Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

OV NEW PT EXPANDED PROBL FOCUS

Facility

$446.00

Service Code	HCPCS 99202
Hospital Charge Code	84506095
Hospital Revenue Code	510
Min. Negotiated Rate	$12.67
Max. Negotiated Rate	$223.00
Rate for Payer: Aetna Commercial	$169.48
Rate for Payer: Aetna Medicare Advantage	$133.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$113.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$113.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$113.73
Rate for Payer: Cigna Commercial	$223.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$115.96
Rate for Payer: Qualcare PPO/HMO/WC	$66.90
Rate for Payer: UnitedHealthcare Community & State	$14.09
Rate for Payer: Wellpoint Medicaid Managed Care	$12.67

OV NEW PT EXPANDED PROBL FOCUS

Facility

$446.00

Service Code	HCPCS 99202
Hospital Charge Code	84506095
Hospital Revenue Code	510
Min. Negotiated Rate	$66.90
Max. Negotiated Rate	$66.90
Rate for Payer: Qualcare PPO/HMO/WC	$66.90

OV NEW PT STRAIGHT FORWARD

Facility

$311.00

Service Code	HCPCS 99201
Hospital Charge Code	84506090
Hospital Revenue Code	510
Min. Negotiated Rate	$8.83
Max. Negotiated Rate	$155.50
Rate for Payer: Aetna Commercial	$118.18
Rate for Payer: Aetna Medicare Advantage	$93.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$79.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$79.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$79.31
Rate for Payer: Cigna Commercial	$155.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$80.86
Rate for Payer: Qualcare PPO/HMO/WC	$46.65
Rate for Payer: UnitedHealthcare Community & State	$9.83
Rate for Payer: Wellpoint Medicaid Managed Care	$8.83

OV NEW PT STRAIGHT FORWARD

Facility

$311.00

Service Code	HCPCS 99201
Hospital Charge Code	84506090
Hospital Revenue Code	510
Min. Negotiated Rate	$46.65
Max. Negotiated Rate	$46.65
Rate for Payer: Qualcare PPO/HMO/WC	$46.65

OVVAN CYSTECTOMY UL/BL

Facility

$6,544.55

Service Code	HCPCS 58925
Hospital Charge Code	1600000356
Hospital Revenue Code	360
Min. Negotiated Rate	$981.68
Max. Negotiated Rate	$981.68
Rate for Payer: Qualcare PPO/HMO/WC	$981.68

OVVAN CYSTECTOMY UL/BL

Facility

$6,544.55

Service Code	HCPCS 58925
Hospital Charge Code	1600000356
Hospital Revenue Code	360
Min. Negotiated Rate	$185.87
Max. Negotiated Rate	$21,558.38
Rate for Payer: Aetna Commercial	$16,165.07
Rate for Payer: Aetna Medicare Advantage	$19,255.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$21,558.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$21,558.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5,943.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$21,558.38
Rate for Payer: Cigna Commercial	$11,912.81
Rate for Payer: Cigna Medicare Advantage	$5,943.04
Rate for Payer: Clover Medicare Advantage	$5,645.89
Rate for Payer: EmblemHealth Commercial	$17,829.12
Rate for Payer: Humana Medicare Advantage	$6,121.33
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5,943.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,701.58
Rate for Payer: Oxford Commercial	$9,354.00
Rate for Payer: Qualcare PPO/HMO/WC	$981.68
Rate for Payer: UnitedHealthcare Commercial	$10,269.00
Rate for Payer: UnitedHealthcare Community & State	$206.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$5,943.04
Rate for Payer: Wellcare Medicare Advantage	$5,943.04
Rate for Payer: Wellpoint Medicaid Managed Care	$185.87

OXALATE

Facility

$517.00

Service Code	HCPCS 83945
Hospital Charge Code	38472427
Hospital Revenue Code	301
Min. Negotiated Rate	$11.56
Max. Negotiated Rate	$258.50
Rate for Payer: Aetna Commercial	$39.30
Rate for Payer: Aetna Medicare Advantage	$46.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$52.42
Rate for Payer: Cigna Commercial	$258.50
Rate for Payer: Cigna Medicare Advantage	$14.45
Rate for Payer: Clover Medicare Advantage	$13.73
Rate for Payer: EmblemHealth Commercial	$43.35
Rate for Payer: Humana Medicare Advantage	$14.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$134.42
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$77.55
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$11.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.45
Rate for Payer: Wellcare Medicare Advantage	$14.45
Rate for Payer: Wellpoint Medicaid Managed Care	$14.68

OXALATE

Facility

$390.00

Service Code	HCPCS 83945
Hospital Charge Code	39990241F
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

OXALATE

Facility

$517.00

Service Code	HCPCS 83945
Hospital Charge Code	38472427
Hospital Revenue Code	301
Min. Negotiated Rate	$77.55
Max. Negotiated Rate	$77.55
Rate for Payer: Qualcare PPO/HMO/WC	$77.55

OXALATE

Facility

$390.00

Service Code	HCPCS 83945
Hospital Charge Code	39990241F
Hospital Revenue Code	301
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$39.30
Rate for Payer: Aetna Medicare Advantage	$46.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$52.42
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$14.45
Rate for Payer: Clover Medicare Advantage	$13.73
Rate for Payer: EmblemHealth Commercial	$43.35
Rate for Payer: Humana Medicare Advantage	$14.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$101.40
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$11.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.45
Rate for Payer: Wellcare Medicare Advantage	$14.45
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

OXALATE,SERUM/PLASMA

Facility

$84.00

Service Code	HCPCS 83945
Hospital Charge Code	401384445
Hospital Revenue Code	301
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Qualcare PPO/HMO/WC	$12.60

OXALATE,SERUM/PLASMA

Facility

$84.00

Service Code	HCPCS 83945
Hospital Charge Code	401384445
Hospital Revenue Code	301
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$39.30
Rate for Payer: Aetna Medicare Advantage	$46.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$52.42
Rate for Payer: Cigna Commercial	$42.00
Rate for Payer: Cigna Medicare Advantage	$14.45
Rate for Payer: Clover Medicare Advantage	$13.73
Rate for Payer: EmblemHealth Commercial	$43.35
Rate for Payer: Humana Medicare Advantage	$14.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$21.84
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.60
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$11.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.45
Rate for Payer: Wellcare Medicare Advantage	$14.45
Rate for Payer: Wellpoint Medicaid Managed Care	$2.39

OXALIC ACD,24HR W/O CREAT

Facility

$88.45

Service Code	HCPCS 83945
Hospital Charge Code	39900115
Hospital Revenue Code	301
Min. Negotiated Rate	$13.27
Max. Negotiated Rate	$13.27
Rate for Payer: Qualcare PPO/HMO/WC	$13.27

OXALIC ACD,24HR W/O CREAT

Facility

$88.45

Service Code	HCPCS 83945
Hospital Charge Code	39900115
Hospital Revenue Code	301
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$39.30
Rate for Payer: Aetna Medicare Advantage	$46.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$52.42
Rate for Payer: Cigna Commercial	$44.23
Rate for Payer: Cigna Medicare Advantage	$14.45
Rate for Payer: Clover Medicare Advantage	$13.73
Rate for Payer: EmblemHealth Commercial	$43.35
Rate for Payer: Humana Medicare Advantage	$14.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$23.00
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$13.27
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$11.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.45
Rate for Payer: Wellcare Medicare Advantage	$14.45
Rate for Payer: Wellpoint Medicaid Managed Care	$2.51

OXALIC ACID,24HR UR(W/CR) I

Facility

$390.00

Service Code	HCPCS 82570
Hospital Charge Code	39990064A
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

OXALIC ACID,24HR UR(W/CR) I

Facility

$390.00

Service Code	HCPCS 82570
Hospital Charge Code	3990129A
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

OXALIC ACID,24HR UR(W/CR) I

Facility

$390.00

Service Code	HCPCS 82570
Hospital Charge Code	39990064A
Hospital Revenue Code	301
Min. Negotiated Rate	$4.14
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$14.09
Rate for Payer: Aetna Medicare Advantage	$16.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.79
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$5.18
Rate for Payer: Clover Medicare Advantage	$4.92
Rate for Payer: EmblemHealth Commercial	$15.54
Rate for Payer: Humana Medicare Advantage	$5.34
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$101.40
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$4.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.18
Rate for Payer: Wellcare Medicare Advantage	$5.18
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

OXALIC ACID,24HR UR(W/CR) I

Facility

$390.00

Service Code	HCPCS 82570
Hospital Charge Code	3990129A
Hospital Revenue Code	301
Min. Negotiated Rate	$4.14
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$14.09
Rate for Payer: Aetna Medicare Advantage	$16.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$18.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$18.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$18.79
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$5.18
Rate for Payer: Clover Medicare Advantage	$4.92
Rate for Payer: EmblemHealth Commercial	$15.54
Rate for Payer: Humana Medicare Advantage	$5.34
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$101.40
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$4.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.18
Rate for Payer: Wellcare Medicare Advantage	$5.18
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

OXALIC ACID,24HR UR(W/CR) II

Facility

$390.00

Service Code	HCPCS 83945
Hospital Charge Code	3990129B
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

OXALIC ACID,24HR UR(W/CR) II

Facility

$390.00

Service Code	HCPCS 83945
Hospital Charge Code	3990129B
Hospital Revenue Code	301
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$39.30
Rate for Payer: Aetna Medicare Advantage	$46.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$52.42
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$14.45
Rate for Payer: Clover Medicare Advantage	$13.73
Rate for Payer: EmblemHealth Commercial	$43.35
Rate for Payer: Humana Medicare Advantage	$14.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$101.40
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$11.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.45
Rate for Payer: Wellcare Medicare Advantage	$14.45
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

OXALIC ACID,24HR UR(W/CR) II

Facility

$390.00

Service Code	HCPCS 83945
Hospital Charge Code	39990064B
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

OXALIC ACID,24HR UR(W/CR) II

Facility

$390.00

Service Code	HCPCS 83945
Hospital Charge Code	39990064B
Hospital Revenue Code	301
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$39.30
Rate for Payer: Aetna Medicare Advantage	$46.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$52.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$14.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$28.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$52.42
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$14.45
Rate for Payer: Clover Medicare Advantage	$13.73
Rate for Payer: EmblemHealth Commercial	$43.35
Rate for Payer: Humana Medicare Advantage	$14.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$14.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$101.40
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$11.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.45
Rate for Payer: Wellcare Medicare Advantage	$14.45
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

OXANDROLONE 2.5MG TABLET

Facility

$46.43

Service Code	NDC 68084042421
Hospital Charge Code	60632260
Hospital Revenue Code	250
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$23.21
Rate for Payer: Aetna Commercial	$17.64
Rate for Payer: Aetna Medicare Advantage	$13.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.84
Rate for Payer: Cigna Commercial	$23.21
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.07
Rate for Payer: Oxford Commercial	$9.29
Rate for Payer: Qualcare PPO/HMO/WC	$6.96
Rate for Payer: UnitedHealthcare Commercial	$9.29
Rate for Payer: UnitedHealthcare Community & State	$1.47
Rate for Payer: Wellpoint Medicaid Managed Care	$1.32

OXANDROLONE 2.5MG TABLET

Facility

$46.43

Service Code	NDC 68084042421
Hospital Charge Code	60632260
Hospital Revenue Code	250
Min. Negotiated Rate	$6.96
Max. Negotiated Rate	$6.96
Rate for Payer: Qualcare PPO/HMO/WC	$6.96

OXAZEPAM

Facility

$127.15

Service Code	HCPCS 80346
Hospital Charge Code	39900445
Hospital Revenue Code	301
Min. Negotiated Rate	$3.61
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$48.32
Rate for Payer: Aetna Medicare Advantage	$38.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$32.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$32.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$32.42
Rate for Payer: Cigna Commercial	$63.58
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$33.06
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$19.07
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$20.96
Rate for Payer: Wellpoint Medicaid Managed Care	$3.61

Know your out-of-pocket cost for care.

All Charges