Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

MRI SHLDER W/&W/O CONTRST RGHT

Facility

$5,910.00

Service Code	HCPCS 73223RT
Hospital Charge Code	2400516
Hospital Revenue Code	614
Min. Negotiated Rate	$886.50
Max. Negotiated Rate	$886.50
Rate for Payer: Qualcare PPO/HMO/WC	$886.50

MRI SHLDER W/&W/O CONTRST RGHT

Facility

$5,910.00

Service Code	HCPCS 73223RT
Hospital Charge Code	2400516
Hospital Revenue Code	614
Min. Negotiated Rate	$142.43
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$2,245.80
Rate for Payer: Aetna Medicare Advantage	$1,773.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,507.05
Rate for Payer: Cigna Commercial	$2,955.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,773.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$886.50
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$142.43
Rate for Payer: Wellpoint Medicaid Managed Care	$156.62

MRI SHOULDER W/CONTRAST BILTRL

Facility

$11,820.00

Service Code	HCPCS 7322250
Hospital Charge Code	2400517
Hospital Revenue Code	614
Min. Negotiated Rate	$1,773.00
Max. Negotiated Rate	$1,773.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,773.00

MRI SHOULDER W/CONTRAST BILTRL

Facility

$11,820.00

Service Code	HCPCS 7322250
Hospital Charge Code	2400517
Hospital Revenue Code	614
Min. Negotiated Rate	$284.86
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$4,491.60
Rate for Payer: Aetna Medicare Advantage	$3,546.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,014.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,014.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,014.10
Rate for Payer: Cigna Commercial	$5,910.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,546.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,773.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$284.86
Rate for Payer: Wellpoint Medicaid Managed Care	$313.23

MRI SHOULDER W/CONTRAST LEFT

Facility

$5,910.00

Service Code	HCPCS 73222LT
Hospital Charge Code	2400518
Hospital Revenue Code	614
Min. Negotiated Rate	$142.43
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$2,245.80
Rate for Payer: Aetna Medicare Advantage	$1,773.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,507.05
Rate for Payer: Cigna Commercial	$2,955.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,773.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$886.50
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$142.43
Rate for Payer: Wellpoint Medicaid Managed Care	$156.62

MRI SHOULDER W/CONTRAST LEFT

Facility

$5,910.00

Service Code	HCPCS 73222LT
Hospital Charge Code	2400518
Hospital Revenue Code	614
Min. Negotiated Rate	$886.50
Max. Negotiated Rate	$886.50
Rate for Payer: Qualcare PPO/HMO/WC	$886.50

MRI SHOULDER W/CONTRAST RIGHT

Facility

$5,910.00

Service Code	HCPCS 73222RT
Hospital Charge Code	2400519
Hospital Revenue Code	614
Min. Negotiated Rate	$142.43
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$2,245.80
Rate for Payer: Aetna Medicare Advantage	$1,773.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,507.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,507.05
Rate for Payer: Cigna Commercial	$2,955.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,773.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$886.50
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$142.43
Rate for Payer: Wellpoint Medicaid Managed Care	$156.62

MRI SHOULDER W/CONTRAST RIGHT

Facility

$5,910.00

Service Code	HCPCS 73222RT
Hospital Charge Code	2400519
Hospital Revenue Code	614
Min. Negotiated Rate	$886.50
Max. Negotiated Rate	$886.50
Rate for Payer: Qualcare PPO/HMO/WC	$886.50

MRI SHOULDER W/O CONTRAST LEFT

Facility

$4,287.95

Service Code	HCPCS 73221LT
Hospital Charge Code	2400521
Hospital Revenue Code	614
Min. Negotiated Rate	$643.19
Max. Negotiated Rate	$643.19
Rate for Payer: Qualcare PPO/HMO/WC	$643.19

MRI SHOULDER W/O CONTRAST LEFT

Facility

$4,287.95

Service Code	HCPCS 73221LT
Hospital Charge Code	2400521
Hospital Revenue Code	614
Min. Negotiated Rate	$103.34
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,629.42
Rate for Payer: Aetna Medicare Advantage	$1,286.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,093.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,093.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,093.43
Rate for Payer: Cigna Commercial	$2,143.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,286.38
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$643.19
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$103.34
Rate for Payer: Wellpoint Medicaid Managed Care	$113.63

MRI SHOULDER W/O CONTRAST RGHT

Facility

$4,287.95

Service Code	HCPCS 73221RT
Hospital Charge Code	2400522
Hospital Revenue Code	614
Min. Negotiated Rate	$643.19
Max. Negotiated Rate	$643.19
Rate for Payer: Qualcare PPO/HMO/WC	$643.19

MRI SHOULDER W/O CONTRAST RGHT

Facility

$4,287.95

Service Code	HCPCS 73221RT
Hospital Charge Code	2400522
Hospital Revenue Code	614
Min. Negotiated Rate	$103.34
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,629.42
Rate for Payer: Aetna Medicare Advantage	$1,286.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,093.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,093.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,093.43
Rate for Payer: Cigna Commercial	$2,143.97
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,286.38
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$643.19
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$103.34
Rate for Payer: Wellpoint Medicaid Managed Care	$113.63

MRI SHOULDER W/O CONTRST BLTRL

Facility

$8,575.90

Service Code	HCPCS 7322150
Hospital Charge Code	2400520
Hospital Revenue Code	614
Min. Negotiated Rate	$206.68
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$3,258.84
Rate for Payer: Aetna Medicare Advantage	$2,572.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,186.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,186.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,186.85
Rate for Payer: Cigna Commercial	$4,287.95
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,572.77
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,286.38
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$206.68
Rate for Payer: Wellpoint Medicaid Managed Care	$227.26

MRI SHOULDER W/O CONTRST BLTRL

Facility

$8,575.90

Service Code	HCPCS 7322150
Hospital Charge Code	2400520
Hospital Revenue Code	614
Min. Negotiated Rate	$1,286.38
Max. Negotiated Rate	$1,286.38
Rate for Payer: Qualcare PPO/HMO/WC	$1,286.38

MRI SPINAL CERV W/ CONT

Facility

$13,500.00

Service Code	HCPCS 72142
Hospital Charge Code	2400133
Hospital Revenue Code	612
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$683.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,496.11
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$693.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI SPINAL CERV W/ CONT

Facility

$13,500.00

Service Code	HCPCS 72142
Hospital Charge Code	2400133
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL CERV W/O CON

Facility

$13,500.00

Service Code	HCPCS 72141
Hospital Charge Code	2400125
Hospital Revenue Code	612
Min. Negotiated Rate	$269.30
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$638.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,023.24
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$534.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI SPINAL CERV W/O CON

Facility

$13,500.00

Service Code	HCPCS 72141
Hospital Charge Code	2400125
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL CERV W + W/O GAD

Facility

$13,500.00

Service Code	HCPCS 72156
Hospital Charge Code	2400182
Hospital Revenue Code	612
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$927.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,496.11
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$878.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI SPINAL CERV W + W/O GAD

Facility

$13,500.00

Service Code	HCPCS 72156
Hospital Charge Code	2400182
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL LUMBAR W/O CONT

Facility

$13,500.00

Service Code	HCPCS 72148
Hospital Charge Code	2400166
Hospital Revenue Code	612
Min. Negotiated Rate	$269.30
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$771.04
Rate for Payer: Aetna Medicare Advantage	$918.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,023.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$283.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$638.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,023.24
Rate for Payer: Cigna Commercial	$568.20
Rate for Payer: Cigna Medicare Advantage	$283.47
Rate for Payer: Clover Medicare Advantage	$269.30
Rate for Payer: EmblemHealth Commercial	$850.41
Rate for Payer: Humana Medicare Advantage	$291.97
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$283.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$567.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$283.47
Rate for Payer: Wellcare Medicare Advantage	$283.47
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$817.38
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI SPINAL LUMBAR W/O CONT

Facility

$13,500.00

Service Code	HCPCS 72148
Hospital Charge Code	2400166
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL LUMB W/ 7 + GAD

Facility

$13,500.00

Service Code	HCPCS 72158
Hospital Charge Code	2400208
Hospital Revenue Code	612
Min. Negotiated Rate	$2,025.00
Max. Negotiated Rate	$2,025.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00

MRI SPINAL LUMB W/ 7 + GAD

Facility

$13,500.00

Service Code	HCPCS 72158
Hospital Charge Code	2400208
Hospital Revenue Code	612
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,053.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,496.11
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$877.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$1,543.21
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

MRI SPINAL THOR W/ CONT

Facility

$13,500.00

Service Code	HCPCS 72147
Hospital Charge Code	2400158
Hospital Revenue Code	612
Min. Negotiated Rate	$325.35
Max. Negotiated Rate	$6,162.00
Rate for Payer: Aetna Commercial	$1,127.36
Rate for Payer: Aetna Medicare Advantage	$1,342.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,496.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$414.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$638.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,496.11
Rate for Payer: Cigna Commercial	$830.80
Rate for Payer: Cigna Medicare Advantage	$414.47
Rate for Payer: Clover Medicare Advantage	$393.75
Rate for Payer: EmblemHealth Commercial	$1,243.41
Rate for Payer: Humana Medicare Advantage	$426.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$414.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,050.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$616.00
Rate for Payer: Oxford Commercial	$3,513.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,025.00
Rate for Payer: UnitedHealthcare Commercial	$6,162.00
Rate for Payer: UnitedHealthcare Community & State	$325.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.47
Rate for Payer: Wellcare Medicare Advantage	$414.47
Rate for Payer: Wellpoint Medicaid Managed Care	$357.75

Know your out-of-pocket cost for care.

All Charges