Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION [160715]

Facility

$106.00

Service Code	HCPCS Q5105
Hospital Revenue Code	634
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: MDX Hawaii PPO	$102.82

EPTIFIBATIDE 0.75 MG/ML INTRAVENOUS SOLUTION [23123]

Facility

$2,055.00

Service Code	NDC 67457063110
Hospital Revenue Code	250
Min. Negotiated Rate	$1,746.75
Max. Negotiated Rate	$1,993.35
Rate for Payer: Cash Price	$1,233.00
Rate for Payer: Health Management Network Commercial	$1,746.75
Rate for Payer: Kaiser Permanente Commercial	$1,849.50
Rate for Payer: MDX Hawaii PPO	$1,993.35

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [131638]

Facility

$469.00

Service Code	NDC 67457062910
Hospital Revenue Code	250
Min. Negotiated Rate	$398.65
Max. Negotiated Rate	$454.93
Rate for Payer: Cash Price	$281.40
Rate for Payer: Health Management Network Commercial	$398.65
Rate for Payer: Kaiser Permanente Commercial	$422.10
Rate for Payer: MDX Hawaii PPO	$454.93

EPTIFIBATIDE 2 MG/ML INTRAVENOUS SOLUTION [131638]

Facility

$189.00

Service Code	NDC 55150021910
Hospital Revenue Code	250
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$113.40
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: MDX Hawaii PPO	$183.33

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$7.00

Service Code	NDC 50268029711
Hospital Revenue Code	637
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$6.79
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$5.32
Rate for Payer: Cash Price	$4.20
Rate for Payer: Devoted Health Medicare	$5.88
Rate for Payer: Hawaii Medical Service Association Medicare	$5.32
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Humana Medicare	$5.32
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicare	$5.32
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$5.32
Rate for Payer: Ohana Health Plan Medicare	$5.32
Rate for Payer: UnitedHealthcare Medicare	$5.32
Rate for Payer: University Health Alliance Commercial	$5.10

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$3.00

Service Code	NDC 69452015120
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$2.28
Rate for Payer: Cash Price	$1.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2.28
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$2.28
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$2.28
Rate for Payer: Ohana Health Plan Medicare	$2.28
Rate for Payer: UnitedHealthcare Medicare	$2.28
Rate for Payer: University Health Alliance Commercial	$2.19

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$3.00

Service Code	NDC 69452015120
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE [2863]

Facility

$7.00

Service Code	NDC 50268029711
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$6.79
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79

ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION [106773]

Facility

$2,538.00

Service Code	HCPCS J9179
Hospital Revenue Code	636
Min. Negotiated Rate	$95.95
Max. Negotiated Rate	$2,461.86
Rate for Payer: AlohaCare Medicaid	$1,269.00
Rate for Payer: AlohaCare Medicaid	$2,066.00
Rate for Payer: AlohaCare Medicare	$3,140.32
Rate for Payer: AlohaCare Medicare	$1,928.88
Rate for Payer: Cash Price	$2,479.20
Rate for Payer: Cash Price	$1,522.80
Rate for Payer: Cash Price	$1,522.80
Rate for Payer: Cash Price	$2,479.20
Rate for Payer: Devoted Health Medicare	$3,470.88
Rate for Payer: Devoted Health Medicare	$2,131.92
Rate for Payer: Hawaii Medical Service Association ABD	$104.58
Rate for Payer: Hawaii Medical Service Association ABD	$104.58
Rate for Payer: Hawaii Medical Service Association Commercial	$95.95
Rate for Payer: Hawaii Medical Service Association Commercial	$95.95
Rate for Payer: Hawaii Medical Service Association Medicare	$1,928.88
Rate for Payer: Hawaii Medical Service Association Medicare	$3,140.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.58
Rate for Payer: Hawaii Medical Service Association Non-ABD	$104.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,925.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,411.10
Rate for Payer: Health Management Network Commercial	$3,512.20
Rate for Payer: Health Management Network Commercial	$2,157.30
Rate for Payer: Humana Medicare	$3,140.32
Rate for Payer: Humana Medicare	$1,928.88
Rate for Payer: Kaiser Permanente Commercial	$2,284.20
Rate for Payer: Kaiser Permanente Commercial	$3,718.80
Rate for Payer: Kaiser Permanente Medicaid	$2,107.32
Rate for Payer: Kaiser Permanente Medicaid	$1,294.38
Rate for Payer: Kaiser Permanente Medicare	$1,928.88
Rate for Payer: Kaiser Permanente Medicare	$3,140.32
Rate for Payer: MDX Hawaii PPO	$2,461.86
Rate for Payer: MDX Hawaii PPO	$4,008.04
Rate for Payer: Ohana Health Plan Medicaid	$1,928.88
Rate for Payer: Ohana Health Plan Medicaid	$3,140.32
Rate for Payer: Ohana Health Plan Medicare	$3,140.32
Rate for Payer: Ohana Health Plan Medicare	$1,928.88
Rate for Payer: UnitedHealthcare Medicaid	$2,479.20
Rate for Payer: UnitedHealthcare Medicaid	$1,522.80
Rate for Payer: UnitedHealthcare Medicare	$3,140.32
Rate for Payer: UnitedHealthcare Medicare	$1,928.88
Rate for Payer: University Health Alliance Commercial	$1,849.95
Rate for Payer: University Health Alliance Commercial	$3,011.81

ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION [106773]

Facility

$4,132.00

Service Code	HCPCS J9179
Hospital Revenue Code	250
Min. Negotiated Rate	$3,512.20
Max. Negotiated Rate	$4,008.04
Rate for Payer: Cash Price	$2,479.20
Rate for Payer: Cash Price	$1,522.80
Rate for Payer: Health Management Network Commercial	$3,512.20
Rate for Payer: Health Management Network Commercial	$2,157.30
Rate for Payer: Kaiser Permanente Commercial	$2,284.20
Rate for Payer: Kaiser Permanente Commercial	$3,718.80
Rate for Payer: MDX Hawaii PPO	$2,461.86
Rate for Payer: MDX Hawaii PPO	$4,008.04

ERTAPENEM 1 G IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080039]

Facility

$253.00

Service Code	HCPCS J1335
Hospital Revenue Code	636
Min. Negotiated Rate	$59.71
Max. Negotiated Rate	$245.41
Rate for Payer: AlohaCare Medicaid	$126.50
Rate for Payer: AlohaCare Medicare	$192.28
Rate for Payer: Cash Price	$151.80
Rate for Payer: Cash Price	$151.80
Rate for Payer: Devoted Health Medicare	$212.52
Rate for Payer: Hawaii Medical Service Association ABD	$59.71
Rate for Payer: Hawaii Medical Service Association Medicare	$192.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.71
Rate for Payer: Hawaii Western Management Group Commercial	$240.35
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: Humana Medicare	$192.28
Rate for Payer: Kaiser Permanente Commercial	$227.70
Rate for Payer: Kaiser Permanente Medicaid	$129.03
Rate for Payer: Kaiser Permanente Medicare	$192.28
Rate for Payer: MDX Hawaii PPO	$245.41
Rate for Payer: Ohana Health Plan Medicaid	$192.28
Rate for Payer: Ohana Health Plan Medicare	$192.28
Rate for Payer: UnitedHealthcare Medicaid	$151.80
Rate for Payer: UnitedHealthcare Medicare	$192.28
Rate for Payer: University Health Alliance Commercial	$184.41

ERTAPENEM 1 G IN 50 ML NS ADD-A-VIAL (SIMPLE) [4080039]

Facility

$253.00

Service Code	HCPCS J1335
Hospital Revenue Code	250
Min. Negotiated Rate	$215.05
Max. Negotiated Rate	$245.41
Rate for Payer: Cash Price	$151.80
Rate for Payer: Health Management Network Commercial	$215.05
Rate for Payer: Kaiser Permanente Commercial	$227.70
Rate for Payer: MDX Hawaii PPO	$245.41

ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]

Facility

$144.00

Service Code	HCPCS J1335
Hospital Revenue Code	250
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: MDX Hawaii PPO	$139.68

ERTAPENEM 1 GRAM SOLUTION FOR INJECTION [31922]

Facility

$144.00

Service Code	HCPCS J1335
Hospital Revenue Code	636
Min. Negotiated Rate	$59.71
Max. Negotiated Rate	$139.68
Rate for Payer: AlohaCare Medicaid	$72.00
Rate for Payer: AlohaCare Medicare	$109.44
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Devoted Health Medicare	$120.96
Rate for Payer: Hawaii Medical Service Association ABD	$59.71
Rate for Payer: Hawaii Medical Service Association Medicare	$109.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.71
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Humana Medicare	$109.44
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: Kaiser Permanente Medicare	$109.44
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: Ohana Health Plan Medicaid	$109.44
Rate for Payer: Ohana Health Plan Medicare	$109.44
Rate for Payer: UnitedHealthcare Medicaid	$86.40
Rate for Payer: UnitedHealthcare Medicare	$109.44
Rate for Payer: University Health Alliance Commercial	$104.96

ERTAPENEM SODIUM 1 G/10ML IJ (WET SOLR VIAL) [43031922]

Facility

$144.00

Service Code	HCPCS J1335
Hospital Revenue Code	636
Min. Negotiated Rate	$59.71
Max. Negotiated Rate	$139.68
Rate for Payer: AlohaCare Medicaid	$72.00
Rate for Payer: AlohaCare Medicaid	$46.50
Rate for Payer: AlohaCare Medicare	$70.68
Rate for Payer: AlohaCare Medicare	$109.44
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$55.80
Rate for Payer: Devoted Health Medicare	$120.96
Rate for Payer: Devoted Health Medicare	$78.12
Rate for Payer: Hawaii Medical Service Association ABD	$59.71
Rate for Payer: Hawaii Medical Service Association ABD	$59.71
Rate for Payer: Hawaii Medical Service Association Medicare	$70.68
Rate for Payer: Hawaii Medical Service Association Medicare	$109.44
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.71
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.71
Rate for Payer: Hawaii Western Management Group Commercial	$136.80
Rate for Payer: Hawaii Western Management Group Commercial	$88.35
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Humana Medicare	$109.44
Rate for Payer: Humana Medicare	$70.68
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: Kaiser Permanente Medicaid	$47.43
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: Kaiser Permanente Medicare	$109.44
Rate for Payer: Kaiser Permanente Medicare	$70.68
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: MDX Hawaii PPO	$90.21
Rate for Payer: Ohana Health Plan Medicaid	$70.68
Rate for Payer: Ohana Health Plan Medicaid	$109.44
Rate for Payer: Ohana Health Plan Medicare	$109.44
Rate for Payer: Ohana Health Plan Medicare	$70.68
Rate for Payer: UnitedHealthcare Medicaid	$55.80
Rate for Payer: UnitedHealthcare Medicaid	$86.40
Rate for Payer: UnitedHealthcare Medicare	$109.44
Rate for Payer: UnitedHealthcare Medicare	$70.68
Rate for Payer: University Health Alliance Commercial	$104.96
Rate for Payer: University Health Alliance Commercial	$67.79

ERTAPENEM SODIUM 1 G/10ML IJ (WET SOLR VIAL) [43031922]

Facility

$144.00

Service Code	HCPCS J1335
Hospital Revenue Code	250
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$55.80
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Health Management Network Commercial	$79.05
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: Kaiser Permanente Commercial	$83.70
Rate for Payer: MDX Hawaii PPO	$90.21
Rate for Payer: MDX Hawaii PPO	$139.68

ERYTHROMYCIN 0.5% OPHTH OINTMENT (1 GRAM) (TAKE HOME) [4080360]

Facility

$15.00

Service Code	NDC 00004080148
Hospital Revenue Code	253
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$14.55
Rate for Payer: AlohaCare Medicaid	$7.50
Rate for Payer: AlohaCare Medicare	$11.40
Rate for Payer: Cash Price	$9.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Hawaii Medical Service Association Medicare	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$14.25
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Humana Medicare	$11.40
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: Kaiser Permanente Medicaid	$7.65
Rate for Payer: Kaiser Permanente Medicare	$11.40
Rate for Payer: MDX Hawaii PPO	$14.55
Rate for Payer: Ohana Health Plan Medicaid	$11.40
Rate for Payer: Ohana Health Plan Medicare	$11.40
Rate for Payer: UnitedHealthcare Medicare	$11.40
Rate for Payer: University Health Alliance Commercial	$10.93

ERYTHROMYCIN 0.5% OPHTH OINTMENT (1 GRAM) (TAKE HOME) [4080360]

Facility

$15.00

Service Code	NDC 00004080148
Hospital Revenue Code	253
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Management Network Commercial	$12.75
Rate for Payer: Kaiser Permanente Commercial	$13.50
Rate for Payer: MDX Hawaii PPO	$14.55

ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]

Facility

$51.00

Service Code	NDC 72485067031
Hospital Revenue Code	637
Min. Negotiated Rate	$25.50
Max. Negotiated Rate	$49.47
Rate for Payer: AlohaCare Medicaid	$25.50
Rate for Payer: AlohaCare Medicare	$38.76
Rate for Payer: Cash Price	$30.60
Rate for Payer: Devoted Health Medicare	$42.84
Rate for Payer: Hawaii Medical Service Association Medicare	$38.76
Rate for Payer: Hawaii Western Management Group Commercial	$48.45
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Humana Medicare	$38.76
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: Kaiser Permanente Medicaid	$26.01
Rate for Payer: Kaiser Permanente Medicare	$38.76
Rate for Payer: MDX Hawaii PPO	$49.47
Rate for Payer: Ohana Health Plan Medicaid	$38.76
Rate for Payer: Ohana Health Plan Medicare	$38.76
Rate for Payer: UnitedHealthcare Medicare	$38.76
Rate for Payer: University Health Alliance Commercial	$37.17

ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]

Facility

$59.00

Service Code	NDC 24208091055
Hospital Revenue Code	637
Min. Negotiated Rate	$29.50
Max. Negotiated Rate	$57.23
Rate for Payer: AlohaCare Medicaid	$29.50
Rate for Payer: AlohaCare Medicare	$44.84
Rate for Payer: Cash Price	$35.40
Rate for Payer: Devoted Health Medicare	$49.56
Rate for Payer: Hawaii Medical Service Association Medicare	$44.84
Rate for Payer: Hawaii Western Management Group Commercial	$56.05
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Humana Medicare	$44.84
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: Kaiser Permanente Medicaid	$30.09
Rate for Payer: Kaiser Permanente Medicare	$44.84
Rate for Payer: MDX Hawaii PPO	$57.23
Rate for Payer: Ohana Health Plan Medicaid	$44.84
Rate for Payer: Ohana Health Plan Medicare	$44.84
Rate for Payer: UnitedHealthcare Medicare	$44.84
Rate for Payer: University Health Alliance Commercial	$43.01

ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]

Facility

$32.00

Service Code	NDC 24208091019
Hospital Revenue Code	637
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$31.04
Rate for Payer: AlohaCare Medicaid	$16.00
Rate for Payer: AlohaCare Medicare	$24.32
Rate for Payer: Cash Price	$19.20
Rate for Payer: Devoted Health Medicare	$26.88
Rate for Payer: Hawaii Medical Service Association Medicare	$24.32
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Humana Medicare	$24.32
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicare	$24.32
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: Ohana Health Plan Medicaid	$24.32
Rate for Payer: Ohana Health Plan Medicare	$24.32
Rate for Payer: UnitedHealthcare Medicare	$24.32
Rate for Payer: University Health Alliance Commercial	$23.32

ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]

Facility

$27.00

Service Code	NDC 00574402450
Hospital Revenue Code	250
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$26.19
Rate for Payer: Cash Price	$16.20
Rate for Payer: Health Management Network Commercial	$22.95
Rate for Payer: Kaiser Permanente Commercial	$24.30
Rate for Payer: MDX Hawaii PPO	$26.19

ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]

Facility

$32.00

Service Code	NDC 24208091019
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: MDX Hawaii PPO	$31.04

ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]

Facility

$51.00

Service Code	NDC 72485067031
Hospital Revenue Code	250
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$49.47
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Management Network Commercial	$43.35
Rate for Payer: Kaiser Permanente Commercial	$45.90
Rate for Payer: MDX Hawaii PPO	$49.47

ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT [2888]

Facility

$59.00

Service Code	NDC 24208091055
Hospital Revenue Code	250
Min. Negotiated Rate	$50.15
Max. Negotiated Rate	$57.23
Rate for Payer: Cash Price	$35.40
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Kaiser Permanente Commercial	$53.10
Rate for Payer: MDX Hawaii PPO	$57.23

Know your out-of-pocket cost for care.

All Charges