Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

US Breast Complete Bilat

Facility

$932.00

Service Code	HCPCS 76641 50
Hospital Charge Code	8111061
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$904.04
Rate for Payer: AlohaCare Medicaid	$466.00
Rate for Payer: AlohaCare Medicare	$466.00
Rate for Payer: Cash Price	$605.80
Rate for Payer: Cash Price	$605.80
Rate for Payer: Devoted Health Medicare	$512.60
Rate for Payer: Hawaii Medical Service Association ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Medicare	$466.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.51
Rate for Payer: Hawaii Western Management Group Commercial	$885.40
Rate for Payer: Health Management Network Commercial	$792.20
Rate for Payer: Humana Medicare	$466.00
Rate for Payer: Kaiser Permanente Commercial	$838.80
Rate for Payer: Kaiser Permanente Medicaid	$475.32
Rate for Payer: Kaiser Permanente Medicare	$466.00
Rate for Payer: MDX Hawaii PPO	$904.04
Rate for Payer: Ohana Health Plan Medicaid	$466.00
Rate for Payer: Ohana Health Plan Medicare	$466.00
Rate for Payer: UnitedHealthcare Medicaid	$67.92
Rate for Payer: UnitedHealthcare Medicare	$466.00
Rate for Payer: University Health Alliance Commercial	$223.66

US Breast Complete Bilat

Facility

$932.00

Service Code	HCPCS 76641 50
Hospital Charge Code	8111064
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$904.04
Rate for Payer: AlohaCare Medicaid	$466.00
Rate for Payer: AlohaCare Medicare	$466.00
Rate for Payer: Cash Price	$605.80
Rate for Payer: Cash Price	$605.80
Rate for Payer: Devoted Health Medicare	$512.60
Rate for Payer: Hawaii Medical Service Association ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Medicare	$466.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.51
Rate for Payer: Hawaii Western Management Group Commercial	$885.40
Rate for Payer: Health Management Network Commercial	$792.20
Rate for Payer: Humana Medicare	$466.00
Rate for Payer: Kaiser Permanente Commercial	$838.80
Rate for Payer: Kaiser Permanente Medicaid	$475.32
Rate for Payer: Kaiser Permanente Medicare	$466.00
Rate for Payer: MDX Hawaii PPO	$904.04
Rate for Payer: Ohana Health Plan Medicaid	$466.00
Rate for Payer: Ohana Health Plan Medicare	$466.00
Rate for Payer: UnitedHealthcare Medicaid	$67.92
Rate for Payer: UnitedHealthcare Medicare	$466.00
Rate for Payer: University Health Alliance Commercial	$223.66

US Breast Complete Bilat

Facility

$932.00

Service Code	HCPCS 76641 50
Hospital Charge Code	8111061
Hospital Revenue Code	402
Min. Negotiated Rate	$792.20
Max. Negotiated Rate	$904.04
Rate for Payer: Cash Price	$605.80
Rate for Payer: Health Management Network Commercial	$792.20
Rate for Payer: Kaiser Permanente Commercial	$838.80
Rate for Payer: MDX Hawaii PPO	$904.04

US Breast Complete Bilat

Facility

$932.00

Service Code	HCPCS 76641 50
Hospital Charge Code	8111064
Hospital Revenue Code	402
Min. Negotiated Rate	$792.20
Max. Negotiated Rate	$904.04
Rate for Payer: Cash Price	$605.80
Rate for Payer: Health Management Network Commercial	$792.20
Rate for Payer: Kaiser Permanente Commercial	$838.80
Rate for Payer: MDX Hawaii PPO	$904.04

US Breast Complete Bilat - Report

Professional

Both

$145.00

Service Code	HCPCS 76641 26,50
Hospital Charge Code	8111066
Hospital Revenue Code	972
Min. Negotiated Rate	$67.92
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$67.92
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$121.81
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$67.92
Rate for Payer: UnitedHealthcare Medicaid	$67.92

US Breast Complete Bilat - Report

Professional

Both

$145.00

Service Code	HCPCS 76641 26,50
Hospital Charge Code	8111063
Hospital Revenue Code	972
Min. Negotiated Rate	$67.92
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$67.92
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$121.81
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$67.92
Rate for Payer: UnitedHealthcare Medicaid	$67.92

US Breast Complete Left

Facility

$932.00

Service Code	HCPCS 76641 LT
Hospital Charge Code	4645474
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$904.04
Rate for Payer: AlohaCare Medicaid	$466.00
Rate for Payer: AlohaCare Medicare	$466.00
Rate for Payer: Cash Price	$605.80
Rate for Payer: Cash Price	$605.80
Rate for Payer: Devoted Health Medicare	$512.60
Rate for Payer: Hawaii Medical Service Association ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Medicare	$466.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.51
Rate for Payer: Hawaii Western Management Group Commercial	$885.40
Rate for Payer: Health Management Network Commercial	$792.20
Rate for Payer: Humana Medicare	$466.00
Rate for Payer: Kaiser Permanente Commercial	$838.80
Rate for Payer: Kaiser Permanente Medicaid	$475.32
Rate for Payer: Kaiser Permanente Medicare	$466.00
Rate for Payer: MDX Hawaii PPO	$904.04
Rate for Payer: Ohana Health Plan Medicaid	$466.00
Rate for Payer: Ohana Health Plan Medicare	$466.00
Rate for Payer: UnitedHealthcare Medicaid	$67.92
Rate for Payer: UnitedHealthcare Medicare	$466.00
Rate for Payer: University Health Alliance Commercial	$223.66

US Breast Complete Left

Facility

$932.00

Service Code	HCPCS 76641 LT
Hospital Charge Code	4645474
Hospital Revenue Code	402
Min. Negotiated Rate	$792.20
Max. Negotiated Rate	$904.04
Rate for Payer: Cash Price	$605.80
Rate for Payer: Health Management Network Commercial	$792.20
Rate for Payer: Kaiser Permanente Commercial	$838.80
Rate for Payer: MDX Hawaii PPO	$904.04

US Breast Complete Left - Report

Professional

Both

$145.00

Service Code	HCPCS 76641 26,LT
Hospital Charge Code	4645476
Hospital Revenue Code	972
Min. Negotiated Rate	$67.92
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$67.92
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$121.81
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$67.92
Rate for Payer: UnitedHealthcare Medicaid	$67.92

US Breast Complete Right

Facility

$932.00

Service Code	HCPCS 76641 RT
Hospital Charge Code	4645477
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$904.04
Rate for Payer: AlohaCare Medicaid	$466.00
Rate for Payer: AlohaCare Medicare	$466.00
Rate for Payer: Cash Price	$605.80
Rate for Payer: Cash Price	$605.80
Rate for Payer: Devoted Health Medicare	$512.60
Rate for Payer: Hawaii Medical Service Association ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Medicare	$466.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.51
Rate for Payer: Hawaii Western Management Group Commercial	$885.40
Rate for Payer: Health Management Network Commercial	$792.20
Rate for Payer: Humana Medicare	$466.00
Rate for Payer: Kaiser Permanente Commercial	$838.80
Rate for Payer: Kaiser Permanente Medicaid	$475.32
Rate for Payer: Kaiser Permanente Medicare	$466.00
Rate for Payer: MDX Hawaii PPO	$904.04
Rate for Payer: Ohana Health Plan Medicaid	$466.00
Rate for Payer: Ohana Health Plan Medicare	$466.00
Rate for Payer: UnitedHealthcare Medicaid	$67.92
Rate for Payer: UnitedHealthcare Medicare	$466.00
Rate for Payer: University Health Alliance Commercial	$223.66

US Breast Complete Right

Facility

$932.00

Service Code	HCPCS 76641 RT
Hospital Charge Code	4645477
Hospital Revenue Code	402
Min. Negotiated Rate	$792.20
Max. Negotiated Rate	$904.04
Rate for Payer: Cash Price	$605.80
Rate for Payer: Health Management Network Commercial	$792.20
Rate for Payer: Kaiser Permanente Commercial	$838.80
Rate for Payer: MDX Hawaii PPO	$904.04

US Breast Complete Right - Report

Professional

Both

$145.00

Service Code	HCPCS 76641 26,RT
Hospital Charge Code	4645479
Hospital Revenue Code	972
Min. Negotiated Rate	$67.92
Max. Negotiated Rate	$123.25
Rate for Payer: AlohaCare Medicaid	$67.92
Rate for Payer: Cash Price	$94.25
Rate for Payer: Cash Price	$94.25
Rate for Payer: Hawaii Western Management Group Commercial	$121.81
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Ohana Health Plan Medicaid	$67.92
Rate for Payer: UnitedHealthcare Medicaid	$67.92

US Breast Cyst Aspiration Each Addl

Facility

$555.00

Service Code	HCPCS 19001
Hospital Charge Code	9042554
Hospital Revenue Code	402
Min. Negotiated Rate	$471.75
Max. Negotiated Rate	$538.35
Rate for Payer: Cash Price	$360.75
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Kaiser Permanente Commercial	$499.50
Rate for Payer: MDX Hawaii PPO	$538.35

US Breast Cyst Aspiration Each Addl

Facility

$555.00

Service Code	HCPCS 19001
Hospital Charge Code	9042554
Hospital Revenue Code	402
Min. Negotiated Rate	$15.86
Max. Negotiated Rate	$538.35
Rate for Payer: AlohaCare Medicaid	$277.50
Rate for Payer: AlohaCare Medicare	$277.50
Rate for Payer: Cash Price	$360.75
Rate for Payer: Cash Price	$360.75
Rate for Payer: Devoted Health Medicare	$305.25
Rate for Payer: Hawaii Medical Service Association Medicare	$277.50
Rate for Payer: Hawaii Western Management Group Commercial	$527.25
Rate for Payer: Health Management Network Commercial	$471.75
Rate for Payer: Humana Medicare	$277.50
Rate for Payer: Kaiser Permanente Commercial	$499.50
Rate for Payer: Kaiser Permanente Medicaid	$283.05
Rate for Payer: Kaiser Permanente Medicare	$277.50
Rate for Payer: MDX Hawaii PPO	$538.35
Rate for Payer: Ohana Health Plan Medicaid	$277.50
Rate for Payer: Ohana Health Plan Medicare	$277.50
Rate for Payer: UnitedHealthcare Medicaid	$15.86
Rate for Payer: UnitedHealthcare Medicare	$277.50
Rate for Payer: University Health Alliance Commercial	$404.54

US Breast Cyst Aspiration Each Addl - Report

Professional

Both

$42.00

Service Code	HCPCS 19001
Hospital Charge Code	9042556
Hospital Revenue Code	972
Min. Negotiated Rate	$17.70
Max. Negotiated Rate	$35.70
Rate for Payer: AlohaCare Medicaid	$20.65
Rate for Payer: AlohaCare Medicare	$17.70
Rate for Payer: Cash Price	$27.30
Rate for Payer: Cash Price	$27.30
Rate for Payer: Devoted Health Medicare	$19.47
Rate for Payer: Hawaii Medical Service Association ABD	$20.65
Rate for Payer: Hawaii Medical Service Association Commercial	$35.12
Rate for Payer: Hawaii Medical Service Association Medicare	$17.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.65
Rate for Payer: Hawaii Western Management Group Commercial	$23.92
Rate for Payer: Health Management Network Commercial	$35.70
Rate for Payer: Kaiser Permanente Commercial	$19.47
Rate for Payer: Kaiser Permanente Medicaid	$19.47
Rate for Payer: Kaiser Permanente Medicare	$19.47
Rate for Payer: Ohana Health Plan Medicaid	$20.65
Rate for Payer: Ohana Health Plan Medicare	$17.70
Rate for Payer: UnitedHealthcare Medicaid	$20.65
Rate for Payer: UnitedHealthcare Medicare	$17.70
Rate for Payer: University Health Alliance Commercial	$24.18

US Breast Cyst Aspiration Left

Facility

$1,643.00

Service Code	HCPCS 19000
Hospital Charge Code	2425311
Hospital Revenue Code	361
Min. Negotiated Rate	$1,396.55
Max. Negotiated Rate	$1,593.71
Rate for Payer: Cash Price	$1,067.95
Rate for Payer: Health Management Network Commercial	$1,396.55
Rate for Payer: Kaiser Permanente Commercial	$1,478.70
Rate for Payer: MDX Hawaii PPO	$1,593.71

US Breast Cyst Aspiration Left

Facility

$1,643.00

Service Code	HCPCS 19000
Hospital Charge Code	2425311
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$821.50
Rate for Payer: AlohaCare Medicare	$821.50
Rate for Payer: Cash Price	$1,067.95
Rate for Payer: Cash Price	$1,067.95
Rate for Payer: Cash Price	$1,067.95
Rate for Payer: Devoted Health Medicare	$903.65
Rate for Payer: Hawaii Medical Service Association Commercial	$904.34
Rate for Payer: Hawaii Medical Service Association Medicare	$821.50
Rate for Payer: Health Management Network Commercial	$1,396.55
Rate for Payer: Humana Medicare	$821.50
Rate for Payer: Kaiser Permanente Commercial	$1,478.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$821.50
Rate for Payer: MDX Hawaii PPO	$1,593.71
Rate for Payer: Ohana Health Plan Medicaid	$821.50
Rate for Payer: Ohana Health Plan Medicare	$821.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$821.50
Rate for Payer: University Health Alliance Commercial	$1,197.58

US Breast Cyst Aspiration Left - Report

Professional

Both

$986.00

Service Code	HCPCS 19000
Hospital Charge Code	2425313
Hospital Revenue Code	972
Min. Negotiated Rate	$35.59
Max. Negotiated Rate	$838.10
Rate for Payer: AlohaCare Medicaid	$41.49
Rate for Payer: AlohaCare Medicare	$35.59
Rate for Payer: Cash Price	$640.90
Rate for Payer: Cash Price	$640.90
Rate for Payer: Devoted Health Medicare	$39.15
Rate for Payer: Hawaii Medical Service Association ABD	$41.49
Rate for Payer: Hawaii Medical Service Association Commercial	$70.89
Rate for Payer: Hawaii Medical Service Association Medicare	$35.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$41.49
Rate for Payer: Hawaii Western Management Group Commercial	$47.58
Rate for Payer: Health Management Network Commercial	$838.10
Rate for Payer: Kaiser Permanente Commercial	$39.15
Rate for Payer: Kaiser Permanente Medicaid	$39.15
Rate for Payer: Kaiser Permanente Medicare	$39.15
Rate for Payer: Ohana Health Plan Medicaid	$41.49
Rate for Payer: Ohana Health Plan Medicare	$35.59
Rate for Payer: UnitedHealthcare Medicaid	$41.49
Rate for Payer: UnitedHealthcare Medicare	$35.59
Rate for Payer: University Health Alliance Commercial	$48.80

US Breast Cyst Aspiration Right

Facility

$1,643.00

Service Code	HCPCS 19000
Hospital Charge Code	2425314
Hospital Revenue Code	361
Min. Negotiated Rate	$1,396.55
Max. Negotiated Rate	$1,593.71
Rate for Payer: Cash Price	$1,067.95
Rate for Payer: Health Management Network Commercial	$1,396.55
Rate for Payer: Kaiser Permanente Commercial	$1,478.70
Rate for Payer: MDX Hawaii PPO	$1,593.71

US Breast Cyst Aspiration Right

Facility

$1,643.00

Service Code	HCPCS 19000
Hospital Charge Code	2425314
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$821.50
Rate for Payer: AlohaCare Medicare	$821.50
Rate for Payer: Cash Price	$1,067.95
Rate for Payer: Cash Price	$1,067.95
Rate for Payer: Cash Price	$1,067.95
Rate for Payer: Devoted Health Medicare	$903.65
Rate for Payer: Hawaii Medical Service Association Commercial	$904.34
Rate for Payer: Hawaii Medical Service Association Medicare	$821.50
Rate for Payer: Health Management Network Commercial	$1,396.55
Rate for Payer: Humana Medicare	$821.50
Rate for Payer: Kaiser Permanente Commercial	$1,478.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$821.50
Rate for Payer: MDX Hawaii PPO	$1,593.71
Rate for Payer: Ohana Health Plan Medicaid	$821.50
Rate for Payer: Ohana Health Plan Medicare	$821.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$821.50
Rate for Payer: University Health Alliance Commercial	$1,197.58

US Breast Cyst Aspiration Right - Report

Professional

Both

$986.00

Service Code	HCPCS 19000
Hospital Charge Code	2425316
Hospital Revenue Code	972
Min. Negotiated Rate	$35.59
Max. Negotiated Rate	$838.10
Rate for Payer: AlohaCare Medicaid	$41.49
Rate for Payer: AlohaCare Medicare	$35.59
Rate for Payer: Cash Price	$640.90
Rate for Payer: Cash Price	$640.90
Rate for Payer: Devoted Health Medicare	$39.15
Rate for Payer: Hawaii Medical Service Association ABD	$41.49
Rate for Payer: Hawaii Medical Service Association Commercial	$70.89
Rate for Payer: Hawaii Medical Service Association Medicare	$35.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$41.49
Rate for Payer: Hawaii Western Management Group Commercial	$47.58
Rate for Payer: Health Management Network Commercial	$838.10
Rate for Payer: Kaiser Permanente Commercial	$39.15
Rate for Payer: Kaiser Permanente Medicaid	$39.15
Rate for Payer: Kaiser Permanente Medicare	$39.15
Rate for Payer: Ohana Health Plan Medicaid	$41.49
Rate for Payer: Ohana Health Plan Medicare	$35.59
Rate for Payer: UnitedHealthcare Medicaid	$41.49
Rate for Payer: UnitedHealthcare Medicare	$35.59
Rate for Payer: University Health Alliance Commercial	$48.80

US Breast Device Plcmnt w/US Guide Left

Facility

$1,377.00

Service Code	HCPCS 19285
Hospital Charge Code	2425317
Hospital Revenue Code	361
Min. Negotiated Rate	$1,170.45
Max. Negotiated Rate	$1,335.69
Rate for Payer: Cash Price	$895.05
Rate for Payer: Health Management Network Commercial	$1,170.45
Rate for Payer: Kaiser Permanente Commercial	$1,239.30
Rate for Payer: MDX Hawaii PPO	$1,335.69

US Breast Device Plcmnt w/US Guide Left

Facility

$1,377.00

Service Code	HCPCS 19285
Hospital Charge Code	2425317
Hospital Revenue Code	361
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$5,655.00
Rate for Payer: AlohaCare Medicaid	$688.50
Rate for Payer: AlohaCare Medicare	$688.50
Rate for Payer: Cash Price	$895.05
Rate for Payer: Cash Price	$895.05
Rate for Payer: Devoted Health Medicare	$757.35
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,655.00
Rate for Payer: Hawaii Medical Service Association Medicare	$688.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Health Management Network Commercial	$1,170.45
Rate for Payer: Humana Medicare	$688.50
Rate for Payer: Kaiser Permanente Commercial	$1,239.30
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$688.50
Rate for Payer: MDX Hawaii PPO	$1,335.69
Rate for Payer: Ohana Health Plan Medicaid	$688.50
Rate for Payer: Ohana Health Plan Medicare	$688.50
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$688.50
Rate for Payer: University Health Alliance Commercial	$1,003.70

US Breast Device Plcmnt w/US Guide Left - Report

Professional

Both

$986.00

Service Code	HCPCS 19285
Hospital Charge Code	2425319
Hospital Revenue Code	972
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$838.10
Rate for Payer: AlohaCare Medicaid	$82.71
Rate for Payer: AlohaCare Medicare	$70.70
Rate for Payer: Cash Price	$640.90
Rate for Payer: Cash Price	$640.90
Rate for Payer: Devoted Health Medicare	$77.77
Rate for Payer: Hawaii Medical Service Association ABD	$82.71
Rate for Payer: Hawaii Medical Service Association Commercial	$141.13
Rate for Payer: Hawaii Medical Service Association Medicare	$70.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$82.71
Rate for Payer: Hawaii Western Management Group Commercial	$534.56
Rate for Payer: Health Management Network Commercial	$838.10
Rate for Payer: Kaiser Permanente Commercial	$77.77
Rate for Payer: Kaiser Permanente Medicaid	$77.77
Rate for Payer: Kaiser Permanente Medicare	$77.77
Rate for Payer: Ohana Health Plan Medicaid	$82.71
Rate for Payer: Ohana Health Plan Medicare	$70.70
Rate for Payer: UnitedHealthcare Medicaid	$82.71
Rate for Payer: UnitedHealthcare Medicare	$70.70
Rate for Payer: University Health Alliance Commercial	$89.84

US Breast Device Plcmnt w/US Guide Right

Facility

$1,577.00

Service Code	HCPCS 19285
Hospital Charge Code	2425320
Hospital Revenue Code	361
Min. Negotiated Rate	$1,340.45
Max. Negotiated Rate	$1,529.69
Rate for Payer: Cash Price	$1,025.05
Rate for Payer: Health Management Network Commercial	$1,340.45
Rate for Payer: Kaiser Permanente Commercial	$1,419.30
Rate for Payer: MDX Hawaii PPO	$1,529.69

Know your out-of-pocket cost for care.

All Charges