Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

LUNDERQIST EXTRA STIFF WIRE

Facility

$1,506.25

Hospital Charge Code	270658322
Hospital Revenue Code	272
Min. Negotiated Rate	$225.94
Max. Negotiated Rate	$225.94
Rate for Payer: Qualcare PPO/HMO/WC	$225.94

LUNDERQIST EXTRA STIFF WIRE

Facility

$1,506.25

Hospital Charge Code	270658322
Hospital Revenue Code	272
Min. Negotiated Rate	$36.30
Max. Negotiated Rate	$753.12
Rate for Payer: Aetna Commercial	$572.38
Rate for Payer: Aetna Medicare Advantage	$451.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$384.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$384.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$384.09
Rate for Payer: Cigna Commercial	$753.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$451.88
Rate for Payer: Oxford Commercial	$301.25
Rate for Payer: Qualcare PPO/HMO/WC	$225.94
Rate for Payer: UnitedHealthcare Commercial	$301.25
Rate for Payer: UnitedHealthcare Community & State	$36.30
Rate for Payer: Wellpoint Medicaid Managed Care	$39.92

LUNG MATURITY PROFILE II***

Facility

$83.00

Service Code	HCPCS 83661
Hospital Charge Code	3007598
Hospital Revenue Code	301
Min. Negotiated Rate	$12.45
Max. Negotiated Rate	$12.45
Rate for Payer: Qualcare PPO/HMO/WC	$12.45

LUNG MATURITY PROFILE II***

Facility

$83.00

Service Code	HCPCS 83661
Hospital Charge Code	3007598
Hospital Revenue Code	301
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$59.81
Rate for Payer: Aetna Medicare Advantage	$71.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$79.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$79.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$21.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$20.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$79.38
Rate for Payer: Cigna Commercial	$41.50
Rate for Payer: Cigna Medicare Advantage	$21.99
Rate for Payer: Clover Medicare Advantage	$20.89
Rate for Payer: EmblemHealth Commercial	$65.97
Rate for Payer: Humana Medicare Advantage	$22.65
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$21.99
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$24.90
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.45
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$17.59
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.99
Rate for Payer: Wellcare Medicare Advantage	$21.99
Rate for Payer: Wellpoint Medicaid Managed Care	$2.20

LUNG PERF & VENT SCAN

Facility

$12,000.00

Service Code	HCPCS 78582
Hospital Charge Code	4500928
Hospital Revenue Code	341
Min. Negotiated Rate	$277.64
Max. Negotiated Rate	$5,021.00
Rate for Payer: Aetna Commercial	$1,754.56
Rate for Payer: Aetna Medicare Advantage	$2,089.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,328.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,328.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$645.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$277.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,328.47
Rate for Payer: Cigna Commercial	$1,293.03
Rate for Payer: Cigna Medicare Advantage	$451.54
Rate for Payer: Clover Medicare Advantage	$612.81
Rate for Payer: EmblemHealth Commercial	$1,935.18
Rate for Payer: Humana Medicare Advantage	$664.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$645.06
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,600.00
Rate for Payer: Oxford Commercial	$3,120.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Commercial	$5,021.00
Rate for Payer: UnitedHealthcare Community & State	$289.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$645.06
Rate for Payer: Wellcare Medicare Advantage	$645.06
Rate for Payer: Wellpoint Medicaid Managed Care	$318.00

LUNG PERF & VENT SCAN

Facility

$12,000.00

Service Code	HCPCS 78582
Hospital Charge Code	4500928
Hospital Revenue Code	341
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$1,800.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

LUNG TRANSPLANT

Facility

$420,705.95

Service Code	MSDRG 007
Min. Negotiated Rate	$128,099.57
Max. Negotiated Rate	$420,705.95
Rate for Payer: Aetna Medicare Advantage	$420,705.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$285,412.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$285,412.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$134,841.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$285,412.47
Rate for Payer: Cigna Commercial	$242,350.04
Rate for Payer: Cigna Medicare Advantage	$134,841.65
Rate for Payer: Clover Medicare Advantage	$128,099.57
Rate for Payer: EmblemHealth Commercial	$404,524.95
Rate for Payer: Humana Medicare Advantage	$138,886.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$134,841.65
Rate for Payer: UnitedHealthcare Medicare Advantage	$134,841.65
Rate for Payer: Wellcare Medicare Advantage	$134,841.65

LUNG VOLUMES UP TO 2 YRS

Facility

$1,434.60

Service Code	HCPCS 94013
Hospital Charge Code	9501293
Hospital Revenue Code	460
Min. Negotiated Rate	$215.19
Max. Negotiated Rate	$215.19
Rate for Payer: Qualcare PPO/HMO/WC	$215.19

LUNG VOLUMES UP TO 2 YRS

Facility

$1,434.60

Service Code	HCPCS 94013
Hospital Charge Code	9501293
Hospital Revenue Code	460
Min. Negotiated Rate	$34.57
Max. Negotiated Rate	$2,770.00
Rate for Payer: Aetna Commercial	$1,205.83
Rate for Payer: Aetna Medicare Advantage	$1,436.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,600.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,600.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$443.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,600.25
Rate for Payer: Cigna Commercial	$888.63
Rate for Payer: Cigna Medicare Advantage	$443.32
Rate for Payer: Clover Medicare Advantage	$421.15
Rate for Payer: EmblemHealth Commercial	$1,329.96
Rate for Payer: Humana Medicare Advantage	$456.62
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$443.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$430.38
Rate for Payer: Oxford Commercial	$1,580.00
Rate for Payer: Qualcare PPO/HMO/WC	$215.19
Rate for Payer: UnitedHealthcare Commercial	$2,770.00
Rate for Payer: UnitedHealthcare Community & State	$34.57
Rate for Payer: UnitedHealthcare Medicare Advantage	$443.32
Rate for Payer: Wellcare Medicare Advantage	$443.32
Rate for Payer: Wellpoint Medicaid Managed Care	$38.02

LUPRON/1MG/0.2ML

Facility

$1,241.00

Hospital Charge Code	60633336
Hospital Revenue Code	636
Min. Negotiated Rate	$29.91
Max. Negotiated Rate	$620.50
Rate for Payer: Aetna Commercial	$471.58
Rate for Payer: Aetna Medicare Advantage	$372.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$316.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$316.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$316.45
Rate for Payer: Cigna Commercial	$620.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$300.32
Rate for Payer: Qualcare PPO/HMO/WC	$186.15
Rate for Payer: UnitedHealthcare Community & State	$29.91
Rate for Payer: Wellpoint Medicaid Managed Care	$32.89

LUPRON/1MG/0.2ML

Facility

$1,241.00

Hospital Charge Code	60633336
Hospital Revenue Code	636
Min. Negotiated Rate	$186.15
Max. Negotiated Rate	$300.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$300.32
Rate for Payer: Qualcare PPO/HMO/WC	$186.15

LUPRON DEPOT/3.75MG/EACH

Facility

$2,064.00

Hospital Charge Code	60633337
Hospital Revenue Code	636
Min. Negotiated Rate	$49.74
Max. Negotiated Rate	$1,032.00
Rate for Payer: Aetna Commercial	$784.32
Rate for Payer: Aetna Medicare Advantage	$619.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$526.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$526.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$526.32
Rate for Payer: Cigna Commercial	$1,032.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$499.49
Rate for Payer: Qualcare PPO/HMO/WC	$309.60
Rate for Payer: UnitedHealthcare Community & State	$49.74
Rate for Payer: Wellpoint Medicaid Managed Care	$54.70

LUPRON DEPOT/3.75MG/EACH

Facility

$2,064.00

Hospital Charge Code	60633337
Hospital Revenue Code	636
Min. Negotiated Rate	$309.60
Max. Negotiated Rate	$499.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$499.49
Rate for Payer: Qualcare PPO/HMO/WC	$309.60

LUPUS ANTICOAG,HEXAGONAL

Facility

$667.59

Service Code	HCPCS 85598
Hospital Charge Code	39900179
Hospital Revenue Code	305
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$333.80
Rate for Payer: Aetna Commercial	$48.91
Rate for Payer: Aetna Medicare Advantage	$58.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$64.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$64.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$17.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$64.90
Rate for Payer: Cigna Commercial	$333.80
Rate for Payer: Cigna Medicare Advantage	$17.98
Rate for Payer: Clover Medicare Advantage	$17.08
Rate for Payer: EmblemHealth Commercial	$53.94
Rate for Payer: Humana Medicare Advantage	$18.52
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$17.98
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	$14.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.98
Rate for Payer: Wellcare Medicare Advantage	$17.98
Rate for Payer: Wellpoint Medicaid Managed Care	$17.69

LUPUS ANTICOAG,HEXAGONAL

Facility

$667.59

Service Code	HCPCS 85598
Hospital Charge Code	39900179
Hospital Revenue Code	305
Min. Negotiated Rate	$100.14
Max. Negotiated Rate	$100.14
Rate for Payer: Qualcare PPO/HMO/WC	$100.14

LUPUS ANTICOAGULANT

Facility

$107.00

Service Code	HCPCS 85613
Hospital Charge Code	38478074
Hospital Revenue Code	305
Min. Negotiated Rate	$16.05
Max. Negotiated Rate	$16.05
Rate for Payer: Qualcare PPO/HMO/WC	$16.05

LUPUS ANTICOAGULANT

Facility

$107.00

Service Code	HCPCS 85613
Hospital Charge Code	38478074
Hospital Revenue Code	305
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$26.06
Rate for Payer: Aetna Medicare Advantage	$31.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$9.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.58
Rate for Payer: Cigna Commercial	$53.50
Rate for Payer: Cigna Medicare Advantage	$9.58
Rate for Payer: Clover Medicare Advantage	$9.10
Rate for Payer: EmblemHealth Commercial	$28.74
Rate for Payer: Humana Medicare Advantage	$9.87
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$9.58
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$32.10
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$16.05
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$7.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.58
Rate for Payer: Wellcare Medicare Advantage	$9.58
Rate for Payer: Wellpoint Medicaid Managed Care	$2.84

LUPUS DRVVT CONFIRM

Facility

$123.55

Service Code	HCPCS 85597
Hospital Charge Code	39900178
Hospital Revenue Code	305
Min. Negotiated Rate	$18.53
Max. Negotiated Rate	$18.53
Rate for Payer: Qualcare PPO/HMO/WC	$18.53

LUPUS DRVVT CONFIRM

Facility

$123.55

Service Code	HCPCS 85597
Hospital Charge Code	39900178
Hospital Revenue Code	305
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$48.91
Rate for Payer: Aetna Medicare Advantage	$58.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$64.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$64.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$17.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$42.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$64.90
Rate for Payer: Cigna Commercial	$61.77
Rate for Payer: Cigna Medicare Advantage	$17.98
Rate for Payer: Clover Medicare Advantage	$17.08
Rate for Payer: EmblemHealth Commercial	$53.94
Rate for Payer: Humana Medicare Advantage	$18.52
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$17.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$37.06
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$18.53
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$14.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.98
Rate for Payer: Wellcare Medicare Advantage	$17.98
Rate for Payer: Wellpoint Medicaid Managed Care	$3.27

LUPUS EV

Facility

$226.45

Service Code	HCPCS 85613
Hospital Charge Code	3035076A
Hospital Revenue Code	300
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$26.06
Rate for Payer: Aetna Medicare Advantage	$31.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$9.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.58
Rate for Payer: Cigna Commercial	$113.22
Rate for Payer: Cigna Medicare Advantage	$9.58
Rate for Payer: Clover Medicare Advantage	$9.10
Rate for Payer: EmblemHealth Commercial	$28.74
Rate for Payer: Humana Medicare Advantage	$9.87
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$9.58
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$67.94
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$33.97
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$7.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.58
Rate for Payer: Wellcare Medicare Advantage	$9.58
Rate for Payer: Wellpoint Medicaid Managed Care	$6.00

LUPUS EV

Facility

$226.45

Service Code	HCPCS 85613
Hospital Charge Code	3035076A
Hospital Revenue Code	300
Min. Negotiated Rate	$33.97
Max. Negotiated Rate	$33.97
Rate for Payer: Qualcare PPO/HMO/WC	$33.97

LUPUS;HEX PHASE NEUT

Facility

$123.55

Service Code	HCPCS 85598
Hospital Charge Code	39900180
Hospital Revenue Code	305
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$48.91
Rate for Payer: Aetna Medicare Advantage	$58.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$64.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$64.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$17.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$64.90
Rate for Payer: Cigna Commercial	$61.77
Rate for Payer: Cigna Medicare Advantage	$17.98
Rate for Payer: Clover Medicare Advantage	$17.08
Rate for Payer: EmblemHealth Commercial	$53.94
Rate for Payer: Humana Medicare Advantage	$18.52
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$17.98
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$37.06
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$18.53
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$14.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.98
Rate for Payer: Wellcare Medicare Advantage	$17.98
Rate for Payer: Wellpoint Medicaid Managed Care	$3.27

LUPUS;HEX PHASE NEUT

Facility

$123.55

Service Code	HCPCS 85598
Hospital Charge Code	39900180
Hospital Revenue Code	305
Min. Negotiated Rate	$18.53
Max. Negotiated Rate	$18.53
Rate for Payer: Qualcare PPO/HMO/WC	$18.53

LUPUS PROFILE I

Facility

$667.59

Service Code	HCPCS 85613
Hospital Charge Code	39990077A
Hospital Revenue Code	305
Min. Negotiated Rate	$100.14
Max. Negotiated Rate	$100.14
Rate for Payer: Qualcare PPO/HMO/WC	$100.14

LUPUS PROFILE I

Facility

$667.59

Service Code	HCPCS 85613
Hospital Charge Code	39990077A
Hospital Revenue Code	305
Min. Negotiated Rate	$7.66
Max. Negotiated Rate	$333.80
Rate for Payer: Aetna Commercial	$26.06
Rate for Payer: Aetna Medicare Advantage	$31.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$9.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$19.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.58
Rate for Payer: Cigna Commercial	$333.80
Rate for Payer: Cigna Medicare Advantage	$9.58
Rate for Payer: Clover Medicare Advantage	$9.10
Rate for Payer: EmblemHealth Commercial	$28.74
Rate for Payer: Humana Medicare Advantage	$9.87
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$9.58
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	$7.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.58
Rate for Payer: Wellcare Medicare Advantage	$9.58
Rate for Payer: Wellpoint Medicaid Managed Care	$17.69

Know your out-of-pocket cost for care.

All Charges