Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

imatinib 400 mg Tab

Facility

$1,457.63

Service Code	NDC 59651024130
Hospital Revenue Code	250
Min. Negotiated Rate	$612.20
Max. Negotiated Rate	$1,413.90
Rate for Payer: AlohaCare Medicaid	$728.82
Rate for Payer: AlohaCare Medicare	$612.20
Rate for Payer: Cash Price	$947.46
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,341.02
Rate for Payer: Devoted Health Medicare	$612.20
Rate for Payer: Hawaii Medical Service Association Medicare	$612.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,384.75
Rate for Payer: Health Management Network Commercial	$1,238.99
Rate for Payer: Humana Medicare	$612.20
Rate for Payer: Kaiser Permanente Commercial	$1,311.87
Rate for Payer: Kaiser Permanente Medicaid	$743.39
Rate for Payer: Kaiser Permanente Medicare	$612.20
Rate for Payer: MDX Hawaii PPO	$1,413.90
Rate for Payer: Ohana Health Plan Medicaid	$612.20
Rate for Payer: Ohana Health Plan Medicare	$612.20
Rate for Payer: UnitedHealthcare Medicaid	$874.58
Rate for Payer: UnitedHealthcare Medicare	$612.20
Rate for Payer: University Health Alliance Commercial	$1,062.47

imatinib 400 mg Tab

Facility

$1,457.63

Service Code	NDC 59651024130
Hospital Revenue Code	250
Min. Negotiated Rate	$1,238.99
Max. Negotiated Rate	$1,413.90
Rate for Payer: Cash Price	$947.46
Rate for Payer: Health Management Network Commercial	$1,238.99
Rate for Payer: Kaiser Permanente Commercial	$1,311.87
Rate for Payer: MDX Hawaii PPO	$1,413.90

imipenem-cilastatin 500-500 mg vial [KMC]

Facility

$50.40

Service Code	HCPCS J0743
Hospital Revenue Code	636
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$48.89
Rate for Payer: Cash Price	$32.76
Rate for Payer: Health Management Network Commercial	$42.84
Rate for Payer: Kaiser Permanente Commercial	$45.36
Rate for Payer: MDX Hawaii PPO	$48.89

imipenem-cilastatin 500-500 mg vial [KMC]

Facility

$50.40

Service Code	HCPCS J0743
Hospital Revenue Code	636
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$48.89
Rate for Payer: AlohaCare Medicaid	$25.20
Rate for Payer: AlohaCare Medicare	$21.17
Rate for Payer: Cash Price	$32.76
Rate for Payer: Cash Price	$32.76
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$46.37
Rate for Payer: Devoted Health Medicare	$21.17
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.97
Rate for Payer: Hawaii Medical Service Association Medicare	$21.17
Rate for Payer: Hawaii Western Management Group Commercial	$47.88
Rate for Payer: Health Management Network Commercial	$42.84
Rate for Payer: Humana Medicare	$21.17
Rate for Payer: Kaiser Permanente Commercial	$45.36
Rate for Payer: Kaiser Permanente Medicaid	$25.70
Rate for Payer: Kaiser Permanente Medicare	$21.17
Rate for Payer: MDX Hawaii PPO	$48.89
Rate for Payer: Ohana Health Plan Medicaid	$21.17
Rate for Payer: Ohana Health Plan Medicare	$21.17
Rate for Payer: UnitedHealthcare Medicaid	$30.24
Rate for Payer: UnitedHealthcare Medicare	$21.17
Rate for Payer: University Health Alliance Commercial	$36.74

imipramine 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 49884005501
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

imipramine 25 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 49884005501
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

imipramine 50 mg Tab [KMC]

Facility

$4.88

Service Code	NDC 69584042710
Hospital Revenue Code	250
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$4.73
Rate for Payer: AlohaCare Medicaid	$2.44
Rate for Payer: AlohaCare Medicare	$2.05
Rate for Payer: Cash Price	$3.17
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$4.49
Rate for Payer: Devoted Health Medicare	$2.05
Rate for Payer: Hawaii Medical Service Association Medicare	$2.05
Rate for Payer: Hawaii Western Management Group Commercial	$4.64
Rate for Payer: Health Management Network Commercial	$4.15
Rate for Payer: Humana Medicare	$2.05
Rate for Payer: Kaiser Permanente Commercial	$4.39
Rate for Payer: Kaiser Permanente Medicaid	$2.49
Rate for Payer: Kaiser Permanente Medicare	$2.05
Rate for Payer: MDX Hawaii PPO	$4.73
Rate for Payer: Ohana Health Plan Medicaid	$2.05
Rate for Payer: Ohana Health Plan Medicare	$2.05
Rate for Payer: UnitedHealthcare Medicaid	$2.93
Rate for Payer: UnitedHealthcare Medicare	$2.05
Rate for Payer: University Health Alliance Commercial	$3.56

imipramine 50 mg Tab [KMC]

Facility

$4.88

Service Code	NDC 69584042710
Hospital Revenue Code	250
Min. Negotiated Rate	$4.15
Max. Negotiated Rate	$4.73
Rate for Payer: Cash Price	$3.17
Rate for Payer: Health Management Network Commercial	$4.15
Rate for Payer: Kaiser Permanente Commercial	$4.39
Rate for Payer: MDX Hawaii PPO	$4.73

imiquimod 5% topical Cream [KMC]

Facility

$73.58

Service Code	HCPCS J0743
Hospital Revenue Code	636
Min. Negotiated Rate	$62.54
Max. Negotiated Rate	$71.37
Rate for Payer: Cash Price	$47.83
Rate for Payer: Health Management Network Commercial	$62.54
Rate for Payer: Kaiser Permanente Commercial	$66.22
Rate for Payer: MDX Hawaii PPO	$71.37

imiquimod 5% topical Cream [KMC]

Facility

$73.58

Service Code	HCPCS J0743
Hospital Revenue Code	636
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$71.37
Rate for Payer: AlohaCare Medicaid	$36.79
Rate for Payer: AlohaCare Medicare	$30.90
Rate for Payer: Cash Price	$47.83
Rate for Payer: Cash Price	$47.83
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$67.69
Rate for Payer: Devoted Health Medicare	$30.90
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$6.97
Rate for Payer: Hawaii Medical Service Association Medicare	$30.90
Rate for Payer: Hawaii Western Management Group Commercial	$69.90
Rate for Payer: Health Management Network Commercial	$62.54
Rate for Payer: Humana Medicare	$30.90
Rate for Payer: Kaiser Permanente Commercial	$66.22
Rate for Payer: Kaiser Permanente Medicaid	$37.53
Rate for Payer: Kaiser Permanente Medicare	$30.90
Rate for Payer: MDX Hawaii PPO	$71.37
Rate for Payer: Ohana Health Plan Medicaid	$30.90
Rate for Payer: Ohana Health Plan Medicare	$30.90
Rate for Payer: UnitedHealthcare Medicaid	$44.15
Rate for Payer: UnitedHealthcare Medicare	$30.90
Rate for Payer: University Health Alliance Commercial	$53.63

INATION FOOT 2 VIEWS

Facility

$369.00

Service Code	HCPCS 73620
Hospital Charge Code	424736200
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

INATION FOOT 2 VIEWS

Facility

$369.00

Service Code	HCPCS 73620
Hospital Charge Code	424736200
Hospital Revenue Code	320
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.41
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$16.41
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$54.67

INATION HAND 2 VIEWS

Facility

$369.00

Service Code	HCPCS 73120
Hospital Charge Code	424731200
Hospital Revenue Code	320
Min. Negotiated Rate	$313.65
Max. Negotiated Rate	$357.93
Rate for Payer: Cash Price	$239.85
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: MDX Hawaii PPO	$357.93

INATION HAND 2 VIEWS

Facility

$369.00

Service Code	HCPCS 73120
Hospital Charge Code	424731200
Hospital Revenue Code	320
Min. Negotiated Rate	$17.55
Max. Negotiated Rate	$357.93
Rate for Payer: AlohaCare Medicaid	$184.50
Rate for Payer: AlohaCare Medicare	$154.98
Rate for Payer: Cash Price	$239.85
Rate for Payer: Cash Price	$239.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$339.48
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$17.55
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$154.98
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$313.65
Rate for Payer: Humana Medicare	$154.98
Rate for Payer: Kaiser Permanente Commercial	$332.10
Rate for Payer: Kaiser Permanente Medicaid	$188.19
Rate for Payer: Kaiser Permanente Medicare	$154.98
Rate for Payer: MDX Hawaii PPO	$357.93
Rate for Payer: Ohana Health Plan Medicaid	$154.98
Rate for Payer: Ohana Health Plan Medicare	$154.98
Rate for Payer: UnitedHealthcare Medicaid	$17.55
Rate for Payer: UnitedHealthcare Medicare	$154.98
Rate for Payer: University Health Alliance Commercial	$55.46

INATION KNEE 3 VIEWS

Facility

$384.00

Service Code	HCPCS 73562
Hospital Charge Code	424735620
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$372.48
Rate for Payer: AlohaCare Medicaid	$192.00
Rate for Payer: AlohaCare Medicare	$161.28
Rate for Payer: Cash Price	$249.60
Rate for Payer: Cash Price	$249.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$353.28
Rate for Payer: Devoted Health Medicare	$161.28
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$18.84
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$161.28
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$326.40
Rate for Payer: Humana Medicare	$161.28
Rate for Payer: Kaiser Permanente Commercial	$345.60
Rate for Payer: Kaiser Permanente Medicaid	$195.84
Rate for Payer: Kaiser Permanente Medicare	$161.28
Rate for Payer: MDX Hawaii PPO	$372.48
Rate for Payer: Ohana Health Plan Medicaid	$161.28
Rate for Payer: Ohana Health Plan Medicare	$161.28
Rate for Payer: UnitedHealthcare Medicaid	$18.84
Rate for Payer: UnitedHealthcare Medicare	$161.28
Rate for Payer: University Health Alliance Commercial	$68.32

INATION KNEE 3 VIEWS

Facility

$384.00

Service Code	HCPCS 73562
Hospital Charge Code	424735620
Hospital Revenue Code	320
Min. Negotiated Rate	$326.40
Max. Negotiated Rate	$372.48
Rate for Payer: Cash Price	$249.60
Rate for Payer: Health Management Network Commercial	$326.40
Rate for Payer: Kaiser Permanente Commercial	$345.60
Rate for Payer: MDX Hawaii PPO	$372.48

INBORN AND OTHER DISORDERS OF METABOLISM

Facility

$85,327.20

Service Code	MSDRG 642
Min. Negotiated Rate	$85,327.20
Max. Negotiated Rate	$85,327.20
Rate for Payer: Hawaii Medical Service Association Commercial	$85,327.20

Incentive Spirometer

Facility

$3.00

Hospital Charge Code	10003
Hospital Revenue Code	270
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

Incentive Spirometer

Facility

$3.00

Hospital Charge Code	10003
Hospital Revenue Code	270
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
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

INC & FB REM SUBCU COMPLX ED Charge

Facility

$5,853.00

Service Code	HCPCS 10121
Hospital Charge Code	440101210
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$5,677.41
Rate for Payer: AlohaCare Medicaid	$2,926.50
Rate for Payer: AlohaCare Medicare	$2,458.26
Rate for Payer: Cash Price	$3,804.45
Rate for Payer: Cash Price	$3,804.45
Rate for Payer: Cash Price	$3,804.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$5,384.76
Rate for Payer: Devoted Health Medicare	$2,458.26
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,458.26
Rate for Payer: Hawaii Western Management Group Commercial	$5,560.35
Rate for Payer: Health Management Network Commercial	$4,975.05
Rate for Payer: Humana Medicare	$2,458.26
Rate for Payer: Kaiser Permanente Commercial	$5,267.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$2,458.26
Rate for Payer: MDX Hawaii PPO	$5,677.41
Rate for Payer: Ohana Health Plan Medicaid	$2,458.26
Rate for Payer: Ohana Health Plan Medicare	$2,458.26
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,458.26
Rate for Payer: University Health Alliance Commercial	$5,160.40

INC & FB REM SUBCU COMPLX ED Charge

Facility

$5,853.00

Service Code	HCPCS 10121
Hospital Charge Code	440101210
Hospital Revenue Code	450
Min. Negotiated Rate	$4,975.05
Max. Negotiated Rate	$5,677.41
Rate for Payer: Cash Price	$3,804.45
Rate for Payer: Health Management Network Commercial	$4,975.05
Rate for Payer: Kaiser Permanente Commercial	$5,267.70
Rate for Payer: MDX Hawaii PPO	$5,677.41

INC & FB REM SUBCU SIMPLE ED Charge

Facility

$1,405.00

Service Code	HCPCS 10120
Hospital Charge Code	440101200
Hospital Revenue Code	450
Min. Negotiated Rate	$417.00
Max. Negotiated Rate	$5,160.40
Rate for Payer: AlohaCare Medicaid	$702.50
Rate for Payer: AlohaCare Medicare	$590.10
Rate for Payer: Cash Price	$913.25
Rate for Payer: Cash Price	$913.25
Rate for Payer: Cash Price	$913.25
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,292.60
Rate for Payer: Devoted Health Medicare	$590.10
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$590.10
Rate for Payer: Hawaii Western Management Group Commercial	$1,334.75
Rate for Payer: Health Management Network Commercial	$1,194.25
Rate for Payer: Humana Medicare	$590.10
Rate for Payer: Kaiser Permanente Commercial	$1,264.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$590.10
Rate for Payer: MDX Hawaii PPO	$1,362.85
Rate for Payer: Ohana Health Plan Medicaid	$590.10
Rate for Payer: Ohana Health Plan Medicare	$590.10
Rate for Payer: UnitedHealthcare Medicare	$590.10
Rate for Payer: University Health Alliance Commercial	$5,160.40

INC & FB REM SUBCU SIMPLE ED Charge

Facility

$1,405.00

Service Code	HCPCS 10120
Hospital Charge Code	440101200
Hospital Revenue Code	450
Min. Negotiated Rate	$1,194.25
Max. Negotiated Rate	$1,362.85
Rate for Payer: Cash Price	$913.25
Rate for Payer: Health Management Network Commercial	$1,194.25
Rate for Payer: Kaiser Permanente Commercial	$1,264.50
Rate for Payer: MDX Hawaii PPO	$1,362.85

INCISIONAL BIOPSY SKIN EA SEP/ADDITIONAL LESION

Professional

Both

$297.00

Service Code	HCPCS 11107
Hospital Revenue Code	361
Min. Negotiated Rate	$24.94
Max. Negotiated Rate	$252.45
Rate for Payer: AlohaCare Medicaid	$30.76
Rate for Payer: AlohaCare Medicare	$24.94
Rate for Payer: Cash Price	$193.05
Rate for Payer: Cash Price	$193.05
Rate for Payer: Devoted Health Medicare	$24.94
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$30.76
Rate for Payer: Hawaii Medical Service Association Commercial	$48.57
Rate for Payer: Hawaii Medical Service Association Medicare	$24.94
Rate for Payer: Hawaii Western Management Group Commercial	$80.08
Rate for Payer: Health Management Network Commercial	$252.45
Rate for Payer: Kaiser Permanente Commercial	$29.93
Rate for Payer: Kaiser Permanente Medicaid	$29.93
Rate for Payer: Kaiser Permanente Medicare	$29.93
Rate for Payer: Ohana Health Plan Medicaid	$30.76
Rate for Payer: Ohana Health Plan Medicare	$24.94
Rate for Payer: UnitedHealthcare Medicaid	$30.76
Rate for Payer: UnitedHealthcare Medicare	$24.94
Rate for Payer: University Health Alliance Commercial	$35.94

INCISIONAL BIOPSY SKIN SINGLE LESION

Professional

Both

$230.00

Service Code	HCPCS 11106
Hospital Revenue Code	361
Min. Negotiated Rate	$46.07
Max. Negotiated Rate	$195.50
Rate for Payer: AlohaCare Medicaid	$56.70
Rate for Payer: AlohaCare Medicare	$46.07
Rate for Payer: Cash Price	$149.50
Rate for Payer: Cash Price	$149.50
Rate for Payer: Devoted Health Medicare	$46.07
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$56.70
Rate for Payer: Hawaii Medical Service Association Commercial	$91.58
Rate for Payer: Hawaii Medical Service Association Medicare	$46.07
Rate for Payer: Hawaii Western Management Group Commercial	$167.96
Rate for Payer: Health Management Network Commercial	$195.50
Rate for Payer: Kaiser Permanente Commercial	$55.28
Rate for Payer: Kaiser Permanente Medicaid	$55.28
Rate for Payer: Kaiser Permanente Medicare	$55.28
Rate for Payer: Ohana Health Plan Medicaid	$56.70
Rate for Payer: Ohana Health Plan Medicare	$46.07
Rate for Payer: UnitedHealthcare Medicaid	$56.70
Rate for Payer: UnitedHealthcare Medicare	$46.07
Rate for Payer: University Health Alliance Commercial	$65.75

Know your out-of-pocket cost for care.

All Charges