$676.09
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$662.15
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$662.15
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$592.45
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$557.60
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$557.60
|
|
|
LAB CONGENITAL HYPOTHYROIDISM
|
Facility
IP
|
$31.00
|
|
|
Service Code
|
CPT 84437
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.70 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: AETNA Commercial |
$29.45
|
| Rate for Payer: AETNA Medicare |
$27.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$29.45
|
| Rate for Payer: BCBS Healthlink |
$27.90
|
| Rate for Payer: BCBS HMK CHIP |
$27.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.90
|
| Rate for Payer: BCBS POS |
$29.45
|
| Rate for Payer: BCBS Traditional |
$31.00
|
| Rate for Payer: CASH_PRICE |
$24.80
|
| Rate for Payer: CIGNA Commercial |
$29.45
|
| Rate for Payer: CIGNA Medicare |
$27.90
|
| Rate for Payer: HUMANA Commercial |
$27.90
|
| Rate for Payer: MEDICAID Medicaid |
$28.52
|
| Rate for Payer: MEDICARE Medicare |
$21.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$29.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$30.07
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$29.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$29.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$26.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.80
|
|
|
LAB CONGENITAL HYPOTHYROIDISM
|
Facility
OP
|
$31.00
|
|
|
Service Code
|
CPT 84437
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.70 |
| Max. Negotiated Rate |
$31.00 |
| Rate for Payer: AETNA Commercial |
$29.45
|
| Rate for Payer: AETNA Medicare |
$27.90
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$29.45
|
| Rate for Payer: BCBS Healthlink |
$27.90
|
| Rate for Payer: BCBS HMK CHIP |
$27.90
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$27.90
|
| Rate for Payer: BCBS POS |
$29.45
|
| Rate for Payer: BCBS Traditional |
$31.00
|
| Rate for Payer: CASH_PRICE |
$24.80
|
| Rate for Payer: CIGNA Commercial |
$29.45
|
| Rate for Payer: CIGNA Medicare |
$27.90
|
| Rate for Payer: HUMANA Commercial |
$27.90
|
| Rate for Payer: MEDICAID Medicaid |
$28.52
|
| Rate for Payer: MEDICARE Medicare |
$21.70
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$29.45
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$30.07
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$29.45
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$29.45
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$26.35
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$24.80
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$24.80
|
|
|
LAB COOMBS DIRECT
|
Facility
IP
|
$60.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: BCBS HMK CHIP |
$54.00
|
| Rate for Payer: AETNA Commercial |
$57.00
|
| Rate for Payer: AETNA Medicare |
$54.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$57.00
|
| Rate for Payer: BCBS Healthlink |
$54.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$54.00
|
| Rate for Payer: BCBS POS |
$57.00
|
| Rate for Payer: BCBS Traditional |
$60.00
|
| Rate for Payer: CASH_PRICE |
$48.00
|
| Rate for Payer: CIGNA Commercial |
$57.00
|
| Rate for Payer: CIGNA Medicare |
$54.00
|
| Rate for Payer: HUMANA Commercial |
$54.00
|
| Rate for Payer: MEDICAID Medicaid |
$55.20
|
| Rate for Payer: MEDICARE Medicare |
$42.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$57.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$58.20
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$57.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$57.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$51.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$48.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$48.00
|
|
|
LAB COOMBS DIRECT
|
Facility
OP
|
$60.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: AETNA Commercial |
$57.00
|
| Rate for Payer: AETNA Medicare |
$54.00
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$57.00
|
| Rate for Payer: BCBS Healthlink |
$54.00
|
| Rate for Payer: BCBS HMK CHIP |
$54.00
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$54.00
|
| Rate for Payer: BCBS POS |
$57.00
|
| Rate for Payer: BCBS Traditional |
$60.00
|
| Rate for Payer: CASH_PRICE |
$48.00
|
| Rate for Payer: CIGNA Commercial |
$57.00
|
| Rate for Payer: CIGNA Medicare |
$54.00
|
| Rate for Payer: HUMANA Commercial |
$54.00
|
| Rate for Payer: MEDICAID Medicaid |
$55.20
|
| Rate for Payer: MEDICARE Medicare |
$42.00
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$57.00
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$58.20
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$57.00
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$57.00
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$51.00
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$48.00
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$48.00
|
|
|
LAB CREATINE URINE
|
Facility
OP
|
$154.00
|
|
|
Service Code
|
CPT 82540
|
| Hospital Charge Code |
20211001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$107.80 |
| Max. Negotiated Rate |
$154.00 |
| Rate for Payer: AETNA Commercial |
$146.30
|
| Rate for Payer: AETNA Medicare |
$138.60
|
| Rate for Payer: BCBS CLOSED PLAN NETWORK |
$146.30
|
| Rate for Payer: BCBS Healthlink |
$138.60
|
| Rate for Payer: BCBS HMK CHIP |
$138.60
|
| Rate for Payer: BCBS MCR ADVANTAGE Medicare Part A |
$138.60
|
| Rate for Payer: BCBS POS |
$146.30
|
| Rate for Payer: BCBS Traditional |
$154.00
|
| Rate for Payer: CASH_PRICE |
$123.20
|
| Rate for Payer: CIGNA Commercial |
$146.30
|
| Rate for Payer: CIGNA Medicare |
$138.60
|
| Rate for Payer: HUMANA Commercial |
$138.60
|
| Rate for Payer: MEDICAID Medicaid |
$141.68
|
| Rate for Payer: MEDICARE Medicare |
$107.80
|
| Rate for Payer: MONIDA - ALLEGIANCE Commercial |
$146.30
|
| Rate for Payer: MONIDA - FIRST CHOICE HEALTH Commercial |
$149.38
|
| Rate for Payer: MONIDA - MONTANA HEALTH COOP Commercial |
$146.30
|
| Rate for Payer: MONIDA - PACIFICSOURCE Commercial |
$146.30
|
| Rate for Payer: UNITED HEALTHCARE Commercial |
$130.90
|
| Rate for Payer: UNITED HEALTHCARE MCD ADVANTAGE Medicaid |
$123.20
|
| Rate for Payer: UNITED HEALTHCARE MCR ADVANTAGE RHC Medicare |
$123.20
|
|
