Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

SME 14 FMT STD

Facility

$15,945.85

Hospital Charge Code	270657118
Hospital Revenue Code	278
Min. Negotiated Rate	$384.29
Max. Negotiated Rate	$7,972.93
Rate for Payer: Aetna Commercial	$6,059.42
Rate for Payer: Aetna Medicare Advantage	$4,783.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,066.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,066.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,189.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,066.19
Rate for Payer: Cigna Commercial	$7,972.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,858.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,508.09
Rate for Payer: Qualcare PPO/HMO/WC	$2,391.88
Rate for Payer: UnitedHealthcare Community & State	$384.29
Rate for Payer: Wellpoint Medicaid Managed Care	$422.57

SMEAR FLUORESCENT/ACID STAIN

Facility

$390.00

Service Code	HCPCS 87206
Hospital Charge Code	401087206
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

SMEAR FLUORESCENT/ACID STAIN

Facility

$390.00

Service Code	HCPCS 87206
Hospital Charge Code	401087206
Hospital Revenue Code	306
Min. Negotiated Rate	$4.31
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$14.66
Rate for Payer: Aetna Medicare Advantage	$17.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$19.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$19.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$19.46
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$5.39
Rate for Payer: Clover Medicare Advantage	$5.12
Rate for Payer: EmblemHealth Commercial	$16.17
Rate for Payer: Humana Medicare Advantage	$5.55
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.39
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	$4.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.39
Rate for Payer: Wellcare Medicare Advantage	$5.39
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

SMEAR,FOR OVA& PARASITES

Facility

$127.29

Service Code	HCPCS 87209
Hospital Charge Code	38475079
Hospital Revenue Code	309
Min. Negotiated Rate	$19.09
Max. Negotiated Rate	$19.09
Rate for Payer: Qualcare PPO/HMO/WC	$19.09

SMEAR,FOR OVA& PARASITES

Facility

$127.29

Service Code	HCPCS 87209
Hospital Charge Code	38475079
Hospital Revenue Code	309
Min. Negotiated Rate	$3.37
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	$19.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$64.90
Rate for Payer: Cigna Commercial	$63.65
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	$38.19
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.09
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	$3.37

SMEAR GRAM STAIN-SO

Facility

$103.94

Service Code	HCPCS 87205
Hospital Charge Code	40134469B
Hospital Revenue Code	306
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$11.61
Rate for Payer: Aetna Medicare Advantage	$13.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.41
Rate for Payer: Cigna Commercial	$51.97
Rate for Payer: Cigna Medicare Advantage	$4.27
Rate for Payer: Clover Medicare Advantage	$4.06
Rate for Payer: EmblemHealth Commercial	$12.81
Rate for Payer: Humana Medicare Advantage	$4.40
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4.27
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$31.18
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$15.59
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.27
Rate for Payer: Wellcare Medicare Advantage	$4.27
Rate for Payer: Wellpoint Medicaid Managed Care	$2.75

SMEAR GRAM STAIN-SO

Facility

$149.72

Service Code	HCPCS 87205
Hospital Charge Code	40464556B
Hospital Revenue Code	306
Min. Negotiated Rate	$3.42
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$11.61
Rate for Payer: Aetna Medicare Advantage	$13.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.41
Rate for Payer: Cigna Commercial	$74.86
Rate for Payer: Cigna Medicare Advantage	$4.27
Rate for Payer: Clover Medicare Advantage	$4.06
Rate for Payer: EmblemHealth Commercial	$12.81
Rate for Payer: Humana Medicare Advantage	$4.40
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4.27
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$44.92
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.46
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.27
Rate for Payer: Wellcare Medicare Advantage	$4.27
Rate for Payer: Wellpoint Medicaid Managed Care	$3.97

SMEAR GRAM STAIN-SO

Facility

$149.72

Service Code	HCPCS 87205
Hospital Charge Code	40464556B
Hospital Revenue Code	306
Min. Negotiated Rate	$22.46
Max. Negotiated Rate	$22.46
Rate for Payer: Qualcare PPO/HMO/WC	$22.46

SMEAR GRAM STAIN-SO

Facility

$94.66

Service Code	HCPCS 87205
Hospital Charge Code	4013388B
Hospital Revenue Code	306
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$11.61
Rate for Payer: Aetna Medicare Advantage	$13.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.41
Rate for Payer: Cigna Commercial	$47.33
Rate for Payer: Cigna Medicare Advantage	$4.27
Rate for Payer: Clover Medicare Advantage	$4.06
Rate for Payer: EmblemHealth Commercial	$12.81
Rate for Payer: Humana Medicare Advantage	$4.40
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4.27
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$28.40
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$14.20
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.27
Rate for Payer: Wellcare Medicare Advantage	$4.27
Rate for Payer: Wellpoint Medicaid Managed Care	$2.51

SMEAR GRAM STAIN-SO

Facility

$63.94

Service Code	HCPCS 87205
Hospital Charge Code	40134446C
Hospital Revenue Code	306
Min. Negotiated Rate	$9.59
Max. Negotiated Rate	$9.59
Rate for Payer: Qualcare PPO/HMO/WC	$9.59

SMEAR GRAM STAIN-SO

Facility

$103.94

Service Code	HCPCS 87205
Hospital Charge Code	40134469B
Hospital Revenue Code	306
Min. Negotiated Rate	$15.59
Max. Negotiated Rate	$15.59
Rate for Payer: Qualcare PPO/HMO/WC	$15.59

SMEAR GRAM STAIN-SO

Facility

$63.94

Service Code	HCPCS 87205
Hospital Charge Code	40134446C
Hospital Revenue Code	306
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$11.61
Rate for Payer: Aetna Medicare Advantage	$13.83
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15.41
Rate for Payer: Cigna Commercial	$31.97
Rate for Payer: Cigna Medicare Advantage	$4.27
Rate for Payer: Clover Medicare Advantage	$4.06
Rate for Payer: EmblemHealth Commercial	$12.81
Rate for Payer: Humana Medicare Advantage	$4.40
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4.27
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$19.18
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$9.59
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$3.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.27
Rate for Payer: Wellcare Medicare Advantage	$4.27
Rate for Payer: Wellpoint Medicaid Managed Care	$1.69

SMEAR GRAM STAIN-SO

Facility

$94.66

Service Code	HCPCS 87205
Hospital Charge Code	4013388B
Hospital Revenue Code	306
Min. Negotiated Rate	$14.20
Max. Negotiated Rate	$14.20
Rate for Payer: Qualcare PPO/HMO/WC	$14.20

SM INTESTINE F/U MULT ADD-ON

Facility

$5,100.00

Service Code	HCPCS 74248
Hospital Charge Code	404174248
Hospital Revenue Code	320
Min. Negotiated Rate	$71.24
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,938.00
Rate for Payer: Aetna Medicare Advantage	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,300.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$71.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,300.50
Rate for Payer: Cigna Commercial	$2,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,530.00
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$122.91
Rate for Payer: Wellpoint Medicaid Managed Care	$135.15

SM INTESTINE F/U MULT ADD-ON

Facility

$5,100.00

Service Code	HCPCS 74248
Hospital Charge Code	404174248
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Qualcare PPO/HMO/WC	$765.00

SML BONE FIXATION SYST 1.6MM

Facility

$575.00

Hospital Charge Code	270339447
Hospital Revenue Code	278
Min. Negotiated Rate	$86.25
Max. Negotiated Rate	$139.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$115.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$139.15
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$126.50
Rate for Payer: Qualcare PPO/HMO/WC	$86.25

SML BONE FIXATION SYST 1.6MM

Facility

$575.00

Hospital Charge Code	270339447
Hospital Revenue Code	278
Min. Negotiated Rate	$13.86
Max. Negotiated Rate	$287.50
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare Advantage	$172.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$146.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$146.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$115.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$146.62
Rate for Payer: Cigna Commercial	$287.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$139.15
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$126.50
Rate for Payer: Qualcare PPO/HMO/WC	$86.25
Rate for Payer: UnitedHealthcare Community & State	$13.86
Rate for Payer: Wellpoint Medicaid Managed Care	$15.24

SMN1 COPY NUMBER ANALYSIS

Facility

$200.00

Service Code	HCPCS 81401
Hospital Charge Code	3038122
Hospital Revenue Code	310
Min. Negotiated Rate	$5.30
Max. Negotiated Rate	$494.53
Rate for Payer: Aetna Commercial	$372.64
Rate for Payer: Aetna Medicare Advantage	$443.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$494.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$494.53
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$137.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$494.53
Rate for Payer: Cigna Commercial	$100.00
Rate for Payer: Cigna Medicare Advantage	$137.00
Rate for Payer: Clover Medicare Advantage	$130.15
Rate for Payer: EmblemHealth Commercial	$411.00
Rate for Payer: Humana Medicare Advantage	$141.11
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$137.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$60.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$30.00
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Community & State	$109.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$137.00
Rate for Payer: Wellcare Medicare Advantage	$137.00
Rate for Payer: Wellpoint Medicaid Managed Care	$5.30

SMN1 COPY NUMBER ANALYSIS

Facility

$200.00

Service Code	HCPCS 81401
Hospital Charge Code	3038122
Hospital Revenue Code	310
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$30.00
Rate for Payer: Qualcare PPO/HMO/WC	$30.00

SMOFLIPID 20% FAT EMULS 500ML

Facility

$273.36

Service Code	NDC 63323082050
Hospital Charge Code	606390484
Hospital Revenue Code	250
Min. Negotiated Rate	$41.00
Max. Negotiated Rate	$41.00
Rate for Payer: Qualcare PPO/HMO/WC	$41.00

SMOFLIPID 20% FAT EMULS 500ML

Facility

$273.36

Service Code	NDC 63323082050
Hospital Charge Code	606390484
Hospital Revenue Code	250
Min. Negotiated Rate	$6.59
Max. Negotiated Rate	$136.68
Rate for Payer: Aetna Commercial	$103.88
Rate for Payer: Aetna Medicare Advantage	$82.01
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$69.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$69.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$69.71
Rate for Payer: Cigna Commercial	$136.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$82.01
Rate for Payer: Oxford Commercial	$54.67
Rate for Payer: Qualcare PPO/HMO/WC	$41.00
Rate for Payer: UnitedHealthcare Commercial	$54.67
Rate for Payer: UnitedHealthcare Community & State	$6.59
Rate for Payer: Wellpoint Medicaid Managed Care	$7.24

SMOOTH LOCK PEG 2.2MM X 16MM

Facility

$650.00

Hospital Charge Code	270663847
Hospital Revenue Code	278
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare Advantage	$195.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$165.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$165.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$130.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$165.75
Rate for Payer: Cigna Commercial	$325.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$157.30
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$143.00
Rate for Payer: Qualcare PPO/HMO/WC	$97.50
Rate for Payer: UnitedHealthcare Community & State	$15.66
Rate for Payer: Wellpoint Medicaid Managed Care	$17.23

SMOOTH LOCK PEG 2.2MM X 16MM

Facility

$650.00

Hospital Charge Code	270663847
Hospital Revenue Code	278
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$157.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$130.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$157.30
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$143.00
Rate for Payer: Qualcare PPO/HMO/WC	$97.50

SMOOTH LOCK PEG 2.2MM X 18MM

Facility

$650.00

Hospital Charge Code	270663848
Hospital Revenue Code	278
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$157.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$130.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$157.30
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$143.00
Rate for Payer: Qualcare PPO/HMO/WC	$97.50

SMOOTH LOCK PEG 2.2MM X 18MM

Facility

$650.00

Hospital Charge Code	270663848
Hospital Revenue Code	278
Min. Negotiated Rate	$15.66
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare Advantage	$195.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$165.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$165.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$130.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$165.75
Rate for Payer: Cigna Commercial	$325.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$157.30
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$143.00
Rate for Payer: Qualcare PPO/HMO/WC	$97.50
Rate for Payer: UnitedHealthcare Community & State	$15.66
Rate for Payer: Wellpoint Medicaid Managed Care	$17.23

Know your out-of-pocket cost for care.

All Charges