Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

CAGE COIPECTOMY 13.5x24MM

Facility

$14,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270679302
Hospital Revenue Code	278
Min. Negotiated Rate	$2,100.00
Max. Negotiated Rate	$3,388.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,800.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,388.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,080.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,100.00

CAGE COIPECTOMY 13.5x24MM

Facility

$14,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270679302
Hospital Revenue Code	278
Min. Negotiated Rate	$337.40
Max. Negotiated Rate	$7,000.00
Rate for Payer: Aetna Commercial	$5,320.00
Rate for Payer: Aetna Medicare Advantage	$4,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,570.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,570.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,570.00
Rate for Payer: Cigna Commercial	$7,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,388.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,080.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,100.00
Rate for Payer: UnitedHealthcare Community & State	$337.40
Rate for Payer: Wellpoint Medicaid Managed Care	$371.00

CAGE CONC INLINE 5 LOR 9x10x21

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270661523
Hospital Revenue Code	278
Min. Negotiated Rate	$2,887.50
Max. Negotiated Rate	$4,658.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50

CAGE CONC INLINE 5 LOR 9x10x21

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270661523
Hospital Revenue Code	278
Min. Negotiated Rate	$463.93
Max. Negotiated Rate	$9,625.00
Rate for Payer: Aetna Commercial	$7,315.00
Rate for Payer: Aetna Medicare Advantage	$5,775.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,908.75
Rate for Payer: Cigna Commercial	$9,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50
Rate for Payer: UnitedHealthcare Community & State	$463.93
Rate for Payer: Wellpoint Medicaid Managed Care	$510.12

CAGE CONC INLINE 5 LOR 9x9x21

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270667975
Hospital Revenue Code	278
Min. Negotiated Rate	$463.93
Max. Negotiated Rate	$9,625.00
Rate for Payer: Aetna Commercial	$7,315.00
Rate for Payer: Aetna Medicare Advantage	$5,775.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,908.75
Rate for Payer: Cigna Commercial	$9,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50
Rate for Payer: UnitedHealthcare Community & State	$463.93
Rate for Payer: Wellpoint Medicaid Managed Care	$510.12

CAGE CONC INLINE 5 LOR 9x9x21

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270667975
Hospital Revenue Code	278
Min. Negotiated Rate	$2,887.50
Max. Negotiated Rate	$4,658.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50

CAGE CONC INLINE 5 LOR 9x9x25

Facility

$19,250.00

Hospital Charge Code	270669382
Hospital Revenue Code	278
Min. Negotiated Rate	$463.93
Max. Negotiated Rate	$9,625.00
Rate for Payer: Aetna Commercial	$7,315.00
Rate for Payer: Aetna Medicare Advantage	$5,775.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,908.75
Rate for Payer: Cigna Commercial	$9,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50
Rate for Payer: UnitedHealthcare Community & State	$463.93
Rate for Payer: Wellpoint Medicaid Managed Care	$510.12

CAGE CONC INLINE 5 LOR 9x9x25

Facility

$19,250.00

Hospital Charge Code	270669382
Hospital Revenue Code	278
Min. Negotiated Rate	$2,887.50
Max. Negotiated Rate	$4,658.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50

CAGE CONCORDE INLINE 9X 10 MM

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270684060
Hospital Revenue Code	278
Min. Negotiated Rate	$2,887.50
Max. Negotiated Rate	$4,658.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50

CAGE CONCORDE INLINE 9X 10 MM

Facility

$19,250.00

Service Code	HCPCS C1713
Hospital Charge Code	270684060
Hospital Revenue Code	278
Min. Negotiated Rate	$463.93
Max. Negotiated Rate	$9,625.00
Rate for Payer: Aetna Commercial	$7,315.00
Rate for Payer: Aetna Medicare Advantage	$5,775.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,908.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,850.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,908.75
Rate for Payer: Cigna Commercial	$9,625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,658.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,235.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,887.50
Rate for Payer: UnitedHealthcare Community & State	$463.93
Rate for Payer: Wellpoint Medicaid Managed Care	$510.12

CAGE CORENT SM 7X15X12MM 10D

Facility

$17,495.00

Service Code	HCPCS C1889
Hospital Charge Code	270698448
Hospital Revenue Code	278
Min. Negotiated Rate	$421.63
Max. Negotiated Rate	$8,747.50
Rate for Payer: Aetna Commercial	$6,648.10
Rate for Payer: Aetna Medicare Advantage	$5,248.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,461.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,461.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,499.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,461.23
Rate for Payer: Cigna Commercial	$8,747.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,233.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,848.90
Rate for Payer: Qualcare PPO/HMO/WC	$2,624.25
Rate for Payer: UnitedHealthcare Community & State	$421.63
Rate for Payer: Wellpoint Medicaid Managed Care	$463.62

CAGE CORENT SM 7X15X12MM 10D

Facility

$17,495.00

Service Code	HCPCS C1889
Hospital Charge Code	270698448
Hospital Revenue Code	278
Min. Negotiated Rate	$2,624.25
Max. Negotiated Rate	$4,233.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,499.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,233.79
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,848.90
Rate for Payer: Qualcare PPO/HMO/WC	$2,624.25

CAGE CORPECT 12DX14WX27H6D

Facility

$30,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270694311
Hospital Revenue Code	278
Min. Negotiated Rate	$4,500.00
Max. Negotiated Rate	$7,260.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,260.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,600.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,500.00

CAGE CORPECT 12DX14WX27H6D

Facility

$30,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270694311
Hospital Revenue Code	278
Min. Negotiated Rate	$723.00
Max. Negotiated Rate	$15,000.00
Rate for Payer: Aetna Commercial	$11,400.00
Rate for Payer: Aetna Medicare Advantage	$9,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,650.00
Rate for Payer: Cigna Commercial	$15,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,260.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,600.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,500.00
Rate for Payer: UnitedHealthcare Community & State	$723.00
Rate for Payer: Wellpoint Medicaid Managed Care	$795.00

CAGE CORPECT 12X14MM 20-24MM0D

Facility

$29,950.00

Service Code	HCPCS C1889
Hospital Charge Code	270699463
Hospital Revenue Code	278
Min. Negotiated Rate	$721.79
Max. Negotiated Rate	$14,975.00
Rate for Payer: Aetna Commercial	$11,381.00
Rate for Payer: Aetna Medicare Advantage	$8,985.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,637.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,637.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,990.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,637.25
Rate for Payer: Cigna Commercial	$14,975.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,247.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,589.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,492.50
Rate for Payer: UnitedHealthcare Community & State	$721.79
Rate for Payer: Wellpoint Medicaid Managed Care	$793.67

CAGE CORPECT 12X14MM 20-24MM0D

Facility

$29,950.00

Service Code	HCPCS C1889
Hospital Charge Code	270699463
Hospital Revenue Code	278
Min. Negotiated Rate	$4,492.50
Max. Negotiated Rate	$7,247.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,990.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,247.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,589.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,492.50

CAGE CORPECT MATRIXX14X16X196D

Facility

$39,990.00

Service Code	HCPCS C1889
Hospital Charge Code	270698813
Hospital Revenue Code	278
Min. Negotiated Rate	$963.76
Max. Negotiated Rate	$19,995.00
Rate for Payer: Aetna Commercial	$15,196.20
Rate for Payer: Aetna Medicare Advantage	$11,997.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10,197.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10,197.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,998.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10,197.45
Rate for Payer: Cigna Commercial	$19,995.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,677.58
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$8,797.80
Rate for Payer: Qualcare PPO/HMO/WC	$5,998.50
Rate for Payer: UnitedHealthcare Community & State	$963.76
Rate for Payer: Wellpoint Medicaid Managed Care	$1,059.73

CAGE CORPECT MATRIXX14X16X196D

Facility

$39,990.00

Service Code	HCPCS C1889
Hospital Charge Code	270698813
Hospital Revenue Code	278
Min. Negotiated Rate	$5,998.50
Max. Negotiated Rate	$9,677.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,998.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,677.58
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$8,797.80
Rate for Payer: Qualcare PPO/HMO/WC	$5,998.50

CAGE CORPECTOMY 12DX14WX34H 6D

Facility

$30,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270696966
Hospital Revenue Code	278
Min. Negotiated Rate	$723.00
Max. Negotiated Rate	$15,000.00
Rate for Payer: Aetna Commercial	$11,400.00
Rate for Payer: Aetna Medicare Advantage	$9,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,650.00
Rate for Payer: Cigna Commercial	$15,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,260.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,600.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,500.00
Rate for Payer: UnitedHealthcare Community & State	$723.00
Rate for Payer: Wellpoint Medicaid Managed Care	$795.00

CAGE CORPECTOMY 12DX14WX34H 6D

Facility

$30,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270696966
Hospital Revenue Code	278
Min. Negotiated Rate	$4,500.00
Max. Negotiated Rate	$7,260.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,260.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,600.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,500.00

CAGE CORPECTOMY 12X14X21 6D

Facility

$39,975.00

Service Code	HCPCS C1889
Hospital Charge Code	270699208
Hospital Revenue Code	278
Min. Negotiated Rate	$963.40
Max. Negotiated Rate	$19,987.50
Rate for Payer: Aetna Commercial	$15,190.50
Rate for Payer: Aetna Medicare Advantage	$11,992.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10,193.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10,193.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,995.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10,193.62
Rate for Payer: Cigna Commercial	$19,987.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,673.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$8,794.50
Rate for Payer: Qualcare PPO/HMO/WC	$5,996.25
Rate for Payer: UnitedHealthcare Community & State	$963.40
Rate for Payer: Wellpoint Medicaid Managed Care	$1,059.34

CAGE CORPECTOMY 12X14X21 6D

Facility

$39,975.00

Service Code	HCPCS C1889
Hospital Charge Code	270699208
Hospital Revenue Code	278
Min. Negotiated Rate	$5,996.25
Max. Negotiated Rate	$9,673.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,995.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,673.95
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$8,794.50
Rate for Payer: Qualcare PPO/HMO/WC	$5,996.25

CAGE CORPECTOMY 12X14X55 6D

Facility

$30,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270694537
Hospital Revenue Code	278
Min. Negotiated Rate	$723.00
Max. Negotiated Rate	$15,000.00
Rate for Payer: Aetna Commercial	$11,400.00
Rate for Payer: Aetna Medicare Advantage	$9,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,650.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,650.00
Rate for Payer: Cigna Commercial	$15,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,260.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,600.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,500.00
Rate for Payer: UnitedHealthcare Community & State	$723.00
Rate for Payer: Wellpoint Medicaid Managed Care	$795.00

CAGE CORPECTOMY 12X14X55 6D

Facility

$30,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270694537
Hospital Revenue Code	278
Min. Negotiated Rate	$4,500.00
Max. Negotiated Rate	$7,260.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,260.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,600.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,500.00

CAGE CRYSTAL 7D 16X13X10MM

Facility

$5,600.00

Service Code	HCPCS C1889
Hospital Charge Code	270694726
Hospital Revenue Code	278
Min. Negotiated Rate	$134.96
Max. Negotiated Rate	$2,800.00
Rate for Payer: Aetna Commercial	$2,128.00
Rate for Payer: Aetna Medicare Advantage	$1,680.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,428.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,428.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,120.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,428.00
Rate for Payer: Cigna Commercial	$2,800.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,355.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,232.00
Rate for Payer: Qualcare PPO/HMO/WC	$840.00
Rate for Payer: UnitedHealthcare Community & State	$134.96
Rate for Payer: Wellpoint Medicaid Managed Care	$148.40

Know your out-of-pocket cost for care.

All Charges