Bayonne University Hospital

All Charges

Charge

Type

Setting

Price

STEM SMOOTH 14x80MM

Facility

$8,565.00

Service Code	HCPCS C1776
Hospital Charge Code	270677285
Hospital Revenue Code	278
Min. Negotiated Rate	$206.42
Max. Negotiated Rate	$4,282.50
Rate for Payer: Aetna Commercial	$3,254.70
Rate for Payer: Aetna Medicare Advantage	$2,569.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,184.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,184.07
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,713.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,184.07
Rate for Payer: Cigna Commercial	$4,282.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,072.73
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,884.30
Rate for Payer: Qualcare PPO/HMO/WC	$1,284.75
Rate for Payer: UnitedHealthcare Community & State	$206.42
Rate for Payer: Wellpoint Medicaid Managed Care	$226.97

STEM SMOOTH BIO 18 X 40 MM

Facility

$7,620.00

Service Code	HCPCS C1776
Hospital Charge Code	270692923
Hospital Revenue Code	278
Min. Negotiated Rate	$183.64
Max. Negotiated Rate	$3,810.00
Rate for Payer: Aetna Commercial	$2,895.60
Rate for Payer: Aetna Medicare Advantage	$2,286.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,943.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,943.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,524.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,943.10
Rate for Payer: Cigna Commercial	$3,810.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,844.04
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,676.40
Rate for Payer: Qualcare PPO/HMO/WC	$1,143.00
Rate for Payer: UnitedHealthcare Community & State	$183.64
Rate for Payer: Wellpoint Medicaid Managed Care	$201.93

STEM SMOOTH BIO 18 X 40 MM

Facility

$7,620.00

Service Code	HCPCS C1776
Hospital Charge Code	270692923
Hospital Revenue Code	278
Min. Negotiated Rate	$1,143.00
Max. Negotiated Rate	$1,844.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,524.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,844.04
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,676.40
Rate for Payer: Qualcare PPO/HMO/WC	$1,143.00

STEM SMR 16 MM X 150MM

Facility

$17,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270682890
Hospital Revenue Code	278
Min. Negotiated Rate	$421.75
Max. Negotiated Rate	$8,750.00
Rate for Payer: Aetna Commercial	$6,650.00
Rate for Payer: Aetna Medicare Advantage	$5,250.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,462.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,462.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,462.50
Rate for Payer: Cigna Commercial	$8,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,235.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,850.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,625.00
Rate for Payer: UnitedHealthcare Community & State	$421.75
Rate for Payer: Wellpoint Medicaid Managed Care	$463.75

STEM SMR 16 MM X 150MM

Facility

$17,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270682890
Hospital Revenue Code	278
Min. Negotiated Rate	$2,625.00
Max. Negotiated Rate	$4,235.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,235.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,850.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,625.00

STEM SMR SHOULDER 13 L X 36MM

Facility

$4,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270679033
Hospital Revenue Code	278
Min. Negotiated Rate	$117.49
Max. Negotiated Rate	$2,437.50
Rate for Payer: Aetna Commercial	$1,852.50
Rate for Payer: Aetna Medicare Advantage	$1,462.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,243.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,243.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$975.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,243.12
Rate for Payer: Cigna Commercial	$2,437.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,179.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,072.50
Rate for Payer: Qualcare PPO/HMO/WC	$731.25
Rate for Payer: UnitedHealthcare Community & State	$117.49
Rate for Payer: Wellpoint Medicaid Managed Care	$129.19

STEM SMR SHOULDER 13 L X 36MM

Facility

$4,875.00

Service Code	HCPCS C1776
Hospital Charge Code	270679033
Hospital Revenue Code	278
Min. Negotiated Rate	$731.25
Max. Negotiated Rate	$1,179.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$975.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,179.75
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,072.50
Rate for Payer: Qualcare PPO/HMO/WC	$731.25

STEM SMR SHOULDER 13x150MM

Facility

$11,650.00

Service Code	HCPCS C1776
Hospital Charge Code	270677040
Hospital Revenue Code	278
Min. Negotiated Rate	$1,747.50
Max. Negotiated Rate	$2,819.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,330.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,819.30
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,563.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,747.50

STEM SMR SHOULDER 13x150MM

Facility

$11,650.00

Service Code	HCPCS C1776
Hospital Charge Code	270677040
Hospital Revenue Code	278
Min. Negotiated Rate	$280.76
Max. Negotiated Rate	$5,825.00
Rate for Payer: Aetna Commercial	$4,427.00
Rate for Payer: Aetna Medicare Advantage	$3,495.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,970.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,970.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,330.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,970.75
Rate for Payer: Cigna Commercial	$5,825.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,819.30
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,563.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,747.50
Rate for Payer: UnitedHealthcare Community & State	$280.76
Rate for Payer: Wellpoint Medicaid Managed Care	$308.73

STEM SMR SHOULDER 13x180MM

Facility

$17,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270677334
Hospital Revenue Code	278
Min. Negotiated Rate	$421.75
Max. Negotiated Rate	$8,750.00
Rate for Payer: Aetna Commercial	$6,650.00
Rate for Payer: Aetna Medicare Advantage	$5,250.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4,462.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4,462.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,500.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4,462.50
Rate for Payer: Cigna Commercial	$8,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,235.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,850.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,625.00
Rate for Payer: UnitedHealthcare Community & State	$421.75
Rate for Payer: Wellpoint Medicaid Managed Care	$463.75

STEM SMR SHOULDER 13x180MM

Facility

$17,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270677334
Hospital Revenue Code	278
Min. Negotiated Rate	$2,625.00
Max. Negotiated Rate	$4,235.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,500.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4,235.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,850.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,625.00

STEM SPHERE CEMENTED LEFT S4+

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270681127
Hospital Revenue Code	278
Min. Negotiated Rate	$192.80
Max. Negotiated Rate	$4,000.00
Rate for Payer: Aetna Commercial	$3,040.00
Rate for Payer: Aetna Medicare Advantage	$2,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,040.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,040.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,040.00
Rate for Payer: Cigna Commercial	$4,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,936.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,760.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,200.00
Rate for Payer: UnitedHealthcare Community & State	$192.80
Rate for Payer: Wellpoint Medicaid Managed Care	$212.00

STEM SPHERE CEMENTED LEFT S4+

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270681127
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,936.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,600.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,936.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,760.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,200.00

STEM STD 11MM X 122MM LONG

Facility

$21,545.00

Service Code	HCPCS C1776
Hospital Charge Code	270668583
Hospital Revenue Code	278
Min. Negotiated Rate	$3,231.75
Max. Negotiated Rate	$5,213.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,309.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,213.89
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,739.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,231.75

STEM STD 11MM X 122MM LONG

Facility

$21,545.00

Service Code	HCPCS C1776
Hospital Charge Code	270668583
Hospital Revenue Code	278
Min. Negotiated Rate	$519.23
Max. Negotiated Rate	$10,772.50
Rate for Payer: Aetna Commercial	$8,187.10
Rate for Payer: Aetna Medicare Advantage	$6,463.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5,493.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5,493.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$4,309.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5,493.98
Rate for Payer: Cigna Commercial	$10,772.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5,213.89
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$4,739.90
Rate for Payer: Qualcare PPO/HMO/WC	$3,231.75
Rate for Payer: UnitedHealthcare Community & State	$519.23
Rate for Payer: Wellpoint Medicaid Managed Care	$570.94

STEM STD COMP 8MMX120MM

Facility

$14,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270693835
Hospital Revenue Code	278
Min. Negotiated Rate	$2,175.00
Max. Negotiated Rate	$3,509.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,900.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,509.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,190.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,175.00

STEM STD COMP 8MMX120MM

Facility

$14,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270693835
Hospital Revenue Code	278
Min. Negotiated Rate	$349.45
Max. Negotiated Rate	$7,250.00
Rate for Payer: Aetna Commercial	$5,510.00
Rate for Payer: Aetna Medicare Advantage	$4,350.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,697.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,697.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,900.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,697.50
Rate for Payer: Cigna Commercial	$7,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3,509.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$3,190.00
Rate for Payer: Qualcare PPO/HMO/WC	$2,175.00
Rate for Payer: UnitedHealthcare Community & State	$349.45
Rate for Payer: Wellpoint Medicaid Managed Care	$384.25

STEM STD DISTAL TAPERLOC 14MM

Facility

$12,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270675680
Hospital Revenue Code	278
Min. Negotiated Rate	$295.23
Max. Negotiated Rate	$6,125.00
Rate for Payer: Aetna Commercial	$4,655.00
Rate for Payer: Aetna Medicare Advantage	$3,675.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,123.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,123.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,123.75
Rate for Payer: Cigna Commercial	$6,125.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,964.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,695.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,837.50
Rate for Payer: UnitedHealthcare Community & State	$295.23
Rate for Payer: Wellpoint Medicaid Managed Care	$324.62

STEM STD DISTAL TAPERLOC 14MM

Facility

$12,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270675680
Hospital Revenue Code	278
Min. Negotiated Rate	$1,837.50
Max. Negotiated Rate	$2,964.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,450.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,964.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,695.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,837.50

STEM STD DISTAL TAPERLOC 15MM

Facility

$12,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270675787
Hospital Revenue Code	278
Min. Negotiated Rate	$1,837.50
Max. Negotiated Rate	$2,964.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,450.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,964.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,695.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,837.50

STEM STD DISTAL TAPERLOC 15MM

Facility

$12,250.00

Service Code	HCPCS C1776
Hospital Charge Code	270675787
Hospital Revenue Code	278
Min. Negotiated Rate	$295.23
Max. Negotiated Rate	$6,125.00
Rate for Payer: Aetna Commercial	$4,655.00
Rate for Payer: Aetna Medicare Advantage	$3,675.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,123.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,123.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,123.75
Rate for Payer: Cigna Commercial	$6,125.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,964.50
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,695.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,837.50
Rate for Payer: UnitedHealthcare Community & State	$295.23
Rate for Payer: Wellpoint Medicaid Managed Care	$324.62

STEM STD DISTAL TAPERLOC 16MM

Facility

$10,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270676897
Hospital Revenue Code	278
Min. Negotiated Rate	$1,575.00
Max. Negotiated Rate	$2,541.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,100.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,541.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,310.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,575.00

STEM STD DISTAL TAPERLOC 16MM

Facility

$10,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270676897
Hospital Revenue Code	278
Min. Negotiated Rate	$253.05
Max. Negotiated Rate	$5,250.00
Rate for Payer: Aetna Commercial	$3,990.00
Rate for Payer: Aetna Medicare Advantage	$3,150.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,677.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,677.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,100.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,677.50
Rate for Payer: Cigna Commercial	$5,250.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,541.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$2,310.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,575.00
Rate for Payer: UnitedHealthcare Community & State	$253.05
Rate for Payer: Wellpoint Medicaid Managed Care	$278.25

STEM STD FEMORAL HA SZ 2SN

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270674074
Hospital Revenue Code	278
Min. Negotiated Rate	$192.80
Max. Negotiated Rate	$4,000.00
Rate for Payer: Aetna Commercial	$3,040.00
Rate for Payer: Aetna Medicare Advantage	$2,400.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,040.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,040.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,600.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,040.00
Rate for Payer: Cigna Commercial	$4,000.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,936.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,760.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,200.00
Rate for Payer: UnitedHealthcare Community & State	$192.80
Rate for Payer: Wellpoint Medicaid Managed Care	$212.00

STEM STD FEMORAL HA SZ 2SN

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Charge Code	270674074
Hospital Revenue Code	278
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$1,936.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,600.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,936.00
Rate for Payer: New Jersey Carpenters Health Fund Self Funded Medical Benefit Plan	$1,760.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,200.00

Know your out-of-pocket cost for care.

All Charges