Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

THEOPHYLLINE TAB SR 600MG

Facility

$8.35

Hospital Charge Code	60628720
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$4.17
Rate for Payer: Aetna Commercial	$3.17
Rate for Payer: Aetna Medicare Advantage	$2.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.13
Rate for Payer: Cigna Commercial	$4.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.50
Rate for Payer: Oxford Commercial	$1.67
Rate for Payer: Qualcare PPO/HMO/WC	$1.25
Rate for Payer: UnitedHealthcare Commercial	$1.67
Rate for Payer: UnitedHealthcare Community & State	$0.20
Rate for Payer: Wellpoint Medicaid Managed Care	$0.22

THERABAND BLUE EXTRA HEAVY

Facility

$608.85

Hospital Charge Code	270609834
Hospital Revenue Code	270
Min. Negotiated Rate	$14.67
Max. Negotiated Rate	$304.43
Rate for Payer: Aetna Commercial	$231.36
Rate for Payer: Aetna Medicare Advantage	$182.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$155.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$155.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$155.26
Rate for Payer: Cigna Commercial	$304.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$182.66
Rate for Payer: Oxford Commercial	$121.77
Rate for Payer: Qualcare PPO/HMO/WC	$91.33
Rate for Payer: UnitedHealthcare Commercial	$121.77
Rate for Payer: UnitedHealthcare Community & State	$14.67
Rate for Payer: Wellpoint Medicaid Managed Care	$16.13

THERABAND BLUE EXTRA HEAVY

Facility

$608.85

Hospital Charge Code	270609834
Hospital Revenue Code	270
Min. Negotiated Rate	$91.33
Max. Negotiated Rate	$91.33
Rate for Payer: Qualcare PPO/HMO/WC	$91.33

THERABAND GREEN HEAVY A521-3

Facility

$571.25

Hospital Charge Code	270608153
Hospital Revenue Code	270
Min. Negotiated Rate	$85.69
Max. Negotiated Rate	$85.69
Rate for Payer: Qualcare PPO/HMO/WC	$85.69

THERABAND GREEN HEAVY A521-3

Facility

$571.25

Hospital Charge Code	270608153
Hospital Revenue Code	270
Min. Negotiated Rate	$13.77
Max. Negotiated Rate	$285.62
Rate for Payer: Aetna Commercial	$217.07
Rate for Payer: Aetna Medicare Advantage	$171.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$145.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$145.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$145.67
Rate for Payer: Cigna Commercial	$285.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$171.38
Rate for Payer: Oxford Commercial	$114.25
Rate for Payer: Qualcare PPO/HMO/WC	$85.69
Rate for Payer: UnitedHealthcare Commercial	$114.25
Rate for Payer: UnitedHealthcare Community & State	$13.77
Rate for Payer: Wellpoint Medicaid Managed Care	$15.14

THERABAND RED 50YD ROLL A521-2

Facility

$405.65

Hospital Charge Code	270612322
Hospital Revenue Code	270
Min. Negotiated Rate	$60.85
Max. Negotiated Rate	$60.85
Rate for Payer: Qualcare PPO/HMO/WC	$60.85

THERABAND RED 50YD ROLL A521-2

Facility

$405.65

Hospital Charge Code	270612322
Hospital Revenue Code	270
Min. Negotiated Rate	$9.78
Max. Negotiated Rate	$202.82
Rate for Payer: Aetna Commercial	$154.15
Rate for Payer: Aetna Medicare Advantage	$121.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$103.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$103.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$103.44
Rate for Payer: Cigna Commercial	$202.82
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$121.69
Rate for Payer: Oxford Commercial	$81.13
Rate for Payer: Qualcare PPO/HMO/WC	$60.85
Rate for Payer: UnitedHealthcare Commercial	$81.13
Rate for Payer: UnitedHealthcare Community & State	$9.78
Rate for Payer: Wellpoint Medicaid Managed Care	$10.75

THERABAND RED MEDIUM A521-2

Facility

$540.00

Hospital Charge Code	270608154
Hospital Revenue Code	270
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$205.20
Rate for Payer: Aetna Medicare Advantage	$162.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$137.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$137.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$137.70
Rate for Payer: Cigna Commercial	$270.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$162.00
Rate for Payer: Oxford Commercial	$108.00
Rate for Payer: Qualcare PPO/HMO/WC	$81.00
Rate for Payer: UnitedHealthcare Commercial	$108.00
Rate for Payer: UnitedHealthcare Community & State	$13.01
Rate for Payer: Wellpoint Medicaid Managed Care	$14.31

THERABAND RED MEDIUM A521-2

Facility

$540.00

Hospital Charge Code	270608154
Hospital Revenue Code	270
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$81.00
Rate for Payer: Qualcare PPO/HMO/WC	$81.00

THERABAND YELLOW THIN A521-1

Facility

$500.85

Hospital Charge Code	270609831
Hospital Revenue Code	270
Min. Negotiated Rate	$75.13
Max. Negotiated Rate	$75.13
Rate for Payer: Qualcare PPO/HMO/WC	$75.13

THERABAND YELLOW THIN A521-1

Facility

$500.85

Hospital Charge Code	270609831
Hospital Revenue Code	270
Min. Negotiated Rate	$12.07
Max. Negotiated Rate	$250.43
Rate for Payer: Aetna Commercial	$190.32
Rate for Payer: Aetna Medicare Advantage	$150.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$127.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$127.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$127.72
Rate for Payer: Cigna Commercial	$250.43
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$150.25
Rate for Payer: Oxford Commercial	$100.17
Rate for Payer: Qualcare PPO/HMO/WC	$75.13
Rate for Payer: UnitedHealthcare Commercial	$100.17
Rate for Payer: UnitedHealthcare Community & State	$12.07
Rate for Payer: Wellpoint Medicaid Managed Care	$13.27

THER ACTIVITY & TRAINING 1/4 H

Facility

$434.00

Service Code	HCPCS 97110GO
Hospital Charge Code	1008210
Hospital Revenue Code	430
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$65.10
Rate for Payer: Qualcare PPO/HMO/WC	$65.10

THER ACTIVITY & TRAINING 1/4 H

Facility

$434.00

Service Code	HCPCS 97110GO
Hospital Charge Code	1008210
Hospital Revenue Code	430
Min. Negotiated Rate	$10.46
Max. Negotiated Rate	$1,060.00
Rate for Payer: Aetna Commercial	$164.92
Rate for Payer: Aetna Medicare Advantage	$130.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$110.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$110.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$116.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$110.67
Rate for Payer: Cigna Commercial	$217.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$130.20
Rate for Payer: Oxford Commercial	$604.00
Rate for Payer: Qualcare PPO/HMO/WC	$65.10
Rate for Payer: UnitedHealthcare Commercial	$1,060.00
Rate for Payer: UnitedHealthcare Community & State	$10.46
Rate for Payer: Wellpoint Medicaid Managed Care	$11.50

THERAGENEMESHBILAMATRIX82X60MM

Facility

$11,000.00

Service Code	HCPCS A2008
Hospital Charge Code	270694227
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$2,662.00
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,662.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,420.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,650.00
Rate for Payer: UnitedHealthcare Community & State	$265.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$291.50

THERAGENEMESHBILAMATRIX82X60MM

Facility

$11,000.00

Service Code	HCPCS A2008
Hospital Charge Code	270694227
Hospital Revenue Code	278
Min. Negotiated Rate	$1,650.00
Max. Negotiated Rate	$2,662.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,662.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,420.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,650.00

THERAGENESISBILAMATRIX82X120MM

Facility

$12,500.00

Service Code	HCPCS A2008
Hospital Charge Code	270694313
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$3,025.00
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,025.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,750.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.00
Rate for Payer: UnitedHealthcare Community & State	$301.25
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$331.25

THERAGENESISBILAMATRIX82X120MM

Facility

$12,500.00

Service Code	HCPCS A2008
Hospital Charge Code	270694313
Hospital Revenue Code	278
Min. Negotiated Rate	$1,875.00
Max. Negotiated Rate	$3,025.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,025.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,750.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,875.00

THERAGENESISBILAYMATRIX40X60MM

Facility

$7,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270694307
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$1,875.50
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,550.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,875.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,705.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,162.50
Rate for Payer: UnitedHealthcare Community & State	$186.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$205.38

THERAGENESISBILAYMATRIX40X60MM

Facility

$7,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270694307
Hospital Revenue Code	278
Min. Negotiated Rate	$1,162.50
Max. Negotiated Rate	$1,875.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,550.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,875.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,705.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,162.50

THERAGENESIS BILAYMATRIX 4X6CM

Facility

$8,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270695638
Hospital Revenue Code	278
Min. Negotiated Rate	$1,312.50
Max. Negotiated Rate	$2,117.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,117.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,925.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,312.50

THERAGENESIS BILAYMATRIX 4X6CM

Facility

$8,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270695638
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$2,117.50
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,750.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,117.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,925.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,312.50
Rate for Payer: UnitedHealthcare Community & State	$210.88
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$231.88

THERAGENESISBILAYMATRIX82X60MM

Facility

$10,000.00

Service Code	HCPCS A2008
Hospital Charge Code	270694172
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$2,420.00
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,420.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,200.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,500.00
Rate for Payer: UnitedHealthcare Community & State	$241.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$265.00

THERAGENESISBILAYMATRIX82X60MM

Facility

$10,000.00

Service Code	HCPCS A2008
Hospital Charge Code	270694172
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.00
Max. Negotiated Rate	$2,420.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,420.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,200.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,500.00

THERAGENSISBILAYDMATR200X240MM

Facility

$39,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270697670
Hospital Revenue Code	278
Min. Negotiated Rate	$5,962.50
Max. Negotiated Rate	$9,619.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,950.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,619.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$8,745.00
Rate for Payer: Qualcare PPO/HMO/WC	$5,962.50

THERAGENSISBILAYDMATR200X240MM

Facility

$39,750.00

Service Code	HCPCS A2008
Hospital Charge Code	270697670
Hospital Revenue Code	278
Min. Negotiated Rate	$140.45
Max. Negotiated Rate	$9,619.50
Rate for Payer: Aetna Commercial	$402.12
Rate for Payer: Aetna Medicare Advantage	$479.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$147.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$533.66
Rate for Payer: Cigna Commercial	$296.35
Rate for Payer: Cigna Medicare Advantage	$147.84
Rate for Payer: Clover Medicare Advantage	$140.45
Rate for Payer: EmblemHealth Commercial	$443.52
Rate for Payer: Humana Medicare Advantage	$152.28
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$147.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,619.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$8,745.00
Rate for Payer: Qualcare PPO/HMO/WC	$5,962.50
Rate for Payer: UnitedHealthcare Community & State	$957.98
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.84
Rate for Payer: Wellcare Medicare Advantage	$147.84
Rate for Payer: Wellpoint Medicaid Managed Care	$1,053.38

Know your out-of-pocket cost for care.

All Charges