Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PLATE HUM DISTAL 1H LT 69MM

Facility

$5,049.05

Service Code	HCPCS C1713
Hospital Charge Code	270676865
Hospital Revenue Code	278
Min. Negotiated Rate	$121.68
Max. Negotiated Rate	$2,524.53
Rate for Payer: Aetna Commercial	$1,918.64
Rate for Payer: Aetna Medicare Advantage	$1,514.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,287.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,287.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,009.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,287.51
Rate for Payer: Cigna Commercial	$2,524.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,221.87
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,110.79
Rate for Payer: Qualcare PPO/HMO/WC	$757.36
Rate for Payer: UnitedHealthcare Community & State	$121.68
Rate for Payer: Wellpoint Medicaid Managed Care	$133.80

PLATE HUM DISTAL 1H LT 69MM

Facility

$4,842.05

Hospital Charge Code	270677667
Hospital Revenue Code	278
Min. Negotiated Rate	$116.69
Max. Negotiated Rate	$2,421.03
Rate for Payer: Aetna Commercial	$1,839.98
Rate for Payer: Aetna Medicare Advantage	$1,452.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,234.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,234.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$968.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,234.72
Rate for Payer: Cigna Commercial	$2,421.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,171.78
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,065.25
Rate for Payer: Qualcare PPO/HMO/WC	$726.31
Rate for Payer: UnitedHealthcare Community & State	$116.69
Rate for Payer: Wellpoint Medicaid Managed Care	$128.31

PLATE HUM DISTAL 1H LT 72MM

Facility

$4,993.05

Service Code	HCPCS C1713
Hospital Charge Code	270676238
Hospital Revenue Code	278
Min. Negotiated Rate	$748.96
Max. Negotiated Rate	$1,208.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$998.61
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,208.32
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,098.47
Rate for Payer: Qualcare PPO/HMO/WC	$748.96

PLATE HUM DISTAL 1H LT 72MM

Facility

$4,993.05

Service Code	HCPCS C1713
Hospital Charge Code	270676238
Hospital Revenue Code	278
Min. Negotiated Rate	$120.33
Max. Negotiated Rate	$2,496.53
Rate for Payer: Aetna Commercial	$1,897.36
Rate for Payer: Aetna Medicare Advantage	$1,497.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,273.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,273.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$998.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,273.23
Rate for Payer: Cigna Commercial	$2,496.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,208.32
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,098.47
Rate for Payer: Qualcare PPO/HMO/WC	$748.96
Rate for Payer: UnitedHealthcare Community & State	$120.33
Rate for Payer: Wellpoint Medicaid Managed Care	$132.32

PLATE HUM DISTAL 1H LT 72MM ST

Facility

$5,197.40

Service Code	HCPCS C1713
Hospital Charge Code	270676910
Hospital Revenue Code	278
Min. Negotiated Rate	$779.61
Max. Negotiated Rate	$1,257.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,039.48
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,257.77
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,143.43
Rate for Payer: Qualcare PPO/HMO/WC	$779.61

PLATE HUM DISTAL 1H LT 72MM ST

Facility

$5,197.40

Service Code	HCPCS C1713
Hospital Charge Code	270676910
Hospital Revenue Code	278
Min. Negotiated Rate	$125.26
Max. Negotiated Rate	$2,598.70
Rate for Payer: Aetna Commercial	$1,975.01
Rate for Payer: Aetna Medicare Advantage	$1,559.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,325.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,325.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,039.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,325.34
Rate for Payer: Cigna Commercial	$2,598.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,257.77
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,143.43
Rate for Payer: Qualcare PPO/HMO/WC	$779.61
Rate for Payer: UnitedHealthcare Community & State	$125.26
Rate for Payer: Wellpoint Medicaid Managed Care	$137.73

PLATE HUM DISTAL 1H RT 69MM

Facility

$4,842.05

Hospital Charge Code	270677663
Hospital Revenue Code	278
Min. Negotiated Rate	$116.69
Max. Negotiated Rate	$2,421.03
Rate for Payer: Aetna Commercial	$1,839.98
Rate for Payer: Aetna Medicare Advantage	$1,452.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,234.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,234.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$968.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,234.72
Rate for Payer: Cigna Commercial	$2,421.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,171.78
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,065.25
Rate for Payer: Qualcare PPO/HMO/WC	$726.31
Rate for Payer: UnitedHealthcare Community & State	$116.69
Rate for Payer: Wellpoint Medicaid Managed Care	$128.31

PLATE HUM DISTAL 1H RT 69MM

Facility

$4,842.05

Hospital Charge Code	270677663
Hospital Revenue Code	278
Min. Negotiated Rate	$726.31
Max. Negotiated Rate	$1,171.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$968.41
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,171.78
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,065.25
Rate for Payer: Qualcare PPO/HMO/WC	$726.31

PLATE HUM DISTAL 1H RT 72MM

Facility

$4,993.45

Hospital Charge Code	270677628
Hospital Revenue Code	278
Min. Negotiated Rate	$749.02
Max. Negotiated Rate	$1,208.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$998.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,208.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,098.56
Rate for Payer: Qualcare PPO/HMO/WC	$749.02

PLATE HUM DISTAL 1H RT 72MM

Facility

$4,993.45

Hospital Charge Code	270677628
Hospital Revenue Code	278
Min. Negotiated Rate	$120.34
Max. Negotiated Rate	$2,496.72
Rate for Payer: Aetna Commercial	$1,897.51
Rate for Payer: Aetna Medicare Advantage	$1,498.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,273.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,273.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$998.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,273.33
Rate for Payer: Cigna Commercial	$2,496.72
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,208.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,098.56
Rate for Payer: Qualcare PPO/HMO/WC	$749.02
Rate for Payer: UnitedHealthcare Community & State	$120.34
Rate for Payer: Wellpoint Medicaid Managed Care	$132.33

PLATE HUM DISTAL 1H RT 72MM ST

Facility

$5,197.40

Service Code	HCPCS C1713
Hospital Charge Code	270678412
Hospital Revenue Code	278
Min. Negotiated Rate	$125.26
Max. Negotiated Rate	$2,598.70
Rate for Payer: Aetna Commercial	$1,975.01
Rate for Payer: Aetna Medicare Advantage	$1,559.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,325.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,325.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,039.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,325.34
Rate for Payer: Cigna Commercial	$2,598.70
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,257.77
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,143.43
Rate for Payer: Qualcare PPO/HMO/WC	$779.61
Rate for Payer: UnitedHealthcare Community & State	$125.26
Rate for Payer: Wellpoint Medicaid Managed Care	$137.73

PLATE HUM DISTAL 1H RT 72MM ST

Facility

$5,197.40

Service Code	HCPCS C1713
Hospital Charge Code	270678412
Hospital Revenue Code	278
Min. Negotiated Rate	$779.61
Max. Negotiated Rate	$1,257.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,039.48
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,257.77
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,143.43
Rate for Payer: Qualcare PPO/HMO/WC	$779.61

PLATE HUM DISTAL 2H 23480602

Facility

$3,102.95

Hospital Charge Code	270634817
Hospital Revenue Code	278
Min. Negotiated Rate	$74.78
Max. Negotiated Rate	$1,551.47
Rate for Payer: Aetna Commercial	$1,179.12
Rate for Payer: Aetna Medicare Advantage	$930.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$791.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$791.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$620.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$791.25
Rate for Payer: Cigna Commercial	$1,551.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$750.91
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$682.65
Rate for Payer: Qualcare PPO/HMO/WC	$465.44
Rate for Payer: UnitedHealthcare Community & State	$74.78
Rate for Payer: Wellpoint Medicaid Managed Care	$82.23

PLATE HUM DISTAL 2H 23480602

Facility

$3,102.95

Hospital Charge Code	270634817
Hospital Revenue Code	278
Min. Negotiated Rate	$465.44
Max. Negotiated Rate	$750.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$620.59
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$750.91
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$682.65
Rate for Payer: Qualcare PPO/HMO/WC	$465.44

PLATE HUM DISTAL 2H LT 82MM

Facility

$4,842.05

Hospital Charge Code	270677668
Hospital Revenue Code	278
Min. Negotiated Rate	$726.31
Max. Negotiated Rate	$1,171.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$968.41
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,171.78
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,065.25
Rate for Payer: Qualcare PPO/HMO/WC	$726.31

PLATE HUM DISTAL 2H LT 82MM

Facility

$4,842.05

Hospital Charge Code	270677668
Hospital Revenue Code	278
Min. Negotiated Rate	$116.69
Max. Negotiated Rate	$2,421.03
Rate for Payer: Aetna Commercial	$1,839.98
Rate for Payer: Aetna Medicare Advantage	$1,452.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,234.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,234.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$968.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,234.72
Rate for Payer: Cigna Commercial	$2,421.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,171.78
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,065.25
Rate for Payer: Qualcare PPO/HMO/WC	$726.31
Rate for Payer: UnitedHealthcare Community & State	$116.69
Rate for Payer: Wellpoint Medicaid Managed Care	$128.31

PLATE HUM DISTAL 2H LT 82MM ST

Facility

$5,200.50

Service Code	HCPCS C1713
Hospital Charge Code	270684231
Hospital Revenue Code	278
Min. Negotiated Rate	$780.08
Max. Negotiated Rate	$1,258.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,040.10
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,258.52
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,144.11
Rate for Payer: Qualcare PPO/HMO/WC	$780.08

PLATE HUM DISTAL 2H LT 82MM ST

Facility

$5,200.50

Service Code	HCPCS C1713
Hospital Charge Code	270684231
Hospital Revenue Code	278
Min. Negotiated Rate	$125.33
Max. Negotiated Rate	$2,600.25
Rate for Payer: Aetna Commercial	$1,976.19
Rate for Payer: Aetna Medicare Advantage	$1,560.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,326.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,326.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,040.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,326.13
Rate for Payer: Cigna Commercial	$2,600.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,258.52
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,144.11
Rate for Payer: Qualcare PPO/HMO/WC	$780.08
Rate for Payer: UnitedHealthcare Community & State	$125.33
Rate for Payer: Wellpoint Medicaid Managed Care	$137.81

PLATE HUM DISTAL 2H LT 85MM

Facility

$4,993.45

Hospital Charge Code	270677632
Hospital Revenue Code	278
Min. Negotiated Rate	$120.34
Max. Negotiated Rate	$2,496.72
Rate for Payer: Aetna Commercial	$1,897.51
Rate for Payer: Aetna Medicare Advantage	$1,498.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,273.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,273.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$998.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,273.33
Rate for Payer: Cigna Commercial	$2,496.72
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,208.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,098.56
Rate for Payer: Qualcare PPO/HMO/WC	$749.02
Rate for Payer: UnitedHealthcare Community & State	$120.34
Rate for Payer: Wellpoint Medicaid Managed Care	$132.33

PLATE HUM DISTAL 2H LT 85MM

Facility

$4,993.45

Hospital Charge Code	270677632
Hospital Revenue Code	278
Min. Negotiated Rate	$749.02
Max. Negotiated Rate	$1,208.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$998.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,208.41
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,098.56
Rate for Payer: Qualcare PPO/HMO/WC	$749.02

PLATE HUM DISTAL 2H LT 85MM ST

Facility

$5,353.30

Service Code	HCPCS C1713
Hospital Charge Code	270684232
Hospital Revenue Code	278
Min. Negotiated Rate	$129.01
Max. Negotiated Rate	$2,676.65
Rate for Payer: Aetna Commercial	$2,034.25
Rate for Payer: Aetna Medicare Advantage	$1,605.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,365.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,365.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,070.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,365.09
Rate for Payer: Cigna Commercial	$2,676.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,295.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,177.73
Rate for Payer: Qualcare PPO/HMO/WC	$803.00
Rate for Payer: UnitedHealthcare Community & State	$129.01
Rate for Payer: Wellpoint Medicaid Managed Care	$141.86

PLATE HUM DISTAL 2H LT 85MM ST

Facility

$5,353.30

Service Code	HCPCS C1713
Hospital Charge Code	270684232
Hospital Revenue Code	278
Min. Negotiated Rate	$803.00
Max. Negotiated Rate	$1,295.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,070.66
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,295.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,177.73
Rate for Payer: Qualcare PPO/HMO/WC	$803.00

PLATE HUM DISTAL 2H RT 82MM

Facility

$4,842.05

Hospital Charge Code	270677664
Hospital Revenue Code	278
Min. Negotiated Rate	$116.69
Max. Negotiated Rate	$2,421.03
Rate for Payer: Aetna Commercial	$1,839.98
Rate for Payer: Aetna Medicare Advantage	$1,452.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,234.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,234.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$968.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,234.72
Rate for Payer: Cigna Commercial	$2,421.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,171.78
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,065.25
Rate for Payer: Qualcare PPO/HMO/WC	$726.31
Rate for Payer: UnitedHealthcare Community & State	$116.69
Rate for Payer: Wellpoint Medicaid Managed Care	$128.31

PLATE HUM DISTAL 2H RT 82MM

Facility

$4,842.05

Hospital Charge Code	270677664
Hospital Revenue Code	278
Min. Negotiated Rate	$726.31
Max. Negotiated Rate	$1,171.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$968.41
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,171.78
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,065.25
Rate for Payer: Qualcare PPO/HMO/WC	$726.31

PLATE HUM DISTAL 2H RT 82MM ME

Facility

$5,049.05

Service Code	HCPCS C1713
Hospital Charge Code	270678411
Hospital Revenue Code	278
Min. Negotiated Rate	$121.68
Max. Negotiated Rate	$2,524.53
Rate for Payer: Aetna Commercial	$1,918.64
Rate for Payer: Aetna Medicare Advantage	$1,514.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,287.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,287.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,009.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,287.51
Rate for Payer: Cigna Commercial	$2,524.53
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,221.87
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,110.79
Rate for Payer: Qualcare PPO/HMO/WC	$757.36
Rate for Payer: UnitedHealthcare Community & State	$121.68
Rate for Payer: Wellpoint Medicaid Managed Care	$133.80

Know your out-of-pocket cost for care.

All Charges