Price of Localized Retinal Laser Treatment at NYU Langone
Last Updated: 2024-07-01
Locations
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NYU Langone|Tisch Hospital
550 1st Ave., New York, NY 10016About Localized Retinal Laser Treatment
Service Codes: CPT 67210, LOCAL 2020625
This procedure involves using a laser to treat specific areas of the retina to address conditions such as retinal tears or diabetic retinopathy, aiming to preserve vision and prevent further complications.
Pricing Overview
Cash Price
$1,005.50
Median Price
$3,810.00
Price Range
$291.08 - $13,547.57
Insurance Plan Prices
| Insurance Provider | Plan Type | Price |
|---|---|---|
| Anthem BCBS HealthPlus | Special Needs Plan (SNP) | $742.07 |
| MultiPlan | Guardian Life Insurance Co | $4,127.85 |
| EmblemHealth | Enhanced Care (Medicaid) SNP HARP (SOMOS) | $779.18 |
| HealthSmart | WTC Health Program - Stony Brook | $650.19 |
| EmblemHealth | Essential Plan 2 | $890.49 |
| EmblemHealth | HIP Access II | $7,558.00 |
| EmblemHealth | Select Care Gold Exchange | $9,585.45 |
| UnitedHealthcare - Oxford | Medicare Advantage | $650.19 |
| Blue Cross Blue Shield | Pathway Enhanced | $890.49 |
| UnitedHealthcare - Oxford | Metro | $3,967.00 |
| EmblemHealth | Healthcare Partners Essential Plan 2 | $890.49 |
| MagnaCare | National Health Plan | $13,547.57 |
| VNS Health | SelectHealth (Medicaid) | $742.07 |
| Fidelis Care | Gold for Children (Exchange) | $1,335.73 |
| UnitedHealthcare | Optum Health | $5,044.00 |
| EmblemHealth | HIP VIP Medicare Affinity | $650.19 |
| AgeWell (Deprecated) | Medicare Advantage | $650.19 |
| Healthfirst | Personal Wellness Plan (HARP) | $291.08 |
| EmblemHealth | Enhanced Care (Medicaid) Essential Plan 3 (SOMOS) | $779.18 |
| UnitedHealthcare | Choice (NY Power Authority) | $5,044.00 |
| HealthSmart | WTC Health Program - Northwell | $650.19 |
| Aetna | POS | $11,805.71 |
| EmblemHealth | CMO Essential Plan 4 | $742.07 |
| EmblemHealth | HIP PPO | $7,558.00 |
| Aetna | Chesterfield Resources ASA PPO | $11,805.71 |
| BCBS (Out of State) | EPO (Suitcase Logo) | $3,810.00 |
| MultiPlan | PHCS Savility | $4,127.85 |
| MultiPlan | Global Health Management | $4,127.85 |
| Aetna | Indemnity | $4,286.62 |
| EmblemHealth | Enhanced Care (Medicaid) Montefiore | $742.07 |
| BCBS (Out of State) | HMO (Suitcase Logo) | $3,810.00 |
| UnitedHealthcare | POMCO (UMR) | $5,044.00 |
| Centers Plan for Healthy Living | All Plans | $650.19 |
| Fidelis Care | Essential Plan 3 | $920.17 |
| MultiPlan | PHP Healthcare (Champus) | $4,127.85 |
| Carelon Behavioral Health | Medicaid Managed Care (Home-based Only) | $742.07 |
| EmblemHealth | Healthcare Partners Essential Plan 3 | $742.07 |
| HealthSmart | WTC Health Program - Mt. Sinai | $650.19 |
| VNS Health | EasyCare Plus (Medicare+Medicaid) | $650.19 |
| CenterLight | PACE Medicare HMO | $663.20 |
| EmblemHealth | Enhanced Care (Medicaid) Essential Plan 2 (SOMOS) | $1,001.80 |
| Aetna | Open Access Elect Choice EPO | $11,805.71 |
| EmblemHealth | HIP | $7,558.00 |
| UnitedHealthcare | EPO | $5,044.00 |
| EmblemHealth | American Plan Administrators | $11,277.00 |
| Aetna | Meritain Health | $11,805.71 |
| EmblemHealth | GHI Medicare Supplement | $650.19 |
| Blue Cross Blue Shield | PPO/EPO (Small Group) | $3,048.00 |
| Cigna | MVP-Cigna Network | $5,418.00 |
| BCBS (Out of State) | EPO | $3,810.00 |
| Blue Cross Blue Shield | MediBlue (Medicare Advantage) Select/Extra HMO (HCP) | $650.19 |
| Health Net | PPO | $4,127.85 |
| AgeWell (Deprecated) | Medicaid Managed Care | $742.07 |
| EmblemHealth | BCBS GHI Composite | $3,810.00 |
| Anthem BCBS HealthPlus | Medicaid | $742.07 |
| Fidelis Care | Bronze (Exchange) | $1,335.73 |
| Anthem BCBS HealthPlus | SOMOS Essential Plan 1 & 200-250 | $1,001.80 |
| Healthfirst | Personal Wellness Plan (HARP) | $742.07 |
| Aetna | Nippon Life ASA PPO | $11,805.71 |
| EmblemHealth | Enhanced Care (Medicaid) Essential Plan 4 (SOMOS) | $779.18 |
| Horizon BCBS | Direct | $3,810.00 |
| UnitedHealthcare | Choice (North Shore - LIJ) | $5,044.00 |
| MetroPlus | GoldCare 2 | $1,588.04 |
| Blue Cross Blue Shield | Federal Program | $3,810.00 |
| EmblemHealth | HIP VIP Medicare Bold | $650.19 |
| Fidelis Care | Platinum (Exchange) | $1,335.73 |
| MultiPlan | Principal Financial Group | $4,127.85 |
| EmblemHealth | HIP Optum Health | $7,558.00 |
| Anthem BCBS HealthPlus | SOMOS Special Needs HARP | $779.18 |
| EmblemHealth | HIP Montefiore | $7,558.00 |
| Champus | Unysis Corp | $650.19 |
| Anthem BCBS HealthPlus | SOMOS Essential Plan 4 | $779.18 |
| Aetna | Christian Brothers ASA PPO | $11,805.71 |
| BCBS (Out of State) | POS (No Suitcase Logo) | $3,810.00 |
| MultiPlan | Kaiser Permanente | $4,127.85 |
| EmblemHealth | Healthcare Partners Essential Plan 1-2 | $890.49 |
| UnitedHealthcare | Medicare Advantage | $650.19 |
| Blue Cross Blue Shield | MediBlue (Medicare Advantage) HMO (HCP) | $650.19 |
| EmblemHealth | Healthcare Partners Essential Plan 3-4 | $742.07 |
| EmblemHealth | Enhanced Care (Medicaid) | $742.07 |
| Aetna | Coresource ASA PPO | $11,805.71 |
| Blue Cross Blue Shield | Blue Access HMO (Small Group) | $3,048.00 |
| MultiPlan | Humana Health Plan | $4,127.85 |
| UnitedHealthcare | AARP Medicare Advantage Complete Essentials | $650.19 |
| MultiPlan | QualCare Inc | $4,127.85 |
| Blue Cross Blue Shield | Blue Access gEPO (Small Group) | $3,048.00 |
| MetroPlus | Essential Plan 2 | $742.07 |
| Cigna | NALC PPO | $5,418.00 |
| MultiPlan | Paramount Insurance | $4,127.85 |
| Partners Health Plan | Medicaid MLTC | $742.07 |
| Cigna | Great West HMO | $5,418.00 |
| Cigna | Wellfleet Student | $5,418.00 |
| EmblemHealth | HIP compre health epo | $7,558.00 |
| Hamaspik | Medicare Advantage | $1,300.39 |
| BCBS (Out of State) | POS | $3,810.00 |
| MagnaCare | Independent Care Plus | $13,547.57 |
| Humana | All Commercial Plans | $4,127.85 |
| Aetna | Starmark ASA PPO | $11,805.71 |
| Cigna | Great West PPO | $5,418.00 |
| MagnaCare | Capital District Physicians Health Plan | $13,547.57 |
| EmblemHealth | HIP POS | $7,558.00 |
| UnitedHealthcare | AARP Medicare Advantage Complete | $650.19 |
| VA Community Care Network | Optum | $650.19 |
| MetroPlus | BronzePlus | $1,287.38 |
| MultiPlan | PHCS Director Guild | $4,127.85 |
| Partners Health Plan | FIDA | $650.19 |
| EmblemHealth | HIP Long Island College Hospital (LICH) | $7,558.00 |
| MultiPlan | Fiserv Health | $4,127.85 |
| EmblemHealth | HIP VIP Medicare Healthcare Partners | $650.19 |
| MultiPlan | Nippon Life | $4,127.85 |
| EmblemHealth | HIP Healthcare Partners HMO | $7,558.00 |
| MagnaCare | Cement & Concrete Workers District Council | $13,547.57 |
| MetroPlus | Essential Plan 3-4 | $742.07 |
| Blue Cross Blue Shield | HMO | $3,810.00 |
| EmblemHealth | GHI Medicare HMO | $650.19 |
| CenterLight | Select | $663.20 |
| Healthfirst | Essential Plan 4 | $291.08 |
| MultiPlan | Administrative Concepts | $4,127.85 |
| 1199SEIU Funds | Home Care Benefit Fund | $3,403.00 |
| Blue Cross Blue Shield | Healthy New York | $3,810.00 |
| Blue Cross Blue Shield | Senior Care Supplemental | $650.19 |
| Fidelis Care | Bronze for Children (Exchange) | $1,335.73 |
| UnitedHealthcare | Student Resources | $5,044.00 |
| EmblemHealth | Select Care Catastrophic Exchangeu00a0 | $9,585.45 |
| EmblemHealth | American Plan Administrators c/o H.D.A | $11,277.00 |
| VNS Health | EasyCare (Medicare Advantage) | $650.19 |
| EmblemHealth | Prime Silver | $9,585.45 |
| Elderplan | FIDA | $650.19 |
| MultiPlan | Capital District Physicians Health Plan | $4,127.85 |
| Healthfirst | Medicaid Managed Care | $291.08 |
| EmblemHealth | Select Care Silver Exchange | $9,585.45 |
| CenterLight | PACE | $663.20 |
| BCBS (Out of State) | HMO | $3,810.00 |
| MetroPlus | Child Health Plus (CHP) | $742.07 |
| Aetna | PPO | $11,805.71 |
| Anthem BCBS HealthPlus | SOMOS Child Health Plus (CHP) | $779.18 |
| UnitedHealthcare | HMO | $5,044.00 |
| Blue Cross Blue Shield | EPO | $3,810.00 |
| Cigna | Tufts Health Plan | $5,418.00 |
| EmblemHealth | Healthcare Partners Essential Plan 4 | $742.07 |
| Partners Health Plan | Medicaid | $742.07 |
| Veterans Choice | Veterans Choice Program | $650.19 |
| Aetna | Healthscope ASA PPO | $11,805.71 |
| EmblemHealth | HIP VIP Medicare Reserve | $650.19 |
| MultiPlan | Screen Actors Guild | $4,127.85 |
| EmblemHealth | Enhanced Care (Medicaid) Child Health Plus (SOMOS) | $779.18 |
| First Health | Commercial HMO | $4,445.38 |
| EmblemHealth | VIP Prime HMO Medicare Advantage | $650.19 |
| MagnaCare | JIB Employees Security Fund | $13,547.57 |
| UnitedHealthcare | POMCO (UMR) | $4,127.85 |
| HealthSmart | WTC Health Program - UMDNJ Rutgers | $650.19 |
| Blue Cross Blue Shield | Hotel Trades Council | $3,810.00 |
| Partners Health Plan | Medicare Advantage | $650.19 |
| Fidelis Care | Silver for Children (Exchange) | $1,335.73 |
| Maksin Group | Consolidated Health Plan (Home-based only) | $5,418.00 |
| 1199SEIU Funds | Member Choice Home Care Select | $3,403.00 |
| Elderplan | All Plans | $650.19 |
| Cigna | PPO | $5,418.00 |
| Fidelis Care | Platinum for Children (Exchange) | $1,335.73 |
| BCBS (Out of State) | POS (Suitcase Logo) | $3,810.00 |
| Blue Cross Blue Shield | Blue Access EPO (Large Group) | $3,429.00 |
| EmblemHealth | Select Care Bronze Exchange | $9,585.45 |
| EmblemHealth | Healthcare Partners Essential Plan 1, 200-250 | $890.49 |
| Fidelis Care | Essential Plan 1 | $1,595.46 |
| MultiPlan | Healthnet of California | $4,127.85 |
| MultiPlan | PHCS | $4,127.85 |
| Aetna | Medicare Advantage | $650.19 |
| UnitedHealthcare - Oxford | Optum Health | $3,967.00 |
| Healthfirst | Essential Plan 3 | $291.08 |
| Cigna | Open Access | $5,418.00 |
| EmblemHealth | Select Care Silver Small Group | $9,585.45 |
| Aetna | Global National Transplant | $11,805.71 |
| EmblemHealth | CMO Essential Plan 2 | $890.49 |
| Partners Health Plan | Medicare Advantage (Home-based Only) | $650.19 |
| MetroPlus | SilverPlus | $1,287.38 |
| MagnaCare | Direct Plus | $13,547.57 |
| EmblemHealth | Prime Bronze | $9,585.45 |
| Blue Cross Blue Shield | Blue Access EPO (Small Group) | $3,048.00 |
| UnitedHealthcare | POS | $5,044.00 |
| EmblemHealth | Select Care Healthcare Partners | $9,585.45 |
| HealthSmart | WTC Health Program - Logistic Health Inc | $650.19 |
| Blue Cross Blue Shield | POS | $3,810.00 |
| UnitedHealthcare | PPO | $5,044.00 |
| Better Health Plan | All Plans | $4,445.38 |
| Blue Cross Blue Shield | Global Transplants | $3,810.00 |
| Blue Cross Blue Shield | MediBlue (Medicare Advantage) HMO | $650.19 |
| BCBS (Out of State) | Medicare (No Suitcase Logo) | $650.19 |
| MultiPlan | Mutual of Omaha | $4,127.85 |
| EmblemHealth | GHI HMO | $11,277.00 |
| CenterLight | Direct | $663.20 |
| Blue Cross Blue Shield | MediBlue (Medicare Advantage) PPO | $650.19 |
| EmblemHealth | Select Care Platinum Small Group | $9,585.45 |
| Anthem BCBS HealthPlus | Essential Plan 4 | $742.07 |
| BCBS (Out of State) | Medicare | $650.19 |
| Blue Cross Blue Shield | Child Health Plus (CHP) | $742.07 |
| EmblemHealth | GHI Medicare PPO | $650.19 |
| UnitedHealthcare | AARP | $650.19 |
| Anthem BCBS HealthPlus | Medicare Advantage | $650.19 |
| Fidelis Care | Child Health Plus (CHP) | $920.17 |
| UnitedHealthcare | Golden Rule Insurance | $5,044.00 |
| UnitedHealthcare - Oxford | Freedom | $3,967.00 |
| Blue Cross Blue Shield | Pathway | $890.49 |
| Blue Cross Blue Shield | Blue Access gEPO (Large Group) | $3,429.00 |
| EmblemHealth | Enhanced Care (Medicaid) Healthcare Partners | $742.07 |
| Blue Cross Blue Shield | Local 32 BJ | $3,810.00 |
| Cigna | Premier Plus | $5,418.00 |
| Anthem BCBS | Optum | $3,810.00 |
| EmblemHealth | Select Care Basic Exchange | $9,585.45 |
| Cigna | Indemnity | $5,418.00 |
| BCBS (Out of State) | PPO | $3,810.00 |
| Fidelis Care | Native American (Exchange) | $1,335.73 |
| Cigna | LifeSOURCE | $5,418.00 |
| Blue Cross Blue Shield | Open Access HMO (Home-based Only) | $3,810.00 |
| Aetna | Wellnet ASA PPO | $11,805.71 |
| EmblemHealth | Vytra HMO | $7,558.00 |
| Fidelis Care | Silver 250 (Exchange) | $1,335.73 |
| UnitedHealthcare | Core | $5,044.00 |
| Cigna | Cigna Managed Care/POS | $5,418.00 |
| MultiPlan | AXA Global Insurance | $4,127.85 |
| MultiPlan | PPO | $4,127.85 |
| UnitedHealthcare | Navigate | $5,044.00 |
| Blue Cross Blue Shield | MediBlue (Medicare Advantage) Select HMO/Extra HMO | $650.19 |
| BCBS (Out of State) | EPO (No Suitcase Logo) | $3,810.00 |
| HealthSmart | WTC Health Program - FDNY | $650.19 |
| Blue Cross Blue Shield | Pathway X Enhanced | $890.49 |
| UnitedHealthcare | Charter | $5,044.00 |
| EmblemHealth | Enhanced Care (Medicaid) (SOMOS) | $779.18 |
| Three Rivers | All Plans (Home-based Only) | $4,762.91 |
| EmblemHealth | HIP Child Health Plus | $742.07 |
| MetroPlus | PlatinumPlus | $1,287.38 |
| Fidelis Care | Wellcare Medicare Advantage | $650.19 |
| Blue Cross Blue Shield | Blue Connection | $3,810.00 |
| EmblemHealth | HIP VIP Medicare Montefiore | $650.19 |
| Anthem BCBS HealthPlus | Essential Plan 1, 200-250 | $1,484.15 |
| MetroPlus | GoldPlus | $1,287.38 |
| Healthfirst | Child Health Plus (CHP) | $291.08 |
| Cigna | Evernorth Behavioral Health | $5,418.00 |
| HealthSmart | WTC Health Program - NYCHHC | $650.19 |
| Anthem BCBS HealthPlus | All Exchange Plans | $890.49 |
| VNS Health | Total (Medicare + Medicaid) | $650.19 |
| MultiPlan | Meritain Health | $4,127.85 |
| UnitedHealthcare | WTC Health Program | $650.19 |
| Anthem BCBS HealthPlus | SOMOS ny medicaid | $779.18 |
| Fidelis Care | Gold (Exchange) | $1,335.73 |
| EmblemHealth | GHI EPO | $11,277.00 |
| MetroPlus | MedPlus | $1,287.38 |
| Anthem BCBS | All Plans | $3,810.00 |
| EmblemHealth | Select Care HMO | $9,585.45 |
| EmblemHealth | Select Care PPOu00a0 | $9,585.45 |
| MultiPlan | Diversified Admin Corp | $4,127.85 |
| MagnaCare | JIB Members | $13,547.57 |
| EmblemHealth | Select Care EPO | $9,585.45 |
| Senior Whole Health | All Plans | $650.19 |
| Healthfirst | Senior Health Partners (MLTC) | $291.08 |
| BCBS (Out of State) | Indemnity | $3,810.00 |
| MultiPlan | Teamsters Allied Benefits | $4,127.85 |
| UnitedHealthcare | Medicare Advantage Complete Choice Regional PPO | $650.19 |
| EmblemHealth | GHI Comprehensive Benefits Plan (CBP) | $11,277.00 |
| Fidelis Care | Silver (Exchange) | $1,335.73 |
| EmblemHealth | HIP Prime Basic | $9,585.45 |
| EmblemHealth | Prime Platinum | $9,585.45 |
| Anthem BCBS HealthPlus | SOMOS Essential Plan 3 | $779.18 |
| MetroPlus | Medicare Advantage | $650.19 |
| Blue Cross Blue Shield | UniCare | $3,810.00 |
| First Health | PPO | $4,127.85 |
| Anthem BCBS HealthPlus | Essential Plan 3 | $742.07 |
| Fidelis Care | Catastrophic (Exchange) | $1,335.73 |
| BCBS (Out of State) | Medicare (Suitcase Logo) | $650.19 |
| MultiPlan | Global Excel Management | $4,127.85 |
| VillageCareMAX | All Plans | $650.19 |
| MetroPlus | Essential Plan 1 | $742.07 |
| BCBS (Out of State) | HMO (No Suitcase Logo) | $3,810.00 |
| EmblemHealth | GHI PPO | $11,277.00 |
| EmblemHealth | Bridge | $7,558.00 |
| VNS Health | MLTC (Medicaid) | $742.07 |
| EmblemHealth | CMO Essential Plan 3 | $742.07 |
| Blue Cross Blue Shield | Blue Access PPO (Large Group) | $3,429.00 |
| MagnaCare | Direct Plus Preferred | $13,547.57 |
| EmblemHealth | GHI composite | $11,277.00 |
| MetroPlus | Medicaid Managed Care | $742.07 |
| Blue Cross Blue Shield | Blue Priority HMO | $3,810.00 |
| Blue Cross Blue Shield | Open Access PPO (Home-based Only) | $3,810.00 |
| EmblemHealth | IUOE Local 14-14B | $11,277.00 |
| UnitedHealthcare - Oxford | Liberty | $3,967.00 |
| HealthSmart | WTC Health Program - NYU | $650.19 |
| MetroPlus | Essential Plan 4 | $742.07 |
| Cigna | Open Access PPO | $5,418.00 |
| EmblemHealth | Essential Plan 4 | $742.07 |
| EmblemHealth | Healthcare Partners Essential Plans | $890.49 |
| UnitedHealthcare | Independent | $5,044.00 |
| MagnaCare | PPO | $13,547.57 |
| Cigna | Open Access HMO | $5,418.00 |
| MagnaCare | American Plan Administrators | $13,547.57 |
| Aetna | Open Access HMO | $11,805.71 |
| EmblemHealth | HIP SmartStart | $7,558.00 |
| Sedgwick | WTC Health Program - Northwell | $650.19 |
| Blue Cross Blue Shield | PPO | $3,810.00 |
| Anthem BCBS HealthPlus | Essential Plan 2 | $1,484.15 |
| BCBS (Out of State) | PPO (No Suitcase Logo) | $3,810.00 |
| Anthem BCBS HealthPlus | Child Health Plus (CHP) | $742.07 |
| Aetna | HMO | $11,805.71 |
| Blue Cross Blue Shield | Blue Priority PPO | $3,810.00 |
| EmblemHealth | Enhanced Care (Medicaid) Essential Plan 1, 200-250 (SOMOS) | $1,001.80 |
| GEHA | All Plans | $11,805.71 |
| EmblemHealth | Essential Plan 1, 200-250 | $890.49 |
| Anthem BCBS HealthPlus | SOMOS Essential Plan 2 | $1,001.80 |
| UnitedHealthcare | AARP Medicare Advantage Complete Mosaic | $650.19 |
| EmblemHealth | CMO Essential Plan 1 | $890.49 |
| MetroPlus | Gold | $1,588.04 |
| Carelon Behavioral Health | All Exchange Plans (Home-based Only) | $650.19 |
| EmblemHealth | HIP Access I | $7,558.00 |
| MetroPlus | Essential Plan 3 | $742.07 |
| Healthfirst | Essential Plan 3-4 | $291.08 |
| MetroPlus | Essential Plan 1-2, 200-250 | $742.07 |
| EmblemHealth | Select Care Bronze Small Group | $9,585.45 |
| Carelon Behavioral Health | Medicare Advantage (Home-based Only) | $650.19 |
| Amida Care | Medicaid Managed Care | $742.07 |
| Anthem BCBS HealthPlus | Family Health Plus (Deprecated) | $742.07 |
| Cigna | HMO | $5,418.00 |
| EmblemHealth | HIP EPO | $7,558.00 |
| EmblemHealth | GHI Behavioral Management Program | $11,277.00 |
| Anthem BCBS | Empire Plan, Value Options | $3,810.00 |
| Aetna | Allied ASA PPO | $11,805.71 |
| Fidelis Care | Essential Plan 2 | $1,595.46 |
| EmblemHealth | HIP HMO | $7,558.00 |
| Blue Cross Blue Shield | Blue Priority EPO (Small Group) | $3,048.00 |
| EmblemHealth | HIP Medicare Supplement | $650.19 |
| EmblemHealth | HIP compre health | $7,558.00 |
| MultiPlan | US Life Insurance Co | $4,127.85 |
| EmblemHealth | WLNY-TV | $11,277.00 |
| UnitedHealthcare | Choice | $5,044.00 |
| Aetna | Signature Administrators PPO | $11,805.71 |
| Riverspring Health Plans | Medicare Advantage | $650.19 |
| EmblemHealth | Prime Gold | $9,585.45 |
| Fidelis Care | Medicaid Managed Care | $920.17 |
| 1199SEIU Funds | PPO | $3,403.00 |
| EmblemHealth | Essential Plan 3 | $742.07 |
| EmblemHealth | Select Care Gold Small Group | $9,585.45 |
| Blue Cross Blue Shield | Blue Access EPO (Large Group) (NY LI Local 1199SEIU) | $3,429.00 |
| Aetna | Student Health | $11,805.71 |
| EmblemHealth | Select Care Platinum Exchange | $9,585.45 |
| Blue Cross Blue Shield | Indemnity | $3,810.00 |
| Fidelis Care | Essential Plan 4 | $920.17 |
| BCBS (Out of State) | PPO (Suitcase Logo) | $3,810.00 |