Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Genital Culture DLS

Facility

$129.00

Service Code	HCPCS 87070
Hospital Charge Code	422870705
Hospital Revenue Code	306
Min. Negotiated Rate	$8.62
Max. Negotiated Rate	$125.13
Rate for Payer: AlohaCare Medicaid	$64.50
Rate for Payer: AlohaCare Medicare	$54.18
Rate for Payer: Cash Price	$83.85
Rate for Payer: Cash Price	$83.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$118.68
Rate for Payer: Devoted Health Medicare	$54.18
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$11.90
Rate for Payer: Hawaii Medical Service Association Commercial	$10.78
Rate for Payer: Hawaii Medical Service Association Medicare	$54.18
Rate for Payer: Hawaii Western Management Group Commercial	$8.62
Rate for Payer: Health Management Network Commercial	$109.65
Rate for Payer: Humana Medicare	$54.18
Rate for Payer: Kaiser Permanente Commercial	$116.10
Rate for Payer: Kaiser Permanente Medicaid	$65.79
Rate for Payer: Kaiser Permanente Medicare	$54.18
Rate for Payer: MDX Hawaii PPO	$125.13
Rate for Payer: Ohana Health Plan Medicaid	$54.18
Rate for Payer: Ohana Health Plan Medicare	$54.18
Rate for Payer: UnitedHealthcare Medicaid	$11.90
Rate for Payer: UnitedHealthcare Medicare	$54.18
Rate for Payer: University Health Alliance Commercial	$22.26

gentamicin 0.1% Cream [KMC]

Facility

$13.17

Service Code	NDC 45802005635
Hospital Revenue Code	250
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$12.77
Rate for Payer: AlohaCare Medicaid	$6.58
Rate for Payer: AlohaCare Medicare	$5.53
Rate for Payer: Cash Price	$8.56
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$12.12
Rate for Payer: Devoted Health Medicare	$5.53
Rate for Payer: Hawaii Medical Service Association Medicare	$5.53
Rate for Payer: Hawaii Western Management Group Commercial	$12.51
Rate for Payer: Health Management Network Commercial	$11.19
Rate for Payer: Humana Medicare	$5.53
Rate for Payer: Kaiser Permanente Commercial	$11.85
Rate for Payer: Kaiser Permanente Medicaid	$6.72
Rate for Payer: Kaiser Permanente Medicare	$5.53
Rate for Payer: MDX Hawaii PPO	$12.77
Rate for Payer: Ohana Health Plan Medicaid	$5.53
Rate for Payer: Ohana Health Plan Medicare	$5.53
Rate for Payer: UnitedHealthcare Medicaid	$7.90
Rate for Payer: UnitedHealthcare Medicare	$5.53
Rate for Payer: University Health Alliance Commercial	$9.60

gentamicin 0.1% Cream [KMC]

Facility

$13.17

Service Code	NDC 45802005635
Hospital Revenue Code	250
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$12.77
Rate for Payer: Cash Price	$8.56
Rate for Payer: Health Management Network Commercial	$11.19
Rate for Payer: Kaiser Permanente Commercial	$11.85
Rate for Payer: MDX Hawaii PPO	$12.77

gentamicin 120 mg / 100 mL NS [KMC]

Facility

$0.20

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$2.62
Rate for Payer: AlohaCare Medicaid	$0.10
Rate for Payer: AlohaCare Medicare	$0.08
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cash Price	$0.13
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.18
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$0.08
Rate for Payer: Hawaii Western Management Group Commercial	$0.19
Rate for Payer: Health Management Network Commercial	$0.17
Rate for Payer: Humana Medicare	$0.08
Rate for Payer: Kaiser Permanente Commercial	$0.18
Rate for Payer: Kaiser Permanente Medicaid	$0.10
Rate for Payer: Kaiser Permanente Medicare	$0.08
Rate for Payer: MDX Hawaii PPO	$0.19
Rate for Payer: Ohana Health Plan Medicaid	$0.08
Rate for Payer: Ohana Health Plan Medicare	$0.08
Rate for Payer: UnitedHealthcare Medicaid	$0.12
Rate for Payer: UnitedHealthcare Medicare	$0.08
Rate for Payer: University Health Alliance Commercial	$0.15

gentamicin 120 mg / 100 mL NS [KMC]

Facility

$0.20

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.13
Rate for Payer: Health Management Network Commercial	$0.17
Rate for Payer: Kaiser Permanente Commercial	$0.18
Rate for Payer: MDX Hawaii PPO	$0.19

gentamicin 800 mg / 20 mL vial [KMC]

Facility

$6.10

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$5.92
Rate for Payer: AlohaCare Medicaid	$3.05
Rate for Payer: AlohaCare Medicare	$2.56
Rate for Payer: Cash Price	$3.96
Rate for Payer: Cash Price	$3.96
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5.61
Rate for Payer: Devoted Health Medicare	$2.56
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$2.56
Rate for Payer: Hawaii Western Management Group Commercial	$5.79
Rate for Payer: Health Management Network Commercial	$5.18
Rate for Payer: Humana Medicare	$2.56
Rate for Payer: Kaiser Permanente Commercial	$5.49
Rate for Payer: Kaiser Permanente Medicaid	$3.11
Rate for Payer: Kaiser Permanente Medicare	$2.56
Rate for Payer: MDX Hawaii PPO	$5.92
Rate for Payer: Ohana Health Plan Medicaid	$2.56
Rate for Payer: Ohana Health Plan Medicare	$2.56
Rate for Payer: UnitedHealthcare Medicaid	$3.66
Rate for Payer: UnitedHealthcare Medicare	$2.56
Rate for Payer: University Health Alliance Commercial	$4.45

gentamicin 800 mg / 20 mL vial [KMC]

Facility

$6.10

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$5.92
Rate for Payer: Cash Price	$3.96
Rate for Payer: Health Management Network Commercial	$5.18
Rate for Payer: Kaiser Permanente Commercial	$5.49
Rate for Payer: MDX Hawaii PPO	$5.92

gentamicin 80 mg / 2 mL IV/IM Soln [KMC]

Facility

$2.14

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$2.62
Rate for Payer: AlohaCare Medicaid	$1.07
Rate for Payer: AlohaCare Medicare	$0.90
Rate for Payer: Cash Price	$1.39
Rate for Payer: Cash Price	$1.39
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1.97
Rate for Payer: Devoted Health Medicare	$0.90
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$2.62
Rate for Payer: Hawaii Medical Service Association Medicare	$0.90
Rate for Payer: Hawaii Western Management Group Commercial	$2.03
Rate for Payer: Health Management Network Commercial	$1.82
Rate for Payer: Humana Medicare	$0.90
Rate for Payer: Kaiser Permanente Commercial	$1.93
Rate for Payer: Kaiser Permanente Medicaid	$1.09
Rate for Payer: Kaiser Permanente Medicare	$0.90
Rate for Payer: MDX Hawaii PPO	$2.08
Rate for Payer: Ohana Health Plan Medicaid	$0.90
Rate for Payer: Ohana Health Plan Medicare	$0.90
Rate for Payer: UnitedHealthcare Medicaid	$1.28
Rate for Payer: UnitedHealthcare Medicare	$0.90
Rate for Payer: University Health Alliance Commercial	$1.56

gentamicin 80 mg / 2 mL IV/IM Soln [KMC]

Facility

$2.14

Service Code	HCPCS J1580
Hospital Revenue Code	636
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$2.08
Rate for Payer: Cash Price	$1.39
Rate for Payer: Health Management Network Commercial	$1.82
Rate for Payer: Kaiser Permanente Commercial	$1.93
Rate for Payer: MDX Hawaii PPO	$2.08

Gentamicin (Peak) DLS

Facility

$152.00

Service Code	HCPCS 80170
Hospital Charge Code	422801705
Hospital Revenue Code	301
Min. Negotiated Rate	$129.20
Max. Negotiated Rate	$147.44
Rate for Payer: Cash Price	$98.80
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: MDX Hawaii PPO	$147.44

Gentamicin (Peak) DLS

Facility

$152.00

Service Code	HCPCS 80170
Hospital Charge Code	422801705
Hospital Revenue Code	301
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$147.44
Rate for Payer: AlohaCare Medicaid	$76.00
Rate for Payer: AlohaCare Medicare	$63.84
Rate for Payer: Cash Price	$98.80
Rate for Payer: Cash Price	$98.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$139.84
Rate for Payer: Devoted Health Medicare	$63.84
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$22.65
Rate for Payer: Hawaii Medical Service Association Commercial	$20.48
Rate for Payer: Hawaii Medical Service Association Medicare	$63.84
Rate for Payer: Hawaii Western Management Group Commercial	$16.38
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Humana Medicare	$63.84
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: Kaiser Permanente Medicaid	$77.52
Rate for Payer: Kaiser Permanente Medicare	$63.84
Rate for Payer: MDX Hawaii PPO	$147.44
Rate for Payer: Ohana Health Plan Medicaid	$63.84
Rate for Payer: Ohana Health Plan Medicare	$63.84
Rate for Payer: UnitedHealthcare Medicaid	$22.65
Rate for Payer: UnitedHealthcare Medicare	$63.84
Rate for Payer: University Health Alliance Commercial	$42.37

Gentamicin (Trough) DLS

Facility

$152.00

Service Code	HCPCS 80170
Hospital Charge Code	422801705
Hospital Revenue Code	301
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$147.44
Rate for Payer: AlohaCare Medicaid	$76.00
Rate for Payer: AlohaCare Medicare	$63.84
Rate for Payer: Cash Price	$98.80
Rate for Payer: Cash Price	$98.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$139.84
Rate for Payer: Devoted Health Medicare	$63.84
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$22.65
Rate for Payer: Hawaii Medical Service Association Commercial	$20.48
Rate for Payer: Hawaii Medical Service Association Medicare	$63.84
Rate for Payer: Hawaii Western Management Group Commercial	$16.38
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Humana Medicare	$63.84
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: Kaiser Permanente Medicaid	$77.52
Rate for Payer: Kaiser Permanente Medicare	$63.84
Rate for Payer: MDX Hawaii PPO	$147.44
Rate for Payer: Ohana Health Plan Medicaid	$63.84
Rate for Payer: Ohana Health Plan Medicare	$63.84
Rate for Payer: UnitedHealthcare Medicaid	$22.65
Rate for Payer: UnitedHealthcare Medicare	$63.84
Rate for Payer: University Health Alliance Commercial	$42.37

Gentamicin (Trough) DLS

Facility

$152.00

Service Code	HCPCS 80170
Hospital Charge Code	422801705
Hospital Revenue Code	301
Min. Negotiated Rate	$129.20
Max. Negotiated Rate	$147.44
Rate for Payer: Cash Price	$98.80
Rate for Payer: Health Management Network Commercial	$129.20
Rate for Payer: Kaiser Permanente Commercial	$136.80
Rate for Payer: MDX Hawaii PPO	$147.44

gentian violet topical 1% Sol [KMC]

Facility

$0.50

Service Code	NDC 00395100392
Hospital Revenue Code	250
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.32
Rate for Payer: Health Management Network Commercial	$0.43
Rate for Payer: Kaiser Permanente Commercial	$0.45
Rate for Payer: MDX Hawaii PPO	$0.49

gentian violet topical 1% Sol [KMC]

Facility

$0.50

Service Code	NDC 00395100392
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.49
Rate for Payer: AlohaCare Medicaid	$0.25
Rate for Payer: AlohaCare Medicare	$0.21
Rate for Payer: Cash Price	$0.32
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.46
Rate for Payer: Devoted Health Medicare	$0.21
Rate for Payer: Hawaii Medical Service Association Medicare	$0.21
Rate for Payer: Hawaii Western Management Group Commercial	$0.48
Rate for Payer: Health Management Network Commercial	$0.43
Rate for Payer: Humana Medicare	$0.21
Rate for Payer: Kaiser Permanente Commercial	$0.45
Rate for Payer: Kaiser Permanente Medicaid	$0.26
Rate for Payer: Kaiser Permanente Medicare	$0.21
Rate for Payer: MDX Hawaii PPO	$0.49
Rate for Payer: Ohana Health Plan Medicaid	$0.21
Rate for Payer: Ohana Health Plan Medicare	$0.21
Rate for Payer: UnitedHealthcare Medicaid	$0.30
Rate for Payer: UnitedHealthcare Medicare	$0.21
Rate for Payer: University Health Alliance Commercial	$0.36

Giardia DLS

Facility

$416.00

Service Code	HCPCS 86674
Hospital Charge Code	422866745
Hospital Revenue Code	302
Min. Negotiated Rate	$14.72
Max. Negotiated Rate	$403.52
Rate for Payer: AlohaCare Medicaid	$208.00
Rate for Payer: AlohaCare Medicare	$174.72
Rate for Payer: Cash Price	$270.40
Rate for Payer: Cash Price	$270.40
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$382.72
Rate for Payer: Devoted Health Medicare	$174.72
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.34
Rate for Payer: Hawaii Medical Service Association Commercial	$18.40
Rate for Payer: Hawaii Medical Service Association Medicare	$174.72
Rate for Payer: Hawaii Western Management Group Commercial	$14.72
Rate for Payer: Health Management Network Commercial	$353.60
Rate for Payer: Humana Medicare	$174.72
Rate for Payer: Kaiser Permanente Commercial	$374.40
Rate for Payer: Kaiser Permanente Medicaid	$212.16
Rate for Payer: Kaiser Permanente Medicare	$174.72
Rate for Payer: MDX Hawaii PPO	$403.52
Rate for Payer: Ohana Health Plan Medicaid	$174.72
Rate for Payer: Ohana Health Plan Medicare	$174.72
Rate for Payer: UnitedHealthcare Medicaid	$20.34
Rate for Payer: UnitedHealthcare Medicare	$174.72
Rate for Payer: University Health Alliance Commercial	$38.04

Giardia DLS

Facility

$416.00

Service Code	HCPCS 86674
Hospital Charge Code	422866745
Hospital Revenue Code	302
Min. Negotiated Rate	$353.60
Max. Negotiated Rate	$403.52
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Management Network Commercial	$353.60
Rate for Payer: Kaiser Permanente Commercial	$374.40
Rate for Payer: MDX Hawaii PPO	$403.52

Giardia Lamblia Antigen Test DLS

Facility

$184.00

Service Code	HCPCS 86674
Hospital Charge Code	422866745
Hospital Revenue Code	302
Min. Negotiated Rate	$14.72
Max. Negotiated Rate	$178.48
Rate for Payer: AlohaCare Medicaid	$92.00
Rate for Payer: AlohaCare Medicare	$77.28
Rate for Payer: Cash Price	$119.60
Rate for Payer: Cash Price	$119.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$169.28
Rate for Payer: Devoted Health Medicare	$77.28
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$20.34
Rate for Payer: Hawaii Medical Service Association Commercial	$18.40
Rate for Payer: Hawaii Medical Service Association Medicare	$77.28
Rate for Payer: Hawaii Western Management Group Commercial	$14.72
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Humana Medicare	$77.28
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: Kaiser Permanente Medicaid	$93.84
Rate for Payer: Kaiser Permanente Medicare	$77.28
Rate for Payer: MDX Hawaii PPO	$178.48
Rate for Payer: Ohana Health Plan Medicaid	$77.28
Rate for Payer: Ohana Health Plan Medicare	$77.28
Rate for Payer: UnitedHealthcare Medicaid	$20.34
Rate for Payer: UnitedHealthcare Medicare	$77.28
Rate for Payer: University Health Alliance Commercial	$38.04

Giardia Lamblia Antigen Test DLS

Facility

$184.00

Service Code	HCPCS 86674
Hospital Charge Code	422866745
Hospital Revenue Code	302
Min. Negotiated Rate	$156.40
Max. Negotiated Rate	$178.48
Rate for Payer: Cash Price	$119.60
Rate for Payer: Health Management Network Commercial	$156.40
Rate for Payer: Kaiser Permanente Commercial	$165.60
Rate for Payer: MDX Hawaii PPO	$178.48

GIZMO

Facility

$5.00

Hospital Charge Code	8127
Hospital Revenue Code	272
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$4.85
Rate for Payer: AlohaCare Medicaid	$2.50
Rate for Payer: AlohaCare Medicare	$2.10
Rate for Payer: Cash Price	$3.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.60
Rate for Payer: Devoted Health Medicare	$2.10
Rate for Payer: Hawaii Medical Service Association Medicare	$2.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.75
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Humana Medicare	$2.10
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: Kaiser Permanente Medicaid	$2.55
Rate for Payer: Kaiser Permanente Medicare	$2.10
Rate for Payer: MDX Hawaii PPO	$4.85
Rate for Payer: Ohana Health Plan Medicaid	$2.10
Rate for Payer: Ohana Health Plan Medicare	$2.10
Rate for Payer: UnitedHealthcare Medicare	$2.10
Rate for Payer: University Health Alliance Commercial	$3.64

GIZMO

Facility

$5.00

Hospital Charge Code	8127
Hospital Revenue Code	272
Min. Negotiated Rate	$4.25
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Health Management Network Commercial	$4.25
Rate for Payer: Kaiser Permanente Commercial	$4.50
Rate for Payer: MDX Hawaii PPO	$4.85

glatiramer 40 mg/mL Soln [KMC]

Facility

$2,097.20

Service Code	HCPCS J1595
Hospital Revenue Code	636
Min. Negotiated Rate	$67.64
Max. Negotiated Rate	$2,034.28
Rate for Payer: AlohaCare Medicaid	$1,048.60
Rate for Payer: AlohaCare Medicare	$880.82
Rate for Payer: Cash Price	$1,363.18
Rate for Payer: Cash Price	$1,363.18
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,929.42
Rate for Payer: Devoted Health Medicare	$880.82
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$67.64
Rate for Payer: Hawaii Medical Service Association Medicare	$880.82
Rate for Payer: Hawaii Western Management Group Commercial	$1,992.34
Rate for Payer: Health Management Network Commercial	$1,782.62
Rate for Payer: Humana Medicare	$880.82
Rate for Payer: Kaiser Permanente Commercial	$1,887.48
Rate for Payer: Kaiser Permanente Medicaid	$1,069.57
Rate for Payer: Kaiser Permanente Medicare	$880.82
Rate for Payer: MDX Hawaii PPO	$2,034.28
Rate for Payer: Ohana Health Plan Medicaid	$880.82
Rate for Payer: Ohana Health Plan Medicare	$880.82
Rate for Payer: UnitedHealthcare Medicaid	$1,258.32
Rate for Payer: UnitedHealthcare Medicare	$880.82
Rate for Payer: University Health Alliance Commercial	$1,528.65

glatiramer 40 mg/mL Soln [KMC]

Facility

$2,097.20

Service Code	HCPCS J1595
Hospital Revenue Code	636
Min. Negotiated Rate	$1,782.62
Max. Negotiated Rate	$2,034.28
Rate for Payer: Cash Price	$1,363.18
Rate for Payer: Health Management Network Commercial	$1,782.62
Rate for Payer: Kaiser Permanente Commercial	$1,887.48
Rate for Payer: MDX Hawaii PPO	$2,034.28

GLIDE SCOPE 1

Facility

$137.00

Hospital Charge Code	8128
Hospital Revenue Code	270
Min. Negotiated Rate	$116.45
Max. Negotiated Rate	$132.89
Rate for Payer: Cash Price	$89.05
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: Kaiser Permanente Commercial	$123.30
Rate for Payer: MDX Hawaii PPO	$132.89

GLIDE SCOPE 1

Facility

$137.00

Hospital Charge Code	8128
Hospital Revenue Code	270
Min. Negotiated Rate	$57.54
Max. Negotiated Rate	$132.89
Rate for Payer: AlohaCare Medicaid	$68.50
Rate for Payer: AlohaCare Medicare	$57.54
Rate for Payer: Cash Price	$89.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$126.04
Rate for Payer: Devoted Health Medicare	$57.54
Rate for Payer: Hawaii Medical Service Association Medicare	$57.54
Rate for Payer: Hawaii Western Management Group Commercial	$130.15
Rate for Payer: Health Management Network Commercial	$116.45
Rate for Payer: Humana Medicare	$57.54
Rate for Payer: Kaiser Permanente Commercial	$123.30
Rate for Payer: Kaiser Permanente Medicaid	$69.87
Rate for Payer: Kaiser Permanente Medicare	$57.54
Rate for Payer: MDX Hawaii PPO	$132.89
Rate for Payer: Ohana Health Plan Medicaid	$57.54
Rate for Payer: Ohana Health Plan Medicare	$57.54
Rate for Payer: UnitedHealthcare Medicare	$57.54
Rate for Payer: University Health Alliance Commercial	$99.86

Know your out-of-pocket cost for care.

All Charges