Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

HCG,QUANT

Facility

$886.20

Service Code	HCPCS 84702
Hospital Charge Code	38479096
Hospital Revenue Code	301
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$443.10
Rate for Payer: Aetna Commercial	$40.94
Rate for Payer: Aetna Medicare Advantage	$48.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$22.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$54.33
Rate for Payer: Cigna Commercial	$443.10
Rate for Payer: Cigna Medicare Advantage	$15.05
Rate for Payer: Clover Medicare Advantage	$14.30
Rate for Payer: EmblemHealth Commercial	$45.15
Rate for Payer: Humana Medicare Advantage	$15.50
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$265.86
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$132.93
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$12.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.05
Rate for Payer: Wellcare Medicare Advantage	$15.05
Rate for Payer: Wellpoint Medicaid Managed Care	$23.48

HCG,QUANT

Facility

$886.20

Service Code	HCPCS 84702
Hospital Charge Code	38479096
Hospital Revenue Code	301
Min. Negotiated Rate	$132.93
Max. Negotiated Rate	$132.93
Rate for Payer: Qualcare PPO/HMO/WC	$132.93

HCG,QUANT

Facility

$886.20

Service Code	HCPCS 84702
Hospital Charge Code	38472203
Hospital Revenue Code	301
Min. Negotiated Rate	$132.93
Max. Negotiated Rate	$132.93
Rate for Payer: Qualcare PPO/HMO/WC	$132.93

HCG QUANTTV

Facility

$886.20

Service Code	HCPCS 84702
Hospital Charge Code	38479481
Hospital Revenue Code	301
Min. Negotiated Rate	$132.93
Max. Negotiated Rate	$132.93
Rate for Payer: Qualcare PPO/HMO/WC	$132.93

HCG QUANTTV

Facility

$886.20

Service Code	HCPCS 84702
Hospital Charge Code	38479481
Hospital Revenue Code	301
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$443.10
Rate for Payer: Aetna Commercial	$40.94
Rate for Payer: Aetna Medicare Advantage	$48.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$22.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$54.33
Rate for Payer: Cigna Commercial	$443.10
Rate for Payer: Cigna Medicare Advantage	$15.05
Rate for Payer: Clover Medicare Advantage	$14.30
Rate for Payer: EmblemHealth Commercial	$45.15
Rate for Payer: Humana Medicare Advantage	$15.50
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$265.86
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$132.93
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$12.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.05
Rate for Payer: Wellcare Medicare Advantage	$15.05
Rate for Payer: Wellpoint Medicaid Managed Care	$23.48

HCG TOTAL

Facility

$520.00

Service Code	HCPCS 82677
Hospital Charge Code	38479484
Hospital Revenue Code	301
Min. Negotiated Rate	$78.00
Max. Negotiated Rate	$78.00
Rate for Payer: Qualcare PPO/HMO/WC	$78.00

HCG TOTAL

Facility

$520.00

Service Code	HCPCS 82677
Hospital Charge Code	38479484
Hospital Revenue Code	301
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$65.77
Rate for Payer: Aetna Medicare Advantage	$78.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$87.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$87.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$24.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$54.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$87.28
Rate for Payer: Cigna Commercial	$260.00
Rate for Payer: Cigna Medicare Advantage	$24.18
Rate for Payer: Clover Medicare Advantage	$22.97
Rate for Payer: EmblemHealth Commercial	$72.54
Rate for Payer: Humana Medicare Advantage	$24.91
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$24.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$156.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$78.00
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$19.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.18
Rate for Payer: Wellcare Medicare Advantage	$24.18
Rate for Payer: Wellpoint Medicaid Managed Care	$13.78

HCG,TUMOR MARKER

Facility

$390.00

Service Code	HCPCS 84702
Hospital Charge Code	3007243
Hospital Revenue Code	301
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$40.94
Rate for Payer: Aetna Medicare Advantage	$48.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$54.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$54.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$22.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$54.33
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$15.05
Rate for Payer: Clover Medicare Advantage	$14.30
Rate for Payer: EmblemHealth Commercial	$45.15
Rate for Payer: Humana Medicare Advantage	$15.50
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$12.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.05
Rate for Payer: Wellcare Medicare Advantage	$15.05
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

HCG,TUMOR MARKER

Facility

$390.00

Service Code	HCPCS 84702
Hospital Charge Code	3007243
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

HCL, FREE AND TOTAL

Facility

$63.00

Service Code	HCPCS 82926
Hospital Charge Code	38472377
Hospital Revenue Code	301
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$9.45
Rate for Payer: Qualcare PPO/HMO/WC	$9.45

HCL, FREE AND TOTAL

Facility

$63.00

Service Code	HCPCS 82926
Hospital Charge Code	38472377
Hospital Revenue Code	301
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$23.94
Rate for Payer: Aetna Medicare Advantage	$18.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16.07
Rate for Payer: Cigna Commercial	$31.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$18.90
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.45
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$1.52
Rate for Payer: Wellpoint Medicaid Managed Care	$1.67

HC PEGGED GLENOID A-40

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270686873
Hospital Revenue Code	278
Min. Negotiated Rate	$750.00
Max. Negotiated Rate	$1,210.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00

HC PEGGED GLENOID A-40

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270686873
Hospital Revenue Code	278
Min. Negotiated Rate	$120.50
Max. Negotiated Rate	$2,500.00
Rate for Payer: Aetna Commercial	$1,900.00
Rate for Payer: Aetna Medicare Advantage	$1,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,275.00
Rate for Payer: Cigna Commercial	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,210.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,100.00
Rate for Payer: Qualcare PPO/HMO/WC	$750.00
Rate for Payer: UnitedHealthcare Community & State	$120.50
Rate for Payer: Wellpoint Medicaid Managed Care	$132.50

HCT

Facility

$22.45

Service Code	HCPCS 85014
Hospital Charge Code	8200337RS
Hospital Revenue Code	305
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$6.45
Rate for Payer: Aetna Medicare Advantage	$7.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$2.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.55
Rate for Payer: Cigna Commercial	$11.22
Rate for Payer: Cigna Medicare Advantage	$2.37
Rate for Payer: Clover Medicare Advantage	$2.25
Rate for Payer: EmblemHealth Commercial	$7.11
Rate for Payer: Humana Medicare Advantage	$2.44
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$2.37
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6.74
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$3.37
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$1.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$2.37
Rate for Payer: Wellcare Medicare Advantage	$2.37
Rate for Payer: Wellpoint Medicaid Managed Care	$0.59

HCT

Facility

$22.45

Service Code	HCPCS 85014
Hospital Charge Code	8200337RS
Hospital Revenue Code	305
Min. Negotiated Rate	$3.37
Max. Negotiated Rate	$3.37
Rate for Payer: Qualcare PPO/HMO/WC	$3.37

HCT (HEMATOCRIT)

Facility

$667.59

Service Code	HCPCS 85014
Hospital Charge Code	3002912
Hospital Revenue Code	305
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$333.80
Rate for Payer: Aetna Commercial	$6.45
Rate for Payer: Aetna Medicare Advantage	$7.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$2.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.55
Rate for Payer: Cigna Commercial	$333.80
Rate for Payer: Cigna Medicare Advantage	$2.37
Rate for Payer: Clover Medicare Advantage	$2.25
Rate for Payer: EmblemHealth Commercial	$7.11
Rate for Payer: Humana Medicare Advantage	$2.44
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$2.37
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$200.28
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$100.14
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$1.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$2.37
Rate for Payer: Wellcare Medicare Advantage	$2.37
Rate for Payer: Wellpoint Medicaid Managed Care	$17.69

HCT (HEMATOCRIT)

Facility

$667.59

Service Code	HCPCS 85014
Hospital Charge Code	3002912
Hospital Revenue Code	305
Min. Negotiated Rate	$100.14
Max. Negotiated Rate	$100.14
Rate for Payer: Qualcare PPO/HMO/WC	$100.14

HCV AB

Facility

$98.10

Service Code	HCPCS 86803
Hospital Charge Code	39900260
Hospital Revenue Code	302
Min. Negotiated Rate	$14.71
Max. Negotiated Rate	$14.71
Rate for Payer: Qualcare PPO/HMO/WC	$14.71

HCV AB

Facility

$98.10

Service Code	HCPCS 86803
Hospital Charge Code	39900260
Hospital Revenue Code	302
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$38.81
Rate for Payer: Aetna Medicare Advantage	$46.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$40.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.51
Rate for Payer: Cigna Commercial	$49.05
Rate for Payer: Cigna Medicare Advantage	$14.27
Rate for Payer: Clover Medicare Advantage	$13.56
Rate for Payer: EmblemHealth Commercial	$42.81
Rate for Payer: Humana Medicare Advantage	$14.70
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.27
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$29.43
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$14.71
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.27
Rate for Payer: Wellcare Medicare Advantage	$14.27
Rate for Payer: Wellpoint Medicaid Managed Care	$2.60

HCV AB,RIBA

Facility

$106.50

Service Code	HCPCS 86804
Hospital Charge Code	39900261
Hospital Revenue Code	302
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$42.13
Rate for Payer: Aetna Medicare Advantage	$50.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$55.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$55.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$16.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$55.91
Rate for Payer: Cigna Commercial	$53.25
Rate for Payer: Cigna Medicare Advantage	$15.49
Rate for Payer: Clover Medicare Advantage	$14.72
Rate for Payer: EmblemHealth Commercial	$46.47
Rate for Payer: Humana Medicare Advantage	$15.95
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$31.95
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$15.97
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$12.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.49
Rate for Payer: Wellcare Medicare Advantage	$15.49
Rate for Payer: Wellpoint Medicaid Managed Care	$2.82

HCV AB,RIBA

Facility

$106.50

Service Code	HCPCS 86804
Hospital Charge Code	39900261
Hospital Revenue Code	302
Min. Negotiated Rate	$15.97
Max. Negotiated Rate	$15.97
Rate for Payer: Qualcare PPO/HMO/WC	$15.97

HCV Antibody

Facility

$98.10

Service Code	HCPCS 86803
Hospital Charge Code	39888008
Hospital Revenue Code	302
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$38.81
Rate for Payer: Aetna Medicare Advantage	$46.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$51.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$51.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$40.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$51.51
Rate for Payer: Cigna Commercial	$49.05
Rate for Payer: Cigna Medicare Advantage	$14.27
Rate for Payer: Clover Medicare Advantage	$13.56
Rate for Payer: EmblemHealth Commercial	$42.81
Rate for Payer: Humana Medicare Advantage	$14.70
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.27
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$29.43
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$14.71
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$11.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.27
Rate for Payer: Wellcare Medicare Advantage	$14.27
Rate for Payer: Wellpoint Medicaid Managed Care	$2.60

HCV Antibody

Facility

$98.10

Service Code	HCPCS 86803
Hospital Charge Code	39888008
Hospital Revenue Code	302
Min. Negotiated Rate	$14.71
Max. Negotiated Rate	$14.71
Rate for Payer: Qualcare PPO/HMO/WC	$14.71

HCV FIBROSURE I

Facility

$150.00

Service Code	HCPCS 83883
Hospital Charge Code	3036014A
Hospital Revenue Code	301
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: Qualcare PPO/HMO/WC	$22.50

HCV FIBROSURE I

Facility

$150.00

Service Code	HCPCS 83883
Hospital Charge Code	3036014A
Hospital Revenue Code	301
Min. Negotiated Rate	$3.98
Max. Negotiated Rate	$171.49
Rate for Payer: Aetna Commercial	$36.99
Rate for Payer: Aetna Medicare Advantage	$44.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$49.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$49.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$171.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$49.09
Rate for Payer: Cigna Commercial	$75.00
Rate for Payer: Cigna Medicare Advantage	$13.60
Rate for Payer: Clover Medicare Advantage	$12.92
Rate for Payer: EmblemHealth Commercial	$40.80
Rate for Payer: Humana Medicare Advantage	$14.01
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$45.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$10.88
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.60
Rate for Payer: Wellcare Medicare Advantage	$13.60
Rate for Payer: Wellpoint Medicaid Managed Care	$3.98

Know your out-of-pocket cost for care.

All Charges