Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

IR ILIAC REVASC W/STENT ADD-ON

Facility

$15,877.00

Service Code	HCPCS 37259
Hospital Charge Code	411037223
Hospital Revenue Code	361
Min. Negotiated Rate	$2,381.55
Max. Negotiated Rate	$2,381.55
Rate for Payer: Qualcare PPO/HMO/WC	$2,381.55

IR ILIAC REVASC W/STENT ADD-ON

Facility

$35,674.97

Service Code	HCPCS 37223
Hospital Charge Code	7411513
Hospital Revenue Code	361
Min. Negotiated Rate	$5,351.25
Max. Negotiated Rate	$5,351.25
Rate for Payer: Qualcare PPO/HMO/WC	$5,351.25

IR ILIAC REVASC W/STENT ADD-ON

Facility

$35,674.97

Service Code	HCPCS 37223
Hospital Charge Code	7411513
Hospital Revenue Code	361
Min. Negotiated Rate	$859.77
Max. Negotiated Rate	$17,837.49
Rate for Payer: Aetna Commercial	$13,556.49
Rate for Payer: Aetna Medicare Advantage	$10,702.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9,097.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9,097.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9,097.12
Rate for Payer: Cigna Commercial	$17,837.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10,702.49
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$5,351.25
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$859.77
Rate for Payer: Wellpoint Medicaid Managed Care	$945.39

IR ILIAC REVASC W/STENT ADD-ON

Facility

$35,674.97

Service Code	HCPCS 37223
Hospital Charge Code	321037223
Hospital Revenue Code	361
Min. Negotiated Rate	$859.77
Max. Negotiated Rate	$17,837.49
Rate for Payer: Aetna Commercial	$13,556.49
Rate for Payer: Aetna Medicare Advantage	$10,702.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9,097.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9,097.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9,097.12
Rate for Payer: Cigna Commercial	$17,837.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10,702.49
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$5,351.25
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$859.77
Rate for Payer: Wellpoint Medicaid Managed Care	$945.39

IR ILIAC REVASC W/STENT ADD-ON

Facility

$15,877.00

Service Code	HCPCS 37223
Hospital Charge Code	366837223
Hospital Revenue Code	361
Min. Negotiated Rate	$382.64
Max. Negotiated Rate	$14,834.00
Rate for Payer: Aetna Commercial	$6,033.26
Rate for Payer: Aetna Medicare Advantage	$4,763.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,048.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,048.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,048.64
Rate for Payer: Cigna Commercial	$7,938.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,763.10
Rate for Payer: Oxford Commercial	$8,679.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,381.55
Rate for Payer: UnitedHealthcare Commercial	$14,834.00
Rate for Payer: UnitedHealthcare Community & State	$382.64
Rate for Payer: Wellpoint Medicaid Managed Care	$420.74

IR IMAGE CATH FLUID COLXN VISC

Facility

$5,392.12

Service Code	HCPCS 49405
Hospital Charge Code	93000108
Hospital Revenue Code	361
Min. Negotiated Rate	$129.95
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	$1,626.00
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	$1,617.64
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: Qualcare PPO/HMO/WC	$808.82
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Community & State	$129.95
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	$142.89

IR IMAGE CATH FLUID COLXN VISC

Facility

$5,392.12

Service Code	HCPCS 49405
Hospital Charge Code	93000108
Hospital Revenue Code	361
Min. Negotiated Rate	$808.82
Max. Negotiated Rate	$808.82
Rate for Payer: Qualcare PPO/HMO/WC	$808.82

IR-INCISION BREAST LESION

Facility

$3,801.00

Service Code	HCPCS 19020
Hospital Charge Code	7411338
Hospital Revenue Code	361
Min. Negotiated Rate	$570.15
Max. Negotiated Rate	$570.15
Rate for Payer: Qualcare PPO/HMO/WC	$570.15

IR-INCISION BREAST LESION

Facility

$3,801.00

Service Code	HCPCS 19020
Hospital Charge Code	7411338
Hospital Revenue Code	361
Min. Negotiated Rate	$91.60
Max. Negotiated Rate	$8,157.00
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	$1,140.30
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$570.15
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$91.60
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	$100.73

IR-INCISION BREAST LESION

Facility

$3,801.00

Service Code	HCPCS 19020
Hospital Charge Code	2690005
Hospital Revenue Code	361
Min. Negotiated Rate	$570.15
Max. Negotiated Rate	$570.15
Rate for Payer: Qualcare PPO/HMO/WC	$570.15

IR-INCISION BREAST LESION

Facility

$3,801.00

Service Code	HCPCS 19020
Hospital Charge Code	2690005
Hospital Revenue Code	361
Min. Negotiated Rate	$91.60
Max. Negotiated Rate	$8,157.00
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	$1,140.30
Rate for Payer: Oxford Commercial	$4,871.00
Rate for Payer: Qualcare PPO/HMO/WC	$570.15
Rate for Payer: UnitedHealthcare Commercial	$8,157.00
Rate for Payer: UnitedHealthcare Community & State	$91.60
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	$100.73

IR INCISION OF GALL BLADDER

Facility

$10,885.55

Service Code	HCPCS 47490
Hospital Charge Code	7411558
Hospital Revenue Code	360
Min. Negotiated Rate	$1,632.83
Max. Negotiated Rate	$1,632.83
Rate for Payer: Qualcare PPO/HMO/WC	$1,632.83

IR INCISION OF GALL BLADDER

Facility

$17,259.20

Service Code	HCPCS 47490
Hospital Charge Code	2011281
Hospital Revenue Code	361
Min. Negotiated Rate	$415.95
Max. Negotiated Rate	$15,354.26
Rate for Payer: Aetna Commercial	$11,569.82
Rate for Payer: Aetna Medicare Advantage	$13,781.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15,354.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15,354.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4,253.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15,354.26
Rate for Payer: Cigna Commercial	$8,526.35
Rate for Payer: Cigna Medicare Advantage	$4,253.61
Rate for Payer: Clover Medicare Advantage	$4,040.93
Rate for Payer: EmblemHealth Commercial	$12,760.83
Rate for Payer: Humana Medicare Advantage	$4,381.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4,253.61
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,177.76
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,588.88
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$415.95
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,253.61
Rate for Payer: Wellcare Medicare Advantage	$4,253.61
Rate for Payer: Wellpoint Medicaid Managed Care	$457.37

IR INCISION OF GALL BLADDER

Facility

$17,259.20

Service Code	HCPCS 47490
Hospital Charge Code	2011281
Hospital Revenue Code	361
Min. Negotiated Rate	$2,588.88
Max. Negotiated Rate	$2,588.88
Rate for Payer: Qualcare PPO/HMO/WC	$2,588.88

IR INCISION OF GALL BLADDER

Facility

$10,885.55

Service Code	HCPCS 47490
Hospital Charge Code	7411558
Hospital Revenue Code	360
Min. Negotiated Rate	$262.34
Max. Negotiated Rate	$15,354.26
Rate for Payer: Aetna Commercial	$11,569.82
Rate for Payer: Aetna Medicare Advantage	$13,781.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15,354.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15,354.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4,253.61
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,626.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15,354.26
Rate for Payer: Cigna Commercial	$8,526.35
Rate for Payer: Cigna Medicare Advantage	$4,253.61
Rate for Payer: Clover Medicare Advantage	$4,040.93
Rate for Payer: EmblemHealth Commercial	$12,760.83
Rate for Payer: Humana Medicare Advantage	$4,381.22
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4,253.61
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,265.66
Rate for Payer: Oxford Commercial	$6,055.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,632.83
Rate for Payer: UnitedHealthcare Commercial	$10,232.00
Rate for Payer: UnitedHealthcare Community & State	$262.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,253.61
Rate for Payer: Wellcare Medicare Advantage	$4,253.61
Rate for Payer: Wellpoint Medicaid Managed Care	$288.47

IR INFUSION THERAPY ANY METHOD

Facility

$2,998.75

Hospital Charge Code	2600089
Hospital Revenue Code	320
Min. Negotiated Rate	$72.27
Max. Negotiated Rate	$1,975.00
Rate for Payer: Aetna Commercial	$1,139.53
Rate for Payer: Aetna Medicare Advantage	$899.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$764.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$764.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$764.68
Rate for Payer: Cigna Commercial	$1,499.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$899.62
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$449.81
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$72.27
Rate for Payer: Wellpoint Medicaid Managed Care	$79.47

IR INFUSION THERAPY ANY METHOD

Facility

$2,998.75

Hospital Charge Code	2600089
Hospital Revenue Code	320
Min. Negotiated Rate	$449.81
Max. Negotiated Rate	$449.81
Rate for Payer: Qualcare PPO/HMO/WC	$449.81

IR INF VENACAVAGRAM

Facility

$15,468.50

Service Code	HCPCS 75825
Hospital Charge Code	2001154
Hospital Revenue Code	320
Min. Negotiated Rate	$227.67
Max. Negotiated Rate	$13,540.60
Rate for Payer: Aetna Commercial	$10,203.18
Rate for Payer: Aetna Medicare Advantage	$12,153.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,751.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$227.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13,540.60
Rate for Payer: Cigna Commercial	$7,519.21
Rate for Payer: Cigna Medicare Advantage	$2,625.82
Rate for Payer: Clover Medicare Advantage	$3,563.61
Rate for Payer: EmblemHealth Commercial	$11,253.51
Rate for Payer: Humana Medicare Advantage	$3,863.71
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,751.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,640.55
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$372.79
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,751.17
Rate for Payer: Wellcare Medicare Advantage	$3,751.17
Rate for Payer: Wellpoint Medicaid Managed Care	$409.92

IR INF VENACAVAGRAM

Facility

$15,468.50

Service Code	HCPCS 75825
Hospital Charge Code	2001154
Hospital Revenue Code	320
Min. Negotiated Rate	$2,320.28
Max. Negotiated Rate	$2,320.28
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28

IR INF VENACAVAGRAM

Facility

$15,468.50

Service Code	HCPCS 75825
Hospital Charge Code	321075825
Hospital Revenue Code	320
Min. Negotiated Rate	$2,320.28
Max. Negotiated Rate	$2,320.28
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28

IR INF VENACAVAGRAM

Facility

$15,468.50

Service Code	HCPCS 75825
Hospital Charge Code	321075825
Hospital Revenue Code	320
Min. Negotiated Rate	$227.67
Max. Negotiated Rate	$13,540.60
Rate for Payer: Aetna Commercial	$10,203.18
Rate for Payer: Aetna Medicare Advantage	$12,153.79
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,540.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$3,751.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$227.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13,540.60
Rate for Payer: Cigna Commercial	$7,519.21
Rate for Payer: Cigna Medicare Advantage	$2,625.82
Rate for Payer: Clover Medicare Advantage	$3,563.61
Rate for Payer: EmblemHealth Commercial	$11,253.51
Rate for Payer: Humana Medicare Advantage	$3,863.71
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$3,751.17
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,640.55
Rate for Payer: Oxford Commercial	$1,311.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,320.28
Rate for Payer: UnitedHealthcare Commercial	$1,975.00
Rate for Payer: UnitedHealthcare Community & State	$372.79
Rate for Payer: UnitedHealthcare Medicare Advantage	$3,751.17
Rate for Payer: Wellcare Medicare Advantage	$3,751.17
Rate for Payer: Wellpoint Medicaid Managed Care	$409.92

IR INITIAL CONSULT 20 MIN

Facility

$292.50

Service Code	HCPCS 99251
Hospital Charge Code	2011285
Hospital Revenue Code	949
Min. Negotiated Rate	$7.05
Max. Negotiated Rate	$2,407.00
Rate for Payer: Aetna Commercial	$111.15
Rate for Payer: Aetna Medicare Advantage	$87.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$74.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$74.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$74.59
Rate for Payer: Cigna Commercial	$146.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$87.75
Rate for Payer: Oxford Commercial	$1,373.00
Rate for Payer: Qualcare PPO/HMO/WC	$43.88
Rate for Payer: UnitedHealthcare Commercial	$2,407.00
Rate for Payer: UnitedHealthcare Community & State	$7.05
Rate for Payer: Wellpoint Medicaid Managed Care	$7.75

IR INITIAL CONSULT 20 MIN

Facility

$292.50

Service Code	HCPCS 99251
Hospital Charge Code	2011285
Hospital Revenue Code	949
Min. Negotiated Rate	$43.88
Max. Negotiated Rate	$43.88
Rate for Payer: Qualcare PPO/HMO/WC	$43.88

IR INIT INPAT CONSULT FOCUSED

Facility

$588.75

Service Code	HCPCS 99252
Hospital Charge Code	2011286
Hospital Revenue Code	949
Min. Negotiated Rate	$14.19
Max. Negotiated Rate	$2,407.00
Rate for Payer: Aetna Commercial	$223.72
Rate for Payer: Aetna Medicare Advantage	$176.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$150.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$150.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$150.13
Rate for Payer: Cigna Commercial	$294.38
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$176.62
Rate for Payer: Oxford Commercial	$1,373.00
Rate for Payer: Qualcare PPO/HMO/WC	$88.31
Rate for Payer: UnitedHealthcare Commercial	$2,407.00
Rate for Payer: UnitedHealthcare Community & State	$14.19
Rate for Payer: Wellpoint Medicaid Managed Care	$15.60

IR INIT INPAT CONSULT FOCUSED

Facility

$588.75

Service Code	HCPCS 99252
Hospital Charge Code	2011286
Hospital Revenue Code	949
Min. Negotiated Rate	$88.31
Max. Negotiated Rate	$88.31
Rate for Payer: Qualcare PPO/HMO/WC	$88.31

Know your out-of-pocket cost for care.

All Charges