Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

CAGE SHURFIT 2C TPLIF 8X29MM

Facility

$36,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270697143
Hospital Revenue Code	278
Min. Negotiated Rate	$867.60
Max. Negotiated Rate	$18,000.00
Rate for Payer: Aetna Commercial	$13,680.00
Rate for Payer: Aetna Medicare Advantage	$10,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9,180.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9,180.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9,180.00
Rate for Payer: Cigna Commercial	$18,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8,712.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,920.00
Rate for Payer: Qualcare PPO/HMO/WC	$5,400.00
Rate for Payer: UnitedHealthcare Community & State	$867.60
Rate for Payer: Wellpoint Medicaid Managed Care	$954.00

CAGE SHURFIT 2C TPLIF 8X29MM

Facility

$36,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270697143
Hospital Revenue Code	278
Min. Negotiated Rate	$5,400.00
Max. Negotiated Rate	$8,712.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8,712.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$7,920.00
Rate for Payer: Qualcare PPO/HMO/WC	$5,400.00

CAGE SHURFIT ACIF 2C 10DX7MM

Facility

$24,250.00

Service Code	HCPCS C1889
Hospital Charge Code	270697508
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

CAGE SHURFIT ACIF 2C 10DX7MM

Facility

$24,250.00

Service Code	HCPCS C1889
Hospital Charge Code	270697508
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

CAGE SHURFIT ACIF2C 11MM 5D

Facility

$15,442.50

Service Code	HCPCS C1889
Hospital Charge Code	270698206
Hospital Revenue Code	278
Min. Negotiated Rate	$372.16
Max. Negotiated Rate	$7,721.25
Rate for Payer: Aetna Commercial	$5,868.15
Rate for Payer: Aetna Medicare Advantage	$4,632.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,937.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,937.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,088.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,937.84
Rate for Payer: Cigna Commercial	$7,721.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,737.09
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,397.35
Rate for Payer: Qualcare PPO/HMO/WC	$2,316.38
Rate for Payer: UnitedHealthcare Community & State	$372.16
Rate for Payer: Wellpoint Medicaid Managed Care	$409.23

CAGE SHURFIT ACIF2C 11MM 5D

Facility

$15,442.50

Service Code	HCPCS C1889
Hospital Charge Code	270698206
Hospital Revenue Code	278
Min. Negotiated Rate	$2,316.38
Max. Negotiated Rate	$3,737.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,088.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,737.09
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,397.35
Rate for Payer: Qualcare PPO/HMO/WC	$2,316.38

CAGE SHURFIT ACIF 2C 9MM10D

Facility

$24,250.00

Service Code	HCPCS C1889
Hospital Charge Code	270695866
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

CAGE SHURFIT ACIF 2C 9MM10D

Facility

$24,250.00

Service Code	HCPCS C1889
Hospital Charge Code	270695866
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

CAGE SHURFIT ACIF2C PEEK 5D6MM

Facility

$21,097.50

Service Code	HCPCS C1889
Hospital Charge Code	270698233
Hospital Revenue Code	278
Min. Negotiated Rate	$3,164.62
Max. Negotiated Rate	$5,105.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,219.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,105.60
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,641.45
Rate for Payer: Qualcare PPO/HMO/WC	$3,164.62

CAGE SHURFIT ACIF2C PEEK 5D6MM

Facility

$21,097.50

Service Code	HCPCS C1889
Hospital Charge Code	270698233
Hospital Revenue Code	278
Min. Negotiated Rate	$508.45
Max. Negotiated Rate	$10,548.75
Rate for Payer: Aetna Commercial	$8,017.05
Rate for Payer: Aetna Medicare Advantage	$6,329.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,379.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,379.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,219.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,379.86
Rate for Payer: Cigna Commercial	$10,548.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,105.60
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,641.45
Rate for Payer: Qualcare PPO/HMO/WC	$3,164.62
Rate for Payer: UnitedHealthcare Community & State	$508.45
Rate for Payer: Wellpoint Medicaid Managed Care	$559.08

CAGE SHURFIT TPLIF PEEK10X29MM

Facility

$31,320.00

Service Code	HCPCS C1889
Hospital Charge Code	270699943
Hospital Revenue Code	278
Min. Negotiated Rate	$4,698.00
Max. Negotiated Rate	$7,579.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,264.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,579.44
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,890.40
Rate for Payer: Qualcare PPO/HMO/WC	$4,698.00

CAGE SHURFIT TPLIF PEEK10X29MM

Facility

$31,320.00

Service Code	HCPCS C1889
Hospital Charge Code	270699943
Hospital Revenue Code	278
Min. Negotiated Rate	$754.81
Max. Negotiated Rate	$15,660.00
Rate for Payer: Aetna Commercial	$11,901.60
Rate for Payer: Aetna Medicare Advantage	$9,396.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,986.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,986.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,264.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,986.60
Rate for Payer: Cigna Commercial	$15,660.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,579.44
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,890.40
Rate for Payer: Qualcare PPO/HMO/WC	$4,698.00
Rate for Payer: UnitedHealthcare Community & State	$754.81
Rate for Payer: Wellpoint Medicaid Managed Care	$829.98

CAGESPCRSABLE 10X22 7-13MM15D

Facility

$37,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270693573
Hospital Revenue Code	278
Min. Negotiated Rate	$5,625.00
Max. Negotiated Rate	$9,075.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,075.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$8,250.00
Rate for Payer: Qualcare PPO/HMO/WC	$5,625.00

CAGESPCRSABLE 10X22 7-13MM15D

Facility

$37,500.00

Service Code	HCPCS C1889
Hospital Charge Code	270693573
Hospital Revenue Code	278
Min. Negotiated Rate	$903.75
Max. Negotiated Rate	$18,750.00
Rate for Payer: Aetna Commercial	$14,250.00
Rate for Payer: Aetna Medicare Advantage	$11,250.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9,562.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9,562.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$7,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9,562.50
Rate for Payer: Cigna Commercial	$18,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9,075.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$8,250.00
Rate for Payer: Qualcare PPO/HMO/WC	$5,625.00
Rate for Payer: UnitedHealthcare Community & State	$903.75
Rate for Payer: Wellpoint Medicaid Managed Care	$993.75

CAGE SP TI ALLOY CERV DTRAX

Facility

$1,250.00

Service Code	HCPCS C1889
Hospital Charge Code	270692495
Hospital Revenue Code	278
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$302.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$302.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$275.00
Rate for Payer: Qualcare PPO/HMO/WC	$187.50

CAGE SP TI ALLOY CERV DTRAX

Facility

$1,250.00

Service Code	HCPCS C1889
Hospital Charge Code	270692495
Hospital Revenue Code	278
Min. Negotiated Rate	$30.12
Max. Negotiated Rate	$625.00
Rate for Payer: Aetna Commercial	$475.00
Rate for Payer: Aetna Medicare Advantage	$375.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$318.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$318.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$250.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$318.75
Rate for Payer: Cigna Commercial	$625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$302.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$275.00
Rate for Payer: Qualcare PPO/HMO/WC	$187.50
Rate for Payer: UnitedHealthcare Community & State	$30.12
Rate for Payer: Wellpoint Medicaid Managed Care	$33.12

CAGE STALIF C ST PEEK 7.5X12MM

Facility

$22,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270697639
Hospital Revenue Code	278
Min. Negotiated Rate	$3,300.00
Max. Negotiated Rate	$5,324.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,324.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,840.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,300.00

CAGE STALIF C ST PEEK 7.5X12MM

Facility

$22,000.00

Service Code	HCPCS C1889
Hospital Charge Code	270697639
Hospital Revenue Code	278
Min. Negotiated Rate	$530.20
Max. Negotiated Rate	$11,000.00
Rate for Payer: Aetna Commercial	$8,360.00
Rate for Payer: Aetna Medicare Advantage	$6,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,610.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,610.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,610.00
Rate for Payer: Cigna Commercial	$11,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,324.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,840.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,300.00
Rate for Payer: UnitedHealthcare Community & State	$530.20
Rate for Payer: Wellpoint Medicaid Managed Care	$583.00

CAGE STAND ALONE 7X14X16MM

Facility

$15,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270704438
Hospital Revenue Code	278
Min. Negotiated Rate	$361.50
Max. Negotiated Rate	$7,500.00
Rate for Payer: Aetna Commercial	$5,700.00
Rate for Payer: Aetna Medicare Advantage	$4,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,825.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,825.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,825.00
Rate for Payer: Cigna Commercial	$7,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,630.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,300.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,250.00
Rate for Payer: UnitedHealthcare Community & State	$361.50
Rate for Payer: Wellpoint Medicaid Managed Care	$397.50

CAGE STAND ALONE 7X14X16MM

Facility

$15,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270704438
Hospital Revenue Code	278
Min. Negotiated Rate	$2,250.00
Max. Negotiated Rate	$3,630.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,630.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,300.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,250.00

CAGE STAND ALONE 8X14X16MM

Facility

$15,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270704437
Hospital Revenue Code	278
Min. Negotiated Rate	$361.50
Max. Negotiated Rate	$7,500.00
Rate for Payer: Aetna Commercial	$5,700.00
Rate for Payer: Aetna Medicare Advantage	$4,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,825.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,825.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,825.00
Rate for Payer: Cigna Commercial	$7,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,630.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,300.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,250.00
Rate for Payer: UnitedHealthcare Community & State	$361.50
Rate for Payer: Wellpoint Medicaid Managed Care	$397.50

CAGE STAND ALONE 8X14X16MM

Facility

$15,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270704437
Hospital Revenue Code	278
Min. Negotiated Rate	$2,250.00
Max. Negotiated Rate	$3,630.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,630.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,300.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,250.00

CAGE SYSTEM BENGAL 4MM

Facility

$6,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270670996
Hospital Revenue Code	278
Min. Negotiated Rate	$156.65
Max. Negotiated Rate	$3,250.00
Rate for Payer: Aetna Commercial	$2,470.00
Rate for Payer: Aetna Medicare Advantage	$1,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,657.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,657.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,300.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,657.50
Rate for Payer: Cigna Commercial	$3,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,573.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,430.00
Rate for Payer: Qualcare PPO/HMO/WC	$975.00
Rate for Payer: UnitedHealthcare Community & State	$156.65
Rate for Payer: Wellpoint Medicaid Managed Care	$172.25

CAGE SYSTEM BENGAL 4MM

Facility

$6,500.00

Service Code	HCPCS C1713
Hospital Charge Code	270670996
Hospital Revenue Code	278
Min. Negotiated Rate	$975.00
Max. Negotiated Rate	$1,573.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,300.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,573.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,430.00
Rate for Payer: Qualcare PPO/HMO/WC	$975.00

CAGE SYSTEM BENGAL 6mm

Facility

$6,500.00

Hospital Charge Code	270671113
Hospital Revenue Code	278
Min. Negotiated Rate	$156.65
Max. Negotiated Rate	$3,250.00
Rate for Payer: Aetna Commercial	$2,470.00
Rate for Payer: Aetna Medicare Advantage	$1,950.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,657.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,657.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,300.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,657.50
Rate for Payer: Cigna Commercial	$3,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,573.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,430.00
Rate for Payer: Qualcare PPO/HMO/WC	$975.00
Rate for Payer: UnitedHealthcare Community & State	$156.65
Rate for Payer: Wellpoint Medicaid Managed Care	$172.25

Know your out-of-pocket cost for care.

All Charges