Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

AETOS REVERSE LINER 34MM/SMALL

Facility

$3,745.00

Service Code	HCPCS C1713
Hospital Charge Code	270704575
Hospital Revenue Code	278
Min. Negotiated Rate	$561.75
Max. Negotiated Rate	$906.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$749.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$906.29
Rate for Payer: Qualcare PPO/HMO/WC	$561.75

AETOS REVERSE LINER 38MM SMALL

Facility

$3,745.00

Service Code	HCPCS C1765
Hospital Charge Code	270704979
Hospital Revenue Code	278
Min. Negotiated Rate	$561.75
Max. Negotiated Rate	$906.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$749.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$906.29
Rate for Payer: Qualcare PPO/HMO/WC	$561.75

AETOS REVERSE LINER 38MM SMALL

Facility

$3,745.00

Service Code	HCPCS C1765
Hospital Charge Code	270704979
Hospital Revenue Code	278
Min. Negotiated Rate	$106.36
Max. Negotiated Rate	$1,872.50
Rate for Payer: Aetna Commercial	$1,423.10
Rate for Payer: Aetna Medicare Advantage	$1,123.50
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$954.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$954.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$749.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$954.98
Rate for Payer: Cigna Commercial	$1,872.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$906.29
Rate for Payer: Qualcare PPO/HMO/WC	$561.75
Rate for Payer: UnitedHealthcare Community & State	$118.34
Rate for Payer: Wellpoint Medicaid Managed Care	$106.36

AETOS REVERSE LINER RETENT 38M

Facility

$6,531.30

Service Code	HCPCS C1713
Hospital Charge Code	270704903
Hospital Revenue Code	278
Min. Negotiated Rate	$979.70
Max. Negotiated Rate	$1,580.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,306.26
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,580.57
Rate for Payer: Qualcare PPO/HMO/WC	$979.70

AETOS REVERSE LINER RETENT 38M

Facility

$6,531.30

Service Code	HCPCS C1713
Hospital Charge Code	270704903
Hospital Revenue Code	278
Min. Negotiated Rate	$185.49
Max. Negotiated Rate	$3,265.65
Rate for Payer: Aetna Commercial	$2,481.89
Rate for Payer: Aetna Medicare Advantage	$1,959.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,665.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,665.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,306.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,665.48
Rate for Payer: Cigna Commercial	$3,265.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,580.57
Rate for Payer: Qualcare PPO/HMO/WC	$979.70
Rate for Payer: UnitedHealthcare Community & State	$206.39
Rate for Payer: Wellpoint Medicaid Managed Care	$185.49

AETOS SHOULDER SYSTEM 34MM

Facility

$6,530.00

Service Code	HCPCS C1713
Hospital Charge Code	270703978
Hospital Revenue Code	278
Min. Negotiated Rate	$979.50
Max. Negotiated Rate	$1,580.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,306.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,580.26
Rate for Payer: Qualcare PPO/HMO/WC	$979.50

AETOS SHOULDER SYSTEM 34MM

Facility

$6,530.00

Service Code	HCPCS C1713
Hospital Charge Code	270703978
Hospital Revenue Code	278
Min. Negotiated Rate	$185.45
Max. Negotiated Rate	$3,265.00
Rate for Payer: Aetna Commercial	$2,481.40
Rate for Payer: Aetna Medicare Advantage	$1,959.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1,665.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1,665.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$1,306.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1,665.15
Rate for Payer: Cigna Commercial	$3,265.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1,580.26
Rate for Payer: Qualcare PPO/HMO/WC	$979.50
Rate for Payer: UnitedHealthcare Community & State	$206.35
Rate for Payer: Wellpoint Medicaid Managed Care	$185.45

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479501
Hospital Revenue Code	309
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.23
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.36
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$5.28

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479497
Hospital Revenue Code	309
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479499
Hospital Revenue Code	309
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479499
Hospital Revenue Code	309
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.23
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.36
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$5.28

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479497
Hospital Revenue Code	309
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.23
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.36
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$5.28

AFB CULT MISC

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479501
Hospital Revenue Code	309
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

AFB CULT SMEAR

Facility

$152.00

Service Code	HCPCS 87206
Hospital Charge Code	38479500
Hospital Revenue Code	309
Min. Negotiated Rate	$22.80
Max. Negotiated Rate	$22.80
Rate for Payer: Qualcare PPO/HMO/WC	$22.80

AFB CULT SMEAR

Facility

$152.00

Service Code	HCPCS 87206
Hospital Charge Code	38479500
Hospital Revenue Code	309
Min. Negotiated Rate	$4.31
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$14.66
Rate for Payer: Aetna Medicare Advantage	$17.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$19.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$19.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$6.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$19.55
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare Advantage	$5.39
Rate for Payer: Clover Medicare Advantage	$5.12
Rate for Payer: EmblemHealth Commercial	$16.17
Rate for Payer: Humana Medicare Advantage	$5.55
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$5.39
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$39.52
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$22.80
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$4.31
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.39
Rate for Payer: Wellcare Medicare Advantage	$5.39
Rate for Payer: Wellpoint Medicaid Managed Care	$4.32

AFB CULTURE - CONCENTRATED

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38475080
Hospital Revenue Code	309
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.23
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.36
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$5.28

AFB CULTURE - CONCENTRATED

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38475080
Hospital Revenue Code	309
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

AFB CULTURE-CONCENTRATED

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479465
Hospital Revenue Code	309
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Qualcare PPO/HMO/WC	$27.90

AFB CULTURE-CONCENTRATED

Facility

$186.00

Service Code	HCPCS 87015
Hospital Charge Code	38479465
Hospital Revenue Code	309
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$18.17
Rate for Payer: Aetna Medicare Advantage	$21.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$24.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$6.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$8.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$24.23
Rate for Payer: Cigna Commercial	$93.00
Rate for Payer: Cigna Medicare Advantage	$6.68
Rate for Payer: Clover Medicare Advantage	$6.35
Rate for Payer: EmblemHealth Commercial	$20.04
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$6.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.36
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$27.90
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$5.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.68
Rate for Payer: Wellcare Medicare Advantage	$6.68
Rate for Payer: Wellpoint Medicaid Managed Care	$5.28

AFB CULTURE DIRECT

Facility

$124.00

Service Code	HCPCS 87116
Hospital Charge Code	38479467
Hospital Revenue Code	309
Min. Negotiated Rate	$18.60
Max. Negotiated Rate	$18.60
Rate for Payer: Qualcare PPO/HMO/WC	$18.60

AFB CULTURE DIRECT

Facility

$124.00

Service Code	HCPCS 87116
Hospital Charge Code	38479467
Hospital Revenue Code	309
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$29.38
Rate for Payer: Aetna Medicare Advantage	$34.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$10.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.18
Rate for Payer: Cigna Commercial	$62.00
Rate for Payer: Cigna Medicare Advantage	$10.80
Rate for Payer: Clover Medicare Advantage	$10.26
Rate for Payer: EmblemHealth Commercial	$32.40
Rate for Payer: Humana Medicare Advantage	$11.12
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$10.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$32.24
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$18.60
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$8.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80
Rate for Payer: Wellcare Medicare Advantage	$10.80
Rate for Payer: Wellpoint Medicaid Managed Care	$3.52

AFB CULTURE, DIRECT

Facility

$124.00

Service Code	HCPCS 87116
Hospital Charge Code	38475014
Hospital Revenue Code	309
Min. Negotiated Rate	$18.60
Max. Negotiated Rate	$18.60
Rate for Payer: Qualcare PPO/HMO/WC	$18.60

AFB CULTURE, DIRECT

Facility

$124.00

Service Code	HCPCS 87116
Hospital Charge Code	38475014
Hospital Revenue Code	309
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$29.38
Rate for Payer: Aetna Medicare Advantage	$34.99
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$10.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.18
Rate for Payer: Cigna Commercial	$62.00
Rate for Payer: Cigna Medicare Advantage	$10.80
Rate for Payer: Clover Medicare Advantage	$10.26
Rate for Payer: EmblemHealth Commercial	$32.40
Rate for Payer: Humana Medicare Advantage	$11.12
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$10.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$32.24
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$18.60
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$8.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80
Rate for Payer: Wellcare Medicare Advantage	$10.80
Rate for Payer: Wellpoint Medicaid Managed Care	$3.52

AFB ID HPLC-FL and CONVENT

Facility

$86.10

Service Code	HCPCS 87143
Hospital Charge Code	39990164B
Hospital Revenue Code	309
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$34.05
Rate for Payer: Aetna Medicare Advantage	$40.56
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$45.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$45.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$5.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$45.42
Rate for Payer: Cigna Commercial	$43.05
Rate for Payer: Cigna Medicare Advantage	$12.52
Rate for Payer: Clover Medicare Advantage	$11.89
Rate for Payer: EmblemHealth Commercial	$37.56
Rate for Payer: Humana Medicare Advantage	$12.90
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.52
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$22.39
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$12.91
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$10.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.52
Rate for Payer: Wellcare Medicare Advantage	$12.52
Rate for Payer: Wellpoint Medicaid Managed Care	$2.45

AFB ID HPLC-FL and CONVENT

Facility

$86.10

Service Code	HCPCS 87143
Hospital Charge Code	39990164A
Hospital Revenue Code	309
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$12.91
Rate for Payer: Qualcare PPO/HMO/WC	$12.91

Know your out-of-pocket cost for care.

All Charges