Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PLATE ANT CERV 2LEV 30MM

Facility

$15,553.00

Service Code	HCPCS C1713
Hospital Charge Code	270694345
Hospital Revenue Code	278
Min. Negotiated Rate	$2,332.95
Max. Negotiated Rate	$3,763.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,110.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,763.83
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,421.66
Rate for Payer: Qualcare PPO/HMO/WC	$2,332.95

PLATE ANT CERV 2LEV 30MM

Facility

$15,553.00

Service Code	HCPCS C1713
Hospital Charge Code	270694345
Hospital Revenue Code	278
Min. Negotiated Rate	$374.83
Max. Negotiated Rate	$7,776.50
Rate for Payer: Aetna Commercial	$5,910.14
Rate for Payer: Aetna Medicare Advantage	$4,665.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,966.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,966.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,110.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,966.01
Rate for Payer: Cigna Commercial	$7,776.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,763.83
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,421.66
Rate for Payer: Qualcare PPO/HMO/WC	$2,332.95
Rate for Payer: UnitedHealthcare Community & State	$374.83
Rate for Payer: Wellpoint Medicaid Managed Care	$412.15

PLATE ANT CERV 2LEV 36MM

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270695983
Hospital Revenue Code	278
Min. Negotiated Rate	$463.93
Max. Negotiated Rate	$9,625.00
Rate for Payer: Aetna Commercial	$7,315.00
Rate for Payer: Aetna Medicare Advantage	$5,775.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,908.75
Rate for Payer: Cigna Commercial	$9,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50
Rate for Payer: UnitedHealthcare Community & State	$463.93
Rate for Payer: Wellpoint Medicaid Managed Care	$510.12

PLATE ANT CERV 2LEV 36MM

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270695983
Hospital Revenue Code	278
Min. Negotiated Rate	$2,887.50
Max. Negotiated Rate	$4,658.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50

PLATE ANT CERV 3LEV 46MM

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270696725
Hospital Revenue Code	278
Min. Negotiated Rate	$2,887.50
Max. Negotiated Rate	$4,658.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50

PLATE ANT CERV 3LEV 46MM

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270696725
Hospital Revenue Code	278
Min. Negotiated Rate	$463.93
Max. Negotiated Rate	$9,625.00
Rate for Payer: Aetna Commercial	$7,315.00
Rate for Payer: Aetna Medicare Advantage	$5,775.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,908.75
Rate for Payer: Cigna Commercial	$9,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50
Rate for Payer: UnitedHealthcare Community & State	$463.93
Rate for Payer: Wellpoint Medicaid Managed Care	$510.12

PLATE ANT CERV 3 LEVEL 46MM

Facility

$24,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270696981
Hospital Revenue Code	278
Min. Negotiated Rate	$3,637.50
Max. Negotiated Rate	$5,868.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,850.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,868.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,335.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,637.50

PLATE ANT CERV 3 LEVEL 46MM

Facility

$24,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270696981
Hospital Revenue Code	278
Min. Negotiated Rate	$584.42
Max. Negotiated Rate	$12,125.00
Rate for Payer: Aetna Commercial	$9,215.00
Rate for Payer: Aetna Medicare Advantage	$7,275.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,183.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,183.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,850.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,183.75
Rate for Payer: Cigna Commercial	$12,125.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,868.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,335.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,637.50
Rate for Payer: UnitedHealthcare Community & State	$584.42
Rate for Payer: Wellpoint Medicaid Managed Care	$642.62

PLATE ANT CERV 4LEVEL 68MM

Facility

$15,553.00

Service Code	HCPCS C1776
Hospital Charge Code	270694821
Hospital Revenue Code	278
Min. Negotiated Rate	$2,332.95
Max. Negotiated Rate	$3,763.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,110.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,763.83
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,421.66
Rate for Payer: Qualcare PPO/HMO/WC	$2,332.95

PLATE ANT CERV 4LEVEL 68MM

Facility

$15,553.00

Service Code	HCPCS C1776
Hospital Charge Code	270694821
Hospital Revenue Code	278
Min. Negotiated Rate	$374.83
Max. Negotiated Rate	$7,776.50
Rate for Payer: Aetna Commercial	$5,910.14
Rate for Payer: Aetna Medicare Advantage	$4,665.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,966.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,966.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,110.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,966.01
Rate for Payer: Cigna Commercial	$7,776.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,763.83
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,421.66
Rate for Payer: Qualcare PPO/HMO/WC	$2,332.95
Rate for Payer: UnitedHealthcare Community & State	$374.83
Rate for Payer: Wellpoint Medicaid Managed Care	$412.15

PLATE ANT CERV 7MM 2H

Facility

$5,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270694350
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

PLATE ANT CERV 7MM 2H

Facility

$5,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270694350
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

PLATE ANT CERV 8MM 2H

Facility

$5,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270694351
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

PLATE ANT CERV 8MM 2H

Facility

$5,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270694351
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

PLATE ANT CERV ATLANTIS 65 MM

Facility

$12,625.00

Service Code	HCPCS C1713
Hospital Charge Code	270691795
Hospital Revenue Code	278
Min. Negotiated Rate	$304.26
Max. Negotiated Rate	$6,312.50
Rate for Payer: Aetna Commercial	$4,797.50
Rate for Payer: Aetna Medicare Advantage	$3,787.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,219.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,219.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,525.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,219.38
Rate for Payer: Cigna Commercial	$6,312.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,055.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,777.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,893.75
Rate for Payer: UnitedHealthcare Community & State	$304.26
Rate for Payer: Wellpoint Medicaid Managed Care	$334.56

PLATE ANT CERV ATLANTIS 65 MM

Facility

$12,625.00

Service Code	HCPCS C1713
Hospital Charge Code	270691795
Hospital Revenue Code	278
Min. Negotiated Rate	$1,893.75
Max. Negotiated Rate	$3,055.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,525.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,055.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,777.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,893.75

PLATE ANT CERV GRUVE 2LEV 36MM

Facility

$4,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270699026
Hospital Revenue Code	278
Min. Negotiated Rate	$96.40
Max. Negotiated Rate	$2,000.00
Rate for Payer: Aetna Commercial	$1,520.00
Rate for Payer: Aetna Medicare Advantage	$1,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,020.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,020.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,020.00
Rate for Payer: Cigna Commercial	$2,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$968.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$880.00
Rate for Payer: Qualcare PPO/HMO/WC	$600.00
Rate for Payer: UnitedHealthcare Community & State	$96.40
Rate for Payer: Wellpoint Medicaid Managed Care	$106.00

PLATE ANT CERV GRUVE 2LEV 36MM

Facility

$4,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270699026
Hospital Revenue Code	278
Min. Negotiated Rate	$600.00
Max. Negotiated Rate	$968.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$800.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$968.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$880.00
Rate for Payer: Qualcare PPO/HMO/WC	$600.00

PLATE ANT CERV GRUVE 55

Facility

$4,800.00

Service Code	HCPCS C1713
Hospital Charge Code	270699338
Hospital Revenue Code	278
Min. Negotiated Rate	$720.00
Max. Negotiated Rate	$1,161.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$960.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,161.60
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,056.00
Rate for Payer: Qualcare PPO/HMO/WC	$720.00

PLATE ANT CERV GRUVE 55

Facility

$4,800.00

Service Code	HCPCS C1713
Hospital Charge Code	270699338
Hospital Revenue Code	278
Min. Negotiated Rate	$115.68
Max. Negotiated Rate	$2,400.00
Rate for Payer: Aetna Commercial	$1,824.00
Rate for Payer: Aetna Medicare Advantage	$1,440.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,224.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,224.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$960.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,224.00
Rate for Payer: Cigna Commercial	$2,400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,161.60
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,056.00
Rate for Payer: Qualcare PPO/HMO/WC	$720.00
Rate for Payer: UnitedHealthcare Community & State	$115.68
Rate for Payer: Wellpoint Medicaid Managed Care	$127.20

PLATE ANT CERVICAL 2 LEV 32MM

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270697344
Hospital Revenue Code	278
Min. Negotiated Rate	$2,887.50
Max. Negotiated Rate	$4,658.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50

PLATE ANT CERVICAL 2 LEV 32MM

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270697344
Hospital Revenue Code	278
Min. Negotiated Rate	$463.93
Max. Negotiated Rate	$9,625.00
Rate for Payer: Aetna Commercial	$7,315.00
Rate for Payer: Aetna Medicare Advantage	$5,775.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,908.75
Rate for Payer: Cigna Commercial	$9,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50
Rate for Payer: UnitedHealthcare Community & State	$463.93
Rate for Payer: Wellpoint Medicaid Managed Care	$510.12

PLATE ANT CERVICAL 2LEVEL 24MM

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270696964
Hospital Revenue Code	278
Min. Negotiated Rate	$2,887.50
Max. Negotiated Rate	$4,658.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50

PLATE ANT CERVICAL 2LEVEL 24MM

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270696964
Hospital Revenue Code	278
Min. Negotiated Rate	$463.93
Max. Negotiated Rate	$9,625.00
Rate for Payer: Aetna Commercial	$7,315.00
Rate for Payer: Aetna Medicare Advantage	$5,775.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,908.75
Rate for Payer: Cigna Commercial	$9,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50
Rate for Payer: UnitedHealthcare Community & State	$463.93
Rate for Payer: Wellpoint Medicaid Managed Care	$510.12

PLATE ANT CERV SKYLINE 26 MM

Facility

$6,757.50

Service Code	HCPCS C1713
Hospital Charge Code	270691716
Hospital Revenue Code	278
Min. Negotiated Rate	$162.86
Max. Negotiated Rate	$3,378.75
Rate for Payer: Aetna Commercial	$2,567.85
Rate for Payer: Aetna Medicare Advantage	$2,027.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,723.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,723.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,351.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,723.16
Rate for Payer: Cigna Commercial	$3,378.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,635.32
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,486.65
Rate for Payer: Qualcare PPO/HMO/WC	$1,013.62
Rate for Payer: UnitedHealthcare Community & State	$162.86
Rate for Payer: Wellpoint Medicaid Managed Care	$179.07

Know your out-of-pocket cost for care.

All Charges