Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

REVISION OF UPPER EYELID

Facility

$7,356.39

Service Code	HCPCS 15822
Hospital Charge Code	16000661
Hospital Revenue Code	360
Min. Negotiated Rate	$208.92
Max. Negotiated Rate	$8,891.84
Rate for Payer: Aetna Commercial	$6,667.35
Rate for Payer: Aetna Medicare Advantage	$7,941.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,891.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,891.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$2,451.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,891.84
Rate for Payer: Cigna Commercial	$4,913.48
Rate for Payer: Cigna Medicare Advantage	$2,451.23
Rate for Payer: Clover Medicare Advantage	$2,328.67
Rate for Payer: EmblemHealth Commercial	$7,353.69
Rate for Payer: Humana Medicare Advantage	$2,524.77
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$2,451.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,912.66
Rate for Payer: Oxford Commercial	$5,018.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,103.46
Rate for Payer: UnitedHealthcare Commercial	$5,347.00
Rate for Payer: UnitedHealthcare Community & State	$232.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$2,451.23
Rate for Payer: Wellcare Medicare Advantage	$2,451.23
Rate for Payer: Wellpoint Medicaid Managed Care	$208.92

REVISISION TOTAL KNEE(ZIMMER)

Facility

$52,318.00

Hospital Charge Code	270335463
Hospital Revenue Code	278
Min. Negotiated Rate	$1,485.83
Max. Negotiated Rate	$26,159.00
Rate for Payer: Aetna Commercial	$19,880.84
Rate for Payer: Aetna Medicare Advantage	$15,695.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$13,341.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$13,341.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$10,463.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$13,341.09
Rate for Payer: Cigna Commercial	$26,159.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12,660.96
Rate for Payer: Qualcare PPO/HMO/WC	$7,847.70
Rate for Payer: UnitedHealthcare Community & State	$1,653.25
Rate for Payer: Wellpoint Medicaid Managed Care	$1,485.83

REVISISION TOTAL KNEE(ZIMMER)

Facility

$52,318.00

Hospital Charge Code	270335463
Hospital Revenue Code	278
Min. Negotiated Rate	$7,847.70
Max. Negotiated Rate	$12,660.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$10,463.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12,660.96
Rate for Payer: Qualcare PPO/HMO/WC	$7,847.70

REVIS RECONST SHOULDER JOINT

Facility

$2,701.00

Service Code	HCPCS 23474
Hospital Charge Code	1600000674
Hospital Revenue Code	360
Min. Negotiated Rate	$405.15
Max. Negotiated Rate	$405.15
Rate for Payer: Qualcare PPO/HMO/WC	$405.15

REVIS RECONST SHOULDER JOINT

Facility

$2,701.00

Service Code	HCPCS 23474
Hospital Charge Code	16000611
Hospital Revenue Code	360
Min. Negotiated Rate	$76.71
Max. Negotiated Rate	$55,329.13
Rate for Payer: Aetna Commercial	$41,487.32
Rate for Payer: Aetna Medicare Advantage	$49,418.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$55,329.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$55,329.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15,252.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$55,329.13
Rate for Payer: Cigna Commercial	$30,573.98
Rate for Payer: Cigna Medicare Advantage	$15,252.69
Rate for Payer: Clover Medicare Advantage	$14,490.06
Rate for Payer: EmblemHealth Commercial	$45,758.07
Rate for Payer: Humana Medicare Advantage	$15,710.27
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15,252.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$702.26
Rate for Payer: Oxford Commercial	$13,407.00
Rate for Payer: Qualcare PPO/HMO/WC	$405.15
Rate for Payer: UnitedHealthcare Commercial	$14,869.00
Rate for Payer: UnitedHealthcare Community & State	$85.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$15,252.69
Rate for Payer: Wellcare Medicare Advantage	$15,252.69
Rate for Payer: Wellpoint Medicaid Managed Care	$76.71

REVIS RECONST SHOULDER JOINT

Facility

$2,701.00

Service Code	HCPCS 23474
Hospital Charge Code	1600000674
Hospital Revenue Code	360
Min. Negotiated Rate	$76.71
Max. Negotiated Rate	$55,329.13
Rate for Payer: Aetna Commercial	$41,487.32
Rate for Payer: Aetna Medicare Advantage	$49,418.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$55,329.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$55,329.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15,252.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$55,329.13
Rate for Payer: Cigna Commercial	$30,573.98
Rate for Payer: Cigna Medicare Advantage	$15,252.69
Rate for Payer: Clover Medicare Advantage	$14,490.06
Rate for Payer: EmblemHealth Commercial	$45,758.07
Rate for Payer: Humana Medicare Advantage	$15,710.27
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15,252.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$702.26
Rate for Payer: Oxford Commercial	$13,407.00
Rate for Payer: Qualcare PPO/HMO/WC	$405.15
Rate for Payer: UnitedHealthcare Commercial	$14,869.00
Rate for Payer: UnitedHealthcare Community & State	$85.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$15,252.69
Rate for Payer: Wellcare Medicare Advantage	$15,252.69
Rate for Payer: Wellpoint Medicaid Managed Care	$76.71

REVIS RECONST SHOULDER JOINT

Facility

$39,644.20

Service Code	HCPCS 23473
Hospital Charge Code	1600000591
Hospital Revenue Code	360
Min. Negotiated Rate	$1,125.90
Max. Negotiated Rate	$55,329.13
Rate for Payer: Aetna Commercial	$41,487.32
Rate for Payer: Aetna Medicare Advantage	$49,418.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$55,329.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$55,329.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$15,252.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$55,329.13
Rate for Payer: Cigna Commercial	$30,573.98
Rate for Payer: Cigna Medicare Advantage	$15,252.69
Rate for Payer: Clover Medicare Advantage	$14,490.06
Rate for Payer: EmblemHealth Commercial	$45,758.07
Rate for Payer: Humana Medicare Advantage	$15,710.27
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$15,252.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$10,307.49
Rate for Payer: Oxford Commercial	$11,677.00
Rate for Payer: Qualcare PPO/HMO/WC	$5,946.63
Rate for Payer: UnitedHealthcare Commercial	$12,906.00
Rate for Payer: UnitedHealthcare Community & State	$1,252.76
Rate for Payer: UnitedHealthcare Medicare Advantage	$15,252.69
Rate for Payer: Wellcare Medicare Advantage	$15,252.69
Rate for Payer: Wellpoint Medicaid Managed Care	$1,125.90

REVIS RECONST SHOULDER JOINT

Facility

$2,701.00

Service Code	HCPCS 23474
Hospital Charge Code	16000611
Hospital Revenue Code	360
Min. Negotiated Rate	$405.15
Max. Negotiated Rate	$405.15
Rate for Payer: Qualcare PPO/HMO/WC	$405.15

REVIS RECONST SHOULDER JOINT

Facility

$39,644.20

Service Code	HCPCS 23473
Hospital Charge Code	1600000591
Hospital Revenue Code	360
Min. Negotiated Rate	$5,946.63
Max. Negotiated Rate	$5,946.63
Rate for Payer: Qualcare PPO/HMO/WC	$5,946.63

REVOLUTION NOZZLE BREAKAWAY

Facility

$3,503.30

Hospital Charge Code	270689586
Hospital Revenue Code	272
Min. Negotiated Rate	$99.49
Max. Negotiated Rate	$1,751.65
Rate for Payer: Aetna Commercial	$1,331.25
Rate for Payer: Aetna Medicare Advantage	$1,050.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$893.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$893.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$893.34
Rate for Payer: Cigna Commercial	$1,751.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$910.86
Rate for Payer: Oxford Commercial	$700.66
Rate for Payer: Qualcare PPO/HMO/WC	$525.50
Rate for Payer: UnitedHealthcare Commercial	$700.66
Rate for Payer: UnitedHealthcare Community & State	$110.70
Rate for Payer: Wellpoint Medicaid Managed Care	$99.49

REVOLUTION NOZZLE BREAKAWAY

Facility

$3,503.30

Hospital Charge Code	270689586
Hospital Revenue Code	272
Min. Negotiated Rate	$525.50
Max. Negotiated Rate	$525.50
Rate for Payer: Qualcare PPO/HMO/WC	$525.50

REV PRESSFIT STEM NSLT 10 X 10

Facility

$11,322.50

Service Code	HCPCS C1776
Hospital Charge Code	270686903
Hospital Revenue Code	278
Min. Negotiated Rate	$1,698.38
Max. Negotiated Rate	$2,740.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,264.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,740.05
Rate for Payer: Qualcare PPO/HMO/WC	$1,698.38

REV PRESSFIT STEM NSLT 10 X 10

Facility

$11,322.50

Service Code	HCPCS C1776
Hospital Charge Code	270686903
Hospital Revenue Code	278
Min. Negotiated Rate	$321.56
Max. Negotiated Rate	$5,661.25
Rate for Payer: Aetna Commercial	$4,302.55
Rate for Payer: Aetna Medicare Advantage	$3,396.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,887.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,887.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,264.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,887.24
Rate for Payer: Cigna Commercial	$5,661.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,740.05
Rate for Payer: Qualcare PPO/HMO/WC	$1,698.38
Rate for Payer: UnitedHealthcare Community & State	$357.79
Rate for Payer: Wellpoint Medicaid Managed Care	$321.56

REV /REM IMPL SPNL NS PG/REC

Facility

$27,115.93

Service Code	HCPCS 63688
Hospital Charge Code	1600000878
Hospital Revenue Code	360
Min. Negotiated Rate	$4,067.39
Max. Negotiated Rate	$4,067.39
Rate for Payer: Qualcare PPO/HMO/WC	$4,067.39

REV /REM IMPL SPNL NS PG/REC

Facility

$27,115.93

Service Code	HCPCS 63688
Hospital Charge Code	1600000878
Hospital Revenue Code	360
Min. Negotiated Rate	$770.09
Max. Negotiated Rate	$15,066.71
Rate for Payer: Aetna Commercial	$11,297.44
Rate for Payer: Aetna Medicare Advantage	$13,457.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$15,066.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$15,066.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$4,153.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$15,066.71
Rate for Payer: Cigna Commercial	$8,325.61
Rate for Payer: Cigna Medicare Advantage	$4,153.47
Rate for Payer: Clover Medicare Advantage	$3,945.80
Rate for Payer: EmblemHealth Commercial	$12,460.41
Rate for Payer: Humana Medicare Advantage	$4,278.07
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$4,153.47
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7,050.14
Rate for Payer: Oxford Commercial	$9,354.00
Rate for Payer: Qualcare PPO/HMO/WC	$4,067.39
Rate for Payer: UnitedHealthcare Commercial	$10,269.00
Rate for Payer: UnitedHealthcare Community & State	$856.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,153.47
Rate for Payer: Wellcare Medicare Advantage	$4,153.47
Rate for Payer: Wellpoint Medicaid Managed Care	$770.09

REV SH CUP BRNG HMRL 40MM3VITE

Facility

$11,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270700225
Hospital Revenue Code	278
Min. Negotiated Rate	$1,725.00
Max. Negotiated Rate	$2,783.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,300.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,783.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,725.00

REV SH CUP BRNG HMRL 40MM3VITE

Facility

$11,500.00

Service Code	HCPCS C1776
Hospital Charge Code	270700225
Hospital Revenue Code	278
Min. Negotiated Rate	$326.60
Max. Negotiated Rate	$5,750.00
Rate for Payer: Aetna Commercial	$4,370.00
Rate for Payer: Aetna Medicare Advantage	$3,450.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2,932.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2,932.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,300.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2,932.50
Rate for Payer: Cigna Commercial	$5,750.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,783.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,725.00
Rate for Payer: UnitedHealthcare Community & State	$363.40
Rate for Payer: Wellpoint Medicaid Managed Care	$326.60

REV SH HD VERSADIAL GL 3 40 MM

Facility

$6,180.00

Service Code	HCPCS C1776
Hospital Charge Code	270700223
Hospital Revenue Code	278
Min. Negotiated Rate	$175.51
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: Qualcare PPO/HMO/WC	$927.00
Rate for Payer: UnitedHealthcare Community & State	$195.29
Rate for Payer: Wellpoint Medicaid Managed Care	$175.51

REV SH HD VERSADIAL GL 3 40 MM

Facility

$6,180.00

Service Code	HCPCS C1776
Hospital Charge Code	270700223
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: Qualcare PPO/HMO/WC	$927.00

REV SH HUMERAL TRAY NEUTRAL0MM

Facility

$12,075.00

Service Code	HCPCS C1776
Hospital Charge Code	270700224
Hospital Revenue Code	278
Min. Negotiated Rate	$342.93
Max. Negotiated Rate	$6,037.50
Rate for Payer: Aetna Commercial	$4,588.50
Rate for Payer: Aetna Medicare Advantage	$3,622.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3,079.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3,079.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,415.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3,079.12
Rate for Payer: Cigna Commercial	$6,037.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,922.15
Rate for Payer: Qualcare PPO/HMO/WC	$1,811.25
Rate for Payer: UnitedHealthcare Community & State	$381.57
Rate for Payer: Wellpoint Medicaid Managed Care	$342.93

REV SH HUMERAL TRAY NEUTRAL0MM

Facility

$12,075.00

Service Code	HCPCS C1776
Hospital Charge Code	270700224
Hospital Revenue Code	278
Min. Negotiated Rate	$1,811.25
Max. Negotiated Rate	$2,922.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$2,415.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,922.15
Rate for Payer: Qualcare PPO/HMO/WC	$1,811.25

RF ABLTJ NRV NRVTG SI JT

Facility

$10,782.78

Service Code	HCPCS 64625
Hospital Charge Code	321564625
Hospital Revenue Code	361
Min. Negotiated Rate	$1,617.42
Max. Negotiated Rate	$1,617.42
Rate for Payer: Qualcare PPO/HMO/WC	$1,617.42

RF ABLTJ NRV NRVTG SI JT

Facility

$10,782.78

Service Code	HCPCS 64625
Hospital Charge Code	321564625
Hospital Revenue Code	361
Min. Negotiated Rate	$306.23
Max. Negotiated Rate	$8,415.40
Rate for Payer: Aetna Commercial	$6,310.10
Rate for Payer: Aetna Medicare Advantage	$7,516.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8,415.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8,415.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$2,319.89
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$3,536.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8,415.40
Rate for Payer: Cigna Commercial	$4,650.22
Rate for Payer: Cigna Medicare Advantage	$2,319.89
Rate for Payer: Clover Medicare Advantage	$2,203.90
Rate for Payer: EmblemHealth Commercial	$6,959.67
Rate for Payer: Humana Medicare Advantage	$2,389.49
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$2,319.89
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2,803.52
Rate for Payer: Oxford Commercial	$7,525.00
Rate for Payer: Qualcare PPO/HMO/WC	$1,617.42
Rate for Payer: UnitedHealthcare Commercial	$8,192.00
Rate for Payer: UnitedHealthcare Community & State	$340.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$2,319.89
Rate for Payer: Wellcare Medicare Advantage	$2,319.89
Rate for Payer: Wellpoint Medicaid Managed Care	$306.23

RF BIPOLAR 350MM

Facility

$3,750.00

Hospital Charge Code	270688534
Hospital Revenue Code	272
Min. Negotiated Rate	$106.50
Max. Negotiated Rate	$1,875.00
Rate for Payer: Aetna Commercial	$1,425.00
Rate for Payer: Aetna Medicare Advantage	$1,125.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$956.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$956.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$956.25
Rate for Payer: Cigna Commercial	$1,875.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$975.00
Rate for Payer: Oxford Commercial	$750.00
Rate for Payer: Qualcare PPO/HMO/WC	$562.50
Rate for Payer: UnitedHealthcare Commercial	$750.00
Rate for Payer: UnitedHealthcare Community & State	$118.50
Rate for Payer: Wellpoint Medicaid Managed Care	$106.50

RF BIPOLAR 350MM

Facility

$3,750.00

Hospital Charge Code	270688534
Hospital Revenue Code	272
Min. Negotiated Rate	$562.50
Max. Negotiated Rate	$562.50
Rate for Payer: Qualcare PPO/HMO/WC	$562.50

Know your out-of-pocket cost for care.

All Charges