Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

SIGMA SHIM

Facility

$2,950.00

Service Code	HCPCS C1713
Hospital Charge Code	270703545
Hospital Revenue Code	278
Min. Negotiated Rate	$71.09
Max. Negotiated Rate	$1,475.00
Rate for Payer: Aetna Commercial	$1,121.00
Rate for Payer: Aetna Medicare Advantage	$885.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$752.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$752.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$590.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$752.25
Rate for Payer: Cigna Commercial	$1,475.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$713.90
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$649.00
Rate for Payer: Qualcare PPO/HMO/WC	$442.50
Rate for Payer: UnitedHealthcare Community & State	$71.09
Rate for Payer: Wellpoint Medicaid Managed Care	$78.17

SIGMA TLIF MIS

Facility

$6,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270703775
Hospital Revenue Code	278
Min. Negotiated Rate	$937.50
Max. Negotiated Rate	$1,512.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,512.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,375.00
Rate for Payer: Qualcare PPO/HMO/WC	$937.50

SIGMA TLIF MIS

Facility

$6,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270703775
Hospital Revenue Code	278
Min. Negotiated Rate	$150.62
Max. Negotiated Rate	$3,125.00
Rate for Payer: Aetna Commercial	$2,375.00
Rate for Payer: Aetna Medicare Advantage	$1,875.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,593.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,593.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,250.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,593.75
Rate for Payer: Cigna Commercial	$3,125.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,512.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,375.00
Rate for Payer: Qualcare PPO/HMO/WC	$937.50
Rate for Payer: UnitedHealthcare Community & State	$150.62
Rate for Payer: Wellpoint Medicaid Managed Care	$165.62

SIGMOIDOSCOPE DISP

Facility

$19.25

Hospital Charge Code	270301975
Hospital Revenue Code	279
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$2.89
Rate for Payer: Qualcare PPO/HMO/WC	$2.89

SIGMOIDOSCOPE DISP

Facility

$19.25

Hospital Charge Code	270301975
Hospital Revenue Code	279
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$9.62
Rate for Payer: Aetna Commercial	$7.32
Rate for Payer: Aetna Medicare Advantage	$5.78
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.91
Rate for Payer: Cigna Commercial	$9.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.78
Rate for Payer: Oxford Commercial	$3.85
Rate for Payer: Qualcare PPO/HMO/WC	$2.89
Rate for Payer: UnitedHealthcare Commercial	$3.85
Rate for Payer: UnitedHealthcare Community & State	$0.46
Rate for Payer: Wellpoint Medicaid Managed Care	$0.51

SIGMOIDOSCOPE DISP

Facility

$10.15

Hospital Charge Code	270649352
Hospital Revenue Code	270
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$1.52
Rate for Payer: Qualcare PPO/HMO/WC	$1.52

SIGMOIDOSCOPE DISP

Facility

$10.15

Hospital Charge Code	270649352
Hospital Revenue Code	270
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$5.08
Rate for Payer: Aetna Commercial	$3.86
Rate for Payer: Aetna Medicare Advantage	$3.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.59
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.59
Rate for Payer: Cigna Commercial	$5.08
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.04
Rate for Payer: Oxford Commercial	$2.03
Rate for Payer: Qualcare PPO/HMO/WC	$1.52
Rate for Payer: UnitedHealthcare Commercial	$2.03
Rate for Payer: UnitedHealthcare Community & State	$0.24
Rate for Payer: Wellpoint Medicaid Managed Care	$0.27

SIGMOIDOSCOPE W/SUBMUC INJ

Facility

$3,720.52

Service Code	HCPCS 45335
Hospital Charge Code	16000981
Hospital Revenue Code	360
Min. Negotiated Rate	$89.66
Max. Negotiated Rate	$3,988.03
Rate for Payer: Aetna Commercial	$3,005.08
Rate for Payer: Aetna Medicare Advantage	$3,579.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,104.81
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	$3,988.03
Rate for Payer: Cigna Commercial	$2,214.60
Rate for Payer: Cigna Medicare Advantage	$1,104.81
Rate for Payer: Clover Medicare Advantage	$1,049.57
Rate for Payer: EmblemHealth Commercial	$3,314.43
Rate for Payer: Humana Medicare Advantage	$1,137.95
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,104.81
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,116.16
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: Qualcare PPO/HMO/WC	$558.08
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Community & State	$89.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,104.81
Rate for Payer: Wellcare Medicare Advantage	$1,104.81
Rate for Payer: Wellpoint Medicaid Managed Care	$98.59

SIGMOIDOSCOPE W/SUBMUC INJ

Facility

$3,720.52

Service Code	HCPCS 45335
Hospital Charge Code	16000981
Hospital Revenue Code	360
Min. Negotiated Rate	$558.08
Max. Negotiated Rate	$558.08
Rate for Payer: Qualcare PPO/HMO/WC	$558.08

SIGMOIDOSCOPY AND BIOPSY

Facility

$3,330.02

Service Code	HCPCS 45331
Hospital Charge Code	16000403
Hospital Revenue Code	360
Min. Negotiated Rate	$499.50
Max. Negotiated Rate	$499.50
Rate for Payer: Qualcare PPO/HMO/WC	$499.50

SIGMOIDOSCOPY AND BIOPSY

Facility

$3,330.02

Service Code	HCPCS 45331
Hospital Charge Code	16000403
Hospital Revenue Code	360
Min. Negotiated Rate	$80.25
Max. Negotiated Rate	$3,988.03
Rate for Payer: Aetna Commercial	$3,005.08
Rate for Payer: Aetna Medicare Advantage	$3,579.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,104.81
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	$3,988.03
Rate for Payer: Cigna Commercial	$2,214.60
Rate for Payer: Cigna Medicare Advantage	$1,104.81
Rate for Payer: Clover Medicare Advantage	$1,049.57
Rate for Payer: EmblemHealth Commercial	$3,314.43
Rate for Payer: Humana Medicare Advantage	$1,137.95
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,104.81
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$999.01
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: Qualcare PPO/HMO/WC	$499.50
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Community & State	$80.25
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,104.81
Rate for Payer: Wellcare Medicare Advantage	$1,104.81
Rate for Payer: Wellpoint Medicaid Managed Care	$88.25

SIGMOIDOSCOPY DX W/WO BRUSH/W

Facility

$5,319.00

Hospital Charge Code	1600000552
Hospital Revenue Code	360
Min. Negotiated Rate	$128.19
Max. Negotiated Rate	$2,659.50
Rate for Payer: Aetna Commercial	$2,021.22
Rate for Payer: Aetna Medicare Advantage	$1,595.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,356.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,356.35
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	$1,356.35
Rate for Payer: Cigna Commercial	$2,659.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,595.70
Rate for Payer: Qualcare PPO/HMO/WC	$797.85
Rate for Payer: UnitedHealthcare Community & State	$128.19
Rate for Payer: Wellpoint Medicaid Managed Care	$140.95

SIGMOIDOSCOPY DX W/WO BRUSH/W

Facility

$5,319.00

Hospital Charge Code	1600000552
Hospital Revenue Code	360
Min. Negotiated Rate	$797.85
Max. Negotiated Rate	$797.85
Rate for Payer: Qualcare PPO/HMO/WC	$797.85

SIGMOIDOSCOPY FLEXIBLE***

Facility

$1,186.00

Service Code	HCPCS 45331
Hospital Charge Code	1001150
Hospital Revenue Code	759
Min. Negotiated Rate	$28.58
Max. Negotiated Rate	$3,988.03
Rate for Payer: Aetna Commercial	$3,005.08
Rate for Payer: Aetna Medicare Advantage	$3,579.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,104.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$104.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,988.03
Rate for Payer: Cigna Commercial	$2,214.60
Rate for Payer: Cigna Medicare Advantage	$1,104.81
Rate for Payer: Clover Medicare Advantage	$1,049.57
Rate for Payer: EmblemHealth Commercial	$3,314.43
Rate for Payer: Humana Medicare Advantage	$1,137.95
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,104.81
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$355.80
Rate for Payer: Qualcare PPO/HMO/WC	$177.90
Rate for Payer: UnitedHealthcare Community & State	$28.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,104.81
Rate for Payer: Wellcare Medicare Advantage	$1,104.81
Rate for Payer: Wellpoint Medicaid Managed Care	$31.43

SIGMOIDOSCOPY FLEXIBLE***

Facility

$1,186.00

Service Code	HCPCS 45331
Hospital Charge Code	1001150
Hospital Revenue Code	759
Min. Negotiated Rate	$177.90
Max. Negotiated Rate	$177.90
Rate for Payer: Qualcare PPO/HMO/WC	$177.90

SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE)

Facility

$3,988.03

Service Code	CPT 45330
Hospital Revenue Code	750
Min. Negotiated Rate	$91.96
Max. Negotiated Rate	$3,988.03
Rate for Payer: Aetna Commercial	$3,005.08
Rate for Payer: Aetna Medicare Advantage	$3,579.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,104.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$91.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,988.03
Rate for Payer: Cigna Commercial	$2,214.60
Rate for Payer: Cigna Medicare Advantage	$1,104.81
Rate for Payer: Clover Medicare Advantage	$1,049.57
Rate for Payer: EmblemHealth Commercial	$3,314.43
Rate for Payer: Humana Medicare Advantage	$1,137.95
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,104.81
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,104.81
Rate for Payer: Wellcare Medicare Advantage	$1,104.81

SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$3,988.03

Service Code	CPT 45331
Hospital Revenue Code	750
Min. Negotiated Rate	$104.54
Max. Negotiated Rate	$3,988.03
Rate for Payer: Aetna Commercial	$3,005.08
Rate for Payer: Aetna Medicare Advantage	$3,579.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,104.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$104.54
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,988.03
Rate for Payer: Cigna Commercial	$2,214.60
Rate for Payer: Cigna Medicare Advantage	$1,104.81
Rate for Payer: Clover Medicare Advantage	$1,049.57
Rate for Payer: EmblemHealth Commercial	$3,314.43
Rate for Payer: Humana Medicare Advantage	$1,137.95
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,104.81
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,104.81
Rate for Payer: Wellcare Medicare Advantage	$1,104.81

SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE

Facility

$3,988.03

Service Code	CPT 45335
Hospital Revenue Code	750
Min. Negotiated Rate	$251.68
Max. Negotiated Rate	$3,988.03
Rate for Payer: Aetna Commercial	$3,005.08
Rate for Payer: Aetna Medicare Advantage	$3,579.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,988.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,104.81
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$251.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,988.03
Rate for Payer: Cigna Commercial	$2,214.60
Rate for Payer: Cigna Medicare Advantage	$1,104.81
Rate for Payer: Clover Medicare Advantage	$1,049.57
Rate for Payer: EmblemHealth Commercial	$3,314.43
Rate for Payer: Humana Medicare Advantage	$1,137.95
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,104.81
Rate for Payer: Oxford Commercial	$2,269.00
Rate for Payer: UnitedHealthcare Commercial	$3,593.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,104.81
Rate for Payer: Wellcare Medicare Advantage	$1,104.81

SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE

Facility

$5,311.00

Service Code	CPT 45338
Hospital Revenue Code	750
Min. Negotiated Rate	$238.13
Max. Negotiated Rate	$5,311.00
Rate for Payer: Aetna Commercial	$3,866.86
Rate for Payer: Aetna Medicare Advantage	$4,606.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,131.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,131.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$1,421.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$238.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,131.69
Rate for Payer: Cigna Commercial	$2,849.67
Rate for Payer: Cigna Medicare Advantage	$1,421.64
Rate for Payer: Clover Medicare Advantage	$1,350.56
Rate for Payer: EmblemHealth Commercial	$4,264.92
Rate for Payer: Humana Medicare Advantage	$1,464.29
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$1,421.64
Rate for Payer: Oxford Commercial	$3,248.00
Rate for Payer: UnitedHealthcare Commercial	$5,311.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,421.64
Rate for Payer: Wellcare Medicare Advantage	$1,421.64

SIGMOIDOSCOPY FLEX W/BIOPSY***

Facility

$742.00

Hospital Charge Code	2300018
Hospital Revenue Code	759
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$111.30
Rate for Payer: Qualcare PPO/HMO/WC	$111.30

SIGMOIDOSCOPY FLEX W/BIOPSY***

Facility

$742.00

Hospital Charge Code	2300018
Hospital Revenue Code	759
Min. Negotiated Rate	$17.88
Max. Negotiated Rate	$371.00
Rate for Payer: Aetna Commercial	$281.96
Rate for Payer: Aetna Medicare Advantage	$222.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$189.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$189.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$189.21
Rate for Payer: Cigna Commercial	$371.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$222.60
Rate for Payer: Qualcare PPO/HMO/WC	$111.30
Rate for Payer: UnitedHealthcare Community & State	$17.88
Rate for Payer: Wellpoint Medicaid Managed Care	$19.66

SIGMOIDOSCOPY W/DECOMP VOLV***

Facility

$742.00

Hospital Charge Code	2300019
Hospital Revenue Code	759
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$111.30
Rate for Payer: Qualcare PPO/HMO/WC	$111.30

SIGMOIDOSCOPY W/DECOMP VOLV***

Facility

$742.00

Hospital Charge Code	2300019
Hospital Revenue Code	759
Min. Negotiated Rate	$17.88
Max. Negotiated Rate	$371.00
Rate for Payer: Aetna Commercial	$281.96
Rate for Payer: Aetna Medicare Advantage	$222.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$189.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$189.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$189.21
Rate for Payer: Cigna Commercial	$371.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$222.60
Rate for Payer: Qualcare PPO/HMO/WC	$111.30
Rate for Payer: UnitedHealthcare Community & State	$17.88
Rate for Payer: Wellpoint Medicaid Managed Care	$19.66

SIGMOIDOSCP W/REM LESN SNARE**

Facility

$742.00

Hospital Charge Code	2300020
Hospital Revenue Code	759
Min. Negotiated Rate	$17.88
Max. Negotiated Rate	$371.00
Rate for Payer: Aetna Commercial	$281.96
Rate for Payer: Aetna Medicare Advantage	$222.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$189.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$189.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$189.21
Rate for Payer: Cigna Commercial	$371.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$222.60
Rate for Payer: Qualcare PPO/HMO/WC	$111.30
Rate for Payer: UnitedHealthcare Community & State	$17.88
Rate for Payer: Wellpoint Medicaid Managed Care	$19.66

SIGMOIDOSCP W/REM LESN SNARE**

Facility

$742.00

Hospital Charge Code	2300020
Hospital Revenue Code	759
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$111.30
Rate for Payer: Qualcare PPO/HMO/WC	$111.30

Know your out-of-pocket cost for care.

All Charges