Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

STENT RESOLUTE ONYX 3.50 x 38

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682680
Hospital Revenue Code	278
Min. Negotiated Rate	$768.75
Max. Negotiated Rate	$1,240.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75

STENT RESOLUTE ONYX 3.50 x 38

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682680
Hospital Revenue Code	278
Min. Negotiated Rate	$123.51
Max. Negotiated Rate	$2,562.50
Rate for Payer: Aetna Commercial	$1,947.50
Rate for Payer: Aetna Medicare Advantage	$1,537.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,306.88
Rate for Payer: Cigna Commercial	$2,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75
Rate for Payer: UnitedHealthcare Community & State	$123.51
Rate for Payer: Wellpoint Medicaid Managed Care	$135.81

STENT RESOLUTE ONYX 4.00 x 08

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682681
Hospital Revenue Code	278
Min. Negotiated Rate	$123.51
Max. Negotiated Rate	$2,562.50
Rate for Payer: Aetna Commercial	$1,947.50
Rate for Payer: Aetna Medicare Advantage	$1,537.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,306.88
Rate for Payer: Cigna Commercial	$2,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75
Rate for Payer: UnitedHealthcare Community & State	$123.51
Rate for Payer: Wellpoint Medicaid Managed Care	$135.81

STENT RESOLUTE ONYX 4.00 x 08

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682681
Hospital Revenue Code	278
Min. Negotiated Rate	$768.75
Max. Negotiated Rate	$1,240.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75

STENT RESOLUTE ONYX 4.00 x 12

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682682
Hospital Revenue Code	278
Min. Negotiated Rate	$768.75
Max. Negotiated Rate	$1,240.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75

STENT RESOLUTE ONYX 4.00 x 12

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682682
Hospital Revenue Code	278
Min. Negotiated Rate	$123.51
Max. Negotiated Rate	$2,562.50
Rate for Payer: Aetna Commercial	$1,947.50
Rate for Payer: Aetna Medicare Advantage	$1,537.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,306.88
Rate for Payer: Cigna Commercial	$2,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75
Rate for Payer: UnitedHealthcare Community & State	$123.51
Rate for Payer: Wellpoint Medicaid Managed Care	$135.81

STENT RESOLUTE ONYX 4.00 x 15

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682683
Hospital Revenue Code	278
Min. Negotiated Rate	$768.75
Max. Negotiated Rate	$1,240.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75

STENT RESOLUTE ONYX 4.00 x 15

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682683
Hospital Revenue Code	278
Min. Negotiated Rate	$123.51
Max. Negotiated Rate	$2,562.50
Rate for Payer: Aetna Commercial	$1,947.50
Rate for Payer: Aetna Medicare Advantage	$1,537.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,306.88
Rate for Payer: Cigna Commercial	$2,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75
Rate for Payer: UnitedHealthcare Community & State	$123.51
Rate for Payer: Wellpoint Medicaid Managed Care	$135.81

STENT RESOLUTE ONYX 4.00 x 18

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682684
Hospital Revenue Code	278
Min. Negotiated Rate	$768.75
Max. Negotiated Rate	$1,240.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75

STENT RESOLUTE ONYX 4.00 x 18

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682684
Hospital Revenue Code	278
Min. Negotiated Rate	$123.51
Max. Negotiated Rate	$2,562.50
Rate for Payer: Aetna Commercial	$1,947.50
Rate for Payer: Aetna Medicare Advantage	$1,537.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,306.88
Rate for Payer: Cigna Commercial	$2,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75
Rate for Payer: UnitedHealthcare Community & State	$123.51
Rate for Payer: Wellpoint Medicaid Managed Care	$135.81

STENT RESOLUTE ONYX 4.00 x 22

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682685
Hospital Revenue Code	278
Min. Negotiated Rate	$123.51
Max. Negotiated Rate	$2,562.50
Rate for Payer: Aetna Commercial	$1,947.50
Rate for Payer: Aetna Medicare Advantage	$1,537.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,306.88
Rate for Payer: Cigna Commercial	$2,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75
Rate for Payer: UnitedHealthcare Community & State	$123.51
Rate for Payer: Wellpoint Medicaid Managed Care	$135.81

STENT RESOLUTE ONYX 4.00 x 22

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682685
Hospital Revenue Code	278
Min. Negotiated Rate	$768.75
Max. Negotiated Rate	$1,240.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75

STENT RESOLUTE ONYX 4.00 x 26

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682686
Hospital Revenue Code	278
Min. Negotiated Rate	$768.75
Max. Negotiated Rate	$1,240.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75

STENT RESOLUTE ONYX 4.00 x 26

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682686
Hospital Revenue Code	278
Min. Negotiated Rate	$123.51
Max. Negotiated Rate	$2,562.50
Rate for Payer: Aetna Commercial	$1,947.50
Rate for Payer: Aetna Medicare Advantage	$1,537.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,306.88
Rate for Payer: Cigna Commercial	$2,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75
Rate for Payer: UnitedHealthcare Community & State	$123.51
Rate for Payer: Wellpoint Medicaid Managed Care	$135.81

STENT RESOLUTE ONYX 4.00 x 30

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682687
Hospital Revenue Code	278
Min. Negotiated Rate	$768.75
Max. Negotiated Rate	$1,240.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75

STENT RESOLUTE ONYX 4.00 x 30

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682687
Hospital Revenue Code	278
Min. Negotiated Rate	$123.51
Max. Negotiated Rate	$2,562.50
Rate for Payer: Aetna Commercial	$1,947.50
Rate for Payer: Aetna Medicare Advantage	$1,537.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,306.88
Rate for Payer: Cigna Commercial	$2,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75
Rate for Payer: UnitedHealthcare Community & State	$123.51
Rate for Payer: Wellpoint Medicaid Managed Care	$135.81

STENT RESOLUTE ONYX 4.00 x 34

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682688
Hospital Revenue Code	278
Min. Negotiated Rate	$768.75
Max. Negotiated Rate	$1,240.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75

STENT RESOLUTE ONYX 4.00 x 34

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682688
Hospital Revenue Code	278
Min. Negotiated Rate	$123.51
Max. Negotiated Rate	$2,562.50
Rate for Payer: Aetna Commercial	$1,947.50
Rate for Payer: Aetna Medicare Advantage	$1,537.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,306.88
Rate for Payer: Cigna Commercial	$2,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75
Rate for Payer: UnitedHealthcare Community & State	$123.51
Rate for Payer: Wellpoint Medicaid Managed Care	$135.81

STENT RESOLUTE ONYX 4.00 x 38

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682689
Hospital Revenue Code	278
Min. Negotiated Rate	$123.51
Max. Negotiated Rate	$2,562.50
Rate for Payer: Aetna Commercial	$1,947.50
Rate for Payer: Aetna Medicare Advantage	$1,537.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,306.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,306.88
Rate for Payer: Cigna Commercial	$2,562.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75
Rate for Payer: UnitedHealthcare Community & State	$123.51
Rate for Payer: Wellpoint Medicaid Managed Care	$135.81

STENT RESOLUTE ONYX 4.00 x 38

Facility

$5,125.00

Service Code	HCPCS C1874
Hospital Charge Code	270682689
Hospital Revenue Code	278
Min. Negotiated Rate	$768.75
Max. Negotiated Rate	$1,240.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,025.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,240.25
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,127.50
Rate for Payer: Qualcare PPO/HMO/WC	$768.75

STENT RESOLUTE ONYX 4.50 x 12

Facility

$5,500.00

Service Code	HCPCS C1874
Hospital Charge Code	270682690
Hospital Revenue Code	278
Min. Negotiated Rate	$132.55
Max. Negotiated Rate	$2,750.00
Rate for Payer: Aetna Commercial	$2,090.00
Rate for Payer: Aetna Medicare Advantage	$1,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,402.50
Rate for Payer: Cigna Commercial	$2,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00
Rate for Payer: UnitedHealthcare Community & State	$132.55
Rate for Payer: Wellpoint Medicaid Managed Care	$145.75

STENT RESOLUTE ONYX 4.50 x 12

Facility

$5,500.00

Service Code	HCPCS C1874
Hospital Charge Code	270682690
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,331.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00

STENT RESOLUTE ONYX 4.50 x 15

Facility

$5,500.00

Service Code	HCPCS C1874
Hospital Charge Code	270682691
Hospital Revenue Code	278
Min. Negotiated Rate	$132.55
Max. Negotiated Rate	$2,750.00
Rate for Payer: Aetna Commercial	$2,090.00
Rate for Payer: Aetna Medicare Advantage	$1,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,402.50
Rate for Payer: Cigna Commercial	$2,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00
Rate for Payer: UnitedHealthcare Community & State	$132.55
Rate for Payer: Wellpoint Medicaid Managed Care	$145.75

STENT RESOLUTE ONYX 4.50 x 15

Facility

$5,500.00

Service Code	HCPCS C1874
Hospital Charge Code	270682691
Hospital Revenue Code	278
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$1,331.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00

STENT RESOLUTE ONYX 4.50 x 18

Facility

$5,500.00

Service Code	HCPCS C1874
Hospital Charge Code	270682692
Hospital Revenue Code	278
Min. Negotiated Rate	$132.55
Max. Negotiated Rate	$2,750.00
Rate for Payer: Aetna Commercial	$2,090.00
Rate for Payer: Aetna Medicare Advantage	$1,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,402.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,402.50
Rate for Payer: Cigna Commercial	$2,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,331.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,210.00
Rate for Payer: Qualcare PPO/HMO/WC	$825.00
Rate for Payer: UnitedHealthcare Community & State	$132.55
Rate for Payer: Wellpoint Medicaid Managed Care	$145.75

Know your out-of-pocket cost for care.

All Charges