|
ketoconazole topical 2% Shampoo 120 ml[VDMC]
|
Facility
|
OP
|
$62.76
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
21026900
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$31.37 |
| Max. Negotiated Rate |
$56.48 |
| Rate for Payer: Aetna of IA Commercial |
$56.48
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$56.48
|
| Rate for Payer: Aetna of IA Medicare |
$35.77
|
| Rate for Payer: Amerigroup Medicaid |
$31.67
|
| Rate for Payer: Amerigroup Medicare |
$31.69
|
| Rate for Payer: Cash Price |
$50.21
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$47.07
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$31.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$31.37
|
| Rate for Payer: Medical Associates Commercial |
$47.07
|
| Rate for Payer: Medical Associates Managed Medicare |
$31.38
|
| Rate for Payer: Midlands Choice Commercial |
$43.93
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$31.85
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$31.83
|
| Rate for Payer: Oscar Health of IA Commercial |
$47.07
|
| Rate for Payer: Partners Health Alliance Commercial |
$47.07
|
| Rate for Payer: United Healthcare Commercial |
$56.48
|
| Rate for Payer: United Healthcare Managed Medicare |
$37.03
|
|
|
KETONES SERUM
|
Facility
|
OP
|
$61.00
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
4022840
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$20.46 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Aetna of IA Medicare |
$34.77
|
| Rate for Payer: Amerigroup Medicaid |
$30.79
|
| Rate for Payer: Amerigroup Medicare |
$30.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$30.50
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$30.49
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Medical Associates Managed Medicare |
$30.50
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$30.96
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$30.94
|
| Rate for Payer: Oscar Health of IA Commercial |
$45.75
|
| Rate for Payer: Partners Health Alliance Commercial |
$45.75
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
| Rate for Payer: United Healthcare Managed Medicare |
$35.99
|
| Rate for Payer: Wellmark IA HMO |
$20.46
|
| Rate for Payer: Wellmark IA PPO |
$22.51
|
|
|
KETONES SERUM
|
Facility
|
IP
|
$61.00
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
4022840
|
|
Hospital Revenue Code
|
307
|
| Min. Negotiated Rate |
$42.70 |
| Max. Negotiated Rate |
$54.90 |
| Rate for Payer: Aetna of IA Commercial |
$54.90
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$54.90
|
| Rate for Payer: Cash Price |
$48.80
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$45.75
|
| Rate for Payer: Medical Associates Commercial |
$45.75
|
| Rate for Payer: Midlands Choice Commercial |
$42.70
|
| Rate for Payer: United Healthcare Commercial |
$54.90
|
|
|
ketorolac 10 mg Tab [VDMC]
|
Facility
|
OP
|
$3.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10398333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna of IA Commercial |
$3.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.56
|
| Rate for Payer: Aetna of IA Medicare |
$2.26
|
| Rate for Payer: Amerigroup Medicaid |
$2.00
|
| Rate for Payer: Amerigroup Medicare |
$2.00
|
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.97
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$1.98
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$1.98
|
| Rate for Payer: Medical Associates Commercial |
$2.97
|
| Rate for Payer: Medical Associates Managed Medicare |
$1.98
|
| Rate for Payer: Midlands Choice Commercial |
$2.77
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$2.01
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$2.01
|
| Rate for Payer: Oscar Health of IA Commercial |
$2.97
|
| Rate for Payer: Partners Health Alliance Commercial |
$2.97
|
| Rate for Payer: United Healthcare Commercial |
$3.56
|
| Rate for Payer: United Healthcare Managed Medicare |
$2.34
|
|
|
ketorolac 10 mg Tab [VDMC]
|
Facility
|
IP
|
$3.96
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10398333
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna of IA Commercial |
$3.56
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$3.56
|
| Rate for Payer: Cash Price |
$3.17
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$2.97
|
| Rate for Payer: Medical Associates Commercial |
$2.97
|
| Rate for Payer: Midlands Choice Commercial |
$2.77
|
| Rate for Payer: United Healthcare Commercial |
$3.56
|
|
|
ketorolac 15 mg/mL 1ml Inj SDV [VDMC]
|
Facility
|
IP
|
$22.83
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398402
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.98 |
| Max. Negotiated Rate |
$20.55 |
| Rate for Payer: Aetna of IA Commercial |
$20.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.55
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.12
|
| Rate for Payer: Medical Associates Commercial |
$17.12
|
| Rate for Payer: Midlands Choice Commercial |
$15.98
|
| Rate for Payer: United Healthcare Commercial |
$20.55
|
|
|
ketorolac 15 mg/mL 1ml Inj SDV [VDMC]
|
Facility
|
OP
|
$22.83
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398402
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$20.55 |
| Rate for Payer: Aetna of IA Commercial |
$20.55
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.55
|
| Rate for Payer: Aetna of IA Medicare |
$13.01
|
| Rate for Payer: Amerigroup Medicaid |
$11.52
|
| Rate for Payer: Amerigroup Medicare |
$11.53
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.12
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.42
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.41
|
| Rate for Payer: Medical Associates Commercial |
$17.12
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.42
|
| Rate for Payer: Midlands Choice Commercial |
$15.98
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.59
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$11.58
|
| Rate for Payer: Oscar Health of IA Commercial |
$17.12
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.12
|
| Rate for Payer: United Healthcare Commercial |
$20.55
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.47
|
|
|
ketorolac 30 mg/mL Inj 1ml SDV [VDMC]
|
Facility
|
IP
|
$27.60
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$19.32 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna of IA Commercial |
$24.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.84
|
| Rate for Payer: Cash Price |
$22.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.70
|
| Rate for Payer: Medical Associates Commercial |
$20.70
|
| Rate for Payer: Midlands Choice Commercial |
$19.32
|
| Rate for Payer: United Healthcare Commercial |
$24.84
|
|
|
ketorolac 30 mg/mL Inj 1ml SDV [VDMC]
|
Facility
|
OP
|
$27.60
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$13.79 |
| Max. Negotiated Rate |
$24.84 |
| Rate for Payer: Aetna of IA Commercial |
$24.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$24.84
|
| Rate for Payer: Aetna of IA Medicare |
$15.73
|
| Rate for Payer: Amerigroup Medicaid |
$13.93
|
| Rate for Payer: Amerigroup Medicare |
$13.94
|
| Rate for Payer: Cash Price |
$22.08
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$20.70
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$13.80
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$13.79
|
| Rate for Payer: Medical Associates Commercial |
$20.70
|
| Rate for Payer: Medical Associates Managed Medicare |
$13.80
|
| Rate for Payer: Midlands Choice Commercial |
$19.32
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14.01
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$14.00
|
| Rate for Payer: Oscar Health of IA Commercial |
$20.70
|
| Rate for Payer: Partners Health Alliance Commercial |
$20.70
|
| Rate for Payer: United Healthcare Commercial |
$24.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$16.28
|
|
|
ketorolac 60 mg/mL 2 ml SDV inj [VDMC]
|
Facility
|
OP
|
$23.15
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398540
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.57 |
| Max. Negotiated Rate |
$20.84 |
| Rate for Payer: Aetna of IA Commercial |
$20.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.84
|
| Rate for Payer: Aetna of IA Medicare |
$13.20
|
| Rate for Payer: Amerigroup Medicaid |
$11.68
|
| Rate for Payer: Amerigroup Medicare |
$11.69
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.36
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$11.58
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11.57
|
| Rate for Payer: Medical Associates Commercial |
$17.36
|
| Rate for Payer: Medical Associates Managed Medicare |
$11.58
|
| Rate for Payer: Midlands Choice Commercial |
$16.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11.75
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$11.74
|
| Rate for Payer: Oscar Health of IA Commercial |
$17.36
|
| Rate for Payer: Partners Health Alliance Commercial |
$17.36
|
| Rate for Payer: United Healthcare Commercial |
$20.84
|
| Rate for Payer: United Healthcare Managed Medicare |
$13.66
|
|
|
ketorolac 60 mg/mL 2 ml SDV inj [VDMC]
|
Facility
|
IP
|
$23.15
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
10398540
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.20 |
| Max. Negotiated Rate |
$20.84 |
| Rate for Payer: Aetna of IA Commercial |
$20.84
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$20.84
|
| Rate for Payer: Cash Price |
$18.52
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$17.36
|
| Rate for Payer: Medical Associates Commercial |
$17.36
|
| Rate for Payer: Midlands Choice Commercial |
$16.20
|
| Rate for Payer: United Healthcare Commercial |
$20.84
|
|
|
ketotifen 0.025% 5 ml Ophth Sol [VDMC]
|
Facility
|
IP
|
$41.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$29.04 |
| Max. Negotiated Rate |
$37.33 |
| Rate for Payer: Aetna of IA Commercial |
$37.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.33
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.11
|
| Rate for Payer: Medical Associates Commercial |
$31.11
|
| Rate for Payer: Midlands Choice Commercial |
$29.04
|
| Rate for Payer: United Healthcare Commercial |
$37.33
|
|
|
ketotifen 0.025% 5 ml Ophth Sol [VDMC]
|
Facility
|
OP
|
$41.48
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
10435314
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.73 |
| Max. Negotiated Rate |
$37.33 |
| Rate for Payer: Aetna of IA Commercial |
$37.33
|
| Rate for Payer: Aetna of IA Medical Rental Products |
$37.33
|
| Rate for Payer: Aetna of IA Medicare |
$23.64
|
| Rate for Payer: Amerigroup Medicaid |
$20.93
|
| Rate for Payer: Amerigroup Medicare |
$20.95
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial |
$31.11
|
| Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS |
$20.74
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$20.73
|
| Rate for Payer: Medical Associates Commercial |
$31.11
|
| Rate for Payer: Medical Associates Managed Medicare |
$20.74
|
| Rate for Payer: Midlands Choice Commercial |
$29.04
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$21.05
|
| Rate for Payer: Molina Healthcare Managed Medicare |
$21.04
|
| Rate for Payer: Oscar Health of IA Commercial |
$31.11
|
| Rate for Payer: Partners Health Alliance Commercial |
$31.11
|
| Rate for Payer: United Healthcare Commercial |
$37.33
|
| Rate for Payer: United Healthcare Managed Medicare |
$24.47
|
|
|
Kidney and Ureter Procedures for Neoplasm With CC
|
Facility
|
IP
|
$14,945.71
|
|
|
Service Code
|
MS-DRG 657
|
| Hospital Charge Code |
439
|
| Min. Negotiated Rate |
$14,729.11 |
| Max. Negotiated Rate |
$14,945.71 |
| Rate for Payer: Amerigroup Medicaid |
$14,873.51
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$14,729.11
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$14,945.71
|
|
|
Kidney and Ureter Procedures for Neoplasm With MCC
|
Facility
|
IP
|
$24,166.08
|
|
|
Service Code
|
MS-DRG 656
|
| Hospital Charge Code |
438
|
| Min. Negotiated Rate |
$23,815.85 |
| Max. Negotiated Rate |
$24,166.08 |
| Rate for Payer: Amerigroup Medicaid |
$24,049.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$23,815.85
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$24,166.08
|
|
|
Kidney and Ureter Procedures for Neoplasm Without CC/MCC
|
Facility
|
IP
|
$12,698.68
|
|
|
Service Code
|
MS-DRG 658
|
| Hospital Charge Code |
440
|
| Min. Negotiated Rate |
$12,514.65 |
| Max. Negotiated Rate |
$12,698.68 |
| Rate for Payer: Amerigroup Medicaid |
$12,637.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$12,514.65
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12,698.68
|
|
|
Kidney and Ureter Procedures for Non-neoplasm With CC
|
Facility
|
IP
|
$10,175.08
|
|
|
Service Code
|
MS-DRG 660
|
| Hospital Charge Code |
442
|
| Min. Negotiated Rate |
$10,027.62 |
| Max. Negotiated Rate |
$10,175.08 |
| Rate for Payer: Amerigroup Medicaid |
$10,125.93
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$10,027.62
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$10,175.08
|
|
|
Kidney and Ureter Procedures for Non-neoplasm With MCC
|
Facility
|
IP
|
$17,118.91
|
|
|
Service Code
|
MS-DRG 659
|
| Hospital Charge Code |
441
|
| Min. Negotiated Rate |
$16,870.81 |
| Max. Negotiated Rate |
$17,118.91 |
| Rate for Payer: Amerigroup Medicaid |
$17,036.21
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$16,870.81
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$17,118.91
|
|
|
Kidney and Ureter Procedures for Non-neoplasm Without CC/MCC
|
Facility
|
IP
|
$8,562.90
|
|
|
Service Code
|
MS-DRG 661
|
| Hospital Charge Code |
443
|
| Min. Negotiated Rate |
$8,438.80 |
| Max. Negotiated Rate |
$8,562.90 |
| Rate for Payer: Amerigroup Medicaid |
$8,521.53
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8,438.80
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,562.90
|
|
|
Kidney and Urinary Tract Infections With MCC
|
Facility
|
IP
|
$8,911.32
|
|
|
Service Code
|
MS-DRG 689
|
| Hospital Charge Code |
464
|
| Min. Negotiated Rate |
$8,782.17 |
| Max. Negotiated Rate |
$8,911.32 |
| Rate for Payer: Amerigroup Medicaid |
$8,868.27
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$8,782.17
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,911.32
|
|
|
Kidney and Urinary Tract Infections Without MCC
|
Facility
|
IP
|
$6,206.63
|
|
|
Service Code
|
MS-DRG 690
|
| Hospital Charge Code |
465
|
| Min. Negotiated Rate |
$6,116.67 |
| Max. Negotiated Rate |
$6,206.63 |
| Rate for Payer: Amerigroup Medicaid |
$6,176.64
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6,116.67
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,206.63
|
|
|
Kidney and Urinary Tract Neoplasms With CC
|
Facility
|
IP
|
$8,053.07
|
|
|
Service Code
|
MS-DRG 687
|
| Hospital Charge Code |
462
|
| Min. Negotiated Rate |
$7,936.35 |
| Max. Negotiated Rate |
$8,053.07 |
| Rate for Payer: Amerigroup Medicaid |
$8,014.16
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$7,936.35
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$8,053.07
|
|
|
Kidney and Urinary Tract Neoplasms With MCC
|
Facility
|
IP
|
$12,074.67
|
|
|
Service Code
|
MS-DRG 686
|
| Hospital Charge Code |
461
|
| Min. Negotiated Rate |
$11,899.68 |
| Max. Negotiated Rate |
$12,074.67 |
| Rate for Payer: Amerigroup Medicaid |
$12,016.34
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11,899.68
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$12,074.67
|
|
|
Kidney and Urinary Tract Neoplasms Without CC/MCC
|
Facility
|
IP
|
$6,746.98
|
|
|
Service Code
|
MS-DRG 688
|
| Hospital Charge Code |
463
|
| Min. Negotiated Rate |
$6,649.20 |
| Max. Negotiated Rate |
$6,746.98 |
| Rate for Payer: Amerigroup Medicaid |
$6,714.38
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$6,649.20
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$6,746.98
|
|
|
Kidney and Urinary Tract Signs and Symptoms With MCC
|
Facility
|
IP
|
$11,186.89
|
|
|
Service Code
|
MS-DRG 695
|
| Hospital Charge Code |
468
|
| Min. Negotiated Rate |
$11,024.76 |
| Max. Negotiated Rate |
$11,186.89 |
| Rate for Payer: Amerigroup Medicaid |
$11,132.85
|
| Rate for Payer: Iowa Total Care Managed Medicaid |
$11,024.76
|
| Rate for Payer: Molina Healthcare Managed Medicaid |
$11,186.89
|
|
