Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

COIL NESTER 14CM 10MM

Facility

$528.40

Service Code	HCPCS C1884
Hospital Charge Code	270627555
Hospital Revenue Code	278
Min. Negotiated Rate	$12.73
Max. Negotiated Rate	$264.20
Rate for Payer: Aetna Commercial	$200.79
Rate for Payer: Aetna Medicare Advantage	$158.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$134.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$134.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$134.74
Rate for Payer: Cigna Commercial	$264.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.87
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$116.25
Rate for Payer: Qualcare PPO/HMO/WC	$79.26
Rate for Payer: UnitedHealthcare Community & State	$12.73
Rate for Payer: Wellpoint Medicaid Managed Care	$14.00

COIL NESTER 14CM 4MM

Facility

$540.00

Hospital Charge Code	270670448
Hospital Revenue Code	272
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$205.20
Rate for Payer: Aetna Medicare Advantage	$162.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$137.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$137.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$137.70
Rate for Payer: Cigna Commercial	$270.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$162.00
Rate for Payer: Oxford Commercial	$108.00
Rate for Payer: Qualcare PPO/HMO/WC	$81.00
Rate for Payer: UnitedHealthcare Commercial	$108.00
Rate for Payer: UnitedHealthcare Community & State	$13.01
Rate for Payer: Wellpoint Medicaid Managed Care	$14.31

COIL NESTER 14CM 4MM

Facility

$540.00

Hospital Charge Code	270670448
Hospital Revenue Code	272
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$81.00
Rate for Payer: Qualcare PPO/HMO/WC	$81.00

COIL NESTER 14CM 8MM

Facility

$528.40

Service Code	HCPCS C1884
Hospital Charge Code	270626430
Hospital Revenue Code	278
Min. Negotiated Rate	$79.26
Max. Negotiated Rate	$127.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.87
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$116.25
Rate for Payer: Qualcare PPO/HMO/WC	$79.26

COIL NESTER 14CM 8MM

Facility

$528.40

Service Code	HCPCS C1884
Hospital Charge Code	270626430
Hospital Revenue Code	278
Min. Negotiated Rate	$12.73
Max. Negotiated Rate	$264.20
Rate for Payer: Aetna Commercial	$200.79
Rate for Payer: Aetna Medicare Advantage	$158.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$134.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$134.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$105.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$134.74
Rate for Payer: Cigna Commercial	$264.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$127.87
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$116.25
Rate for Payer: Qualcare PPO/HMO/WC	$79.26
Rate for Payer: UnitedHealthcare Community & State	$12.73
Rate for Payer: Wellpoint Medicaid Managed Care	$14.00

COIL NEUROVASC EMBOLIZ 7X3MM

Facility

$82,475.00

Service Code	HCPCS C1884
Hospital Charge Code	270696955S
Hospital Revenue Code	278
Min. Negotiated Rate	$1,987.65
Max. Negotiated Rate	$41,237.50
Rate for Payer: Aetna Commercial	$31,340.50
Rate for Payer: Aetna Medicare Advantage	$24,742.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21,031.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21,031.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16,495.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21,031.12
Rate for Payer: Cigna Commercial	$41,237.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19,958.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$18,144.50
Rate for Payer: Qualcare PPO/HMO/WC	$12,371.25
Rate for Payer: UnitedHealthcare Community & State	$1,987.65
Rate for Payer: Wellpoint Medicaid Managed Care	$2,185.59

COIL NEUROVASC EMBOLIZ 7X3MM

Facility

$82,475.00

Service Code	HCPCS C1884
Hospital Charge Code	270696955S
Hospital Revenue Code	278
Min. Negotiated Rate	$12,371.25
Max. Negotiated Rate	$19,958.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16,495.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19,958.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$18,144.50
Rate for Payer: Qualcare PPO/HMO/WC	$12,371.25

COIL OCCLUSION DEVICE10-12MM 6

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684528N
Hospital Revenue Code	278
Min. Negotiated Rate	$1,342.50
Max. Negotiated Rate	$2,165.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50

COIL OCCLUSION DEVICE10-12MM 6

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684528
Hospital Revenue Code	278
Min. Negotiated Rate	$215.69
Max. Negotiated Rate	$4,475.00
Rate for Payer: Aetna Commercial	$3,401.00
Rate for Payer: Aetna Medicare Advantage	$2,685.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,282.25
Rate for Payer: Cigna Commercial	$4,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50
Rate for Payer: UnitedHealthcare Community & State	$215.69
Rate for Payer: Wellpoint Medicaid Managed Care	$237.18

COIL OCCLUSION DEVICE10-12MM 6

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684528N
Hospital Revenue Code	278
Min. Negotiated Rate	$215.69
Max. Negotiated Rate	$4,475.00
Rate for Payer: Aetna Commercial	$3,401.00
Rate for Payer: Aetna Medicare Advantage	$2,685.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,282.25
Rate for Payer: Cigna Commercial	$4,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50
Rate for Payer: UnitedHealthcare Community & State	$215.69
Rate for Payer: Wellpoint Medicaid Managed Care	$237.18

COIL OCCLUSION DEVICE10-12MM 6

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684528
Hospital Revenue Code	278
Min. Negotiated Rate	$1,342.50
Max. Negotiated Rate	$2,165.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50

COIL OCCLUSION DEVICE12-14MM 6

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684529N
Hospital Revenue Code	278
Min. Negotiated Rate	$215.69
Max. Negotiated Rate	$4,475.00
Rate for Payer: Aetna Commercial	$3,401.00
Rate for Payer: Aetna Medicare Advantage	$2,685.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,282.25
Rate for Payer: Cigna Commercial	$4,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50
Rate for Payer: UnitedHealthcare Community & State	$215.69
Rate for Payer: Wellpoint Medicaid Managed Care	$237.18

COIL OCCLUSION DEVICE12-14MM 6

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684529
Hospital Revenue Code	278
Min. Negotiated Rate	$1,342.50
Max. Negotiated Rate	$2,165.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50

COIL OCCLUSION DEVICE12-14MM 6

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684529N
Hospital Revenue Code	278
Min. Negotiated Rate	$1,342.50
Max. Negotiated Rate	$2,165.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50

COIL OCCLUSION DEVICE12-14MM 6

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684529
Hospital Revenue Code	278
Min. Negotiated Rate	$215.69
Max. Negotiated Rate	$4,475.00
Rate for Payer: Aetna Commercial	$3,401.00
Rate for Payer: Aetna Medicare Advantage	$2,685.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,282.25
Rate for Payer: Cigna Commercial	$4,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50
Rate for Payer: UnitedHealthcare Community & State	$215.69
Rate for Payer: Wellpoint Medicaid Managed Care	$237.18

COIL OCCLUSION DEVICE 5-6MM 5

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684525
Hospital Revenue Code	278
Min. Negotiated Rate	$215.69
Max. Negotiated Rate	$4,475.00
Rate for Payer: Aetna Commercial	$3,401.00
Rate for Payer: Aetna Medicare Advantage	$2,685.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,282.25
Rate for Payer: Cigna Commercial	$4,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50
Rate for Payer: UnitedHealthcare Community & State	$215.69
Rate for Payer: Wellpoint Medicaid Managed Care	$237.18

COIL OCCLUSION DEVICE 5-6MM 5

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684525
Hospital Revenue Code	278
Min. Negotiated Rate	$1,342.50
Max. Negotiated Rate	$2,165.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50

COIL OCCLUSION DEVICE 5-6MM 5

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684525N
Hospital Revenue Code	278
Min. Negotiated Rate	$215.69
Max. Negotiated Rate	$4,475.00
Rate for Payer: Aetna Commercial	$3,401.00
Rate for Payer: Aetna Medicare Advantage	$2,685.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,282.25
Rate for Payer: Cigna Commercial	$4,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50
Rate for Payer: UnitedHealthcare Community & State	$215.69
Rate for Payer: Wellpoint Medicaid Managed Care	$237.18

COIL OCCLUSION DEVICE 5-6MM 5

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684525N
Hospital Revenue Code	278
Min. Negotiated Rate	$1,342.50
Max. Negotiated Rate	$2,165.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50

COIL OCCLUSION DEVICE 6-8MM 60

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684526N
Hospital Revenue Code	278
Min. Negotiated Rate	$215.69
Max. Negotiated Rate	$4,475.00
Rate for Payer: Aetna Commercial	$3,401.00
Rate for Payer: Aetna Medicare Advantage	$2,685.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,282.25
Rate for Payer: Cigna Commercial	$4,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50
Rate for Payer: UnitedHealthcare Community & State	$215.69
Rate for Payer: Wellpoint Medicaid Managed Care	$237.18

COIL OCCLUSION DEVICE 6-8MM 60

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684526
Hospital Revenue Code	278
Min. Negotiated Rate	$215.69
Max. Negotiated Rate	$4,475.00
Rate for Payer: Aetna Commercial	$3,401.00
Rate for Payer: Aetna Medicare Advantage	$2,685.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,282.25
Rate for Payer: Cigna Commercial	$4,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50
Rate for Payer: UnitedHealthcare Community & State	$215.69
Rate for Payer: Wellpoint Medicaid Managed Care	$237.18

COIL OCCLUSION DEVICE 6-8MM 60

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684526N
Hospital Revenue Code	278
Min. Negotiated Rate	$1,342.50
Max. Negotiated Rate	$2,165.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50

COIL OCCLUSION DEVICE 6-8MM 60

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684526
Hospital Revenue Code	278
Min. Negotiated Rate	$1,342.50
Max. Negotiated Rate	$2,165.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50

COIL OCCLUSION DEVICE 8-10MM 6

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684527
Hospital Revenue Code	278
Min. Negotiated Rate	$215.69
Max. Negotiated Rate	$4,475.00
Rate for Payer: Aetna Commercial	$3,401.00
Rate for Payer: Aetna Medicare Advantage	$2,685.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,282.25
Rate for Payer: Cigna Commercial	$4,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50
Rate for Payer: UnitedHealthcare Community & State	$215.69
Rate for Payer: Wellpoint Medicaid Managed Care	$237.18

COIL OCCLUSION DEVICE 8-10MM 6

Facility

$8,950.00

Service Code	HCPCS C1884
Hospital Charge Code	270684527N
Hospital Revenue Code	278
Min. Negotiated Rate	$215.69
Max. Negotiated Rate	$4,475.00
Rate for Payer: Aetna Commercial	$3,401.00
Rate for Payer: Aetna Medicare Advantage	$2,685.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,282.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,790.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,282.25
Rate for Payer: Cigna Commercial	$4,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,165.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,969.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,342.50
Rate for Payer: UnitedHealthcare Community & State	$215.69
Rate for Payer: Wellpoint Medicaid Managed Care	$237.18

Know your out-of-pocket cost for care.

All Charges