Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

SPACERALTERA10X31 10 14MM15DEG

Facility

$32,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270694881
Hospital Revenue Code	278
Min. Negotiated Rate	$771.20
Max. Negotiated Rate	$16,000.00
Rate for Payer: Aetna Commercial	$12,160.00
Rate for Payer: Aetna Medicare Advantage	$9,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,160.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,160.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,160.00
Rate for Payer: Cigna Commercial	$16,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,744.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,040.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,800.00
Rate for Payer: UnitedHealthcare Community & State	$771.20
Rate for Payer: Wellpoint Medicaid Managed Care	$848.00

SPACER ALTERA 10X31 12-16MM15D

Facility

$32,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270695755
Hospital Revenue Code	278
Min. Negotiated Rate	$771.20
Max. Negotiated Rate	$16,000.00
Rate for Payer: Aetna Commercial	$12,160.00
Rate for Payer: Aetna Medicare Advantage	$9,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,160.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,160.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,160.00
Rate for Payer: Cigna Commercial	$16,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,744.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,040.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,800.00
Rate for Payer: UnitedHealthcare Community & State	$771.20
Rate for Payer: Wellpoint Medicaid Managed Care	$848.00

SPACER ALTERA 10X31 12-16MM15D

Facility

$32,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270695755
Hospital Revenue Code	278
Min. Negotiated Rate	$4,800.00
Max. Negotiated Rate	$7,744.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,744.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,040.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,800.00

SPACER ALTERA 10X31 8-12MM 8D

Facility

$32,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270697430
Hospital Revenue Code	278
Min. Negotiated Rate	$771.20
Max. Negotiated Rate	$16,000.00
Rate for Payer: Aetna Commercial	$12,160.00
Rate for Payer: Aetna Medicare Advantage	$9,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,160.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,160.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,160.00
Rate for Payer: Cigna Commercial	$16,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,744.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,040.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,800.00
Rate for Payer: UnitedHealthcare Community & State	$771.20
Rate for Payer: Wellpoint Medicaid Managed Care	$848.00

SPACER ALTERA 10X31 8-12MM 8D

Facility

$32,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270697430
Hospital Revenue Code	278
Min. Negotiated Rate	$4,800.00
Max. Negotiated Rate	$7,744.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,744.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,040.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,800.00

SPACER ALTERA 10X31MM

Facility

$32,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270692200
Hospital Revenue Code	278
Min. Negotiated Rate	$771.20
Max. Negotiated Rate	$16,000.00
Rate for Payer: Aetna Commercial	$12,160.00
Rate for Payer: Aetna Medicare Advantage	$9,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,160.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,160.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,160.00
Rate for Payer: Cigna Commercial	$16,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,744.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,040.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,800.00
Rate for Payer: UnitedHealthcare Community & State	$771.20
Rate for Payer: Wellpoint Medicaid Managed Care	$848.00

SPACER ALTERA 10X31MM

Facility

$32,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270692200
Hospital Revenue Code	278
Min. Negotiated Rate	$4,800.00
Max. Negotiated Rate	$7,744.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,744.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,040.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,800.00

SPACER ALTER LORDOT 8D10X26MM

Facility

$32,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270695397
Hospital Revenue Code	278
Min. Negotiated Rate	$4,800.00
Max. Negotiated Rate	$7,744.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,744.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,040.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,800.00

SPACER ALTER LORDOT 8D10X26MM

Facility

$32,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270695397
Hospital Revenue Code	278
Min. Negotiated Rate	$771.20
Max. Negotiated Rate	$16,000.00
Rate for Payer: Aetna Commercial	$12,160.00
Rate for Payer: Aetna Medicare Advantage	$9,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,160.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,160.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,160.00
Rate for Payer: Cigna Commercial	$16,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,744.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,040.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,800.00
Rate for Payer: UnitedHealthcare Community & State	$771.20
Rate for Payer: Wellpoint Medicaid Managed Care	$848.00

SPACER ANT CERV 12X14X6MM 6D

Facility

$24,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270695486
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

SPACER ANT CERV 12X14X6MM 6D

Facility

$24,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270695486
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

SPACER BLACKHAWK 14X12X6MM 7H

Facility

$23,750.00

Service Code	HCPCS C1889
Hospital Charge Code	270696317
Hospital Revenue Code	278
Min. Negotiated Rate	$572.38
Max. Negotiated Rate	$11,875.00
Rate for Payer: Aetna Commercial	$9,025.00
Rate for Payer: Aetna Medicare Advantage	$7,125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,056.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,056.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,056.25
Rate for Payer: Cigna Commercial	$11,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,747.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,225.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,562.50
Rate for Payer: UnitedHealthcare Community & State	$572.38
Rate for Payer: Wellpoint Medicaid Managed Care	$629.38

SPACER BLACKHAWK 14X12X6MM 7H

Facility

$23,750.00

Service Code	HCPCS C1889
Hospital Charge Code	270696317
Hospital Revenue Code	278
Min. Negotiated Rate	$3,562.50
Max. Negotiated Rate	$5,747.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,747.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,225.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,562.50

SPACER BLACKHAWK TI 14X12X6MM

Facility

$23,750.00

Service Code	HCPCS C1889
Hospital Charge Code	270693531
Hospital Revenue Code	278
Min. Negotiated Rate	$3,562.50
Max. Negotiated Rate	$5,747.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,747.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,225.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,562.50

SPACER BLACKHAWK TI 14X12X6MM

Facility

$23,750.00

Service Code	HCPCS C1889
Hospital Charge Code	270693531
Hospital Revenue Code	278
Min. Negotiated Rate	$572.38
Max. Negotiated Rate	$11,875.00
Rate for Payer: Aetna Commercial	$9,025.00
Rate for Payer: Aetna Medicare Advantage	$7,125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,056.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,056.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,056.25
Rate for Payer: Cigna Commercial	$11,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,747.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,225.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,562.50
Rate for Payer: UnitedHealthcare Community & State	$572.38
Rate for Payer: Wellpoint Medicaid Managed Care	$629.38

SPACER BLACKHAWK TI 14X12X7D

Facility

$23,750.00

Service Code	HCPCS C1889
Hospital Charge Code	270699091
Hospital Revenue Code	278
Min. Negotiated Rate	$3,562.50
Max. Negotiated Rate	$5,747.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,747.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,225.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,562.50

SPACER BLACKHAWK TI 14X12X7D

Facility

$23,750.00

Service Code	HCPCS C1889
Hospital Charge Code	270699091
Hospital Revenue Code	278
Min. Negotiated Rate	$572.38
Max. Negotiated Rate	$11,875.00
Rate for Payer: Aetna Commercial	$9,025.00
Rate for Payer: Aetna Medicare Advantage	$7,125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,056.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,056.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,056.25
Rate for Payer: Cigna Commercial	$11,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,747.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,225.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,562.50
Rate for Payer: UnitedHealthcare Community & State	$572.38
Rate for Payer: Wellpoint Medicaid Managed Care	$629.38

SPACER, CALIBRATE LTX 6X18X50M

Facility

$47,734.40

Hospital Charge Code	270702577
Hospital Revenue Code	278
Min. Negotiated Rate	$1,150.40
Max. Negotiated Rate	$23,867.20
Rate for Payer: Aetna Commercial	$18,139.07
Rate for Payer: Aetna Medicare Advantage	$14,320.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12,172.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12,172.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9,546.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12,172.27
Rate for Payer: Cigna Commercial	$23,867.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11,551.72
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$10,501.57
Rate for Payer: Qualcare PPO/HMO/WC	$7,160.16
Rate for Payer: UnitedHealthcare Community & State	$1,150.40
Rate for Payer: Wellpoint Medicaid Managed Care	$1,264.96

SPACER, CALIBRATE LTX 6X18X50M

Facility

$47,734.40

Hospital Charge Code	270702577
Hospital Revenue Code	278
Min. Negotiated Rate	$7,160.16
Max. Negotiated Rate	$11,551.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9,546.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11,551.72
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$10,501.57
Rate for Payer: Qualcare PPO/HMO/WC	$7,160.16

SPACER CAPSTONE 22X10MM

Facility

$26,030.00

Service Code	HCPCS C1889
Hospital Charge Code	270697028
Hospital Revenue Code	278
Min. Negotiated Rate	$627.32
Max. Negotiated Rate	$13,015.00
Rate for Payer: Aetna Commercial	$9,891.40
Rate for Payer: Aetna Medicare Advantage	$7,809.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,637.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,637.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,206.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,637.65
Rate for Payer: Cigna Commercial	$13,015.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,299.26
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,726.60
Rate for Payer: Qualcare PPO/HMO/WC	$3,904.50
Rate for Payer: UnitedHealthcare Community & State	$627.32
Rate for Payer: Wellpoint Medicaid Managed Care	$689.79

SPACER CAPSTONE 22X10MM

Facility

$26,030.00

Service Code	HCPCS C1889
Hospital Charge Code	270697028
Hospital Revenue Code	278
Min. Negotiated Rate	$3,904.50
Max. Negotiated Rate	$6,299.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,206.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,299.26
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,726.60
Rate for Payer: Qualcare PPO/HMO/WC	$3,904.50

SPACER CAPSTONE 26X10MM

Facility

$26,030.00

Service Code	HCPCS C1889
Hospital Charge Code	270697040
Hospital Revenue Code	278
Min. Negotiated Rate	$3,904.50
Max. Negotiated Rate	$6,299.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,206.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,299.26
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,726.60
Rate for Payer: Qualcare PPO/HMO/WC	$3,904.50

SPACER CAPSTONE 26X10MM

Facility

$26,030.00

Service Code	HCPCS C1889
Hospital Charge Code	270697040
Hospital Revenue Code	278
Min. Negotiated Rate	$627.32
Max. Negotiated Rate	$13,015.00
Rate for Payer: Aetna Commercial	$9,891.40
Rate for Payer: Aetna Medicare Advantage	$7,809.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,637.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,637.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,206.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,637.65
Rate for Payer: Cigna Commercial	$13,015.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,299.26
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,726.60
Rate for Payer: Qualcare PPO/HMO/WC	$3,904.50
Rate for Payer: UnitedHealthcare Community & State	$627.32
Rate for Payer: Wellpoint Medicaid Managed Care	$689.79

SPACER CAPSTONE 26X9MM

Facility

$35,190.00

Service Code	HCPCS C1889
Hospital Charge Code	270696521
Hospital Revenue Code	278
Min. Negotiated Rate	$5,278.50
Max. Negotiated Rate	$8,515.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,038.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8,515.98
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,741.80
Rate for Payer: Qualcare PPO/HMO/WC	$5,278.50

SPACER CAPSTONE 26X9MM

Facility

$35,190.00

Service Code	HCPCS C1889
Hospital Charge Code	270696521
Hospital Revenue Code	278
Min. Negotiated Rate	$848.08
Max. Negotiated Rate	$17,595.00
Rate for Payer: Aetna Commercial	$13,372.20
Rate for Payer: Aetna Medicare Advantage	$10,557.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,973.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,973.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,038.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,973.45
Rate for Payer: Cigna Commercial	$17,595.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8,515.98
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,741.80
Rate for Payer: Qualcare PPO/HMO/WC	$5,278.50
Rate for Payer: UnitedHealthcare Community & State	$848.08
Rate for Payer: Wellpoint Medicaid Managed Care	$932.53

Know your out-of-pocket cost for care.

All Charges