CMS Price Transparency Data
Office visit, established patient (30-39 min)
Facility: Johnson Memorial Hospital
Billing Code: 99214 (CPT)
Factual Cost Summary (Answer Capsule)
- CPT Billing Code: 99214
- Insurance Median: $58
- Cash Discount Price: $128
- vs. Medicare Baseline: 0.43x Medicare
The contracted insurance negotiated median rate for a Office visit, established patient (30-39 min) at Johnson Memorial Hospital is $58. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $128. Compared to the federal Medicare reimbursement reference rate of $135.6, this hospital’s rate is 0.43x the Medicare baseline. Located in 201 Chestnut Hill Road, Stafford Springs, CT.
Cash / Self-Pay
$128
Average discount available for prompt cash payment at this facility.
Insurance Median
$58
Median negotiated contract rate across all mapped commercial carriers.
Medicare Reference Rate
$135.6
Standard federal government reimbursement rate for this code.
Visual Cost Comparison vs. Medicare
Medicare Reference Baseline: $135.6 (100%)
Cash / Self-Pay: $128 (94%)
Insurance Median: $58 (43%)
Cash: $128 (94% of Medicare)
Ins. Median: $58 (43% of Medicare)
Understanding this gauge: We use the federal Medicare rate of $135.6 as the cost baseline. Rates below the baseline represent excellent value. In-network commercial rates commonly hover around 150% - 250% of Medicare, while rates exceeding 300% are elevated. Hover over the green and blue markers to view detailed calculations.
Out-of-Pocket Cost Estimator
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Commercial Insurance Negotiated Rates
Negotiated contract ranges established by major commercial carriers at this facility.
| Carrier / Plan Group | Contract Rate Range | vs. Medicare Reference |
|---|---|---|
| Aetna | $14 - $144 | 10% |
| Align Senior Care | $14 - $86 | 10% |
| Ally Align Care Adv | $14 - $86 | 10% |
| American Health Advantage Of Idaho | $14 - $86 | 10% |
| American Health Plan | $14 - $86 | 10% |
| Aurora Special Needs | $14 - $86 | 10% |
| Blue Care Network Advantage | $14 - $86 | 10% |
| Blue Cross Blue Shield | $14 - $120 | 10% |
| Blue Shield - De (Highmark) Medciare Advantage | $14 - $86 | 10% |
| Care Dimensions | $14 - $86 | 10% |
| Care Improvement Plus | $14 - $86 | 10% |
| Care Resources Pace | $14 - $86 | 10% |
| Careplus Health Plans | $14 - $86 | 10% |
| Cca - Zing Health | $14 - $86 | 10% |
| Central Valley Medical Services Corp Pace | $14 - $86 | 10% |
| Champion Health Plan Mcr Advantage | $14 - $86 | 10% |
| Cigna | $14 - $86 | 10% |
| Clear Spring Health | $14 - $86 | 10% |
| Clover Health | $14 - $86 | 10% |
| Commonwealth Care Alliance | $14 - $93 | 10% |
| Community Pace At Home | $14 - $86 | 10% |
| Eddy Senior Care-Pace | $14 - $86 | 10% |
| Eddy Seniorcare Pace | $14 - $86 | 10% |
| Elementcare | $14 - $86 | 10% |
| Evercare | $14 - $86 | 10% |
| Everence | $14 - $86 | 10% |
| Gateway Health Plan | $14 - $86 | 10% |
| Genesys Pace Of Genesee County | $14 - $86 | 10% |
| Georgia Health Advantage | $14 - $86 | 10% |
| Gold Advantage | $14 - $86 | 10% |
| Gpa Croell Redi Mix | $14 - $86 | 10% |
| Health America Advantra | $14 - $86 | 10% |
| Highmark Health Options Dual Plan | $14 - $86 | 10% |
| Hope Select Pace | $14 - $86 | 10% |
| Horizon Nj Total Care | $14 - $86 | 10% |
| Hudson Headwaters Pace | $14 - $86 | 10% |
| Humana | $14 - $95 | 10% |
| Huron Valley Pace | $14 - $86 | 10% |
| Innovative Integrated Health Community Plans | $14 - $86 | 10% |
| Iowa Health Advantage | $14 - $86 | 10% |
| Johns Hopkins Advantage Md | $14 - $86 | 10% |
| Lasso Healthcare Msa | $14 - $86 | 10% |
| Life St Marys Pace | $14 - $86 | 10% |
| Lifecircles Pace | $14 - $86 | 10% |
| Longevity Health Plan | $14 - $86 | 10% |
| Longevity Ipa Of Michigan Llc Health Plan Isnp | $14 - $86 | 10% |
| Martins Point Generations Advantage | $14 - $86 | 10% |
| Mass General Brigham Mcr Adv | $14 - $86 | 10% |
| Medicare (plans) | $14 - $97 | 10% |
| Medipak Advantage | $14 - $86 | 10% |
| Mercy Life | $14 - $86 | 10% |
| Mercyone Cedar Valley | $14 - $86 | 10% |
| Meridian Complete | $14 - $86 | 10% |
| Michigan Complete Health | $14 - $86 | 10% |
| Nascentia Health Plus | $14 - $86 | 10% |
| New Centry Health Careplus | $14 - $86 | 10% |
| Osu Prime Care Advantage | $14 - $86 | 10% |
| Pace Cny | $14 - $86 | 10% |
| Pace Iowa Immanuel Pathways | $14 - $86 | 10% |
| Pace Of Southwest Michigan | $14 - $86 | 10% |
| Pace Southeast | $14 - $86 | 10% |
| Pace-Trinity Health | $14 - $86 | 10% |
| Peak Pace Solutions | $14 - $86 | 10% |
| Perennial Advantage | $14 - $86 | 10% |
| Preferred Care Partners | $14 - $86 | 10% |
| Presbyterian Senior Plan | $14 - $86 | 10% |
| Provider Partners Health Plan Of Illinois | $14 - $86 | 10% |
| Provider Partners Health Plan Of Indiana | $14 - $86 | 10% |
| Pruitthealth Premier | $14 - $86 | 10% |
| Reliance Community Care Partners Care Resources Pace | $14 - $86 | 10% |
| Rx Allwin | $14 - $86 | 10% |
| Rx Grane Grnmedd | $14 - $86 | 10% |
| Rx Retiree Rx Care | $14 - $86 | 10% |
| Scan Health Plan Mcr Ipa Meritage Oon | $14 - $86 | 10% |
| Secure Horizons Ma Pffs | $14 - $86 | 10% |
| Serenity Pace | $14 - $86 | 10% |
| Siouxland Pace | $14 - $86 | 10% |
| Solis Health Plans | $14 - $86 | 10% |
| Sunnyview-Pace Finance Dept | $14 - $86 | 10% |
| Texan Plus | $14 - $86 | 10% |
| The Health Plan | $14 - $86 | 10% |
| Thome Pace | $14 - $86 | 10% |
| Todays Options | $14 - $86 | 10% |
| Tribute Health Plans | $14 - $86 | 10% |
| Um Health Advantage | $14 - $86 | 10% |
| Union Health Service | $14 - $86 | 10% |
| UnitedHealthcare | $14 - $171 | 10% |
| Veterans Administration | $14 - $88 | 10% |
| Welbe Health | $14 - $86 | 10% |
| Wellmed | $14 - $86 | 10% |
| Cca Senior Care Options | $15 - $91 | 11% |
| Champva | $15 - $95 | 11% |
| Medicaid / KanCare | $15 - $152 | 11% |
| Tricare | $15 - $95 | 11% |
| Triwest Health Alliance | $15 - $95 | 11% |
| Veterans Eval Services | $15 - $95 | 11% |
| Bcn Domestic | $17 - $120 | 13% |
| Blue Benefit Administrators Of Massachusetts | $17 - $120 | 13% |
| Blue Care Network | $17 - $120 | 13% |
| Blue Distinction Transplant | $17 - $120 | 13% |
| Blue Shield - Ca | $17 - $120 | 13% |
| Blue Shield - Id (Regence) | $17 - $120 | 13% |
| Blue Shield - Ny Highmark Northeastern | $17 - $120 | 13% |
| Blue Shield - Ny Highmark Western | $17 - $120 | 13% |
| Blue Shield - Pa (Highmark) | $17 - $120 | 13% |
| Blue Shield - Wa (Regence) | $17 - $120 | 13% |
| Health Choices | $17 - $120 | 13% |
| Kaiser Domestic | $17 - $120 | 13% |
| Pre-Employment | $17 - $120 | 13% |
| Us Family Health Plan | $17 - $170 | 13% |
| Wc Domestic | $17 - $120 | 13% |
| Fallon Health | $18 - $186 | 13% |
| Healthscope | $22 - $136 | 16% |
| Andrie Inc | $23 - $142 | 17% |
| Connecticare | $23 - $178 | 17% |
| Coventry | $23 - $144 | 17% |
| East Greenbush Central School District | $23 - $142 | 17% |
| First Health | $23 - $144 | 17% |
| Genex Wc | $23 - $142 | 17% |
| Guardian | $23 - $144 | 17% |
| Healthsmart Workers Comp | $23 - $142 | 17% |
| Jag Source | $23 - $142 | 17% |
| Mass General Brigham Health Plan | $23 - $209 | 17% |
| Meritain | $23 - $144 | 17% |
| New York State Insurance Fund | $23 - $142 | 17% |
| Njm Insurance Group | $23 - $142 | 17% |
| Rx Heatlhcomp | $23 - $142 | 17% |
| Rx Restat | $23 - $142 | 17% |
| Rx Saif Opdp Wc | $23 - $142 | 17% |
| Rx Worker'S Comp | $23 - $142 | 17% |
| Wc Accident Fund | $23 - $142 | 17% |
| Wc Ace | $23 - $142 | 17% |
| Wc Acs Federal Employees | $23 - $142 | 17% |
| Wc Acuity | $23 - $142 | 17% |
| Wc Advantage | $23 - $142 | 17% |
| Wc Aegis | $23 - $142 | 17% |
| Wc Aig | $23 - $142 | 17% |
| Wc Aims | $23 - $142 | 17% |
| Wc Alaska National Ins | $23 - $142 | 17% |
| Wc Align Network | $23 - $142 | 17% |
| Wc Allied | $23 - $142 | 17% |
| Wc Am Trust N America | $23 - $142 | 17% |
| Wc American Claims Mgmt | $23 - $142 | 17% |
| Wc Amerisure | $23 - $142 | 17% |
| Wc Amtrust | $23 - $142 | 17% |
| Wc Asu Risk Mgt | $23 - $142 | 17% |
| Wc Benetech | $23 - $142 | 17% |
| Wc Berkley Admin | $23 - $142 | 17% |
| Wc Broadspire | $23 - $142 | 17% |
| Wc Broward County | $23 - $142 | 17% |
| Wc Bunch & Associates | $23 - $142 | 17% |
| Wc California State Comp Ins | $23 - $142 | 17% |
| Wc California State Ins Fund | $23 - $142 | 17% |
| Wc Capitol Area Health Consortium | $23 - $142 | 17% |
| Wc Ccmsi | $23 - $142 | 17% |
| Wc Chartis | $23 - $142 | 17% |
| Wc Chubb | $23 - $142 | 17% |
| Wc Cirma | $23 - $142 | 17% |
| Wc City Of Albany | $23 - $142 | 17% |
| Wc City Of Sioux City | $23 - $142 | 17% |
| Wc Claims Mgmt Inc | $23 - $142 | 17% |
| Wc Cna | $23 - $142 | 17% |
| Wc Comp One Admin C/O Manageability | $23 - $142 | 17% |
| Wc Compone Admin | $23 - $142 | 17% |
| Wc Ct Healthcare Trust | $23 - $142 | 17% |
| Wc Donegal Insurance Group | $23 - $142 | 17% |
| Wc Emc Insurance Company | $23 - $142 | 17% |
| Wc Employee Mutual | $23 - $142 | 17% |
| Wc Enablecomp | $23 - $142 | 17% |
| Wc Encore Health Network | $23 - $142 | 17% |
| Wc Erie | $23 - $142 | 17% |
| Wc Esis | $23 - $142 | 17% |
| Wc Evolutions | $23 - $142 | 17% |
| Wc Fcci | $23 - $142 | 17% |
| Wc Fed Ex | $23 - $142 | 17% |
| Wc Federal Black Lung | $23 - $142 | 17% |
| Wc Federated | $23 - $142 | 17% |
| Wc Finley Occupational Health | $23 - $142 | 17% |
| Wc First Agency/Occunet | $23 - $142 | 17% |
| Wc Ford Motor | $23 - $142 | 17% |
| Wc Fresno Unified Emp | $23 - $142 | 17% |
| Wc Gallagher Bassett | $23 - $142 | 17% |
| Wc General Motors | $23 - $142 | 17% |
| Wc Generic | $23 - $142 | 17% |
| Wc Genex Care For Ohio | $23 - $142 | 17% |
| Wc Great West Casualty | $23 - $142 | 17% |
| Wc Guarantee Insurance | $23 - $142 | 17% |
| Wc Guard Insurance Company | $23 - $142 | 17% |
| Wc Hab | $23 - $142 | 17% |
| Wc Hartford | $23 - $142 | 17% |
| Wc Hastings | $23 - $142 | 17% |
| Wc Health Management | $23 - $142 | 17% |
| Wc Heritage Summit | $23 - $142 | 17% |
| Wc Hireright | $23 - $142 | 17% |
| Wc Horizon | $23 - $142 | 17% |
| Wc Icw Group | $23 - $142 | 17% |
| Wc Idaho State Ins Fund | $23 - $142 | 17% |
| Wc Intercare Insurance | $23 - $142 | 17% |
| Wc Intermountain | $23 - $142 | 17% |
| Wc Johns Eastern | $23 - $142 | 17% |
| Wc Kemberton | $23 - $142 | 17% |
| Wc Key Ins & Benefit Solutions | $23 - $142 | 17% |
| Wc Liberty Mutual | $23 - $142 | 17% |
| Wc Mac Risk Management | $23 - $142 | 17% |
| Wc Massachusetts | $23 - $142 | 17% |
| Wc Mdia | $23 - $142 | 17% |
| Wc Meadowbrook Claim | $23 - $142 | 17% |
| Wc Medical Administrators | $23 - $142 | 17% |
| Wc Meijers | $23 - $142 | 17% |
| Wc Memic | $23 - $142 | 17% |
| Wc Mercy Workcare | $23 - $142 | 17% |
| Wc Michigan | $23 - $142 | 17% |
| Wc Michigan Millers Mutual | $23 - $142 | 17% |
| Wc Mitchell Frankenmuth | $23 - $142 | 17% |
| Wc Mra | $23 - $142 | 17% |
| Wc Nationwide | $23 - $142 | 17% |
| Wc Nca Comp | $23 - $142 | 17% |
| Wc New York | $23 - $142 | 17% |
| Wc New York Special Funds | $23 - $142 | 17% |
| Wc North American Rishces | $23 - $142 | 17% |
| Wc Northeast Health | $23 - $142 | 17% |
| Wc Notre Dame | $23 - $142 | 17% |
| Wc Novanet | $23 - $142 | 17% |
| Wc O'Hara Corp | $23 - $142 | 17% |
| Wc Occ Health Allen | $23 - $142 | 17% |
| Wc Ohio Bureau | $23 - $142 | 17% |
| Wc One Call Medical | $23 - $142 | 17% |
| Wc Paradigm | $23 - $142 | 17% |
| Wc Peerless | $23 - $142 | 17% |
| Wc Pma | $23 - $142 | 17% |
| Wc Praxis Health Network | $23 - $142 | 17% |
| Wc Price Chopper | $23 - $142 | 17% |
| Wc Procura Management | $23 - $142 | 17% |
| Wc Qualcare | $23 - $142 | 17% |
| Wc Quiktrip | $23 - $142 | 17% |
| Wc Reny Company | $23 - $142 | 17% |
| Wc Rev Claims | $23 - $142 | 17% |
| Wc Risico | $23 - $142 | 17% |
| Wc Rural Mutual | $23 - $142 | 17% |
| Wc Saif Oregon | $23 - $142 | 17% |
| Wc Secura | $23 - $142 | 17% |
| Wc Sedgwick | $23 - $142 | 17% |
| Wc Sentry | $23 - $142 | 17% |
| Wc Sheakley Unicomp | $23 - $142 | 17% |
| Wc Smile Lodge | $23 - $142 | 17% |
| Wc Society | $23 - $142 | 17% |
| Wc Srs | $23 - $142 | 17% |
| Wc Taconic (Mro) | $23 - $142 | 17% |
| Wc Taconic Farms | $23 - $142 | 17% |
| Wc Travelers | $23 - $142 | 17% |
| Wc Triad Group | $23 - $142 | 17% |
| Wc Tristar | $23 - $142 | 17% |
| Wc Troy Ny | $23 - $142 | 17% |
| Wc Tyson | $23 - $142 | 17% |
| Wc Unified Health Services | $23 - $142 | 17% |
| Wc United Heartland | $23 - $142 | 17% |
| Wc Us Dept Of Labor | $23 - $142 | 17% |
| Wc Velocity | $23 - $142 | 17% |
| Wc Walmart | $23 - $142 | 17% |
| Wc West Bend | $23 - $142 | 17% |
| Wc West Bend Mutual/Argent | $23 - $142 | 17% |
| Wc Winnebago Industries | $23 - $142 | 17% |
| Wc Yankee Trails | $23 - $142 | 17% |
| Wc York Risk | $23 - $142 | 17% |
| Wc Zenith | $23 - $142 | 17% |
| Wc Zurich | $23 - $142 | 17% |
| Unicare | $24 - $152 | 18% |
| Wellpoint | $24 - $152 | 18% |
| Claimdoc | $25 - $154 | 18% |
| Innovative Health Plan Ii | $25 - $154 | 18% |
| Multiplan | $25 - $153 | 18% |
| Centivo | $26 - $163 | 19% |
| Health New England | $27 - $203 | 20% |
| Health Smart | $28 - $284 | 21% |
| Wc Corvel | $28 - $284 | 21% |
| Tufts Health Plan | $32 - $200 | 24% |
| Delta Dental Ga | $33 - $334 | 24% |
| Delta Dental Mi | $33 - $334 | 24% |
| Delta Dental Mo | $33 - $334 | 24% |
| Delta Dental Nj | $33 - $334 | 24% |
| Delta Dental Ny | $33 - $334 | 24% |
| Delta Dental Oh | $33 - $334 | 24% |
| Delta Dental Or | $33 - $334 | 24% |
| Delta Dental Pa | $33 - $334 | 24% |
| Delta Dental Va | $33 - $334 | 24% |
| Delta Dental Wa | $33 - $334 | 24% |
| Harvard Pilgrim Healthcare | $33 - $203 | 24% |
| Liberty Dental | $33 - $334 | 24% |
| Prime Health Services | $33 - $203 | 24% |
| Albany County Correctional Facility | $58 - $65 | 43% |
| Ambetter / Centene | $58 - $65 | 43% |
| Amish Mennonite | $58 - $65 | 43% |
| Ascension St. Vincent Public Safety Medical | $58 - $65 | 43% |
| Bcccp-Michigan | $58 - $65 | 43% |
| Bccp | $58 - $65 | 43% |
| Bmc Healthnet | $58 - $65 | 43% |
| Breast Grant-Connecticut | $58 - $65 | 43% |
| Broward County Dept Of Health | $58 - $65 | 43% |
| California Health And Wellness | $58 - $65 | 43% |
| Can Community Health Inc | $58 - $65 | 43% |
| Cardinal Innovations Lme | $58 - $65 | 43% |
| Care Connections Of Northern Iowa | $58 - $65 | 43% |
| Care Oregon Ohp | $58 - $65 | 43% |
| Cencal Health Plan | $58 - $65 | 43% |
| Cenpatico | $58 - $65 | 43% |
| Chhuny | $58 - $65 | 43% |
| Childrens Comm Health Plan | $58 - $65 | 43% |
| Childrens Medical Services Title 19 | $58 - $65 | 43% |
| City Of Philadelphia | $58 - $65 | 43% |
| Cmh Allegan County | $58 - $65 | 43% |
| Cmh Ausable Valley | $58 - $65 | 43% |
| Cmh Barry County | $58 - $65 | 43% |
| Cmh Bay-Arenac County | $58 - $65 | 43% |
| Cmh Berrien County | $58 - $65 | 43% |
| Cmh Cass County | $58 - $65 | 43% |
| Cmh Central Mi County | $58 - $65 | 43% |
| Cmh Clinton-Eaton-Ingham County | $58 - $65 | 43% |
| Cmh Detroit Wayne Integrated Health Network | $58 - $65 | 43% |
| Cmh Genesee County | $58 - $65 | 43% |
| Cmh Ionia County | $58 - $65 | 43% |
| Cmh Jackson County/Lifeways | $58 - $65 | 43% |
| Cmh Kalamazoo | $58 - $65 | 43% |
| Cmh Kent County | $58 - $65 | 43% |
| Cmh Lenawee County | $58 - $65 | 43% |
| Cmh Livingston County | $58 - $65 | 43% |
| Cmh Macomb | $58 - $65 | 43% |
| Cmh Misc | $58 - $65 | 43% |
| Cmh Monroe County | $58 - $65 | 43% |
| Cmh Montcalm County | $58 - $65 | 43% |
| Cmh Muskegon County | $58 - $65 | 43% |
| Cmh Newaygo County | $58 - $65 | 43% |
| Cmh North Country | $58 - $65 | 43% |
| Cmh Northern Lakes County | $58 - $65 | 43% |
| Cmh Oakland County | $58 - $65 | 43% |
| Cmh Ottawa County | $58 - $65 | 43% |
| Cmh Van Buren County | $58 - $65 | 43% |
| Cmh Washtenaw County | $58 - $65 | 43% |
| Cmh Wayne County/Carelink | $58 - $65 | 43% |
| Cmh Wayne Cty/Com Liv Svcs | $58 - $65 | 43% |
| Cmh West Mi County | $58 - $65 | 43% |
| Community Benefit Health | $58 - $65 | 43% |
| Community Care Behavorial Health | $58 - $65 | 43% |
| Community Care Partners | $58 - $65 | 43% |
| Community Health Choice | $58 - $65 | 43% |
| Connections Csp | $58 - $65 | 43% |
| County Coroner | $58 - $65 | 43% |
| County Funding Generic | $58 - $65 | 43% |
| Covid19 Hrsa Uninsured Testing And Treatment Fund | $58 - $65 | 43% |
| Dean Wi Badgercare | $58 - $65 | 43% |
| Delaware County Department Of Health | $58 - $65 | 43% |
| Delaware First Health | $58 - $65 | 43% |
| Dph Tb Program | $58 - $65 | 43% |
| Dscc | $58 - $65 | 43% |
| Eastpointe Lme | $58 - $65 | 43% |
| Family Health Network | $58 - $65 | 43% |
| Freedom First Healthcare | $58 - $65 | 43% |
| Fresno County Ccs | $58 - $65 | 43% |
| Ghc Scw Wi Badgercare | $58 - $65 | 43% |
| Harbor Health | $58 - $65 | 43% |
| Health Safety Net | $58 - $65 | 43% |
| Healthy Blue Ne | $58 - $65 | 43% |
| Hennepin Health | $58 - $65 | 43% |
| Id County Ada | $58 - $65 | 43% |
| Id County Canyon | $58 - $65 | 43% |
| Id County Cat Fund | $58 - $65 | 43% |
| Id County Other | $58 - $65 | 43% |
| Id County Payette | $58 - $65 | 43% |
| Idaho Dept Health And Wellfare | $58 - $65 | 43% |
| Idaho Womens Health Check | $58 - $65 | 43% |
| Indiana Breast Cervical Cancer | $58 - $65 | 43% |
| Inland Empire Health Plan | $58 - $65 | 43% |
| Intercommunity Health Ohp | $58 - $65 | 43% |
| Iowa Total Care | $58 - $65 | 43% |
| Jai Medical System | $58 - $65 | 43% |
| Kern Family Health Plan | $58 - $65 | 43% |
| Keystone First | $58 - $65 | 43% |
| Keystone First Chip | $58 - $65 | 43% |
| La Care Health Plan | $58 - $65 | 43% |
| Lakeland Care Inc | $58 - $65 | 43% |
| Managed Health Services - Indiana | $58 - $65 | 43% |
| Maryland Breast & Cervical Program | $58 - $65 | 43% |
| Maryland Healthy Smiles - Scion Dental | $58 - $65 | 43% |
| Maryland Physicians Care | $58 - $65 | 43% |
| Massachusetts Behavioral Health Partnership | $58 - $65 | 43% |
| Mdwise | $58 - $65 | 43% |
| Medi-Cal | $58 - $65 | 43% |
| Medi-Cal Healthnet | $58 - $65 | 43% |
| Medstar Dc Healthy Family | $58 - $65 | 43% |
| Medstar Md Health Choice | $58 - $65 | 43% |
| Mo Home State Health Plan | $58 - $65 | 43% |
| Molina Centennial Care | $58 - $65 | 43% |
| Nascentia Health Options | $58 - $65 | 43% |
| Nebraska Total Care | $58 - $65 | 43% |
| New York Cancer Services Program | $58 - $65 | 43% |
| Nextlevel Health | $58 - $65 | 43% |
| Oregon Screenwise | $58 - $65 | 43% |
| Paramount Advantage | $58 - $65 | 43% |
| Parkland Community Health Plan | $58 - $65 | 43% |
| Partners Behavioral Lme | $58 - $65 | 43% |
| Peach State Healthplan | $58 - $65 | 43% |
| Philadelphia County Funding | $58 - $65 | 43% |
| Presbyterian Centennial Care | $58 - $65 | 43% |
| Prestige Health Choice | $58 - $65 | 43% |
| Priority Partners | $58 - $65 | 43% |
| Robert F Sing Program | $58 - $65 | 43% |
| Rx 340B Pass Along | $58 - $65 | 43% |
| Rx Assistance/Rx Manufacturer Assistance 0 Copay | $58 - $65 | 43% |
| Rx Medi-Cal | $58 - $65 | 43% |
| Rx Meridian Rx | $58 - $65 | 43% |
| Ryan White Florida Mssrp | $58 - $65 | 43% |
| Sandhills Center Lme | $58 - $65 | 43% |
| Screening For Life | $58 - $65 | 43% |
| St Joseph County Hlth Dpt | $58 - $65 | 43% |
| Stephenson Cty Health | $58 - $65 | 43% |
| Sunshine State Health Plan | $58 - $65 | 43% |
| Superior Health | $58 - $65 | 43% |
| Tenncare | $58 - $65 | 43% |
| Texas Children'S Health Plan | $58 - $65 | 43% |
| Trillium Community Ohp | $58 - $65 | 43% |
| Tufts Health Public Plans | $58 - $65 | 43% |
| Vaya Health Lme | $58 - $65 | 43% |
| Washtenaw Health Plan | $58 - $65 | 43% |
| Wellsense Health Plan | $58 - $65 | 43% |
| Wi Womens Wellness | $58 - $65 | 43% |