Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC

Facility

$82,591.77

Service Code	MSDRG 854
Min. Negotiated Rate	$25,148.13
Max. Negotiated Rate	$82,591.77
Rate for Payer: Aetna Commercial	$60,681.32
Rate for Payer: Aetna Medicare Advantage	$82,591.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$56,518.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$56,518.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$26,471.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$56,518.20
Rate for Payer: Cigna Commercial	$44,543.64
Rate for Payer: Cigna Medicare Advantage	$26,471.72
Rate for Payer: Clover Medicare Advantage	$25,148.13
Rate for Payer: EmblemHealth Commercial	$79,415.16
Rate for Payer: Humana Medicare Advantage	$27,265.87
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$26,471.72
Rate for Payer: Oxford Commercial	$35,206.52
Rate for Payer: UnitedHealthcare Commercial	$47,125.19
Rate for Payer: UnitedHealthcare Medicare Advantage	$26,471.72
Rate for Payer: Wellcare Medicare Advantage	$26,471.72

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC

Facility

$175,492.64

Service Code	MSDRG 853
Min. Negotiated Rate	$53,435.26
Max. Negotiated Rate	$175,492.64
Rate for Payer: Aetna Commercial	$126,846.37
Rate for Payer: Aetna Medicare Advantage	$175,492.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$138,525.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$138,525.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$56,247.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$138,525.00
Rate for Payer: Cigna Commercial	$110,096.21
Rate for Payer: Cigna Medicare Advantage	$56,247.64
Rate for Payer: Clover Medicare Advantage	$53,435.26
Rate for Payer: EmblemHealth Commercial	$168,742.92
Rate for Payer: Humana Medicare Advantage	$57,935.07
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$56,247.64
Rate for Payer: Oxford Commercial	$87,018.13
Rate for Payer: UnitedHealthcare Commercial	$116,476.88
Rate for Payer: UnitedHealthcare Medicare Advantage	$56,247.64
Rate for Payer: Wellcare Medicare Advantage	$56,247.64

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$66,766.56

Service Code	MSDRG 855
Min. Negotiated Rate	$20,329.56
Max. Negotiated Rate	$66,766.56
Rate for Payer: Aetna Commercial	$49,410.42
Rate for Payer: Aetna Medicare Advantage	$66,766.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$47,098.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$47,098.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$21,399.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$47,098.50
Rate for Payer: Cigna Commercial	$33,377.08
Rate for Payer: Cigna Medicare Advantage	$21,399.54
Rate for Payer: Clover Medicare Advantage	$20,329.56
Rate for Payer: EmblemHealth Commercial	$64,198.62
Rate for Payer: Humana Medicare Advantage	$22,041.53
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$21,399.54
Rate for Payer: Oxford Commercial	$26,380.66
Rate for Payer: UnitedHealthcare Commercial	$35,311.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$21,399.54
Rate for Payer: Wellcare Medicare Advantage	$21,399.54

INFINITY TIPLESS 0.9 MM

Facility

$817.00

Hospital Charge Code	270655294
Hospital Revenue Code	270
Min. Negotiated Rate	$23.20
Max. Negotiated Rate	$408.50
Rate for Payer: Aetna Commercial	$310.46
Rate for Payer: Aetna Medicare Advantage	$245.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$208.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$208.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$208.34
Rate for Payer: Cigna Commercial	$408.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$212.42
Rate for Payer: Oxford Commercial	$163.40
Rate for Payer: Qualcare PPO/HMO/WC	$122.55
Rate for Payer: UnitedHealthcare Commercial	$163.40
Rate for Payer: UnitedHealthcare Community & State	$25.82
Rate for Payer: Wellpoint Medicaid Managed Care	$23.20

INFINITY TIPLESS 0.9 MM

Facility

$817.00

Hospital Charge Code	270655294
Hospital Revenue Code	270
Min. Negotiated Rate	$122.55
Max. Negotiated Rate	$122.55
Rate for Payer: Qualcare PPO/HMO/WC	$122.55

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$66,314.76

Service Code	MSDRG 727
Min. Negotiated Rate	$20,191.99
Max. Negotiated Rate	$66,314.76
Rate for Payer: Aetna Commercial	$49,088.64
Rate for Payer: Aetna Medicare Advantage	$66,314.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$44,882.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$44,882.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$21,254.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$44,882.10
Rate for Payer: Cigna Commercial	$33,058.29
Rate for Payer: Cigna Medicare Advantage	$21,254.73
Rate for Payer: Clover Medicare Advantage	$20,191.99
Rate for Payer: EmblemHealth Commercial	$63,764.19
Rate for Payer: Humana Medicare Advantage	$21,892.37
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$21,254.73
Rate for Payer: Oxford Commercial	$26,128.70
Rate for Payer: UnitedHealthcare Commercial	$34,974.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$21,254.73
Rate for Payer: Wellcare Medicare Advantage	$21,254.73

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC

Facility

$45,093.30

Service Code	MSDRG 728
Min. Negotiated Rate	$13,730.33
Max. Negotiated Rate	$45,093.30
Rate for Payer: Aetna Commercial	$33,974.49
Rate for Payer: Aetna Medicare Advantage	$45,093.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$22,164.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$22,164.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14,452.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$22,164.00
Rate for Payer: Cigna Commercial	$18,084.08
Rate for Payer: Cigna Medicare Advantage	$14,452.98
Rate for Payer: Clover Medicare Advantage	$13,730.33
Rate for Payer: EmblemHealth Commercial	$43,358.94
Rate for Payer: Humana Medicare Advantage	$14,886.57
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14,452.98
Rate for Payer: Oxford Commercial	$14,293.34
Rate for Payer: UnitedHealthcare Commercial	$19,132.15
Rate for Payer: UnitedHealthcare Medicare Advantage	$14,452.98
Rate for Payer: Wellcare Medicare Advantage	$14,452.98

INFLAMMATORY BOWEL DISEASE

Facility

$9,774.47

Service Code	APR-DRG 2452
Min. Negotiated Rate	$9,582.81
Max. Negotiated Rate	$9,774.47
Rate for Payer: UnitedHealthcare Community & State	$9,582.81
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$9,774.47
Rate for Payer: Wellpoint Medicaid Managed Care	$9,582.81

INFLAMMATORY BOWEL DISEASE

Facility

$13,958.13

Service Code	APR-DRG 2453
Min. Negotiated Rate	$13,684.44
Max. Negotiated Rate	$13,958.13
Rate for Payer: UnitedHealthcare Community & State	$13,684.44
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$13,958.13
Rate for Payer: Wellpoint Medicaid Managed Care	$13,684.44

INFLAMMATORY BOWEL DISEASE

Facility

$23,982.58

Service Code	APR-DRG 2454
Min. Negotiated Rate	$23,512.33
Max. Negotiated Rate	$23,982.58
Rate for Payer: UnitedHealthcare Community & State	$23,512.33
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$23,982.58
Rate for Payer: Wellpoint Medicaid Managed Care	$23,512.33

INFLAMMATORY BOWEL DISEASE

Facility

$7,656.69

Service Code	APR-DRG 2451
Min. Negotiated Rate	$7,506.56
Max. Negotiated Rate	$7,656.69
Rate for Payer: UnitedHealthcare Community & State	$7,506.56
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$7,656.69
Rate for Payer: Wellpoint Medicaid Managed Care	$7,506.56

INFLAMMATORY BOWEL DISEASE WITH CC

Facility

$50,309.41

Service Code	MSDRG 386
Min. Negotiated Rate	$15,318.57
Max. Negotiated Rate	$50,309.41
Rate for Payer: Aetna Commercial	$37,689.45
Rate for Payer: Aetna Medicare Advantage	$50,309.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26,873.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26,873.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$16,124.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26,873.85
Rate for Payer: Cigna Commercial	$21,764.66
Rate for Payer: Cigna Medicare Advantage	$16,124.81
Rate for Payer: Clover Medicare Advantage	$15,318.57
Rate for Payer: EmblemHealth Commercial	$48,374.43
Rate for Payer: Humana Medicare Advantage	$16,608.55
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$16,124.81
Rate for Payer: Oxford Commercial	$17,202.41
Rate for Payer: UnitedHealthcare Commercial	$23,026.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$16,124.81
Rate for Payer: Wellcare Medicare Advantage	$16,124.81

INFLAMMATORY BOWEL DISEASE WITH MCC

Facility

$69,455.16

Service Code	MSDRG 385
Min. Negotiated Rate	$21,148.21
Max. Negotiated Rate	$69,455.16
Rate for Payer: Aetna Commercial	$51,325.24
Rate for Payer: Aetna Medicare Advantage	$69,455.16
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43,496.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43,496.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$22,261.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43,496.85
Rate for Payer: Cigna Commercial	$35,274.21
Rate for Payer: Cigna Medicare Advantage	$22,261.27
Rate for Payer: Clover Medicare Advantage	$21,148.21
Rate for Payer: EmblemHealth Commercial	$66,783.81
Rate for Payer: Humana Medicare Advantage	$22,929.11
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$22,261.27
Rate for Payer: Oxford Commercial	$27,880.13
Rate for Payer: UnitedHealthcare Commercial	$37,318.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$22,261.27
Rate for Payer: Wellcare Medicare Advantage	$22,261.27

INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC

Facility

$40,989.37

Service Code	MSDRG 387
Min. Negotiated Rate	$12,004.51
Max. Negotiated Rate	$40,989.37
Rate for Payer: Aetna Commercial	$31,051.59
Rate for Payer: Aetna Medicare Advantage	$40,989.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18,839.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18,839.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13,137.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18,839.40
Rate for Payer: Cigna Commercial	$15,188.22
Rate for Payer: Cigna Medicare Advantage	$13,137.62
Rate for Payer: Clover Medicare Advantage	$12,480.74
Rate for Payer: EmblemHealth Commercial	$39,412.86
Rate for Payer: Humana Medicare Advantage	$13,531.75
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13,137.62
Rate for Payer: Oxford Commercial	$12,004.51
Rate for Payer: UnitedHealthcare Commercial	$16,068.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$13,137.62
Rate for Payer: Wellcare Medicare Advantage	$13,137.62

INFLATABLE PENILE 12MMX24CM

Facility

$65,452.55

Hospital Charge Code	270702098
Hospital Revenue Code	278
Min. Negotiated Rate	$9,817.88
Max. Negotiated Rate	$15,839.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13,090.51
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15,839.52
Rate for Payer: Qualcare PPO/HMO/WC	$9,817.88

INFLATABLE PENILE 12MMX24CM

Facility

$65,452.55

Hospital Charge Code	270702098
Hospital Revenue Code	278
Min. Negotiated Rate	$1,858.85
Max. Negotiated Rate	$32,726.28
Rate for Payer: Aetna Commercial	$24,871.97
Rate for Payer: Aetna Medicare Advantage	$19,635.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16,690.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16,690.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13,090.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16,690.40
Rate for Payer: Cigna Commercial	$32,726.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15,839.52
Rate for Payer: Qualcare PPO/HMO/WC	$9,817.88
Rate for Payer: UnitedHealthcare Community & State	$2,068.30
Rate for Payer: Wellpoint Medicaid Managed Care	$1,858.85

INFLATABLE PENILE PROSTHESIS

Facility

$67,702.55

Hospital Charge Code	270702114
Hospital Revenue Code	278
Min. Negotiated Rate	$1,922.75
Max. Negotiated Rate	$33,851.28
Rate for Payer: Aetna Commercial	$25,726.97
Rate for Payer: Aetna Medicare Advantage	$20,310.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$17,264.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$17,264.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13,540.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$17,264.15
Rate for Payer: Cigna Commercial	$33,851.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$16,384.02
Rate for Payer: Qualcare PPO/HMO/WC	$10,155.38
Rate for Payer: UnitedHealthcare Community & State	$2,139.40
Rate for Payer: Wellpoint Medicaid Managed Care	$1,922.75

INFLATABLE PENILE PROSTHESIS

Facility

$67,702.55

Hospital Charge Code	270702114
Hospital Revenue Code	278
Min. Negotiated Rate	$10,155.38
Max. Negotiated Rate	$16,384.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13,540.51
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$16,384.02
Rate for Payer: Qualcare PPO/HMO/WC	$10,155.38

INFLATABLE PENILE PUMP 12MMX18

Facility

$65,452.55

Hospital Charge Code	270702096
Hospital Revenue Code	278
Min. Negotiated Rate	$1,858.85
Max. Negotiated Rate	$32,726.28
Rate for Payer: Aetna Commercial	$24,871.97
Rate for Payer: Aetna Medicare Advantage	$19,635.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16,690.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16,690.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13,090.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16,690.40
Rate for Payer: Cigna Commercial	$32,726.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15,839.52
Rate for Payer: Qualcare PPO/HMO/WC	$9,817.88
Rate for Payer: UnitedHealthcare Community & State	$2,068.30
Rate for Payer: Wellpoint Medicaid Managed Care	$1,858.85

INFLATABLE PENILE PUMP 12MMX18

Facility

$65,452.55

Hospital Charge Code	270702096
Hospital Revenue Code	278
Min. Negotiated Rate	$9,817.88
Max. Negotiated Rate	$15,839.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$13,090.51
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$15,839.52
Rate for Payer: Qualcare PPO/HMO/WC	$9,817.88

INFLATION DEV MICROTECH BALLN

Facility

$137.00

Hospital Charge Code	270700755
Hospital Revenue Code	272
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$20.55
Rate for Payer: Qualcare PPO/HMO/WC	$20.55

INFLATION DEV MICROTECH BALLN

Facility

$137.00

Hospital Charge Code	270700755
Hospital Revenue Code	272
Min. Negotiated Rate	$3.89
Max. Negotiated Rate	$68.50
Rate for Payer: Aetna Commercial	$52.06
Rate for Payer: Aetna Medicare Advantage	$41.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.94
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.94
Rate for Payer: Cigna Commercial	$68.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$35.62
Rate for Payer: Oxford Commercial	$27.40
Rate for Payer: Qualcare PPO/HMO/WC	$20.55
Rate for Payer: UnitedHealthcare Commercial	$27.40
Rate for Payer: UnitedHealthcare Community & State	$4.33
Rate for Payer: Wellpoint Medicaid Managed Care	$3.89

INFLATION KIT

Facility

$156.80

Hospital Charge Code	270664784
Hospital Revenue Code	272
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$78.40
Rate for Payer: Aetna Commercial	$59.58
Rate for Payer: Aetna Medicare Advantage	$47.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.98
Rate for Payer: Cigna Commercial	$78.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$40.77
Rate for Payer: Oxford Commercial	$31.36
Rate for Payer: Qualcare PPO/HMO/WC	$23.52
Rate for Payer: UnitedHealthcare Commercial	$31.36
Rate for Payer: UnitedHealthcare Community & State	$4.95
Rate for Payer: Wellpoint Medicaid Managed Care	$4.45

INFLATION KIT

Facility

$156.80

Hospital Charge Code	270664784S
Hospital Revenue Code	272
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$78.40
Rate for Payer: Aetna Commercial	$59.58
Rate for Payer: Aetna Medicare Advantage	$47.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.98
Rate for Payer: Cigna Commercial	$78.40
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$40.77
Rate for Payer: Oxford Commercial	$31.36
Rate for Payer: Qualcare PPO/HMO/WC	$23.52
Rate for Payer: UnitedHealthcare Commercial	$31.36
Rate for Payer: UnitedHealthcare Community & State	$4.95
Rate for Payer: Wellpoint Medicaid Managed Care	$4.45

INFLATION KIT

Facility

$154.50

Hospital Charge Code	270664784N
Hospital Revenue Code	272
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$77.25
Rate for Payer: Aetna Commercial	$58.71
Rate for Payer: Aetna Medicare Advantage	$46.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.40
Rate for Payer: Cigna Commercial	$77.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$40.17
Rate for Payer: Oxford Commercial	$30.90
Rate for Payer: Qualcare PPO/HMO/WC	$23.18
Rate for Payer: UnitedHealthcare Commercial	$30.90
Rate for Payer: UnitedHealthcare Community & State	$4.88
Rate for Payer: Wellpoint Medicaid Managed Care	$4.39

Know your out-of-pocket cost for care.

All Charges