Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

COMPONENT FEMORAL CEMTD SZ4+ R

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677557
Hospital Revenue Code	278
Min. Negotiated Rate	$192.80
Max. Negotiated Rate	$4,000.00
Rate for Payer: Aetna Commercial	$3,040.00
Rate for Payer: Aetna Medicare Advantage	$2,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,040.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,040.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,040.00
Rate for Payer: Cigna Commercial	$4,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,936.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,760.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,200.00
Rate for Payer: UnitedHealthcare Community & State	$192.80
Rate for Payer: Wellpoint Medicaid Managed Care	$212.00

COMPONENT FEMORAL CEMTD SZ6 RT

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677520
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,936.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,600.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,936.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,760.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,200.00

COMPONENT FEMORAL CEMTD SZ6 RT

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677520
Hospital Revenue Code	278
Min. Negotiated Rate	$192.80
Max. Negotiated Rate	$4,000.00
Rate for Payer: Aetna Commercial	$3,040.00
Rate for Payer: Aetna Medicare Advantage	$2,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,040.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,040.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,040.00
Rate for Payer: Cigna Commercial	$4,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,936.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,760.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,200.00
Rate for Payer: UnitedHealthcare Community & State	$192.80
Rate for Payer: Wellpoint Medicaid Managed Care	$212.00

COMPONENT FEMORAL PS LEFT 3

Facility

$12,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270687679
Hospital Revenue Code	278
Min. Negotiated Rate	$289.20
Max. Negotiated Rate	$6,000.00
Rate for Payer: Aetna Commercial	$4,560.00
Rate for Payer: Aetna Medicare Advantage	$3,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,060.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,060.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,060.00
Rate for Payer: Cigna Commercial	$6,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,904.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,640.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Community & State	$289.20
Rate for Payer: Wellpoint Medicaid Managed Care	$318.00

COMPONENT FEMORAL PS LEFT 3

Facility

$12,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270687679
Hospital Revenue Code	278
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$2,904.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,904.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,640.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

COMPONENT FEMORAL PS RIGHT 4N

Facility

$12,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270676912
Hospital Revenue Code	278
Min. Negotiated Rate	$1,800.00
Max. Negotiated Rate	$2,904.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,400.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,904.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,640.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00

COMPONENT FEMORAL PS RIGHT 4N

Facility

$12,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270676912
Hospital Revenue Code	278
Min. Negotiated Rate	$289.20
Max. Negotiated Rate	$6,000.00
Rate for Payer: Aetna Commercial	$4,560.00
Rate for Payer: Aetna Medicare Advantage	$3,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,060.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,060.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,060.00
Rate for Payer: Cigna Commercial	$6,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,904.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,640.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,800.00
Rate for Payer: UnitedHealthcare Community & State	$289.20
Rate for Payer: Wellpoint Medicaid Managed Care	$318.00

COMPONENT FEMORAL SZ 1 LM/RL

Facility

$12,100.00

Hospital Charge Code	270668664
Hospital Revenue Code	278
Min. Negotiated Rate	$1,815.00
Max. Negotiated Rate	$2,928.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00

COMPONENT FEMORAL SZ 1 LM/RL

Facility

$12,100.00

Hospital Charge Code	270668664
Hospital Revenue Code	278
Min. Negotiated Rate	$291.61
Max. Negotiated Rate	$6,050.00
Rate for Payer: Aetna Commercial	$4,598.00
Rate for Payer: Aetna Medicare Advantage	$3,630.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,085.50
Rate for Payer: Cigna Commercial	$6,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00
Rate for Payer: UnitedHealthcare Community & State	$291.61
Rate for Payer: Wellpoint Medicaid Managed Care	$320.65

COMPONENT FEMORAL SZ 1 RM/LL

Facility

$12,100.00

Hospital Charge Code	270668671
Hospital Revenue Code	278
Min. Negotiated Rate	$1,815.00
Max. Negotiated Rate	$2,928.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00

COMPONENT FEMORAL SZ 1 RM/LL

Facility

$12,100.00

Hospital Charge Code	270668671
Hospital Revenue Code	278
Min. Negotiated Rate	$291.61
Max. Negotiated Rate	$6,050.00
Rate for Payer: Aetna Commercial	$4,598.00
Rate for Payer: Aetna Medicare Advantage	$3,630.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,085.50
Rate for Payer: Cigna Commercial	$6,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00
Rate for Payer: UnitedHealthcare Community & State	$291.61
Rate for Payer: Wellpoint Medicaid Managed Care	$320.65

COMPONENT FEMORAL SZ 2 LM/RL

Facility

$12,100.00

Hospital Charge Code	270668665
Hospital Revenue Code	278
Min. Negotiated Rate	$1,815.00
Max. Negotiated Rate	$2,928.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00

COMPONENT FEMORAL SZ 2 LM/RL

Facility

$12,100.00

Hospital Charge Code	270668665
Hospital Revenue Code	278
Min. Negotiated Rate	$291.61
Max. Negotiated Rate	$6,050.00
Rate for Payer: Aetna Commercial	$4,598.00
Rate for Payer: Aetna Medicare Advantage	$3,630.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,085.50
Rate for Payer: Cigna Commercial	$6,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00
Rate for Payer: UnitedHealthcare Community & State	$291.61
Rate for Payer: Wellpoint Medicaid Managed Care	$320.65

COMPONENT FEMORAL SZ 2N LEFT

Facility

$7,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270677671
Hospital Revenue Code	278
Min. Negotiated Rate	$180.75
Max. Negotiated Rate	$3,750.00
Rate for Payer: Aetna Commercial	$2,850.00
Rate for Payer: Aetna Medicare Advantage	$2,250.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,912.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,912.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,912.50
Rate for Payer: Cigna Commercial	$3,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,815.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,650.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,125.00
Rate for Payer: UnitedHealthcare Community & State	$180.75
Rate for Payer: Wellpoint Medicaid Managed Care	$198.75

COMPONENT FEMORAL SZ 2N LEFT

Facility

$7,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270677671
Hospital Revenue Code	278
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$1,815.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,815.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,650.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,125.00

COMPONENT FEMORAL SZ 2 RM/LL

Facility

$12,100.00

Service Code	HCPCS C1776
Hospital Charge Code	270668672
Hospital Revenue Code	278
Min. Negotiated Rate	$1,815.00
Max. Negotiated Rate	$2,928.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00

COMPONENT FEMORAL SZ 2 RM/LL

Facility

$12,100.00

Service Code	HCPCS C1776
Hospital Charge Code	270668672
Hospital Revenue Code	278
Min. Negotiated Rate	$291.61
Max. Negotiated Rate	$6,050.00
Rate for Payer: Aetna Commercial	$4,598.00
Rate for Payer: Aetna Medicare Advantage	$3,630.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,085.50
Rate for Payer: Cigna Commercial	$6,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00
Rate for Payer: UnitedHealthcare Community & State	$291.61
Rate for Payer: Wellpoint Medicaid Managed Care	$320.65

COMPONENT FEMORAL SZ 3 LEFT

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677839
Hospital Revenue Code	278
Min. Negotiated Rate	$900.00
Max. Negotiated Rate	$1,452.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,320.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00

COMPONENT FEMORAL SZ 3 LEFT

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270677839
Hospital Revenue Code	278
Min. Negotiated Rate	$144.60
Max. Negotiated Rate	$3,000.00
Rate for Payer: Aetna Commercial	$2,280.00
Rate for Payer: Aetna Medicare Advantage	$1,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,530.00
Rate for Payer: Cigna Commercial	$3,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,320.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00
Rate for Payer: UnitedHealthcare Community & State	$144.60
Rate for Payer: Wellpoint Medicaid Managed Care	$159.00

COMPONENT FEMORAL SZ 3 LM/RL

Facility

$12,100.00

Service Code	HCPCS C1776
Hospital Charge Code	270668487
Hospital Revenue Code	278
Min. Negotiated Rate	$291.61
Max. Negotiated Rate	$6,050.00
Rate for Payer: Aetna Commercial	$4,598.00
Rate for Payer: Aetna Medicare Advantage	$3,630.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,085.50
Rate for Payer: Cigna Commercial	$6,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00
Rate for Payer: UnitedHealthcare Community & State	$291.61
Rate for Payer: Wellpoint Medicaid Managed Care	$320.65

COMPONENT FEMORAL SZ 3 LM/RL

Facility

$12,100.00

Service Code	HCPCS C1776
Hospital Charge Code	270668487
Hospital Revenue Code	278
Min. Negotiated Rate	$1,815.00
Max. Negotiated Rate	$2,928.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00

COMPONENT FEMORAL SZ 3 RIGHT

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270678165
Hospital Revenue Code	278
Min. Negotiated Rate	$900.00
Max. Negotiated Rate	$1,452.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,320.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00

COMPONENT FEMORAL SZ 3 RIGHT

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270678165
Hospital Revenue Code	278
Min. Negotiated Rate	$144.60
Max. Negotiated Rate	$3,000.00
Rate for Payer: Aetna Commercial	$2,280.00
Rate for Payer: Aetna Medicare Advantage	$1,800.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,530.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,200.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,530.00
Rate for Payer: Cigna Commercial	$3,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,452.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,320.00
Rate for Payer: Qualcare PPO/HMO/WC	$900.00
Rate for Payer: UnitedHealthcare Community & State	$144.60
Rate for Payer: Wellpoint Medicaid Managed Care	$159.00

COMPONENT FEMORAL SZ 3 RM/LL

Facility

$12,100.00

Service Code	HCPCS C1776
Hospital Charge Code	270668673
Hospital Revenue Code	278
Min. Negotiated Rate	$291.61
Max. Negotiated Rate	$6,050.00
Rate for Payer: Aetna Commercial	$4,598.00
Rate for Payer: Aetna Medicare Advantage	$3,630.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,085.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,085.50
Rate for Payer: Cigna Commercial	$6,050.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00
Rate for Payer: UnitedHealthcare Community & State	$291.61
Rate for Payer: Wellpoint Medicaid Managed Care	$320.65

COMPONENT FEMORAL SZ 3 RM/LL

Facility

$12,100.00

Service Code	HCPCS C1776
Hospital Charge Code	270668673
Hospital Revenue Code	278
Min. Negotiated Rate	$1,815.00
Max. Negotiated Rate	$2,928.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,420.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,928.20
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,662.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,815.00

Know your out-of-pocket cost for care.

All Charges