Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PSN REV FEM DISTAL AUG SZ9 5MM

Facility

$8,228.75

Service Code	HCPCS C1776
Hospital Charge Code	270696900
Hospital Revenue Code	278
Min. Negotiated Rate	$1,234.31
Max. Negotiated Rate	$1,991.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,645.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,991.36
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,810.33
Rate for Payer: Qualcare PPO/HMO/WC	$1,234.31

PSN REV FEM DISTAL AUG SZ9 5MM

Facility

$8,228.75

Service Code	HCPCS C1776
Hospital Charge Code	270696900
Hospital Revenue Code	278
Min. Negotiated Rate	$198.31
Max. Negotiated Rate	$4,114.38
Rate for Payer: Aetna Commercial	$3,126.93
Rate for Payer: Aetna Medicare Advantage	$2,468.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,098.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,098.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,645.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,098.33
Rate for Payer: Cigna Commercial	$4,114.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,991.36
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,810.33
Rate for Payer: Qualcare PPO/HMO/WC	$1,234.31
Rate for Payer: UnitedHealthcare Community & State	$198.31
Rate for Payer: Wellpoint Medicaid Managed Care	$218.06

PSN REV FEM DIST AUG SZ3 10MM

Facility

$7,975.00

Service Code	HCPCS C1776
Hospital Charge Code	270694075
Hospital Revenue Code	278
Min. Negotiated Rate	$192.20
Max. Negotiated Rate	$3,987.50
Rate for Payer: Aetna Commercial	$3,030.50
Rate for Payer: Aetna Medicare Advantage	$2,392.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,033.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,033.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,595.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,033.62
Rate for Payer: Cigna Commercial	$3,987.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,929.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,754.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,196.25
Rate for Payer: UnitedHealthcare Community & State	$192.20
Rate for Payer: Wellpoint Medicaid Managed Care	$211.34

PSN REV FEM DIST AUG SZ3 10MM

Facility

$7,975.00

Service Code	HCPCS C1776
Hospital Charge Code	270694075
Hospital Revenue Code	278
Min. Negotiated Rate	$1,196.25
Max. Negotiated Rate	$1,929.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,595.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,929.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,754.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,196.25

PSN REV FEM DIST AUG SZ3 5MM

Facility

$7,975.00

Service Code	HCPCS C1776
Hospital Charge Code	270694076
Hospital Revenue Code	278
Min. Negotiated Rate	$192.20
Max. Negotiated Rate	$3,987.50
Rate for Payer: Aetna Commercial	$3,030.50
Rate for Payer: Aetna Medicare Advantage	$2,392.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,033.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,033.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,595.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,033.62
Rate for Payer: Cigna Commercial	$3,987.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,929.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,754.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,196.25
Rate for Payer: UnitedHealthcare Community & State	$192.20
Rate for Payer: Wellpoint Medicaid Managed Care	$211.34

PSN REV FEM DIST AUG SZ3 5MM

Facility

$7,975.00

Service Code	HCPCS C1776
Hospital Charge Code	270694076
Hospital Revenue Code	278
Min. Negotiated Rate	$1,196.25
Max. Negotiated Rate	$1,929.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,595.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,929.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,754.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,196.25

PSN REV FEM DIST AUG SZ5 5MM

Facility

$7,975.00

Service Code	HCPCS C1776
Hospital Charge Code	270695260
Hospital Revenue Code	278
Min. Negotiated Rate	$192.20
Max. Negotiated Rate	$3,987.50
Rate for Payer: Aetna Commercial	$3,030.50
Rate for Payer: Aetna Medicare Advantage	$2,392.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,033.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,033.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,595.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,033.62
Rate for Payer: Cigna Commercial	$3,987.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,929.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,754.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,196.25
Rate for Payer: UnitedHealthcare Community & State	$192.20
Rate for Payer: Wellpoint Medicaid Managed Care	$211.34

PSN REV FEM DIST AUG SZ5 5MM

Facility

$7,975.00

Service Code	HCPCS C1776
Hospital Charge Code	270695260
Hospital Revenue Code	278
Min. Negotiated Rate	$1,196.25
Max. Negotiated Rate	$1,929.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,595.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,929.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,754.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,196.25

PSN REV FEM DIST AUG SZ7 5MM

Facility

$7,975.00

Service Code	HCPCS C1776
Hospital Charge Code	270694630
Hospital Revenue Code	278
Min. Negotiated Rate	$1,196.25
Max. Negotiated Rate	$1,929.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,595.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,929.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,754.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,196.25

PSN REV FEM DIST AUG SZ7 5MM

Facility

$7,975.00

Service Code	HCPCS C1776
Hospital Charge Code	270694630
Hospital Revenue Code	278
Min. Negotiated Rate	$192.20
Max. Negotiated Rate	$3,987.50
Rate for Payer: Aetna Commercial	$3,030.50
Rate for Payer: Aetna Medicare Advantage	$2,392.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,033.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,033.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,595.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,033.62
Rate for Payer: Cigna Commercial	$3,987.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,929.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,754.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,196.25
Rate for Payer: UnitedHealthcare Community & State	$192.20
Rate for Payer: Wellpoint Medicaid Managed Care	$211.34

PSN REV FEM DIST AUG SZ 9 15MM

Facility

$8,228.75

Service Code	HCPCS C1776
Hospital Charge Code	270697459
Hospital Revenue Code	278
Min. Negotiated Rate	$198.31
Max. Negotiated Rate	$4,114.38
Rate for Payer: Aetna Commercial	$3,126.93
Rate for Payer: Aetna Medicare Advantage	$2,468.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,098.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,098.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,645.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,098.33
Rate for Payer: Cigna Commercial	$4,114.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,991.36
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,810.33
Rate for Payer: Qualcare PPO/HMO/WC	$1,234.31
Rate for Payer: UnitedHealthcare Community & State	$198.31
Rate for Payer: Wellpoint Medicaid Managed Care	$218.06

PSN REV FEM DIST AUG SZ 9 15MM

Facility

$8,228.75

Service Code	HCPCS C1776
Hospital Charge Code	270697459
Hospital Revenue Code	278
Min. Negotiated Rate	$1,234.31
Max. Negotiated Rate	$1,991.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,645.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,991.36
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,810.33
Rate for Payer: Qualcare PPO/HMO/WC	$1,234.31

PSN REV FEM POST AUG SZ 55MM

Facility

$6,810.00

Service Code	HCPCS C1776
Hospital Charge Code	270692738
Hospital Revenue Code	278
Min. Negotiated Rate	$164.12
Max. Negotiated Rate	$3,405.00
Rate for Payer: Aetna Commercial	$2,587.80
Rate for Payer: Aetna Medicare Advantage	$2,043.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,736.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,736.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,362.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,736.55
Rate for Payer: Cigna Commercial	$3,405.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,648.02
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,498.20
Rate for Payer: Qualcare PPO/HMO/WC	$1,021.50
Rate for Payer: UnitedHealthcare Community & State	$164.12
Rate for Payer: Wellpoint Medicaid Managed Care	$180.47

PSN REV FEM POST AUG SZ 55MM

Facility

$6,810.00

Service Code	HCPCS C1776
Hospital Charge Code	270692738
Hospital Revenue Code	278
Min. Negotiated Rate	$1,021.50
Max. Negotiated Rate	$1,648.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,362.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,648.02
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,498.20
Rate for Payer: Qualcare PPO/HMO/WC	$1,021.50

PSN REV FEM POST AUG SZ7 5MM

Facility

$7,975.00

Service Code	HCPCS C1776
Hospital Charge Code	270694631
Hospital Revenue Code	278
Min. Negotiated Rate	$192.20
Max. Negotiated Rate	$3,987.50
Rate for Payer: Aetna Commercial	$3,030.50
Rate for Payer: Aetna Medicare Advantage	$2,392.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,033.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,033.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,595.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,033.62
Rate for Payer: Cigna Commercial	$3,987.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,929.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,754.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,196.25
Rate for Payer: UnitedHealthcare Community & State	$192.20
Rate for Payer: Wellpoint Medicaid Managed Care	$211.34

PSN REV FEM POST AUG SZ7 5MM

Facility

$7,975.00

Service Code	HCPCS C1776
Hospital Charge Code	270694631
Hospital Revenue Code	278
Min. Negotiated Rate	$1,196.25
Max. Negotiated Rate	$1,929.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,595.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,929.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,754.50
Rate for Payer: Qualcare PPO/HMO/WC	$1,196.25

PSNREVSTRSPLINESTEMEXT17X135MM

Facility

$12,506.25

Service Code	HCPCS C1776
Hospital Charge Code	270695147
Hospital Revenue Code	278
Min. Negotiated Rate	$1,875.94
Max. Negotiated Rate	$3,026.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,501.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,026.51
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,751.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.94

PSNREVSTRSPLINESTEMEXT17X135MM

Facility

$12,506.25

Service Code	HCPCS C1776
Hospital Charge Code	270695147
Hospital Revenue Code	278
Min. Negotiated Rate	$301.40
Max. Negotiated Rate	$6,253.12
Rate for Payer: Aetna Commercial	$4,752.38
Rate for Payer: Aetna Medicare Advantage	$3,751.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,189.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,189.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,501.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,189.09
Rate for Payer: Cigna Commercial	$6,253.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,026.51
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,751.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.94
Rate for Payer: UnitedHealthcare Community & State	$301.40
Rate for Payer: Wellpoint Medicaid Managed Care	$331.42

PSNREVSTSPLINESTEMEXT16X135MM

Facility

$12,905.00

Service Code	HCPCS C1776
Hospital Charge Code	270697605
Hospital Revenue Code	278
Min. Negotiated Rate	$311.01
Max. Negotiated Rate	$6,452.50
Rate for Payer: Aetna Commercial	$4,903.90
Rate for Payer: Aetna Medicare Advantage	$3,871.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,290.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,290.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,581.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,290.78
Rate for Payer: Cigna Commercial	$6,452.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,123.01
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,839.10
Rate for Payer: Qualcare PPO/HMO/WC	$1,935.75
Rate for Payer: UnitedHealthcare Community & State	$311.01
Rate for Payer: Wellpoint Medicaid Managed Care	$341.98

PSNREVSTSPLINESTEMEXT16X135MM

Facility

$12,905.00

Service Code	HCPCS C1776
Hospital Charge Code	270697605
Hospital Revenue Code	278
Min. Negotiated Rate	$1,935.75
Max. Negotiated Rate	$3,123.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,581.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,123.01
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,839.10
Rate for Payer: Qualcare PPO/HMO/WC	$1,935.75

PSN REV ST SP STEM XT 14X135MM

Facility

$12,506.25

Service Code	HCPCS C1776
Hospital Charge Code	270694634
Hospital Revenue Code	278
Min. Negotiated Rate	$1,875.94
Max. Negotiated Rate	$3,026.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,501.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,026.51
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,751.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.94

PSN REV ST SP STEM XT 14X135MM

Facility

$12,506.25

Service Code	HCPCS C1776
Hospital Charge Code	270694634
Hospital Revenue Code	278
Min. Negotiated Rate	$301.40
Max. Negotiated Rate	$6,253.12
Rate for Payer: Aetna Commercial	$4,752.38
Rate for Payer: Aetna Medicare Advantage	$3,751.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,189.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,189.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,501.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,189.09
Rate for Payer: Cigna Commercial	$6,253.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,026.51
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,751.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.94
Rate for Payer: UnitedHealthcare Community & State	$301.40
Rate for Payer: Wellpoint Medicaid Managed Care	$331.42

PSN REV ST SP STEM XT 15X135MM

Facility

$12,506.25

Service Code	HCPCS C1776
Hospital Charge Code	270694629
Hospital Revenue Code	278
Min. Negotiated Rate	$301.40
Max. Negotiated Rate	$6,253.12
Rate for Payer: Aetna Commercial	$4,752.38
Rate for Payer: Aetna Medicare Advantage	$3,751.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,189.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,189.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,501.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,189.09
Rate for Payer: Cigna Commercial	$6,253.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,026.51
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,751.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.94
Rate for Payer: UnitedHealthcare Community & State	$301.40
Rate for Payer: Wellpoint Medicaid Managed Care	$331.42

PSN REV ST SP STEM XT 15X135MM

Facility

$12,506.25

Service Code	HCPCS C1776
Hospital Charge Code	270694629
Hospital Revenue Code	278
Min. Negotiated Rate	$1,875.94
Max. Negotiated Rate	$3,026.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,501.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,026.51
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,751.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.94

PSN REV TIB FIXED CMT SZ E

Facility

$18,486.25

Service Code	HCPCS C1776
Hospital Charge Code	270694636
Hospital Revenue Code	278
Min. Negotiated Rate	$445.52
Max. Negotiated Rate	$9,243.12
Rate for Payer: Aetna Commercial	$7,024.77
Rate for Payer: Aetna Medicare Advantage	$5,545.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,713.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,713.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,697.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,713.99
Rate for Payer: Cigna Commercial	$9,243.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,473.67
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,066.97
Rate for Payer: Qualcare PPO/HMO/WC	$2,772.94
Rate for Payer: UnitedHealthcare Community & State	$445.52
Rate for Payer: Wellpoint Medicaid Managed Care	$489.89

Know your out-of-pocket cost for care.

All Charges