Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

DETACHMENT HANDLE

Facility

$1,250.00

Hospital Charge Code	270673588
Hospital Revenue Code	272
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$187.50
Rate for Payer: Qualcare PPO/HMO/WC	$187.50

DETACHMENT HANDLE

Facility

$1,250.00

Hospital Charge Code	270673588N
Hospital Revenue Code	272
Min. Negotiated Rate	$35.50
Max. Negotiated Rate	$625.00
Rate for Payer: Aetna Commercial	$475.00
Rate for Payer: Aetna Medicare Advantage	$375.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$318.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$318.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$318.75
Rate for Payer: Cigna Commercial	$625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$325.00
Rate for Payer: Oxford Commercial	$250.00
Rate for Payer: Qualcare PPO/HMO/WC	$187.50
Rate for Payer: UnitedHealthcare Commercial	$250.00
Rate for Payer: UnitedHealthcare Community & State	$39.50
Rate for Payer: Wellpoint Medicaid Managed Care	$35.50

DETACHMENT HANDLE

Facility

$1,250.00

Hospital Charge Code	270673588N
Hospital Revenue Code	272
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$187.50
Rate for Payer: Qualcare PPO/HMO/WC	$187.50

DETACHMENT HANDLE

Facility

$1,250.00

Hospital Charge Code	270673588
Hospital Revenue Code	272
Min. Negotiated Rate	$35.50
Max. Negotiated Rate	$625.00
Rate for Payer: Aetna Commercial	$475.00
Rate for Payer: Aetna Medicare Advantage	$375.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$318.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$318.75
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$318.75
Rate for Payer: Cigna Commercial	$625.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$325.00
Rate for Payer: Oxford Commercial	$250.00
Rate for Payer: Qualcare PPO/HMO/WC	$187.50
Rate for Payer: UnitedHealthcare Commercial	$250.00
Rate for Payer: UnitedHealthcare Community & State	$39.50
Rate for Payer: Wellpoint Medicaid Managed Care	$35.50

DETACHMENT HANDLE

Facility

$1,250.00

Hospital Charge Code	270673588O
Hospital Revenue Code	272
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$187.50
Rate for Payer: Qualcare PPO/HMO/WC	$187.50

DET AGENT NOS DNA AMP

Facility

$390.00

Service Code	HCPCS 87798
Hospital Charge Code	401187798
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

DET AGENT NOS DNA AMP

Facility

$390.00

Service Code	HCPCS 87798
Hospital Charge Code	401187798
Hospital Revenue Code	306
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$95.44
Rate for Payer: Aetna Medicare Advantage	$113.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$127.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$127.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$35.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$130.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$127.29
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$35.09
Rate for Payer: Clover Medicare Advantage	$33.34
Rate for Payer: EmblemHealth Commercial	$105.27
Rate for Payer: Humana Medicare Advantage	$36.14
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$35.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$101.40
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$28.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$35.09
Rate for Payer: Wellcare Medicare Advantage	$35.09
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

DETCT BY NUC ACD CYTOMEGALOVIR

Facility

$301.00

Service Code	HCPCS 87497
Hospital Charge Code	38477203
Hospital Revenue Code	306
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$116.52
Rate for Payer: Aetna Medicare Advantage	$138.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$155.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$155.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$42.84
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$40.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$155.40
Rate for Payer: Cigna Commercial	$150.50
Rate for Payer: Cigna Medicare Advantage	$42.84
Rate for Payer: Clover Medicare Advantage	$40.70
Rate for Payer: EmblemHealth Commercial	$128.52
Rate for Payer: Humana Medicare Advantage	$44.13
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$42.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$78.26
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$45.15
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$34.27
Rate for Payer: UnitedHealthcare Medicare Advantage	$42.84
Rate for Payer: Wellcare Medicare Advantage	$42.84
Rate for Payer: Wellpoint Medicaid Managed Care	$8.55

DETCT BY NUC ACD CYTOMEGALOVIR

Facility

$301.00

Service Code	HCPCS 87497
Hospital Charge Code	38477203
Hospital Revenue Code	306
Min. Negotiated Rate	$45.15
Max. Negotiated Rate	$45.15
Rate for Payer: Qualcare PPO/HMO/WC	$45.15

DETCT/BY/NUC ACD MYCOBACTERIA

Facility

$141.00

Service Code	HCPCS 87555
Hospital Charge Code	38477162
Hospital Revenue Code	306
Min. Negotiated Rate	$21.15
Max. Negotiated Rate	$21.15
Rate for Payer: Qualcare PPO/HMO/WC	$21.15

DETCT/BY/NUC ACD MYCOBACTERIA

Facility

$141.00

Service Code	HCPCS 87555
Hospital Charge Code	38477162
Hospital Revenue Code	306
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$73.11
Rate for Payer: Aetna Medicare Advantage	$87.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$97.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$97.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$26.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$18.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$97.51
Rate for Payer: Cigna Commercial	$70.50
Rate for Payer: Cigna Medicare Advantage	$26.88
Rate for Payer: Clover Medicare Advantage	$25.54
Rate for Payer: EmblemHealth Commercial	$80.64
Rate for Payer: Humana Medicare Advantage	$27.69
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$26.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.66
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$21.15
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$21.50
Rate for Payer: UnitedHealthcare Medicare Advantage	$26.88
Rate for Payer: Wellcare Medicare Advantage	$26.88
Rate for Payer: Wellpoint Medicaid Managed Care	$4.00

DETCT BY NUC ACD STAPHYLOCOCCU

Facility

$247.00

Service Code	HCPCS 87641
Hospital Charge Code	38477198
Hospital Revenue Code	306
Min. Negotiated Rate	$37.05
Max. Negotiated Rate	$37.05
Rate for Payer: Qualcare PPO/HMO/WC	$37.05

DETCT BY NUC ACD STAPHYLOCOCCU

Facility

$247.00

Service Code	HCPCS 87641
Hospital Charge Code	38477198
Hospital Revenue Code	306
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$95.44
Rate for Payer: Aetna Medicare Advantage	$113.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$127.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$127.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$35.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$80.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$127.29
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare Advantage	$35.09
Rate for Payer: Clover Medicare Advantage	$33.34
Rate for Payer: EmblemHealth Commercial	$105.27
Rate for Payer: Humana Medicare Advantage	$36.14
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$35.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$64.22
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$37.05
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$28.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$35.09
Rate for Payer: Wellcare Medicare Advantage	$35.09
Rate for Payer: Wellpoint Medicaid Managed Care	$7.01

DETCT BY NUC ACD STREPTPCOCCUS

Facility

$247.00

Service Code	HCPCS 87653
Hospital Charge Code	38477199
Hospital Revenue Code	306
Min. Negotiated Rate	$37.05
Max. Negotiated Rate	$37.05
Rate for Payer: Qualcare PPO/HMO/WC	$37.05

DETCT BY NUC ACD STREPTPCOCCUS

Facility

$247.00

Service Code	HCPCS 87653
Hospital Charge Code	38477199
Hospital Revenue Code	306
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$95.44
Rate for Payer: Aetna Medicare Advantage	$113.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$127.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$127.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$35.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$80.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$127.29
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare Advantage	$35.09
Rate for Payer: Clover Medicare Advantage	$33.34
Rate for Payer: EmblemHealth Commercial	$105.27
Rate for Payer: Humana Medicare Advantage	$36.14
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$35.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$64.22
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$37.05
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$28.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$35.09
Rate for Payer: Wellcare Medicare Advantage	$35.09
Rate for Payer: Wellpoint Medicaid Managed Care	$7.01

DETECT AGENT NOS DNA AMP

Facility

$390.00

Service Code	HCPCS 87798
Hospital Charge Code	401387798A
Hospital Revenue Code	306
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

DETECT AGENT NOS DNA AMP

Facility

$390.00

Service Code	HCPCS 87798
Hospital Charge Code	401387798A
Hospital Revenue Code	306
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$95.44
Rate for Payer: Aetna Medicare Advantage	$113.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$127.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$127.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$35.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$130.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$127.29
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$35.09
Rate for Payer: Clover Medicare Advantage	$33.34
Rate for Payer: EmblemHealth Commercial	$105.27
Rate for Payer: Humana Medicare Advantage	$36.14
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$35.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$101.40
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$28.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$35.09
Rate for Payer: Wellcare Medicare Advantage	$35.09
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

DETECT AGNT MULT DNA AMPLI

Facility

$433.30

Service Code	HCPCS 87801
Hospital Charge Code	401387501
Hospital Revenue Code	306
Min. Negotiated Rate	$12.31
Max. Negotiated Rate	$254.65
Rate for Payer: Aetna Commercial	$190.94
Rate for Payer: Aetna Medicare Advantage	$227.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$254.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$254.65
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$70.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$65.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$254.65
Rate for Payer: Cigna Commercial	$216.65
Rate for Payer: Cigna Medicare Advantage	$70.20
Rate for Payer: Clover Medicare Advantage	$66.69
Rate for Payer: EmblemHealth Commercial	$210.60
Rate for Payer: Humana Medicare Advantage	$72.31
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$70.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$112.66
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$65.00
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$56.16
Rate for Payer: UnitedHealthcare Medicare Advantage	$70.20
Rate for Payer: Wellcare Medicare Advantage	$70.20
Rate for Payer: Wellpoint Medicaid Managed Care	$12.31

DETECT AGNT MULT DNA AMPLI

Facility

$433.30

Service Code	HCPCS 87801
Hospital Charge Code	401387501
Hospital Revenue Code	306
Min. Negotiated Rate	$65.00
Max. Negotiated Rate	$65.00
Rate for Payer: Qualcare PPO/HMO/WC	$65.00

DETECT BY NUC ACD MYCOBACTERIA

Facility

$247.00

Service Code	HCPCS 87556
Hospital Charge Code	38477196
Hospital Revenue Code	306
Min. Negotiated Rate	$37.05
Max. Negotiated Rate	$37.05
Rate for Payer: Qualcare PPO/HMO/WC	$37.05

DETECT BY NUC ACD MYCOBACTERIA

Facility

$247.00

Service Code	HCPCS 87556
Hospital Charge Code	38477196
Hospital Revenue Code	306
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$113.37
Rate for Payer: Aetna Medicare Advantage	$135.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$151.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$151.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$41.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$32.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$151.19
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare Advantage	$41.68
Rate for Payer: Clover Medicare Advantage	$39.60
Rate for Payer: EmblemHealth Commercial	$125.04
Rate for Payer: Humana Medicare Advantage	$42.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$41.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$64.22
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$37.05
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$33.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.68
Rate for Payer: Wellcare Medicare Advantage	$41.68
Rate for Payer: Wellpoint Medicaid Managed Care	$7.01

DETECT BY NUC ACD STAPHYLOCOCC

Facility

$247.00

Service Code	HCPCS 87640
Hospital Charge Code	38477197
Hospital Revenue Code	306
Min. Negotiated Rate	$37.05
Max. Negotiated Rate	$37.05
Rate for Payer: Qualcare PPO/HMO/WC	$37.05

DETECT BY NUC ACD STAPHYLOCOCC

Facility

$247.00

Service Code	HCPCS 87640
Hospital Charge Code	38477197
Hospital Revenue Code	306
Min. Negotiated Rate	$7.01
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$95.44
Rate for Payer: Aetna Medicare Advantage	$113.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$127.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$127.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$35.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$80.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$127.29
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare Advantage	$35.09
Rate for Payer: Clover Medicare Advantage	$33.34
Rate for Payer: EmblemHealth Commercial	$105.27
Rate for Payer: Humana Medicare Advantage	$36.14
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$35.09
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$64.22
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$37.05
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$28.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$35.09
Rate for Payer: Wellcare Medicare Advantage	$35.09
Rate for Payer: Wellpoint Medicaid Managed Care	$7.01

DETECT BY NUC ACID CYTOMEGALOV

Facility

$141.00

Service Code	HCPCS 87495
Hospital Charge Code	38477160
Hospital Revenue Code	306
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$81.68
Rate for Payer: Aetna Medicare Advantage	$97.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$108.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$108.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$30.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$18.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$108.93
Rate for Payer: Cigna Commercial	$70.50
Rate for Payer: Cigna Medicare Advantage	$30.03
Rate for Payer: Clover Medicare Advantage	$28.53
Rate for Payer: EmblemHealth Commercial	$90.09
Rate for Payer: Humana Medicare Advantage	$30.93
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$30.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$36.66
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$21.15
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$24.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.03
Rate for Payer: Wellcare Medicare Advantage	$30.03
Rate for Payer: Wellpoint Medicaid Managed Care	$4.00

DETECT BY NUC ACID CYTOMEGALOV

Facility

$141.00

Service Code	HCPCS 87495
Hospital Charge Code	38477160
Hospital Revenue Code	306
Min. Negotiated Rate	$21.15
Max. Negotiated Rate	$21.15
Rate for Payer: Qualcare PPO/HMO/WC	$21.15

Know your out-of-pocket cost for care.

All Charges