Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

STENT VIABAHN 35 X 13 MM 10 CM

Facility

$18,760.00

Service Code	HCPCS C1876
Hospital Charge Code	270688211
Hospital Revenue Code	278
Min. Negotiated Rate	$2,814.00
Max. Negotiated Rate	$4,539.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,752.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,539.92
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,127.20
Rate for Payer: Qualcare PPO/HMO/WC	$2,814.00

STENT VIABAHN 35 X 13 MM 10 CM

Facility

$18,760.00

Service Code	HCPCS C1876
Hospital Charge Code	270688211
Hospital Revenue Code	278
Min. Negotiated Rate	$452.12
Max. Negotiated Rate	$9,380.00
Rate for Payer: Aetna Commercial	$7,128.80
Rate for Payer: Aetna Medicare Advantage	$5,628.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,783.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,783.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,752.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,783.80
Rate for Payer: Cigna Commercial	$9,380.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,539.92
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,127.20
Rate for Payer: Qualcare PPO/HMO/WC	$2,814.00
Rate for Payer: UnitedHealthcare Community & State	$452.12
Rate for Payer: Wellpoint Medicaid Managed Care	$497.14

STENT VIABAHN 5MMx10CM 120CM

Facility

$16,760.00

Service Code	HCPCS C1874
Hospital Charge Code	270648635N
Hospital Revenue Code	278
Min. Negotiated Rate	$403.92
Max. Negotiated Rate	$8,380.00
Rate for Payer: Aetna Commercial	$6,368.80
Rate for Payer: Aetna Medicare Advantage	$5,028.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,273.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,273.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,352.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,273.80
Rate for Payer: Cigna Commercial	$8,380.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,055.92
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,687.20
Rate for Payer: Qualcare PPO/HMO/WC	$2,514.00
Rate for Payer: UnitedHealthcare Community & State	$403.92
Rate for Payer: Wellpoint Medicaid Managed Care	$444.14

STENT VIABAHN 5MMx10CM 120CM

Facility

$16,760.00

Service Code	HCPCS C1874
Hospital Charge Code	270648635
Hospital Revenue Code	278
Min. Negotiated Rate	$2,514.00
Max. Negotiated Rate	$4,055.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,352.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,055.92
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,687.20
Rate for Payer: Qualcare PPO/HMO/WC	$2,514.00

STENT VIABAHN 5MMx10CM 120CM

Facility

$16,760.00

Service Code	HCPCS C1874
Hospital Charge Code	270648635N
Hospital Revenue Code	278
Min. Negotiated Rate	$2,514.00
Max. Negotiated Rate	$4,055.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,352.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,055.92
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,687.20
Rate for Payer: Qualcare PPO/HMO/WC	$2,514.00

STENT VIABAHN 5MMx10CM 120CM

Facility

$16,760.00

Service Code	HCPCS C1874
Hospital Charge Code	270648635
Hospital Revenue Code	278
Min. Negotiated Rate	$403.92
Max. Negotiated Rate	$8,380.00
Rate for Payer: Aetna Commercial	$6,368.80
Rate for Payer: Aetna Medicare Advantage	$5,028.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,273.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,273.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,352.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,273.80
Rate for Payer: Cigna Commercial	$8,380.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,055.92
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,687.20
Rate for Payer: Qualcare PPO/HMO/WC	$2,514.00
Rate for Payer: UnitedHealthcare Community & State	$403.92
Rate for Payer: Wellpoint Medicaid Managed Care	$444.14

STENT VIABAHN 5MMX15CMX120CM

Facility

$19,320.00

Service Code	HCPCS C1876
Hospital Charge Code	270648636O
Hospital Revenue Code	278
Min. Negotiated Rate	$2,898.00
Max. Negotiated Rate	$4,675.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,864.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,675.44
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,250.40
Rate for Payer: Qualcare PPO/HMO/WC	$2,898.00

STENT VIABAHN 5MMX15CMX120CM

Facility

$19,320.00

Service Code	HCPCS C1876
Hospital Charge Code	270648636C
Hospital Revenue Code	278
Min. Negotiated Rate	$465.61
Max. Negotiated Rate	$9,660.00
Rate for Payer: Aetna Commercial	$7,341.60
Rate for Payer: Aetna Medicare Advantage	$5,796.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,926.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,926.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,864.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,926.60
Rate for Payer: Cigna Commercial	$9,660.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,675.44
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,250.40
Rate for Payer: Qualcare PPO/HMO/WC	$2,898.00
Rate for Payer: UnitedHealthcare Community & State	$465.61
Rate for Payer: Wellpoint Medicaid Managed Care	$511.98

STENT VIABAHN 5MMX15CMX120CM

Facility

$19,320.00

Service Code	HCPCS C1876
Hospital Charge Code	270648636C
Hospital Revenue Code	278
Min. Negotiated Rate	$2,898.00
Max. Negotiated Rate	$4,675.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,864.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,675.44
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,250.40
Rate for Payer: Qualcare PPO/HMO/WC	$2,898.00

STENT VIABAHN 5MMX15CMX120CM

Facility

$19,320.00

Service Code	HCPCS C1876
Hospital Charge Code	270648636O
Hospital Revenue Code	278
Min. Negotiated Rate	$465.61
Max. Negotiated Rate	$9,660.00
Rate for Payer: Aetna Commercial	$7,341.60
Rate for Payer: Aetna Medicare Advantage	$5,796.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,926.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,926.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,864.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,926.60
Rate for Payer: Cigna Commercial	$9,660.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,675.44
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,250.40
Rate for Payer: Qualcare PPO/HMO/WC	$2,898.00
Rate for Payer: UnitedHealthcare Community & State	$465.61
Rate for Payer: Wellpoint Medicaid Managed Care	$511.98

STENT VIABAHN 6MM 10x120CM

Facility

$17,900.00

Service Code	HCPCS C1876
Hospital Charge Code	270648638N
Hospital Revenue Code	278
Min. Negotiated Rate	$431.39
Max. Negotiated Rate	$8,950.00
Rate for Payer: Aetna Commercial	$6,802.00
Rate for Payer: Aetna Medicare Advantage	$5,370.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,564.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,564.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,580.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,564.50
Rate for Payer: Cigna Commercial	$8,950.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,331.80
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,938.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,685.00
Rate for Payer: UnitedHealthcare Community & State	$431.39
Rate for Payer: Wellpoint Medicaid Managed Care	$474.35

STENT VIABAHN 6MM 10x120CM

Facility

$19,270.00

Service Code	HCPCS C1876
Hospital Charge Code	270648638
Hospital Revenue Code	278
Min. Negotiated Rate	$2,890.50
Max. Negotiated Rate	$4,663.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,854.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,663.34
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,239.40
Rate for Payer: Qualcare PPO/HMO/WC	$2,890.50

STENT VIABAHN 6MM 10x120CM

Facility

$19,270.00

Service Code	HCPCS C1876
Hospital Charge Code	270648638
Hospital Revenue Code	278
Min. Negotiated Rate	$464.41
Max. Negotiated Rate	$9,635.00
Rate for Payer: Aetna Commercial	$7,322.60
Rate for Payer: Aetna Medicare Advantage	$5,781.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,913.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,913.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,854.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,913.85
Rate for Payer: Cigna Commercial	$9,635.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,663.34
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,239.40
Rate for Payer: Qualcare PPO/HMO/WC	$2,890.50
Rate for Payer: UnitedHealthcare Community & State	$464.41
Rate for Payer: Wellpoint Medicaid Managed Care	$510.65

STENT VIABAHN 6MM 10x120CM

Facility

$17,900.00

Service Code	HCPCS C1876
Hospital Charge Code	270648638N
Hospital Revenue Code	278
Min. Negotiated Rate	$2,685.00
Max. Negotiated Rate	$4,331.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,580.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,331.80
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,938.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,685.00

STENT VIABAHN 6MM 15x120CM

Facility

$19,950.00

Service Code	HCPCS C1876
Hospital Charge Code	270648639N
Hospital Revenue Code	278
Min. Negotiated Rate	$480.80
Max. Negotiated Rate	$9,975.00
Rate for Payer: Aetna Commercial	$7,581.00
Rate for Payer: Aetna Medicare Advantage	$5,985.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,087.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,087.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,990.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,087.25
Rate for Payer: Cigna Commercial	$9,975.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,827.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,389.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,992.50
Rate for Payer: UnitedHealthcare Community & State	$480.80
Rate for Payer: Wellpoint Medicaid Managed Care	$528.67

STENT VIABAHN 6MM 15x120CM

Facility

$20,950.00

Service Code	HCPCS C1876
Hospital Charge Code	270648639
Hospital Revenue Code	278
Min. Negotiated Rate	$3,142.50
Max. Negotiated Rate	$5,069.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,190.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,069.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,609.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,142.50

STENT VIABAHN 6MM 15x120CM

Facility

$20,950.00

Service Code	HCPCS C1876
Hospital Charge Code	270648639
Hospital Revenue Code	278
Min. Negotiated Rate	$504.89
Max. Negotiated Rate	$10,475.00
Rate for Payer: Aetna Commercial	$7,961.00
Rate for Payer: Aetna Medicare Advantage	$6,285.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,342.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,342.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,190.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,342.25
Rate for Payer: Cigna Commercial	$10,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,069.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,609.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,142.50
Rate for Payer: UnitedHealthcare Community & State	$504.89
Rate for Payer: Wellpoint Medicaid Managed Care	$555.17

STENT VIABAHN 6MM 15x120CM

Facility

$19,950.00

Service Code	HCPCS C1876
Hospital Charge Code	270648639N
Hospital Revenue Code	278
Min. Negotiated Rate	$2,992.50
Max. Negotiated Rate	$4,827.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,990.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,827.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,389.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,992.50

STENT VIABAHN 6MMX5CMX120CM

Facility

$20,950.00

Service Code	HCPCS C1876
Hospital Charge Code	270648639C
Hospital Revenue Code	278
Min. Negotiated Rate	$504.89
Max. Negotiated Rate	$10,475.00
Rate for Payer: Aetna Commercial	$7,961.00
Rate for Payer: Aetna Medicare Advantage	$6,285.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,342.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,342.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,190.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,342.25
Rate for Payer: Cigna Commercial	$10,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,069.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,609.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,142.50
Rate for Payer: UnitedHealthcare Community & State	$504.89
Rate for Payer: Wellpoint Medicaid Managed Care	$555.17

STENT VIABAHN 6MMX5CMX120CM

Facility

$20,950.00

Service Code	HCPCS C1876
Hospital Charge Code	270648639C
Hospital Revenue Code	278
Min. Negotiated Rate	$3,142.50
Max. Negotiated Rate	$5,069.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,190.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,069.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,609.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,142.50

STENT VIABAHN 7FR 6X10 120CM

Facility

$24,242.84

Hospital Charge Code	270639501C
Hospital Revenue Code	278
Min. Negotiated Rate	$584.25
Max. Negotiated Rate	$12,121.42
Rate for Payer: Aetna Commercial	$9,212.28
Rate for Payer: Aetna Medicare Advantage	$7,272.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,181.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,181.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,848.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,181.92
Rate for Payer: Cigna Commercial	$12,121.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,866.77
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,333.42
Rate for Payer: Qualcare PPO/HMO/WC	$3,636.43
Rate for Payer: UnitedHealthcare Community & State	$584.25
Rate for Payer: Wellpoint Medicaid Managed Care	$642.44

STENT VIABAHN 7FR 6X10 120CM

Facility

$24,242.84

Hospital Charge Code	270639501C
Hospital Revenue Code	278
Min. Negotiated Rate	$3,636.43
Max. Negotiated Rate	$5,866.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,848.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,866.77
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,333.42
Rate for Payer: Qualcare PPO/HMO/WC	$3,636.43

STENT VIABAHN 7FR VBJ071002

Facility

$18,350.00

Service Code	HCPCS C1876
Hospital Charge Code	270647585C
Hospital Revenue Code	278
Min. Negotiated Rate	$442.24
Max. Negotiated Rate	$9,175.00
Rate for Payer: Aetna Commercial	$6,973.00
Rate for Payer: Aetna Medicare Advantage	$5,505.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,679.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,679.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,670.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,679.25
Rate for Payer: Cigna Commercial	$9,175.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,440.70
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,037.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,752.50
Rate for Payer: UnitedHealthcare Community & State	$442.24
Rate for Payer: Wellpoint Medicaid Managed Care	$486.27

STENT VIABAHN 7FR VBJ071002

Facility

$18,350.00

Service Code	HCPCS C1876
Hospital Charge Code	270647585C
Hospital Revenue Code	278
Min. Negotiated Rate	$2,752.50
Max. Negotiated Rate	$4,440.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,670.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,440.70
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,037.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,752.50

STENT VIABAHN 7MM X 29 MM

Facility

$16,680.00

Service Code	HCPCS C1876
Hospital Charge Code	270682404S
Hospital Revenue Code	278
Min. Negotiated Rate	$401.99
Max. Negotiated Rate	$8,340.00
Rate for Payer: Aetna Commercial	$6,338.40
Rate for Payer: Aetna Medicare Advantage	$5,004.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,253.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,253.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,336.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,253.40
Rate for Payer: Cigna Commercial	$8,340.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,036.56
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,669.60
Rate for Payer: Qualcare PPO/HMO/WC	$2,502.00
Rate for Payer: UnitedHealthcare Community & State	$401.99
Rate for Payer: Wellpoint Medicaid Managed Care	$442.02

Know your out-of-pocket cost for care.

All Charges