|
STERI-STRIP 1/4
|
Facility
|
OP
|
$10.45
|
|
| Hospital Charge Code |
270060820
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$5.22 |
| Rate for Payer: Aetna Commercial |
$3.97
|
| Rate for Payer: Aetna Medicare Advantage |
$3.13
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$2.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$2.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$2.66
|
| Rate for Payer: Cigna Commercial |
$5.22
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$2.72
|
| Rate for Payer: Oxford Commercial |
$2.09
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$1.57
|
| Rate for Payer: UnitedHealthcare Commercial |
$2.09
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.33
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.30
|
|
|
STERI-STRIP 1/4 X4
|
Facility
|
OP
|
$4.01
|
|
| Hospital Charge Code |
270649957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna Commercial |
$1.52
|
| Rate for Payer: Aetna Medicare Advantage |
$1.20
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.02
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.02
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.02
|
| Rate for Payer: Cigna Commercial |
$2.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.04
|
| Rate for Payer: Oxford Commercial |
$0.80
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$0.80
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.13
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.11
|
|
|
STERI-STRIP 1/4 X4
|
Facility
|
IP
|
$4.01
|
|
| Hospital Charge Code |
270649957
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.60
|
|
|
STERI-STRIP 1/8
|
Facility
|
OP
|
$5.00
|
|
| Hospital Charge Code |
270060815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna Commercial |
$1.90
|
| Rate for Payer: Aetna Medicare Advantage |
$1.50
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$1.27
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$1.27
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$1.27
|
| Rate for Payer: Cigna Commercial |
$2.50
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1.30
|
| Rate for Payer: Oxford Commercial |
$1.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.75
|
| Rate for Payer: UnitedHealthcare Commercial |
$1.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.16
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.14
|
|
|
STERI-STRIP 1/8
|
Facility
|
IP
|
$5.00
|
|
| Hospital Charge Code |
270060815
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$0.75
|
|
|
STERL SUPPLIES-MRI FOR V ACCES
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2680400
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.26 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$57.00
|
| Rate for Payer: Aetna Medicare Advantage |
$45.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$38.25
|
| Rate for Payer: Cigna Commercial |
$75.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$39.00
|
| Rate for Payer: Oxford Commercial |
$30.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$22.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$4.74
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$4.26
|
|
|
STERL SUPPLIES-MRI FOR V ACCES
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS A4649
|
| Hospital Charge Code |
2680400
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$22.50
|
|
|
STERL SUPPLIES-MRI FOR V ACCES
|
Facility
|
OP
|
$150.00
|
|
| Hospital Charge Code |
7412027
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.26 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$57.00
|
| Rate for Payer: Aetna Medicare Advantage |
$45.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$38.25
|
| Rate for Payer: Cigna Commercial |
$75.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$39.00
|
| Rate for Payer: Oxford Commercial |
$30.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$22.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$4.74
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$4.26
|
|
|
STERL SUPPLIES-MRI FOR V ACCES
|
Facility
|
IP
|
$150.00
|
|
| Hospital Charge Code |
7412027
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$22.50
|
|
|
STERNOCLAVICULAR JT
|
Facility
|
IP
|
$5,100.00
|
|
|
Service Code
|
HCPCS 71130
|
| Hospital Charge Code |
94061273
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$765.00 |
| Max. Negotiated Rate |
$765.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$765.00
|
|
|
STERNOCLAVICULAR JT
|
Facility
|
OP
|
$5,100.00
|
|
|
Service Code
|
HCPCS 71130
|
| Hospital Charge Code |
94061273
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$2,231.00 |
| Rate for Payer: Aetna Commercial |
$281.22
|
| Rate for Payer: Aetna Medicare Advantage |
$334.98
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$375.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$375.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$103.39
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$33.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$375.05
|
| Rate for Payer: Cigna Commercial |
$207.24
|
| Rate for Payer: Cigna Medicare Advantage |
$72.37
|
| Rate for Payer: Clover Medicare Advantage |
$98.22
|
| Rate for Payer: EmblemHealth Commercial |
$310.17
|
| Rate for Payer: Humana Medicare Advantage |
$106.49
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$103.39
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,326.00
|
| Rate for Payer: Oxford Commercial |
$1,955.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$765.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,231.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$161.16
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$103.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$103.39
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$144.84
|
|
|
STERNOCLAVICULAR JT
|
Facility
|
OP
|
$5,100.00
|
|
|
Service Code
|
HCPCS 71130
|
| Hospital Charge Code |
94061275
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$2,231.00 |
| Rate for Payer: Aetna Commercial |
$281.22
|
| Rate for Payer: Aetna Medicare Advantage |
$334.98
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$375.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$375.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$103.39
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$33.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$375.05
|
| Rate for Payer: Cigna Commercial |
$207.24
|
| Rate for Payer: Cigna Medicare Advantage |
$72.37
|
| Rate for Payer: Clover Medicare Advantage |
$98.22
|
| Rate for Payer: EmblemHealth Commercial |
$310.17
|
| Rate for Payer: Humana Medicare Advantage |
$106.49
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$103.39
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,326.00
|
| Rate for Payer: Oxford Commercial |
$1,955.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$765.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,231.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$161.16
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$103.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$103.39
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$144.84
|
|
|
STERNOCLAVICULAR JT
|
Facility
|
IP
|
$5,100.00
|
|
|
Service Code
|
HCPCS 71130
|
| Hospital Charge Code |
94061275
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$765.00 |
| Max. Negotiated Rate |
$765.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$765.00
|
|
|
STERNUM
|
Facility
|
IP
|
$5,100.00
|
|
|
Service Code
|
HCPCS 71120
|
| Hospital Charge Code |
94061045
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$765.00 |
| Max. Negotiated Rate |
$765.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$765.00
|
|
|
STERNUM
|
Facility
|
OP
|
$5,100.00
|
|
|
Service Code
|
HCPCS 71120
|
| Hospital Charge Code |
94061045
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.86 |
| Max. Negotiated Rate |
$2,231.00 |
| Rate for Payer: Aetna Commercial |
$281.22
|
| Rate for Payer: Aetna Medicare Advantage |
$334.98
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$375.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$375.05
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage |
$103.39
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$29.86
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$375.05
|
| Rate for Payer: Cigna Commercial |
$207.24
|
| Rate for Payer: Cigna Medicare Advantage |
$72.37
|
| Rate for Payer: Clover Medicare Advantage |
$98.22
|
| Rate for Payer: EmblemHealth Commercial |
$310.17
|
| Rate for Payer: Humana Medicare Advantage |
$106.49
|
| Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage |
$103.39
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$1,326.00
|
| Rate for Payer: Oxford Commercial |
$1,955.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$765.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,231.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$161.16
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$103.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$103.39
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$144.84
|
|
|
STER SUPLS-CT FOR V ACCESS
|
Facility
|
IP
|
$150.00
|
|
| Hospital Charge Code |
4800965
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$22.50
|
|
|
STER SUPLS-CT FOR V ACCESS
|
Facility
|
OP
|
$150.00
|
|
| Hospital Charge Code |
4800965
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.26 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Aetna Commercial |
$57.00
|
| Rate for Payer: Aetna Medicare Advantage |
$45.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$38.25
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$38.25
|
| Rate for Payer: Cigna Commercial |
$75.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$39.00
|
| Rate for Payer: Oxford Commercial |
$30.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$22.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$4.74
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$4.26
|
|
|
STETHOSCOPE ESOPHAGEAL 18FR
|
Facility
|
OP
|
$18.27
|
|
| Hospital Charge Code |
270615341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$9.13 |
| Rate for Payer: Aetna Commercial |
$6.94
|
| Rate for Payer: Aetna Medicare Advantage |
$5.48
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$4.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$4.66
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$4.66
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$4.75
|
| Rate for Payer: Oxford Commercial |
$3.65
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$2.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$3.65
|
| Rate for Payer: UnitedHealthcare Community & State |
$0.58
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$0.52
|
|
|
STETHOSCOPE ESOPHAGEAL 18FR
|
Facility
|
IP
|
$18.27
|
|
| Hospital Charge Code |
270615341
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$2.74
|
|
|
ST EVAL OF SPEECH SOUND PRODUC
|
Facility
|
OP
|
$2,400.00
|
|
|
Service Code
|
HCPCS 92522GN
|
| Hospital Charge Code |
74204041
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$912.00
|
| Rate for Payer: Aetna Medicare Advantage |
$720.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$612.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$612.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health |
$69.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$612.00
|
| Rate for Payer: Cigna Commercial |
$1,200.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$624.00
|
| Rate for Payer: Oxford Commercial |
$933.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$360.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$1,060.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$75.84
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$65.00
|
|
|
ST EVAL OF SPEECH SOUND PRODUC
|
Facility
|
IP
|
$2,400.00
|
|
|
Service Code
|
HCPCS 92522GN
|
| Hospital Charge Code |
74204041
|
|
Hospital Revenue Code
|
444
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$360.00
|
|
|
ST EVAL SPEECH DEV ADD HR
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS 92608GN
|
| Hospital Charge Code |
74204023
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$19.50 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.50
|
|
|
ST EVAL SPEECH DEV ADD HR
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS 92608GN
|
| Hospital Charge Code |
74204023
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$3.69 |
| Max. Negotiated Rate |
$2,770.00 |
| Rate for Payer: Aetna Commercial |
$49.40
|
| Rate for Payer: Aetna Medicare Advantage |
$39.00
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$33.15
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$33.15
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$33.15
|
| Rate for Payer: Cigna Commercial |
$65.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$33.80
|
| Rate for Payer: Oxford Commercial |
$2,441.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$19.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,770.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$4.11
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$3.69
|
|
|
ST EVAL SPEECH DEVICE 1HR
|
Facility
|
OP
|
$596.00
|
|
|
Service Code
|
HCPCS 92607GN
|
| Hospital Charge Code |
74204021
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$16.93 |
| Max. Negotiated Rate |
$2,770.00 |
| Rate for Payer: Aetna Commercial |
$226.48
|
| Rate for Payer: Aetna Medicare Advantage |
$178.80
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity |
$151.98
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care |
$151.98
|
| Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO |
$151.98
|
| Rate for Payer: Cigna Commercial |
$298.00
|
| Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC |
$154.96
|
| Rate for Payer: Oxford Commercial |
$2,441.00
|
| Rate for Payer: Qualcare PPO/HMO/WC |
$89.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$2,770.00
|
| Rate for Payer: UnitedHealthcare Community & State |
$18.83
|
| Rate for Payer: Wellpoint Medicaid Managed Care |
$16.93
|
|
|
ST EVAL SPEECH DEVICE 1HR
|
Facility
|
IP
|
$596.00
|
|
|
Service Code
|
HCPCS 92607GN
|
| Hospital Charge Code |
74204021
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$89.40 |
| Max. Negotiated Rate |
$89.40 |
| Rate for Payer: Qualcare PPO/HMO/WC |
$89.40
|
|