Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Hepatitis B Core Antibody Total FSI

Facility

$174.00

Service Code	HCPCS 86704
Hospital Charge Code	8117946
Hospital Revenue Code	302
Min. Negotiated Rate	$147.90
Max. Negotiated Rate	$168.78
Rate for Payer: Cash Price	$113.10
Rate for Payer: Health Management Network Commercial	$147.90
Rate for Payer: Kaiser Permanente Commercial	$156.60
Rate for Payer: MDX Hawaii PPO	$168.78

Hepatitis Be Antibody FSI

Facility

$135.00

Service Code	HCPCS 86707
Hospital Charge Code	8117949
Hospital Revenue Code	302
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$130.95
Rate for Payer: AlohaCare Medicaid	$67.50
Rate for Payer: AlohaCare Medicare	$67.50
Rate for Payer: Cash Price	$87.75
Rate for Payer: Cash Price	$87.75
Rate for Payer: Devoted Health Medicare	$74.25
Rate for Payer: Hawaii Medical Service Association ABD	$15.98
Rate for Payer: Hawaii Medical Service Association Commercial	$14.46
Rate for Payer: Hawaii Medical Service Association Medicare	$67.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.78
Rate for Payer: Hawaii Western Management Group Commercial	$11.57
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Humana Medicare	$67.50
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: Kaiser Permanente Medicaid	$68.85
Rate for Payer: Kaiser Permanente Medicare	$67.50
Rate for Payer: MDX Hawaii PPO	$130.95
Rate for Payer: Ohana Health Plan Medicaid	$67.50
Rate for Payer: Ohana Health Plan Medicare	$67.50
Rate for Payer: UnitedHealthcare Medicaid	$15.98
Rate for Payer: UnitedHealthcare Medicare	$67.50
Rate for Payer: University Health Alliance Commercial	$29.90

Hepatitis Be Antibody FSI

Facility

$135.00

Service Code	HCPCS 86707
Hospital Charge Code	8117949
Hospital Revenue Code	302
Min. Negotiated Rate	$114.75
Max. Negotiated Rate	$130.95
Rate for Payer: Cash Price	$87.75
Rate for Payer: Health Management Network Commercial	$114.75
Rate for Payer: Kaiser Permanente Commercial	$121.50
Rate for Payer: MDX Hawaii PPO	$130.95

Hepatitis Be Antigen FSI

Facility

$134.00

Service Code	HCPCS 87350
Hospital Charge Code	8117950
Hospital Revenue Code	306
Min. Negotiated Rate	$113.90
Max. Negotiated Rate	$129.98
Rate for Payer: Cash Price	$87.10
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: MDX Hawaii PPO	$129.98

Hepatitis Be Antigen FSI

Facility

$134.00

Service Code	HCPCS 87350
Hospital Charge Code	8117950
Hospital Revenue Code	306
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$129.98
Rate for Payer: AlohaCare Medicaid	$67.00
Rate for Payer: AlohaCare Medicare	$67.00
Rate for Payer: Cash Price	$87.10
Rate for Payer: Cash Price	$87.10
Rate for Payer: Devoted Health Medicare	$73.70
Rate for Payer: Hawaii Medical Service Association ABD	$15.92
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$67.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.72
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$113.90
Rate for Payer: Humana Medicare	$67.00
Rate for Payer: Kaiser Permanente Commercial	$120.60
Rate for Payer: Kaiser Permanente Medicaid	$68.34
Rate for Payer: Kaiser Permanente Medicare	$67.00
Rate for Payer: MDX Hawaii PPO	$129.98
Rate for Payer: Ohana Health Plan Medicaid	$67.00
Rate for Payer: Ohana Health Plan Medicare	$67.00
Rate for Payer: UnitedHealthcare Medicaid	$15.92
Rate for Payer: UnitedHealthcare Medicare	$67.00
Rate for Payer: University Health Alliance Commercial	$29.79

hepatitis B immune glob neonatal 0.5 mL (private) [HHSC]

Facility

$405.00

Service Code	HCPCS 90371
Hospital Charge Code	2501199
Hospital Revenue Code	250
Min. Negotiated Rate	$175.26
Max. Negotiated Rate	$392.85
Rate for Payer: AlohaCare Medicaid	$202.50
Rate for Payer: AlohaCare Medicare	$202.50
Rate for Payer: Cash Price	$263.25
Rate for Payer: Cash Price	$263.25
Rate for Payer: Devoted Health Medicare	$222.75
Rate for Payer: Hawaii Medical Service Association Commercial	$175.26
Rate for Payer: Hawaii Medical Service Association Medicare	$202.50
Rate for Payer: Hawaii Western Management Group Commercial	$384.75
Rate for Payer: Health Management Network Commercial	$344.25
Rate for Payer: Humana Medicare	$202.50
Rate for Payer: Kaiser Permanente Commercial	$364.50
Rate for Payer: Kaiser Permanente Medicaid	$206.55
Rate for Payer: Kaiser Permanente Medicare	$202.50
Rate for Payer: MDX Hawaii PPO	$392.85
Rate for Payer: Ohana Health Plan Medicaid	$202.50
Rate for Payer: Ohana Health Plan Medicare	$202.50
Rate for Payer: UnitedHealthcare Medicaid	$243.00
Rate for Payer: UnitedHealthcare Medicare	$202.50
Rate for Payer: University Health Alliance Commercial	$295.20

hepatitis B immune glob neonatal 0.5 mL (private) [HHSC]

Facility

$405.00

Service Code	HCPCS 90371
Hospital Charge Code	2501199
Hospital Revenue Code	250
Min. Negotiated Rate	$344.25
Max. Negotiated Rate	$392.85
Rate for Payer: Cash Price	$263.25
Rate for Payer: Health Management Network Commercial	$344.25
Rate for Payer: Kaiser Permanente Commercial	$364.50
Rate for Payer: MDX Hawaii PPO	$392.85

hepatitis B immune globulin (ADULT) 5 mL vial [HHSC]

Facility

$2,021.47

Service Code	NDC 69800420301
Hospital Charge Code	2500381
Hospital Revenue Code	250
Min. Negotiated Rate	$1,010.74
Max. Negotiated Rate	$1,960.83
Rate for Payer: AlohaCare Medicaid	$1,010.74
Rate for Payer: AlohaCare Medicare	$1,010.74
Rate for Payer: Cash Price	$1,313.96
Rate for Payer: Devoted Health Medicare	$1,111.81
Rate for Payer: Hawaii Medical Service Association Medicare	$1,010.74
Rate for Payer: Hawaii Western Management Group Commercial	$1,920.40
Rate for Payer: Health Management Network Commercial	$1,718.25
Rate for Payer: Humana Medicare	$1,010.74
Rate for Payer: Kaiser Permanente Commercial	$1,819.32
Rate for Payer: Kaiser Permanente Medicaid	$1,030.95
Rate for Payer: Kaiser Permanente Medicare	$1,010.74
Rate for Payer: MDX Hawaii PPO	$1,960.83
Rate for Payer: Ohana Health Plan Medicaid	$1,010.74
Rate for Payer: Ohana Health Plan Medicare	$1,010.74
Rate for Payer: UnitedHealthcare Medicaid	$1,212.88
Rate for Payer: UnitedHealthcare Medicare	$1,010.74
Rate for Payer: University Health Alliance Commercial	$1,473.45

hepatitis B immune globulin (ADULT) 5 mL vial [HHSC]

Facility

$2,021.47

Service Code	NDC 69800420301
Hospital Charge Code	2500381
Hospital Revenue Code	250
Min. Negotiated Rate	$1,718.25
Max. Negotiated Rate	$1,960.83
Rate for Payer: Cash Price	$1,313.96
Rate for Payer: Health Management Network Commercial	$1,718.25
Rate for Payer: Kaiser Permanente Commercial	$1,819.32
Rate for Payer: MDX Hawaii PPO	$1,960.83

hepatitis B immune globulin (ADULT) 5 mL vial [HHSC]

Facility

$1,923.28

Service Code	NDC 59730420301
Hospital Charge Code	2500381
Hospital Revenue Code	250
Min. Negotiated Rate	$1,634.79
Max. Negotiated Rate	$1,865.58
Rate for Payer: Cash Price	$1,250.13
Rate for Payer: Health Management Network Commercial	$1,634.79
Rate for Payer: Kaiser Permanente Commercial	$1,730.95
Rate for Payer: MDX Hawaii PPO	$1,865.58

hepatitis B immune globulin (ADULT) 5 mL vial [HHSC]

Facility

$1,923.28

Service Code	NDC 59730420301
Hospital Charge Code	2500381
Hospital Revenue Code	250
Min. Negotiated Rate	$961.64
Max. Negotiated Rate	$1,865.58
Rate for Payer: AlohaCare Medicaid	$961.64
Rate for Payer: AlohaCare Medicare	$961.64
Rate for Payer: Cash Price	$1,250.13
Rate for Payer: Devoted Health Medicare	$1,057.80
Rate for Payer: Hawaii Medical Service Association Medicare	$961.64
Rate for Payer: Hawaii Western Management Group Commercial	$1,827.12
Rate for Payer: Health Management Network Commercial	$1,634.79
Rate for Payer: Humana Medicare	$961.64
Rate for Payer: Kaiser Permanente Commercial	$1,730.95
Rate for Payer: Kaiser Permanente Medicaid	$980.87
Rate for Payer: Kaiser Permanente Medicare	$961.64
Rate for Payer: MDX Hawaii PPO	$1,865.58
Rate for Payer: Ohana Health Plan Medicaid	$961.64
Rate for Payer: Ohana Health Plan Medicare	$961.64
Rate for Payer: UnitedHealthcare Medicaid	$1,153.97
Rate for Payer: UnitedHealthcare Medicare	$961.64
Rate for Payer: University Health Alliance Commercial	$1,401.88

hepatitis B ped vacc 10 mcg/0.5 ml (private) [HHSC]

Facility

$119.72

Service Code	NDC 58160082052
Hospital Charge Code	2500382
Hospital Revenue Code	250
Min. Negotiated Rate	$101.76
Max. Negotiated Rate	$116.13
Rate for Payer: Cash Price	$77.82
Rate for Payer: Health Management Network Commercial	$101.76
Rate for Payer: Kaiser Permanente Commercial	$107.75
Rate for Payer: MDX Hawaii PPO	$116.13

hepatitis B ped vacc 10 mcg/0.5 ml (private) [HHSC]

Facility

$119.72

Service Code	NDC 58160082052
Hospital Charge Code	2500382
Hospital Revenue Code	250
Min. Negotiated Rate	$59.86
Max. Negotiated Rate	$116.13
Rate for Payer: AlohaCare Medicaid	$59.86
Rate for Payer: AlohaCare Medicare	$59.86
Rate for Payer: Cash Price	$77.82
Rate for Payer: Devoted Health Medicare	$65.85
Rate for Payer: Hawaii Medical Service Association Medicare	$59.86
Rate for Payer: Hawaii Western Management Group Commercial	$113.73
Rate for Payer: Health Management Network Commercial	$101.76
Rate for Payer: Humana Medicare	$59.86
Rate for Payer: Kaiser Permanente Commercial	$107.75
Rate for Payer: Kaiser Permanente Medicaid	$61.06
Rate for Payer: Kaiser Permanente Medicare	$59.86
Rate for Payer: MDX Hawaii PPO	$116.13
Rate for Payer: Ohana Health Plan Medicaid	$59.86
Rate for Payer: Ohana Health Plan Medicare	$59.86
Rate for Payer: UnitedHealthcare Medicaid	$71.83
Rate for Payer: UnitedHealthcare Medicare	$59.86
Rate for Payer: University Health Alliance Commercial	$87.26

Hepatitis B Surface Antibody FSI

Facility

$127.00

Service Code	HCPCS 86706
Hospital Charge Code	8117947
Hospital Revenue Code	302
Min. Negotiated Rate	$10.74
Max. Negotiated Rate	$123.19
Rate for Payer: AlohaCare Medicaid	$63.50
Rate for Payer: AlohaCare Medicare	$63.50
Rate for Payer: Cash Price	$82.55
Rate for Payer: Cash Price	$82.55
Rate for Payer: Devoted Health Medicare	$69.85
Rate for Payer: Hawaii Medical Service Association ABD	$14.84
Rate for Payer: Hawaii Medical Service Association Commercial	$13.43
Rate for Payer: Hawaii Medical Service Association Medicare	$63.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$15.58
Rate for Payer: Hawaii Western Management Group Commercial	$10.74
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Humana Medicare	$63.50
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: Kaiser Permanente Medicaid	$64.77
Rate for Payer: Kaiser Permanente Medicare	$63.50
Rate for Payer: MDX Hawaii PPO	$123.19
Rate for Payer: Ohana Health Plan Medicaid	$63.50
Rate for Payer: Ohana Health Plan Medicare	$63.50
Rate for Payer: UnitedHealthcare Medicaid	$14.84
Rate for Payer: UnitedHealthcare Medicare	$63.50
Rate for Payer: University Health Alliance Commercial	$27.77

Hepatitis B Surface Antibody FSI

Facility

$127.00

Service Code	HCPCS 86706
Hospital Charge Code	8117947
Hospital Revenue Code	302
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$123.19
Rate for Payer: Cash Price	$82.55
Rate for Payer: Health Management Network Commercial	$107.95
Rate for Payer: Kaiser Permanente Commercial	$114.30
Rate for Payer: MDX Hawaii PPO	$123.19

Hepatitis B Surface Antigen FSI

Facility

$147.00

Service Code	HCPCS 87340
Hospital Charge Code	8117948
Hospital Revenue Code	306
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$142.59
Rate for Payer: AlohaCare Medicaid	$73.50
Rate for Payer: AlohaCare Medicare	$73.50
Rate for Payer: Cash Price	$95.55
Rate for Payer: Cash Price	$95.55
Rate for Payer: Devoted Health Medicare	$80.85
Rate for Payer: Hawaii Medical Service Association ABD	$14.27
Rate for Payer: Hawaii Medical Service Association Commercial	$12.91
Rate for Payer: Hawaii Medical Service Association Medicare	$73.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.98
Rate for Payer: Hawaii Western Management Group Commercial	$10.33
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Humana Medicare	$73.50
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: Kaiser Permanente Medicaid	$74.97
Rate for Payer: Kaiser Permanente Medicare	$73.50
Rate for Payer: MDX Hawaii PPO	$142.59
Rate for Payer: Ohana Health Plan Medicaid	$73.50
Rate for Payer: Ohana Health Plan Medicare	$73.50
Rate for Payer: UnitedHealthcare Medicaid	$14.27
Rate for Payer: UnitedHealthcare Medicare	$73.50
Rate for Payer: University Health Alliance Commercial	$26.70

Hepatitis B Surface Antigen FSI

Facility

$147.00

Service Code	HCPCS 87340
Hospital Charge Code	8117948
Hospital Revenue Code	306
Min. Negotiated Rate	$124.95
Max. Negotiated Rate	$142.59
Rate for Payer: Cash Price	$95.55
Rate for Payer: Health Management Network Commercial	$124.95
Rate for Payer: Kaiser Permanente Commercial	$132.30
Rate for Payer: MDX Hawaii PPO	$142.59

Hepatitis C Ab by CIA FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	10378951
Hospital Revenue Code	302
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$81.50
Rate for Payer: AlohaCare Medicare	$81.50
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$89.65
Rate for Payer: Hawaii Medical Service Association ABD	$19.73
Rate for Payer: Hawaii Medical Service Association Commercial	$17.84
Rate for Payer: Hawaii Medical Service Association Medicare	$81.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.72
Rate for Payer: Hawaii Western Management Group Commercial	$14.27
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$81.50
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$81.50
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$81.50
Rate for Payer: Ohana Health Plan Medicare	$81.50
Rate for Payer: UnitedHealthcare Medicaid	$19.73
Rate for Payer: UnitedHealthcare Medicare	$81.50
Rate for Payer: University Health Alliance Commercial	$36.89

Hepatitis C Ab by CIA FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	10378951
Hospital Revenue Code	302
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$105.95
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: MDX Hawaii PPO	$158.11

Hepatitis C Antibody FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	8117951
Hospital Revenue Code	302
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$158.11
Rate for Payer: AlohaCare Medicaid	$81.50
Rate for Payer: AlohaCare Medicare	$81.50
Rate for Payer: Cash Price	$105.95
Rate for Payer: Cash Price	$105.95
Rate for Payer: Devoted Health Medicare	$89.65
Rate for Payer: Hawaii Medical Service Association ABD	$19.73
Rate for Payer: Hawaii Medical Service Association Commercial	$17.84
Rate for Payer: Hawaii Medical Service Association Medicare	$81.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.72
Rate for Payer: Hawaii Western Management Group Commercial	$14.27
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Humana Medicare	$81.50
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: Kaiser Permanente Medicaid	$83.13
Rate for Payer: Kaiser Permanente Medicare	$81.50
Rate for Payer: MDX Hawaii PPO	$158.11
Rate for Payer: Ohana Health Plan Medicaid	$81.50
Rate for Payer: Ohana Health Plan Medicare	$81.50
Rate for Payer: UnitedHealthcare Medicaid	$19.73
Rate for Payer: UnitedHealthcare Medicare	$81.50
Rate for Payer: University Health Alliance Commercial	$36.89

Hepatitis C Antibody FSI

Facility

$163.00

Service Code	HCPCS 86803
Hospital Charge Code	8117951
Hospital Revenue Code	302
Min. Negotiated Rate	$138.55
Max. Negotiated Rate	$158.11
Rate for Payer: Cash Price	$105.95
Rate for Payer: Health Management Network Commercial	$138.55
Rate for Payer: Kaiser Permanente Commercial	$146.70
Rate for Payer: MDX Hawaii PPO	$158.11

Hepatitis C Genotype FSI

Facility

$2,876.00

Service Code	HCPCS 87902
Hospital Charge Code	8404559
Hospital Revenue Code	306
Min. Negotiated Rate	$2,444.60
Max. Negotiated Rate	$2,789.72
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Health Management Network Commercial	$2,444.60
Rate for Payer: Kaiser Permanente Commercial	$2,588.40
Rate for Payer: MDX Hawaii PPO	$2,789.72

Hepatitis C Genotype FSI

Facility

$2,876.00

Service Code	HCPCS 87902
Hospital Charge Code	8404559
Hospital Revenue Code	306
Min. Negotiated Rate	$256.16
Max. Negotiated Rate	$2,789.72
Rate for Payer: AlohaCare Medicaid	$1,438.00
Rate for Payer: AlohaCare Medicare	$1,438.00
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Cash Price	$1,869.40
Rate for Payer: Devoted Health Medicare	$1,581.80
Rate for Payer: Hawaii Medical Service Association ABD	$256.16
Rate for Payer: Hawaii Medical Service Association Commercial	$321.81
Rate for Payer: Hawaii Medical Service Association Medicare	$1,438.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$355.58
Rate for Payer: Hawaii Western Management Group Commercial	$257.45
Rate for Payer: Health Management Network Commercial	$2,444.60
Rate for Payer: Humana Medicare	$1,438.00
Rate for Payer: Kaiser Permanente Commercial	$2,588.40
Rate for Payer: Kaiser Permanente Medicaid	$1,466.76
Rate for Payer: Kaiser Permanente Medicare	$1,438.00
Rate for Payer: MDX Hawaii PPO	$2,789.72
Rate for Payer: Ohana Health Plan Medicaid	$1,438.00
Rate for Payer: Ohana Health Plan Medicare	$1,438.00
Rate for Payer: UnitedHealthcare Medicaid	$256.16
Rate for Payer: UnitedHealthcare Medicare	$1,438.00
Rate for Payer: University Health Alliance Commercial	$665.43

Hepatitis C HCV Quant Rfx Genotype FSI

Facility

$478.00

Service Code	HCPCS 87522
Hospital Charge Code	8228882
Hospital Revenue Code	306
Min. Negotiated Rate	$406.30
Max. Negotiated Rate	$463.66
Rate for Payer: Cash Price	$310.70
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: Kaiser Permanente Commercial	$430.20
Rate for Payer: MDX Hawaii PPO	$463.66

Hepatitis C HCV Quant Rfx Genotype FSI

Facility

$478.00

Service Code	HCPCS 87522
Hospital Charge Code	8228882
Hospital Revenue Code	306
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$463.66
Rate for Payer: AlohaCare Medicaid	$239.00
Rate for Payer: AlohaCare Medicare	$239.00
Rate for Payer: Cash Price	$310.70
Rate for Payer: Cash Price	$310.70
Rate for Payer: Devoted Health Medicare	$262.90
Rate for Payer: Hawaii Medical Service Association ABD	$59.20
Rate for Payer: Hawaii Medical Service Association Commercial	$53.55
Rate for Payer: Hawaii Medical Service Association Medicare	$239.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$62.16
Rate for Payer: Hawaii Western Management Group Commercial	$42.84
Rate for Payer: Health Management Network Commercial	$406.30
Rate for Payer: Humana Medicare	$239.00
Rate for Payer: Kaiser Permanente Commercial	$430.20
Rate for Payer: Kaiser Permanente Medicaid	$243.78
Rate for Payer: Kaiser Permanente Medicare	$239.00
Rate for Payer: MDX Hawaii PPO	$463.66
Rate for Payer: Ohana Health Plan Medicaid	$239.00
Rate for Payer: Ohana Health Plan Medicare	$239.00
Rate for Payer: UnitedHealthcare Medicaid	$59.20
Rate for Payer: UnitedHealthcare Medicare	$239.00
Rate for Payer: University Health Alliance Commercial	$110.72

Know your out-of-pocket cost for care.

All Charges