Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

EXC BLES S/N/EX G,0.5CM/<

Facility

$7,612.30

Service Code	HCPCS 11420
Hospital Charge Code	16000227
Hospital Revenue Code	360
Min. Negotiated Rate	$183.46
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$862.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,283.69
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Community & State	$183.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$201.73

EXC BLES S/N/EX G,0.5CM/<

Facility

$7,612.30

Service Code	HCPCS 11420
Hospital Charge Code	16000227
Hospital Revenue Code	360
Min. Negotiated Rate	$1,141.85
Max. Negotiated Rate	$1,141.85
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85

EXC BLES S/N/EX G,0.6-1.0CM

Facility

$7,612.30

Service Code	HCPCS 11421
Hospital Charge Code	16000320
Hospital Revenue Code	360
Min. Negotiated Rate	$183.46
Max. Negotiated Rate	$3,593.00
Rate for Payer: Aetna Commercial	$2,288.28
Rate for Payer: Aetna Medicare Advantage	$2,725.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,036.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,036.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$841.28
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,016.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,036.77
Rate for Payer: Cigna Commercial	$1,686.34
Rate for Payer: Cigna Medicare Advantage	$841.28
Rate for Payer: Clover Medicare Advantage	$799.22
Rate for Payer: EmblemHealth Commercial	$2,523.84
Rate for Payer: Humana Medicare Advantage	$866.52
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$841.28
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,283.69
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Community & State	$183.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$841.28
Rate for Payer: Wellcare Medicare Advantage	$841.28
Rate for Payer: Wellpoint Medicaid Managed Care	$201.73

EXC BLES S/N/EX G,0.6-1.0CM

Facility

$7,612.30

Service Code	HCPCS 11421
Hospital Charge Code	16000320
Hospital Revenue Code	360
Min. Negotiated Rate	$1,141.85
Max. Negotiated Rate	$1,141.85
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85

EXC BLES S/N/EX G,1.1-2.0CM

Facility

$7,612.30

Service Code	HCPCS 11422
Hospital Charge Code	16000210
Hospital Revenue Code	360
Min. Negotiated Rate	$1,141.85
Max. Negotiated Rate	$1,141.85
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85

EXC BLES S/N/EX G,1.1-2.0CM

Facility

$7,612.30

Service Code	HCPCS 11422
Hospital Charge Code	16000210
Hospital Revenue Code	360
Min. Negotiated Rate	$183.46
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,016.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,283.69
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,141.85
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Community & State	$183.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$201.73

EXC BLES S/N/EX G,2.1-3.0CM

Facility

$16,857.75

Service Code	HCPCS 11423
Hospital Charge Code	16000219
Hospital Revenue Code	360
Min. Negotiated Rate	$406.27
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,016.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,057.32
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.66
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$406.27
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$446.73

EXC BLES S/N/EX G,2.1-3.0CM

Facility

$16,857.75

Service Code	HCPCS 11423
Hospital Charge Code	16000219
Hospital Revenue Code	360
Min. Negotiated Rate	$2,528.66
Max. Negotiated Rate	$2,528.66
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.66

EXC BLES S/N/EX G,3.1-4.0CM

Facility

$16,853.95

Service Code	HCPCS 11424
Hospital Charge Code	16000226
Hospital Revenue Code	360
Min. Negotiated Rate	$406.18
Max. Negotiated Rate	$7,082.74
Rate for Payer: Aetna Commercial	$5,337.02
Rate for Payer: Aetna Medicare Advantage	$6,357.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,082.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,962.14
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,016.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,082.74
Rate for Payer: Cigna Commercial	$3,933.12
Rate for Payer: Cigna Medicare Advantage	$1,962.14
Rate for Payer: Clover Medicare Advantage	$1,864.03
Rate for Payer: EmblemHealth Commercial	$5,886.42
Rate for Payer: Humana Medicare Advantage	$2,021.00
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,962.14
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,056.19
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.09
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$406.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,962.14
Rate for Payer: Wellcare Medicare Advantage	$1,962.14
Rate for Payer: Wellpoint Medicaid Managed Care	$446.63

EXC BLES S/N/EX G,3.1-4.0CM

Facility

$16,853.95

Service Code	HCPCS 11424
Hospital Charge Code	16000226
Hospital Revenue Code	360
Min. Negotiated Rate	$2,528.09
Max. Negotiated Rate	$2,528.09
Rate for Payer: Qualcare PPO/HMO/WC	$2,528.09

EXC BLES S/N/EX G,> 4.0CM

Facility

$27,889.82

Service Code	HCPCS 11426
Hospital Charge Code	16000220
Hospital Revenue Code	360
Min. Negotiated Rate	$4,183.47
Max. Negotiated Rate	$4,183.47
Rate for Payer: Qualcare PPO/HMO/WC	$4,183.47

EXC BLES S/N/EX G,> 4.0CM

Facility

$27,889.82

Service Code	HCPCS 11426
Hospital Charge Code	16000220
Hospital Revenue Code	360
Min. Negotiated Rate	$672.14
Max. Negotiated Rate	$12,456.64
Rate for Payer: Aetna Commercial	$9,386.39
Rate for Payer: Aetna Medicare Advantage	$11,180.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12,456.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12,456.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,450.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,016.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12,456.64
Rate for Payer: Cigna Commercial	$6,917.28
Rate for Payer: Cigna Medicare Advantage	$3,450.88
Rate for Payer: Clover Medicare Advantage	$3,278.34
Rate for Payer: EmblemHealth Commercial	$10,352.64
Rate for Payer: Humana Medicare Advantage	$3,554.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,450.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$8,366.95
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,183.47
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$672.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,450.88
Rate for Payer: Wellcare Medicare Advantage	$3,450.88
Rate for Payer: Wellpoint Medicaid Managed Care	$739.08

EXC BONE BX,DEEP

Facility

$20,625.50

Service Code	HCPCS 20245
Hospital Charge Code	16000667
Hospital Revenue Code	360
Min. Negotiated Rate	$497.07
Max. Negotiated Rate	$12,456.64
Rate for Payer: Aetna Commercial	$9,386.39
Rate for Payer: Aetna Medicare Advantage	$11,180.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$12,456.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$12,456.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,450.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,355.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$12,456.64
Rate for Payer: Cigna Commercial	$6,917.28
Rate for Payer: Cigna Medicare Advantage	$3,450.88
Rate for Payer: Clover Medicare Advantage	$3,278.34
Rate for Payer: EmblemHealth Commercial	$10,352.64
Rate for Payer: Humana Medicare Advantage	$3,554.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,450.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,187.65
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,093.82
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$497.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,450.88
Rate for Payer: Wellcare Medicare Advantage	$3,450.88
Rate for Payer: Wellpoint Medicaid Managed Care	$546.58

EXC BONE BX,DEEP

Facility

$20,625.50

Service Code	HCPCS 20245
Hospital Charge Code	16000667
Hospital Revenue Code	360
Min. Negotiated Rate	$3,093.82
Max. Negotiated Rate	$3,093.82
Rate for Payer: Qualcare PPO/HMO/WC	$3,093.82

EXC BREAST LES BY N LOC,SGL

Facility

$10,974.15

Service Code	HCPCS 19125
Hospital Charge Code	16000285
Hospital Revenue Code	360
Min. Negotiated Rate	$264.48
Max. Negotiated Rate	$16,791.02
Rate for Payer: Aetna Commercial	$12,652.46
Rate for Payer: Aetna Medicare Advantage	$15,071.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$16,791.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$16,791.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4,651.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,355.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$16,791.02
Rate for Payer: Cigna Commercial	$9,324.19
Rate for Payer: Cigna Medicare Advantage	$4,651.64
Rate for Payer: Clover Medicare Advantage	$4,419.06
Rate for Payer: EmblemHealth Commercial	$13,954.92
Rate for Payer: Humana Medicare Advantage	$4,791.19
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4,651.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,292.24
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,646.12
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$264.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,651.64
Rate for Payer: Wellcare Medicare Advantage	$4,651.64
Rate for Payer: Wellpoint Medicaid Managed Care	$290.81

EXC BREAST LES BY N LOC,SGL

Facility

$10,974.15

Service Code	HCPCS 19125
Hospital Charge Code	16000285
Hospital Revenue Code	360
Min. Negotiated Rate	$1,646.12
Max. Negotiated Rate	$1,646.12
Rate for Payer: Qualcare PPO/HMO/WC	$1,646.12

EXCEED LORDOTIC 25LX10WX11H

Facility

$25,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270704714
Hospital Revenue Code	278
Min. Negotiated Rate	$602.50
Max. Negotiated Rate	$12,500.00
Rate for Payer: Aetna Commercial	$9,500.00
Rate for Payer: Aetna Medicare Advantage	$7,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6,375.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6,375.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,000.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6,375.00
Rate for Payer: Cigna Commercial	$12,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,500.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,750.00
Rate for Payer: UnitedHealthcare Community & State	$602.50
Rate for Payer: Wellpoint Medicaid Managed Care	$662.50

EXCEED LORDOTIC 25LX10WX11H

Facility

$25,000.00

Service Code	HCPCS C1713
Hospital Charge Code	270704714
Hospital Revenue Code	278
Min. Negotiated Rate	$3,750.00
Max. Negotiated Rate	$6,050.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$6,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$5,500.00
Rate for Payer: Qualcare PPO/HMO/WC	$3,750.00

EXCELSIOR SL-10 STRAIGHT 2 TIP

Facility

$4,726.25

Service Code	HCPCS C1887
Hospital Charge Code	270689725
Hospital Revenue Code	272
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$2,363.12
Rate for Payer: Aetna Commercial	$1,795.97
Rate for Payer: Aetna Medicare Advantage	$1,417.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,205.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,205.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,205.19
Rate for Payer: Cigna Commercial	$2,363.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,417.88
Rate for Payer: Oxford Commercial	$945.25
Rate for Payer: Qualcare PPO/HMO/WC	$708.94
Rate for Payer: UnitedHealthcare Commercial	$945.25
Rate for Payer: UnitedHealthcare Community & State	$113.90
Rate for Payer: Wellpoint Medicaid Managed Care	$125.25

EXCELSIOR SL-10 STRAIGHT 2 TIP

Facility

$4,726.25

Service Code	HCPCS C1887
Hospital Charge Code	270689725
Hospital Revenue Code	272
Min. Negotiated Rate	$708.94
Max. Negotiated Rate	$708.94
Rate for Payer: Qualcare PPO/HMO/WC	$708.94

EXCERCISE MONTHLY INITIAL III

Facility

$40.00

Hospital Charge Code	5200051
Hospital Revenue Code	999
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare Advantage	$12.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.20
Rate for Payer: Cigna Commercial	$20.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.00
Rate for Payer: Qualcare PPO/HMO/WC	$6.00
Rate for Payer: UnitedHealthcare Community & State	$0.96
Rate for Payer: Wellpoint Medicaid Managed Care	$1.06

EXCERCISE MONTHLY INITIAL III

Facility

$40.00

Hospital Charge Code	5200051
Hospital Revenue Code	999
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$6.00
Rate for Payer: Qualcare PPO/HMO/WC	$6.00

EXCERCISE ONE WEEK INITIAL

Facility

$10.00

Hospital Charge Code	5200053
Hospital Revenue Code	943
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1,749.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare Advantage	$3.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.55
Rate for Payer: Cigna Commercial	$5.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.00
Rate for Payer: Oxford Commercial	$997.00
Rate for Payer: Qualcare PPO/HMO/WC	$1.50
Rate for Payer: UnitedHealthcare Commercial	$1,749.00
Rate for Payer: UnitedHealthcare Community & State	$0.24
Rate for Payer: Wellpoint Medicaid Managed Care	$0.27

EXCERCISE ONE WEEK INITIAL

Facility

$10.00

Hospital Charge Code	5200053
Hospital Revenue Code	943
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.50
Rate for Payer: Qualcare PPO/HMO/WC	$1.50

EXCERCISE THREE WEEK INITIAL

Facility

$30.00

Hospital Charge Code	5200055
Hospital Revenue Code	999
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Qualcare PPO/HMO/WC	$4.50

Know your out-of-pocket cost for care.

All Charges