Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG SACRUM AND COCCYX, MIN 2 VIEWS

Facility

$573.00

Service Code	HCPCS 72220
Hospital Charge Code	H3200286
Hospital Revenue Code	320
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$555.81
Rate for Payer: AlohaCare Medicaid	$102.81
Rate for Payer: AlohaCare Medicare	$102.81
Rate for Payer: Cash Price	$372.45
Rate for Payer: Cash Price	$372.45
Rate for Payer: Devoted Health Medicare	$113.09
Rate for Payer: Hawaii Medical Service Association ABD	$18.84
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$102.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.64
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$487.05
Rate for Payer: Humana Medicare	$102.81
Rate for Payer: Kaiser Permanente Commercial	$360.99
Rate for Payer: Kaiser Permanente Medicaid	$292.23
Rate for Payer: Kaiser Permanente Medicare	$102.81
Rate for Payer: MDX Hawaii PPO	$555.81
Rate for Payer: Ohana Health Plan Medicaid	$113.09
Rate for Payer: Ohana Health Plan Medicare	$102.81
Rate for Payer: UnitedHealthcare Medicaid	$18.84
Rate for Payer: UnitedHealthcare Medicare	$102.81
Rate for Payer: University Health Alliance Commercial	$62.01

HCHG SACRUM AND COCCYX, MIN 2 VIEWS

Facility

$573.00

Service Code	HCPCS 72220
Hospital Charge Code	H3200286
Hospital Revenue Code	320
Min. Negotiated Rate	$487.05
Max. Negotiated Rate	$555.81
Rate for Payer: Cash Price	$372.45
Rate for Payer: Health Management Network Commercial	$487.05
Rate for Payer: MDX Hawaii PPO	$555.81

HCHG SALICYLATES

Facility

$138.00

Service Code	HCPCS 80179
Hospital Charge Code	H3011723
Hospital Revenue Code	301
Min. Negotiated Rate	$11.18
Max. Negotiated Rate	$133.86
Rate for Payer: AlohaCare Medicaid	$18.64
Rate for Payer: AlohaCare Medicare	$18.64
Rate for Payer: Cash Price	$89.70
Rate for Payer: Cash Price	$89.70
Rate for Payer: Devoted Health Medicare	$20.50
Rate for Payer: Hawaii Medical Service Association ABD	$18.92
Rate for Payer: Hawaii Medical Service Association Commercial	$23.30
Rate for Payer: Hawaii Medical Service Association Medicare	$18.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.87
Rate for Payer: Hawaii Western Management Group Commercial	$18.64
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Humana Medicare	$18.64
Rate for Payer: Kaiser Permanente Commercial	$86.94
Rate for Payer: Kaiser Permanente Medicaid	$70.38
Rate for Payer: Kaiser Permanente Medicare	$18.64
Rate for Payer: MDX Hawaii PPO	$133.86
Rate for Payer: Ohana Health Plan Medicaid	$20.50
Rate for Payer: Ohana Health Plan Medicare	$18.64
Rate for Payer: UnitedHealthcare Medicaid	$11.18
Rate for Payer: UnitedHealthcare Medicare	$18.64
Rate for Payer: University Health Alliance Commercial	$100.59

HCHG SALICYLATES

Facility

$138.00

Service Code	HCPCS 80179
Hospital Charge Code	H3011723
Hospital Revenue Code	301
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$89.70
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: MDX Hawaii PPO	$133.86

HCHG SALICYLATES BLOOD

Facility

$238.00

Service Code	HCPCS 80307
Hospital Charge Code	K3010019
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$230.86
Rate for Payer: AlohaCare Medicaid	$62.14
Rate for Payer: AlohaCare Medicare	$62.14
Rate for Payer: Cash Price	$154.70
Rate for Payer: Cash Price	$154.70
Rate for Payer: Devoted Health Medicare	$68.35
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$62.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Humana Medicare	$62.14
Rate for Payer: Kaiser Permanente Commercial	$149.94
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: Kaiser Permanente Medicare	$62.14
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: Ohana Health Plan Medicaid	$68.35
Rate for Payer: Ohana Health Plan Medicare	$62.14
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$62.14
Rate for Payer: University Health Alliance Commercial	$147.65

HCHG SALICYLATES BLOOD

Facility

$238.00

Service Code	HCPCS 80307
Hospital Charge Code	K3010019
Hospital Revenue Code	301
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$154.70
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: MDX Hawaii PPO	$230.86

HCHG SARS ANTIGEN - QW

Facility

$268.00

Service Code	HCPCS 87811
Hospital Charge Code	H3060763
Hospital Revenue Code	306
Min. Negotiated Rate	$227.80
Max. Negotiated Rate	$259.96
Rate for Payer: Cash Price	$174.20
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: MDX Hawaii PPO	$259.96

HCHG SARS ANTIGEN - QW

Facility

$268.00

Service Code	HCPCS 87811
Hospital Charge Code	H3060763
Hospital Revenue Code	306
Min. Negotiated Rate	$41.38
Max. Negotiated Rate	$259.96
Rate for Payer: AlohaCare Medicaid	$41.38
Rate for Payer: AlohaCare Medicare	$41.38
Rate for Payer: Cash Price	$174.20
Rate for Payer: Cash Price	$174.20
Rate for Payer: Devoted Health Medicare	$45.52
Rate for Payer: Hawaii Medical Service Association ABD	$41.38
Rate for Payer: Hawaii Medical Service Association Commercial	$51.73
Rate for Payer: Hawaii Medical Service Association Medicare	$41.38
Rate for Payer: Hawaii Medical Service Association Non-ABD	$41.38
Rate for Payer: Hawaii Western Management Group Commercial	$41.38
Rate for Payer: Health Management Network Commercial	$227.80
Rate for Payer: Humana Medicare	$41.38
Rate for Payer: Kaiser Permanente Commercial	$168.84
Rate for Payer: Kaiser Permanente Medicaid	$136.68
Rate for Payer: Kaiser Permanente Medicare	$41.38
Rate for Payer: MDX Hawaii PPO	$259.96
Rate for Payer: Ohana Health Plan Medicaid	$45.52
Rate for Payer: Ohana Health Plan Medicare	$41.38
Rate for Payer: UnitedHealthcare Medicaid	$41.38
Rate for Payer: UnitedHealthcare Medicare	$41.38
Rate for Payer: University Health Alliance Commercial	$195.35

HCHG SARS-COV-2 AMP PR ABBOTT

Facility

$334.00

Service Code	HCPCS 87635
Hospital Charge Code	K3060038
Hospital Revenue Code	306
Min. Negotiated Rate	$283.90
Max. Negotiated Rate	$323.98
Rate for Payer: Cash Price	$217.10
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: MDX Hawaii PPO	$323.98

HCHG SARS-COV-2 AMP PR ABBOTT

Facility

$334.00

Service Code	HCPCS 87635
Hospital Charge Code	K3060038
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$323.98
Rate for Payer: AlohaCare Medicaid	$51.31
Rate for Payer: AlohaCare Medicare	$51.31
Rate for Payer: Cash Price	$217.10
Rate for Payer: Cash Price	$217.10
Rate for Payer: Devoted Health Medicare	$56.44
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$51.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: Humana Medicare	$51.31
Rate for Payer: Kaiser Permanente Commercial	$210.42
Rate for Payer: Kaiser Permanente Medicaid	$170.34
Rate for Payer: Kaiser Permanente Medicare	$51.31
Rate for Payer: MDX Hawaii PPO	$323.98
Rate for Payer: Ohana Health Plan Medicaid	$56.44
Rate for Payer: Ohana Health Plan Medicare	$51.31
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$51.31
Rate for Payer: University Health Alliance Commercial	$94.96

HCHG SARS-COV-2 AMP PRO ABBOTT NC

Facility

$66.00

Service Code	HCPCS 87635
Hospital Charge Code	K3060039
Hospital Revenue Code	306
Min. Negotiated Rate	$33.66
Max. Negotiated Rate	$94.96
Rate for Payer: AlohaCare Medicaid	$51.31
Rate for Payer: AlohaCare Medicare	$51.31
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$56.44
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$51.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$51.31
Rate for Payer: Kaiser Permanente Commercial	$41.58
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$51.31
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$56.44
Rate for Payer: Ohana Health Plan Medicare	$51.31
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$51.31
Rate for Payer: University Health Alliance Commercial	$94.96

HCHG SARS-COV-2 AMP PRO ABBOTT NC

Facility

$66.00

Service Code	HCPCS 87635
Hospital Charge Code	K3060039
Hospital Revenue Code	306
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$64.02
Rate for Payer: Cash Price	$42.90
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: MDX Hawaii PPO	$64.02

HCHG SARS-COV-2 AMP PRO/CEPHIED

Facility

$334.00

Service Code	HCPCS 87635
Hospital Charge Code	K3060037
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$323.98
Rate for Payer: AlohaCare Medicaid	$51.31
Rate for Payer: AlohaCare Medicare	$51.31
Rate for Payer: Cash Price	$217.10
Rate for Payer: Cash Price	$217.10
Rate for Payer: Devoted Health Medicare	$56.44
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$51.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: Humana Medicare	$51.31
Rate for Payer: Kaiser Permanente Commercial	$210.42
Rate for Payer: Kaiser Permanente Medicaid	$170.34
Rate for Payer: Kaiser Permanente Medicare	$51.31
Rate for Payer: MDX Hawaii PPO	$323.98
Rate for Payer: Ohana Health Plan Medicaid	$56.44
Rate for Payer: Ohana Health Plan Medicare	$51.31
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$51.31
Rate for Payer: University Health Alliance Commercial	$94.96

HCHG SARS-COV-2 AMP PRO/CEPHIED

Facility

$334.00

Service Code	HCPCS 87635
Hospital Charge Code	K3060037
Hospital Revenue Code	306
Min. Negotiated Rate	$283.90
Max. Negotiated Rate	$323.98
Rate for Payer: Cash Price	$217.10
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: MDX Hawaii PPO	$323.98

HCHG SARS-COV-2 (COVID-19) AMPLIFIED PROBE TECHNIQUE

Facility

$334.00

Service Code	HCPCS 87635
Hospital Charge Code	H3060781
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$323.98
Rate for Payer: AlohaCare Medicaid	$51.31
Rate for Payer: AlohaCare Medicare	$51.31
Rate for Payer: Cash Price	$217.10
Rate for Payer: Cash Price	$217.10
Rate for Payer: Devoted Health Medicare	$56.44
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$51.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: Humana Medicare	$51.31
Rate for Payer: Kaiser Permanente Commercial	$210.42
Rate for Payer: Kaiser Permanente Medicaid	$170.34
Rate for Payer: Kaiser Permanente Medicare	$51.31
Rate for Payer: MDX Hawaii PPO	$323.98
Rate for Payer: Ohana Health Plan Medicaid	$56.44
Rate for Payer: Ohana Health Plan Medicare	$51.31
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$51.31
Rate for Payer: University Health Alliance Commercial	$94.96

HCHG SARS-COV-2 (COVID-19) AMPLIFIED PROBE TECHNIQUE

Facility

$334.00

Service Code	HCPCS 87635
Hospital Charge Code	H3060781
Hospital Revenue Code	306
Min. Negotiated Rate	$283.90
Max. Negotiated Rate	$323.98
Rate for Payer: Cash Price	$217.10
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: MDX Hawaii PPO	$323.98

HCHG SARS-COV-2 COVID 19 AMP PRB - HIGH THROUGHPUT TECH - 90

Facility

$334.00

Service Code	HCPCS 87635
Hospital Charge Code	H3060743
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$323.98
Rate for Payer: AlohaCare Medicaid	$51.31
Rate for Payer: AlohaCare Medicare	$51.31
Rate for Payer: Cash Price	$217.10
Rate for Payer: Cash Price	$217.10
Rate for Payer: Devoted Health Medicare	$56.44
Rate for Payer: Hawaii Medical Service Association ABD	$51.31
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$51.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$51.31
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: Humana Medicare	$51.31
Rate for Payer: Kaiser Permanente Commercial	$210.42
Rate for Payer: Kaiser Permanente Medicaid	$170.34
Rate for Payer: Kaiser Permanente Medicare	$51.31
Rate for Payer: MDX Hawaii PPO	$323.98
Rate for Payer: Ohana Health Plan Medicaid	$56.44
Rate for Payer: Ohana Health Plan Medicare	$51.31
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$51.31
Rate for Payer: University Health Alliance Commercial	$94.96

HCHG SARS-COV-2 COVID 19 AMP PRB - HIGH THROUGHPUT TECH - 90

Facility

$334.00

Service Code	HCPCS 87635
Hospital Charge Code	H3060743
Hospital Revenue Code	306
Min. Negotiated Rate	$283.90
Max. Negotiated Rate	$323.98
Rate for Payer: Cash Price	$217.10
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: MDX Hawaii PPO	$323.98

HCHG SARS-COV-2 COVID 19 AMP PRB-NON CDC TESTING KITS

Facility

$334.00

Service Code	HCPCS U0002
Hospital Charge Code	H3060749
Hospital Revenue Code	306
Min. Negotiated Rate	$283.90
Max. Negotiated Rate	$323.98
Rate for Payer: Cash Price	$217.10
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: MDX Hawaii PPO	$323.98

HCHG SARS-COV-2 COVID 19 AMP PRB-NON CDC TESTING KITS

Facility

$334.00

Service Code	HCPCS U0002
Hospital Charge Code	H3060749
Hospital Revenue Code	306
Min. Negotiated Rate	$51.31
Max. Negotiated Rate	$323.98
Rate for Payer: AlohaCare Medicaid	$51.31
Rate for Payer: AlohaCare Medicare	$51.31
Rate for Payer: Cash Price	$217.10
Rate for Payer: Cash Price	$217.10
Rate for Payer: Devoted Health Medicare	$56.44
Rate for Payer: Hawaii Medical Service Association Commercial	$64.14
Rate for Payer: Hawaii Medical Service Association Medicare	$51.31
Rate for Payer: Hawaii Western Management Group Commercial	$317.30
Rate for Payer: Health Management Network Commercial	$283.90
Rate for Payer: Humana Medicare	$51.31
Rate for Payer: Kaiser Permanente Commercial	$210.42
Rate for Payer: Kaiser Permanente Medicaid	$170.34
Rate for Payer: Kaiser Permanente Medicare	$51.31
Rate for Payer: MDX Hawaii PPO	$323.98
Rate for Payer: Ohana Health Plan Medicaid	$56.44
Rate for Payer: Ohana Health Plan Medicare	$51.31
Rate for Payer: UnitedHealthcare Medicaid	$51.31
Rate for Payer: UnitedHealthcare Medicare	$51.31
Rate for Payer: University Health Alliance Commercial	$243.45

HCHG SARS-COV-2 COVID 19 ANTIBODY

Facility

$131.00

Service Code	HCPCS 86769
Hospital Charge Code	H3021029
Hospital Revenue Code	302
Min. Negotiated Rate	$42.13
Max. Negotiated Rate	$127.07
Rate for Payer: AlohaCare Medicaid	$42.13
Rate for Payer: AlohaCare Medicare	$42.13
Rate for Payer: Cash Price	$85.15
Rate for Payer: Cash Price	$85.15
Rate for Payer: Devoted Health Medicare	$46.34
Rate for Payer: Hawaii Medical Service Association ABD	$42.13
Rate for Payer: Hawaii Medical Service Association Commercial	$52.66
Rate for Payer: Hawaii Medical Service Association Medicare	$42.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$42.13
Rate for Payer: Hawaii Western Management Group Commercial	$42.13
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Humana Medicare	$42.13
Rate for Payer: Kaiser Permanente Commercial	$82.53
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: Kaiser Permanente Medicare	$42.13
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: Ohana Health Plan Medicaid	$46.34
Rate for Payer: Ohana Health Plan Medicare	$42.13
Rate for Payer: UnitedHealthcare Medicaid	$42.13
Rate for Payer: UnitedHealthcare Medicare	$42.13
Rate for Payer: University Health Alliance Commercial	$95.49

HCHG SARS-COV-2 COVID 19 ANTIBODY

Facility

$131.00

Service Code	HCPCS 86769
Hospital Charge Code	H3021029
Hospital Revenue Code	302
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$85.15
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: MDX Hawaii PPO	$127.07

HCHG SARSCOV2 & INF A&B AMP PRB

Facility

$781.00

Service Code	HCPCS 87636
Hospital Charge Code	K3060052
Hospital Revenue Code	306
Min. Negotiated Rate	$142.63
Max. Negotiated Rate	$757.57
Rate for Payer: AlohaCare Medicaid	$142.63
Rate for Payer: AlohaCare Medicare	$142.63
Rate for Payer: Cash Price	$507.65
Rate for Payer: Cash Price	$507.65
Rate for Payer: Devoted Health Medicare	$156.89
Rate for Payer: Hawaii Medical Service Association ABD	$142.63
Rate for Payer: Hawaii Medical Service Association Commercial	$178.29
Rate for Payer: Hawaii Medical Service Association Medicare	$142.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$142.63
Rate for Payer: Hawaii Western Management Group Commercial	$142.63
Rate for Payer: Health Management Network Commercial	$663.85
Rate for Payer: Humana Medicare	$142.63
Rate for Payer: Kaiser Permanente Commercial	$492.03
Rate for Payer: Kaiser Permanente Medicaid	$398.31
Rate for Payer: Kaiser Permanente Medicare	$142.63
Rate for Payer: MDX Hawaii PPO	$757.57
Rate for Payer: Ohana Health Plan Medicaid	$156.89
Rate for Payer: Ohana Health Plan Medicare	$142.63
Rate for Payer: UnitedHealthcare Medicaid	$142.63
Rate for Payer: UnitedHealthcare Medicare	$142.63
Rate for Payer: University Health Alliance Commercial	$569.27

HCHG SARSCOV2 & INF A&B AMP PRB

Facility

$781.00

Service Code	HCPCS 87636
Hospital Charge Code	K3060052
Hospital Revenue Code	306
Min. Negotiated Rate	$663.85
Max. Negotiated Rate	$757.57
Rate for Payer: Cash Price	$507.65
Rate for Payer: Health Management Network Commercial	$663.85
Rate for Payer: MDX Hawaii PPO	$757.57

HCHG SARSCOV2&INF A&B&RSV AMP PRB

Facility

$850.00

Service Code	HCPCS 87637
Hospital Charge Code	H3060817
Hospital Revenue Code	306
Min. Negotiated Rate	$722.50
Max. Negotiated Rate	$824.50
Rate for Payer: Cash Price	$552.50
Rate for Payer: Health Management Network Commercial	$722.50
Rate for Payer: MDX Hawaii PPO	$824.50

Know your out-of-pocket cost for care.

All Charges