Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

PSN FSM PS POR CCR STD SZ 8

Facility

$30,870.00

Service Code	HCPCS C1776
Hospital Charge Code	270696052
Hospital Revenue Code	278
Min. Negotiated Rate	$743.97
Max. Negotiated Rate	$15,435.00
Rate for Payer: Aetna Commercial	$11,730.60
Rate for Payer: Aetna Medicare Advantage	$9,261.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7,871.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7,871.85
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6,174.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7,871.85
Rate for Payer: Cigna Commercial	$15,435.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,470.54
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$6,791.40
Rate for Payer: Qualcare PPO/HMO/WC	$4,630.50
Rate for Payer: UnitedHealthcare Community & State	$743.97
Rate for Payer: Wellpoint Medicaid Managed Care	$818.05

PSN INSERT TIB BEARING 10MM

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270695437
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

PSN INSERT TIB BEARING 10MM

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270695437
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

PSN LIN TIBIAL INS 12MM CR8-11

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270694749
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

PSN LIN TIBIAL INS 12MM CR8-11

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270694749
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

PSN MC VE ASF L 11MM 8-11 EF

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270699913
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

PSN MC VE ASF L 11MM 8-11 EF

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270699913
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

PSN MC VE ASF L 11MM 8-11 GH

Facility

$6,180.00

Service Code	HCPCS C1776
Hospital Charge Code	270699910
Hospital Revenue Code	278
Min. Negotiated Rate	$927.00
Max. Negotiated Rate	$1,495.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,236.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,495.56
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,359.60
Rate for Payer: Qualcare PPO/HMO/WC	$927.00

PSN MC VE ASF L 11MM 8-11 GH

Facility

$6,180.00

Service Code	HCPCS C1776
Hospital Charge Code	270699910
Hospital Revenue Code	278
Min. Negotiated Rate	$148.94
Max. Negotiated Rate	$3,090.00
Rate for Payer: Aetna Commercial	$2,348.40
Rate for Payer: Aetna Medicare Advantage	$1,854.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,575.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,575.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,236.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,575.90
Rate for Payer: Cigna Commercial	$3,090.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,495.56
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,359.60
Rate for Payer: Qualcare PPO/HMO/WC	$927.00
Rate for Payer: UnitedHealthcare Community & State	$148.94
Rate for Payer: Wellpoint Medicaid Managed Care	$163.77

PSN MC VE ASF L 12MM 12/GH

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270698909
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

PSN MC VE ASF L 12MM 12/GH

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270698909
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

PSN MC VE ASF L 16MM 8-11 EF

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270694797
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

PSN MC VE ASF L 16MM 8-11 EF

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270694797
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

PSN MC VE ASF R 13MM 8-11 EF

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270695091
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

PSN MC VE ASF R 13MM 8-11 EF

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270695091
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

PSN MC VE ASF R 14MM 8-11 GH

Facility

$5,130.00

Service Code	HCPCS C1776
Hospital Charge Code	270694234
Hospital Revenue Code	278
Min. Negotiated Rate	$769.50
Max. Negotiated Rate	$1,241.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,026.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,241.46
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,128.60
Rate for Payer: Qualcare PPO/HMO/WC	$769.50

PSN MC VE ASF R 14MM 8-11 GH

Facility

$5,130.00

Service Code	HCPCS C1776
Hospital Charge Code	270694234
Hospital Revenue Code	278
Min. Negotiated Rate	$123.63
Max. Negotiated Rate	$2,565.00
Rate for Payer: Aetna Commercial	$1,949.40
Rate for Payer: Aetna Medicare Advantage	$1,539.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,308.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,308.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,026.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,308.15
Rate for Payer: Cigna Commercial	$2,565.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,241.46
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,128.60
Rate for Payer: Qualcare PPO/HMO/WC	$769.50
Rate for Payer: UnitedHealthcare Community & State	$123.63
Rate for Payer: Wellpoint Medicaid Managed Care	$135.94

PSN MC VE ASF R 14MM 8-9 CD

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270698698
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

PSN MC VE ASF R 14MM 8-9 CD

Facility

$6,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270698698
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

PSN NAT TIBIA TM SZ C

Facility

$13,830.00

Service Code	HCPCS C1776
Hospital Charge Code	270695785
Hospital Revenue Code	278
Min. Negotiated Rate	$2,074.50
Max. Negotiated Rate	$3,346.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,766.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,346.86
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,042.60
Rate for Payer: Qualcare PPO/HMO/WC	$2,074.50

PSN NAT TIBIA TM SZ C

Facility

$13,830.00

Service Code	HCPCS C1776
Hospital Charge Code	270695785
Hospital Revenue Code	278
Min. Negotiated Rate	$333.30
Max. Negotiated Rate	$6,915.00
Rate for Payer: Aetna Commercial	$5,255.40
Rate for Payer: Aetna Medicare Advantage	$4,149.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,526.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,526.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,766.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,526.65
Rate for Payer: Cigna Commercial	$6,915.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,346.86
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,042.60
Rate for Payer: Qualcare PPO/HMO/WC	$2,074.50
Rate for Payer: UnitedHealthcare Community & State	$333.30
Rate for Payer: Wellpoint Medicaid Managed Care	$366.50

PSNREV3MMOFFSETSTEMEXT13X135MM

Facility

$19,430.00

Service Code	HCPCS C1776
Hospital Charge Code	270697461
Hospital Revenue Code	278
Min. Negotiated Rate	$2,914.50
Max. Negotiated Rate	$4,702.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,886.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,702.06
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,274.60
Rate for Payer: Qualcare PPO/HMO/WC	$2,914.50

PSNREV3MMOFFSETSTEMEXT13X135MM

Facility

$19,430.00

Service Code	HCPCS C1776
Hospital Charge Code	270697461
Hospital Revenue Code	278
Min. Negotiated Rate	$468.26
Max. Negotiated Rate	$9,715.00
Rate for Payer: Aetna Commercial	$7,383.40
Rate for Payer: Aetna Medicare Advantage	$5,829.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,954.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,954.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,886.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,954.65
Rate for Payer: Cigna Commercial	$9,715.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,702.06
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,274.60
Rate for Payer: Qualcare PPO/HMO/WC	$2,914.50
Rate for Payer: UnitedHealthcare Community & State	$468.26
Rate for Payer: Wellpoint Medicaid Managed Care	$514.89

PSN REV 3MM OFFSET STEM EXT 14

Facility

$19,430.00

Service Code	HCPCS C1776
Hospital Charge Code	270700240
Hospital Revenue Code	278
Min. Negotiated Rate	$468.26
Max. Negotiated Rate	$9,715.00
Rate for Payer: Aetna Commercial	$7,383.40
Rate for Payer: Aetna Medicare Advantage	$5,829.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,954.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,954.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,886.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,954.65
Rate for Payer: Cigna Commercial	$9,715.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,702.06
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,274.60
Rate for Payer: Qualcare PPO/HMO/WC	$2,914.50
Rate for Payer: UnitedHealthcare Community & State	$468.26
Rate for Payer: Wellpoint Medicaid Managed Care	$514.89

PSN REV 3MM OFFSET STEM EXT 14

Facility

$19,430.00

Service Code	HCPCS C1776
Hospital Charge Code	270700240
Hospital Revenue Code	278
Min. Negotiated Rate	$2,914.50
Max. Negotiated Rate	$4,702.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,886.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,702.06
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,274.60
Rate for Payer: Qualcare PPO/HMO/WC	$2,914.50

Know your out-of-pocket cost for care.

All Charges