Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PLATE LCP TITA 3.5x190m 14HOLE

Facility

$5,475.00

Hospital Charge Code	270667948
Hospital Revenue Code	272
Min. Negotiated Rate	$131.95
Max. Negotiated Rate	$2,737.50
Rate for Payer: Aetna Commercial	$2,080.50
Rate for Payer: Aetna Medicare Advantage	$1,642.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,396.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,396.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,396.12
Rate for Payer: Cigna Commercial	$2,737.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,642.50
Rate for Payer: Oxford Commercial	$1,095.00
Rate for Payer: Qualcare PPO/HMO/WC	$821.25
Rate for Payer: UnitedHealthcare Commercial	$1,095.00
Rate for Payer: UnitedHealthcare Community & State	$131.95
Rate for Payer: Wellpoint Medicaid Managed Care	$145.09

PLATE LCP VOLAR 2.4MM 9H/5H

Facility

$3,667.85

Service Code	HCPCS C1713
Hospital Charge Code	270641160
Hospital Revenue Code	278
Min. Negotiated Rate	$550.18
Max. Negotiated Rate	$887.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$733.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$887.62
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$806.93
Rate for Payer: Qualcare PPO/HMO/WC	$550.18

PLATE LCP VOLAR 2.4MM 9H/5H

Facility

$3,667.85

Service Code	HCPCS C1713
Hospital Charge Code	270641160
Hospital Revenue Code	278
Min. Negotiated Rate	$88.40
Max. Negotiated Rate	$1,833.92
Rate for Payer: Aetna Commercial	$1,393.78
Rate for Payer: Aetna Medicare Advantage	$1,100.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$935.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$935.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$733.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$935.30
Rate for Payer: Cigna Commercial	$1,833.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$887.62
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$806.93
Rate for Payer: Qualcare PPO/HMO/WC	$550.18
Rate for Payer: UnitedHealthcare Community & State	$88.40
Rate for Payer: Wellpoint Medicaid Managed Care	$97.20

PLATE LCP X-ART 6H 3.5MM LT

Facility

$5,939.00

Service Code	HCPCS C1713
Hospital Charge Code	270643583
Hospital Revenue Code	278
Min. Negotiated Rate	$143.13
Max. Negotiated Rate	$2,969.50
Rate for Payer: Aetna Commercial	$2,256.82
Rate for Payer: Aetna Medicare Advantage	$1,781.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,514.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,514.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,187.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,514.44
Rate for Payer: Cigna Commercial	$2,969.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,437.24
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,306.58
Rate for Payer: Qualcare PPO/HMO/WC	$890.85
Rate for Payer: UnitedHealthcare Community & State	$143.13
Rate for Payer: Wellpoint Medicaid Managed Care	$157.38

PLATE LCP X-ART 6H 3.5MM LT

Facility

$5,939.00

Service Code	HCPCS C1713
Hospital Charge Code	270643583
Hospital Revenue Code	278
Min. Negotiated Rate	$890.85
Max. Negotiated Rate	$1,437.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,187.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,437.24
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,306.58
Rate for Payer: Qualcare PPO/HMO/WC	$890.85

PLATE LCP X-ART 6H 3.5MM RT ST

Facility

$6,146.00

Service Code	HCPCS C1713
Hospital Charge Code	270678905
Hospital Revenue Code	278
Min. Negotiated Rate	$148.12
Max. Negotiated Rate	$3,073.00
Rate for Payer: Aetna Commercial	$2,335.48
Rate for Payer: Aetna Medicare Advantage	$1,843.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,567.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,567.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,229.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,567.23
Rate for Payer: Cigna Commercial	$3,073.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,487.33
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,352.12
Rate for Payer: Qualcare PPO/HMO/WC	$921.90
Rate for Payer: UnitedHealthcare Community & State	$148.12
Rate for Payer: Wellpoint Medicaid Managed Care	$162.87

PLATE LCP X-ART 6H 3.5MM RT ST

Facility

$6,146.00

Service Code	HCPCS C1713
Hospital Charge Code	270678905
Hospital Revenue Code	278
Min. Negotiated Rate	$921.90
Max. Negotiated Rate	$1,487.33
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,229.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,487.33
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,352.12
Rate for Payer: Qualcare PPO/HMO/WC	$921.90

PLATE LCP X-ART 8H 3.5MM LT ST

Facility

$6,510.65

Service Code	HCPCS C1713
Hospital Charge Code	270675067
Hospital Revenue Code	278
Min. Negotiated Rate	$156.91
Max. Negotiated Rate	$3,255.32
Rate for Payer: Aetna Commercial	$2,474.05
Rate for Payer: Aetna Medicare Advantage	$1,953.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,660.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,660.22
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,302.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,660.22
Rate for Payer: Cigna Commercial	$3,255.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,575.58
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,432.34
Rate for Payer: Qualcare PPO/HMO/WC	$976.60
Rate for Payer: UnitedHealthcare Community & State	$156.91
Rate for Payer: Wellpoint Medicaid Managed Care	$172.53

PLATE LCP X-ART 8H 3.5MM LT ST

Facility

$6,510.65

Service Code	HCPCS C1713
Hospital Charge Code	270675067
Hospital Revenue Code	278
Min. Negotiated Rate	$976.60
Max. Negotiated Rate	$1,575.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,302.13
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,575.58
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,432.34
Rate for Payer: Qualcare PPO/HMO/WC	$976.60

PLATE LDF LCK 7-HLE LFT7282-10

Facility

$4,235.00

Hospital Charge Code	270647945
Hospital Revenue Code	278
Min. Negotiated Rate	$635.25
Max. Negotiated Rate	$1,024.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$847.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,024.87
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$931.70
Rate for Payer: Qualcare PPO/HMO/WC	$635.25

PLATE LDF LCK 7-HLE LFT7282-10

Facility

$4,235.00

Hospital Charge Code	270647945
Hospital Revenue Code	278
Min. Negotiated Rate	$102.06
Max. Negotiated Rate	$2,117.50
Rate for Payer: Aetna Commercial	$1,609.30
Rate for Payer: Aetna Medicare Advantage	$1,270.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,079.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,079.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$847.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,079.92
Rate for Payer: Cigna Commercial	$2,117.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,024.87
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$931.70
Rate for Payer: Qualcare PPO/HMO/WC	$635.25
Rate for Payer: UnitedHealthcare Community & State	$102.06
Rate for Payer: Wellpoint Medicaid Managed Care	$112.23

PLATE LEFT FIBULAR 11 HOLE CLU

Facility

$6,861.25

Service Code	HCPCS C1713
Hospital Charge Code	270701204
Hospital Revenue Code	278
Min. Negotiated Rate	$165.36
Max. Negotiated Rate	$3,430.62
Rate for Payer: Aetna Commercial	$2,607.28
Rate for Payer: Aetna Medicare Advantage	$2,058.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,749.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,749.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,372.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,749.62
Rate for Payer: Cigna Commercial	$3,430.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,660.42
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,509.47
Rate for Payer: Qualcare PPO/HMO/WC	$1,029.19
Rate for Payer: UnitedHealthcare Community & State	$165.36
Rate for Payer: Wellpoint Medicaid Managed Care	$181.82

PLATE LEFT FIBULAR 11 HOLE CLU

Facility

$6,861.25

Service Code	HCPCS C1713
Hospital Charge Code	270701204
Hospital Revenue Code	278
Min. Negotiated Rate	$1,029.19
Max. Negotiated Rate	$1,660.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,372.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,660.42
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,509.47
Rate for Payer: Qualcare PPO/HMO/WC	$1,029.19

PLATE LEFT STANDARD LONG VD

Facility

$5,920.00

Hospital Charge Code	270665498
Hospital Revenue Code	278
Min. Negotiated Rate	$888.00
Max. Negotiated Rate	$1,432.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,184.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,432.64
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,302.40
Rate for Payer: Qualcare PPO/HMO/WC	$888.00

PLATE LEFT STANDARD LONG VD

Facility

$5,920.00

Hospital Charge Code	270665498
Hospital Revenue Code	278
Min. Negotiated Rate	$142.67
Max. Negotiated Rate	$2,960.00
Rate for Payer: Aetna Commercial	$2,249.60
Rate for Payer: Aetna Medicare Advantage	$1,776.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,509.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,509.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,184.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,509.60
Rate for Payer: Cigna Commercial	$2,960.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,432.64
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,302.40
Rate for Payer: Qualcare PPO/HMO/WC	$888.00
Rate for Payer: UnitedHealthcare Community & State	$142.67
Rate for Payer: Wellpoint Medicaid Managed Care	$156.88

PLATE LEFT SUPPER 5 HOLE SUPER

Facility

$4,746.60

Service Code	HCPCS C1713
Hospital Charge Code	270690572
Hospital Revenue Code	278
Min. Negotiated Rate	$114.39
Max. Negotiated Rate	$2,373.30
Rate for Payer: Aetna Commercial	$1,803.71
Rate for Payer: Aetna Medicare Advantage	$1,423.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,210.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,210.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$949.32
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,210.38
Rate for Payer: Cigna Commercial	$2,373.30
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,148.68
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,044.25
Rate for Payer: Qualcare PPO/HMO/WC	$711.99
Rate for Payer: UnitedHealthcare Community & State	$114.39
Rate for Payer: Wellpoint Medicaid Managed Care	$125.78

PLATE LEFT SUPPER 5 HOLE SUPER

Facility

$4,746.60

Service Code	HCPCS C1713
Hospital Charge Code	270690572
Hospital Revenue Code	278
Min. Negotiated Rate	$711.99
Max. Negotiated Rate	$1,148.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$949.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,148.68
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,044.25
Rate for Payer: Qualcare PPO/HMO/WC	$711.99

PLATE LEFT T-SHAPED 5-HOLE

Facility

$6,337.45

Hospital Charge Code	270657183
Hospital Revenue Code	278
Min. Negotiated Rate	$950.62
Max. Negotiated Rate	$1,533.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,267.49
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,533.66
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,394.24
Rate for Payer: Qualcare PPO/HMO/WC	$950.62

PLATE LEFT T-SHAPED 5-HOLE

Facility

$6,337.45

Hospital Charge Code	270657183
Hospital Revenue Code	278
Min. Negotiated Rate	$152.73
Max. Negotiated Rate	$3,168.72
Rate for Payer: Aetna Commercial	$2,408.23
Rate for Payer: Aetna Medicare Advantage	$1,901.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,616.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,616.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,267.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,616.05
Rate for Payer: Cigna Commercial	$3,168.72
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,533.66
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,394.24
Rate for Payer: Qualcare PPO/HMO/WC	$950.62
Rate for Payer: UnitedHealthcare Community & State	$152.73
Rate for Payer: Wellpoint Medicaid Managed Care	$167.94

PLATE LEFT VOLAR NARROW DISTAL

Facility

$4,680.00

Service Code	HCPCS C1713
Hospital Charge Code	270647778
Hospital Revenue Code	278
Min. Negotiated Rate	$702.00
Max. Negotiated Rate	$1,132.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$936.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,132.56
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,029.60
Rate for Payer: Qualcare PPO/HMO/WC	$702.00

PLATE LEFT VOLAR NARROW DISTAL

Facility

$4,680.00

Service Code	HCPCS C1713
Hospital Charge Code	270647778
Hospital Revenue Code	278
Min. Negotiated Rate	$112.79
Max. Negotiated Rate	$2,340.00
Rate for Payer: Aetna Commercial	$1,778.40
Rate for Payer: Aetna Medicare Advantage	$1,404.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,193.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,193.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$936.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,193.40
Rate for Payer: Cigna Commercial	$2,340.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,132.56
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,029.60
Rate for Payer: Qualcare PPO/HMO/WC	$702.00
Rate for Payer: UnitedHealthcare Community & State	$112.79
Rate for Payer: Wellpoint Medicaid Managed Care	$124.02

PLATELET AB,HEPARIN IND

Facility

$390.00

Service Code	HCPCS 86022
Hospital Charge Code	39900189
Hospital Revenue Code	302
Min. Negotiated Rate	$10.34
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$49.97
Rate for Payer: Aetna Medicare Advantage	$59.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$66.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$66.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$18.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$17.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$66.31
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$18.37
Rate for Payer: Clover Medicare Advantage	$17.45
Rate for Payer: EmblemHealth Commercial	$55.11
Rate for Payer: Humana Medicare Advantage	$18.92
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$18.37
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$14.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.37
Rate for Payer: Wellcare Medicare Advantage	$18.37
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

PLATELET AB,HEPARIN IND

Facility

$390.00

Service Code	HCPCS 86022
Hospital Charge Code	39900189
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

PLATELET AB (IGG),DIRECT

Facility

$390.00

Service Code	HCPCS 86023
Hospital Charge Code	39900190
Hospital Revenue Code	302
Min. Negotiated Rate	$9.97
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$33.89
Rate for Payer: Aetna Medicare Advantage	$40.37
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$44.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$44.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$29.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$44.98
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$12.46
Rate for Payer: Clover Medicare Advantage	$11.84
Rate for Payer: EmblemHealth Commercial	$37.38
Rate for Payer: Humana Medicare Advantage	$12.83
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.46
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$117.00
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$124.00
Rate for Payer: UnitedHealthcare Community & State	$9.97
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.46
Rate for Payer: Wellcare Medicare Advantage	$12.46
Rate for Payer: Wellpoint Medicaid Managed Care	$10.34

PLATELET AB (IGG),DIRECT

Facility

$390.00

Service Code	HCPCS 86023
Hospital Charge Code	39900190
Hospital Revenue Code	302
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

Know your out-of-pocket cost for care.

All Charges