Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG TREATMENT DEVICE SIMP

Facility

$910.00

Service Code	HCPCS 77332
Hospital Charge Code	H3330200
Hospital Revenue Code	333
Min. Negotiated Rate	$773.50
Max. Negotiated Rate	$882.70
Rate for Payer: Cash Price	$591.50
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: MDX Hawaii PPO	$882.70

HCHG TREATMENT DEVICE SIMP

Facility

$910.00

Service Code	HCPCS 77332
Hospital Charge Code	H3330200
Hospital Revenue Code	333
Min. Negotiated Rate	$47.35
Max. Negotiated Rate	$882.70
Rate for Payer: AlohaCare Medicaid	$158.78
Rate for Payer: AlohaCare Medicare	$158.78
Rate for Payer: Cash Price	$591.50
Rate for Payer: Cash Price	$591.50
Rate for Payer: Devoted Health Medicare	$174.66
Rate for Payer: Hawaii Medical Service Association ABD	$47.35
Rate for Payer: Hawaii Medical Service Association Commercial	$198.47
Rate for Payer: Hawaii Medical Service Association Medicare	$158.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$49.72
Rate for Payer: Hawaii Western Management Group Commercial	$158.78
Rate for Payer: Health Management Network Commercial	$773.50
Rate for Payer: Humana Medicare	$158.78
Rate for Payer: Kaiser Permanente Commercial	$573.30
Rate for Payer: Kaiser Permanente Medicaid	$464.10
Rate for Payer: Kaiser Permanente Medicare	$158.78
Rate for Payer: MDX Hawaii PPO	$882.70
Rate for Payer: Ohana Health Plan Medicaid	$174.66
Rate for Payer: Ohana Health Plan Medicare	$158.78
Rate for Payer: UnitedHealthcare Medicaid	$47.35
Rate for Payer: UnitedHealthcare Medicare	$158.78
Rate for Payer: University Health Alliance Commercial	$161.54

HCHG TREAT SHOULDER BLADE FX

Facility

$4,705.00

Service Code	HCPCS 23575
Hospital Charge Code	H4500936
Hospital Revenue Code	450
Min. Negotiated Rate	$3,999.25
Max. Negotiated Rate	$4,563.85
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Health Management Network Commercial	$3,999.25
Rate for Payer: MDX Hawaii PPO	$4,563.85

HCHG TREAT SHOULDER BLADE FX

Facility

$4,705.00

Service Code	HCPCS 23575
Hospital Charge Code	H4500936
Hospital Revenue Code	450
Min. Negotiated Rate	$695.00
Max. Negotiated Rate	$6,183.00
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.75
Rate for Payer: Health Management Network Commercial	$3,999.25
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$2,964.15
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$4,563.85
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$3,429.47

HCHG TREAT SHOULDER DISLOCATION

Facility

$4,705.00

Service Code	HCPCS 23655
Hospital Charge Code	H3610847
Hospital Revenue Code	361
Min. Negotiated Rate	$393.00
Max. Negotiated Rate	$4,563.85
Rate for Payer: AlohaCare Medicaid	$1,899.59
Rate for Payer: AlohaCare Medicare	$1,899.59
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Devoted Health Medicare	$2,089.55
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,899.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Health Management Network Commercial	$3,999.25
Rate for Payer: Humana Medicare	$1,899.59
Rate for Payer: Kaiser Permanente Commercial	$2,964.15
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$1,899.59
Rate for Payer: MDX Hawaii PPO	$4,563.85
Rate for Payer: Ohana Health Plan Medicaid	$2,089.55
Rate for Payer: Ohana Health Plan Medicare	$1,899.59
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$1,899.59
Rate for Payer: University Health Alliance Commercial	$4,035.20

HCHG TREAT SHOULDER DISLOCATION

Facility

$4,705.00

Service Code	HCPCS 23655
Hospital Charge Code	H3610847
Hospital Revenue Code	361
Min. Negotiated Rate	$3,999.25
Max. Negotiated Rate	$4,563.85
Rate for Payer: Cash Price	$3,058.25
Rate for Payer: Health Management Network Commercial	$3,999.25
Rate for Payer: MDX Hawaii PPO	$4,563.85

HCHG TREPONEMA PALLIDUM AB CSF

Facility

$172.00

Service Code	HCPCS 86780
Hospital Charge Code	H3020796
Hospital Revenue Code	302
Min. Negotiated Rate	$13.24
Max. Negotiated Rate	$166.84
Rate for Payer: AlohaCare Medicaid	$13.24
Rate for Payer: AlohaCare Medicare	$13.24
Rate for Payer: Cash Price	$111.80
Rate for Payer: Cash Price	$111.80
Rate for Payer: Devoted Health Medicare	$14.56
Rate for Payer: Hawaii Medical Service Association ABD	$18.97
Rate for Payer: Hawaii Medical Service Association Commercial	$16.55
Rate for Payer: Hawaii Medical Service Association Medicare	$13.24
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19.22
Rate for Payer: Hawaii Western Management Group Commercial	$13.24
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: Humana Medicare	$13.24
Rate for Payer: Kaiser Permanente Commercial	$108.36
Rate for Payer: Kaiser Permanente Medicaid	$87.72
Rate for Payer: Kaiser Permanente Medicare	$13.24
Rate for Payer: MDX Hawaii PPO	$166.84
Rate for Payer: Ohana Health Plan Medicaid	$14.56
Rate for Payer: Ohana Health Plan Medicare	$13.24
Rate for Payer: UnitedHealthcare Medicaid	$18.97
Rate for Payer: UnitedHealthcare Medicare	$13.24
Rate for Payer: University Health Alliance Commercial	$35.09

HCHG TREPONEMA PALLIDUM AB CSF

Facility

$172.00

Service Code	HCPCS 86780
Hospital Charge Code	H3020796
Hospital Revenue Code	302
Min. Negotiated Rate	$146.20
Max. Negotiated Rate	$166.84
Rate for Payer: Cash Price	$111.80
Rate for Payer: Health Management Network Commercial	$146.20
Rate for Payer: MDX Hawaii PPO	$166.84

HCHG TRICHOMONAS VAG, AMP PROBE

Facility

$244.00

Service Code	HCPCS 87661
Hospital Charge Code	H3060732
Hospital Revenue Code	306
Min. Negotiated Rate	$28.72
Max. Negotiated Rate	$236.68
Rate for Payer: AlohaCare Medicaid	$35.09
Rate for Payer: AlohaCare Medicare	$35.09
Rate for Payer: Cash Price	$158.60
Rate for Payer: Cash Price	$158.60
Rate for Payer: Devoted Health Medicare	$38.60
Rate for Payer: Hawaii Medical Service Association Commercial	$43.86
Rate for Payer: Hawaii Medical Service Association Medicare	$35.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48.48
Rate for Payer: Hawaii Western Management Group Commercial	$35.09
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: Humana Medicare	$35.09
Rate for Payer: Kaiser Permanente Commercial	$153.72
Rate for Payer: Kaiser Permanente Medicaid	$124.44
Rate for Payer: Kaiser Permanente Medicare	$35.09
Rate for Payer: MDX Hawaii PPO	$236.68
Rate for Payer: Ohana Health Plan Medicaid	$38.60
Rate for Payer: Ohana Health Plan Medicare	$35.09
Rate for Payer: UnitedHealthcare Medicaid	$28.72
Rate for Payer: UnitedHealthcare Medicare	$35.09
Rate for Payer: University Health Alliance Commercial	$88.56

HCHG TRICHOMONAS VAG, AMP PROBE

Facility

$244.00

Service Code	HCPCS 87661
Hospital Charge Code	H3060732
Hospital Revenue Code	306
Min. Negotiated Rate	$207.40
Max. Negotiated Rate	$236.68
Rate for Payer: Cash Price	$158.60
Rate for Payer: Health Management Network Commercial	$207.40
Rate for Payer: MDX Hawaii PPO	$236.68

HCHG TRICHOMONAS VAG, DIRECT PROBE

Facility

$226.00

Service Code	HCPCS 87660
Hospital Charge Code	H3060678
Hospital Revenue Code	306
Min. Negotiated Rate	$192.10
Max. Negotiated Rate	$219.22
Rate for Payer: Cash Price	$146.90
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: MDX Hawaii PPO	$219.22

HCHG TRICHOMONAS VAG, DIRECT PROBE

Facility

$226.00

Service Code	HCPCS 87660
Hospital Charge Code	H3060678
Hospital Revenue Code	306
Min. Negotiated Rate	$20.05
Max. Negotiated Rate	$219.22
Rate for Payer: AlohaCare Medicaid	$20.05
Rate for Payer: AlohaCare Medicare	$20.05
Rate for Payer: Cash Price	$146.90
Rate for Payer: Cash Price	$146.90
Rate for Payer: Devoted Health Medicare	$22.05
Rate for Payer: Hawaii Medical Service Association ABD	$20.17
Rate for Payer: Hawaii Medical Service Association Commercial	$25.06
Rate for Payer: Hawaii Medical Service Association Medicare	$20.05
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27.70
Rate for Payer: Hawaii Western Management Group Commercial	$20.05
Rate for Payer: Health Management Network Commercial	$192.10
Rate for Payer: Humana Medicare	$20.05
Rate for Payer: Kaiser Permanente Commercial	$142.38
Rate for Payer: Kaiser Permanente Medicaid	$115.26
Rate for Payer: Kaiser Permanente Medicare	$20.05
Rate for Payer: MDX Hawaii PPO	$219.22
Rate for Payer: Ohana Health Plan Medicaid	$22.05
Rate for Payer: Ohana Health Plan Medicare	$20.05
Rate for Payer: UnitedHealthcare Medicaid	$20.17
Rate for Payer: UnitedHealthcare Medicare	$20.05
Rate for Payer: University Health Alliance Commercial	$51.84

HCHG TRIGLYCERIDES

Facility

$78.00

Service Code	HCPCS 84478
Hospital Charge Code	H3011242
Hospital Revenue Code	301
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$5.74
Rate for Payer: AlohaCare Medicare	$5.74
Rate for Payer: Cash Price	$50.70
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$6.31
Rate for Payer: Hawaii Medical Service Association ABD	$7.95
Rate for Payer: Hawaii Medical Service Association Commercial	$7.17
Rate for Payer: Hawaii Medical Service Association Medicare	$5.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.35
Rate for Payer: Hawaii Western Management Group Commercial	$5.74
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Humana Medicare	$5.74
Rate for Payer: Kaiser Permanente Commercial	$49.14
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$5.74
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$6.31
Rate for Payer: Ohana Health Plan Medicare	$5.74
Rate for Payer: UnitedHealthcare Medicaid	$7.95
Rate for Payer: UnitedHealthcare Medicare	$5.74
Rate for Payer: University Health Alliance Commercial	$14.87

HCHG TRIGLYCERIDES

Facility

$78.00

Service Code	HCPCS 84478
Hospital Charge Code	H3011242
Hospital Revenue Code	301
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: MDX Hawaii PPO	$75.66

HCHG TRIGLYCERIDES BODY FLUID

Facility

$78.00

Service Code	HCPCS 84478
Hospital Charge Code	H3011246
Hospital Revenue Code	301
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$5.74
Rate for Payer: AlohaCare Medicare	$5.74
Rate for Payer: Cash Price	$50.70
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$6.31
Rate for Payer: Hawaii Medical Service Association ABD	$7.95
Rate for Payer: Hawaii Medical Service Association Commercial	$7.17
Rate for Payer: Hawaii Medical Service Association Medicare	$5.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8.35
Rate for Payer: Hawaii Western Management Group Commercial	$5.74
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Humana Medicare	$5.74
Rate for Payer: Kaiser Permanente Commercial	$49.14
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$5.74
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$6.31
Rate for Payer: Ohana Health Plan Medicare	$5.74
Rate for Payer: UnitedHealthcare Medicaid	$7.95
Rate for Payer: UnitedHealthcare Medicare	$5.74
Rate for Payer: University Health Alliance Commercial	$14.87

HCHG TRIGLYCERIDES BODY FLUID

Facility

$78.00

Service Code	HCPCS 84478
Hospital Charge Code	H3011246
Hospital Revenue Code	301
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: MDX Hawaii PPO	$75.66

HCHG TRIM NONDYSTROPHIC NAILS, ANY #

Facility

$431.00

Service Code	HCPCS 11719
Hospital Charge Code	H4501126
Hospital Revenue Code	450
Min. Negotiated Rate	$366.35
Max. Negotiated Rate	$418.07
Rate for Payer: Cash Price	$280.15
Rate for Payer: Health Management Network Commercial	$366.35
Rate for Payer: MDX Hawaii PPO	$418.07

HCHG TRIM NONDYSTROPHIC NAILS, ANY #

Facility

$431.00

Service Code	HCPCS 11719
Hospital Charge Code	H4501126
Hospital Revenue Code	450
Min. Negotiated Rate	$69.69
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$69.69
Rate for Payer: AlohaCare Medicare	$69.69
Rate for Payer: Cash Price	$280.15
Rate for Payer: Cash Price	$280.15
Rate for Payer: Cash Price	$280.15
Rate for Payer: Cash Price	$280.15
Rate for Payer: Devoted Health Medicare	$76.66
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$69.69
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$409.45
Rate for Payer: Health Management Network Commercial	$366.35
Rate for Payer: Humana Medicare	$69.69
Rate for Payer: Kaiser Permanente Commercial	$271.53
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$69.69
Rate for Payer: MDX Hawaii PPO	$418.07
Rate for Payer: Ohana Health Plan Medicaid	$76.66
Rate for Payer: Ohana Health Plan Medicare	$69.69
Rate for Payer: UnitedHealthcare Medicare	$69.69
Rate for Payer: University Health Alliance Commercial	$314.16

HCHG TROPONIN, I HIGH SENSITIVITY

Facility

$87.00

Service Code	HCPCS 84484
Hospital Charge Code	H3011830
Hospital Revenue Code	301
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$56.55
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: MDX Hawaii PPO	$84.39

HCHG TROPONIN, I HIGH SENSITIVITY

Facility

$87.00

Service Code	HCPCS 84484
Hospital Charge Code	H3011830
Hospital Revenue Code	301
Min. Negotiated Rate	$12.47
Max. Negotiated Rate	$84.39
Rate for Payer: AlohaCare Medicaid	$12.47
Rate for Payer: AlohaCare Medicare	$12.47
Rate for Payer: Cash Price	$56.55
Rate for Payer: Cash Price	$56.55
Rate for Payer: Devoted Health Medicare	$13.72
Rate for Payer: Hawaii Medical Service Association ABD	$13.60
Rate for Payer: Hawaii Medical Service Association Commercial	$15.59
Rate for Payer: Hawaii Medical Service Association Medicare	$12.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.28
Rate for Payer: Hawaii Western Management Group Commercial	$12.47
Rate for Payer: Health Management Network Commercial	$73.95
Rate for Payer: Humana Medicare	$12.47
Rate for Payer: Kaiser Permanente Commercial	$54.81
Rate for Payer: Kaiser Permanente Medicaid	$44.37
Rate for Payer: Kaiser Permanente Medicare	$12.47
Rate for Payer: MDX Hawaii PPO	$84.39
Rate for Payer: Ohana Health Plan Medicaid	$13.72
Rate for Payer: Ohana Health Plan Medicare	$12.47
Rate for Payer: UnitedHealthcare Medicaid	$13.60
Rate for Payer: UnitedHealthcare Medicare	$12.47
Rate for Payer: University Health Alliance Commercial	$25.44

HCHG TROPONIN, I HIGH SENSITIVITY - 90

Facility

$91.00

Service Code	HCPCS 84484
Hospital Charge Code	H3011818
Hospital Revenue Code	301
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$59.15
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: MDX Hawaii PPO	$88.27

HCHG TROPONIN, I HIGH SENSITIVITY - 90

Facility

$91.00

Service Code	HCPCS 84484
Hospital Charge Code	H3011818
Hospital Revenue Code	301
Min. Negotiated Rate	$12.47
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$12.47
Rate for Payer: AlohaCare Medicare	$12.47
Rate for Payer: Cash Price	$59.15
Rate for Payer: Cash Price	$59.15
Rate for Payer: Devoted Health Medicare	$13.72
Rate for Payer: Hawaii Medical Service Association ABD	$13.60
Rate for Payer: Hawaii Medical Service Association Commercial	$15.59
Rate for Payer: Hawaii Medical Service Association Medicare	$12.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.28
Rate for Payer: Hawaii Western Management Group Commercial	$12.47
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$12.47
Rate for Payer: Kaiser Permanente Commercial	$57.33
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$12.47
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$13.72
Rate for Payer: Ohana Health Plan Medicare	$12.47
Rate for Payer: UnitedHealthcare Medicaid	$13.60
Rate for Payer: UnitedHealthcare Medicare	$12.47
Rate for Payer: University Health Alliance Commercial	$25.44

HCHG TROPONIN I POC

Facility

$91.00

Service Code	HCPCS 84484
Hospital Charge Code	H3011349
Hospital Revenue Code	301
Min. Negotiated Rate	$12.47
Max. Negotiated Rate	$88.27
Rate for Payer: AlohaCare Medicaid	$12.47
Rate for Payer: AlohaCare Medicare	$12.47
Rate for Payer: Cash Price	$59.15
Rate for Payer: Cash Price	$59.15
Rate for Payer: Devoted Health Medicare	$13.72
Rate for Payer: Hawaii Medical Service Association ABD	$13.60
Rate for Payer: Hawaii Medical Service Association Commercial	$15.59
Rate for Payer: Hawaii Medical Service Association Medicare	$12.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$14.28
Rate for Payer: Hawaii Western Management Group Commercial	$12.47
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Humana Medicare	$12.47
Rate for Payer: Kaiser Permanente Commercial	$57.33
Rate for Payer: Kaiser Permanente Medicaid	$46.41
Rate for Payer: Kaiser Permanente Medicare	$12.47
Rate for Payer: MDX Hawaii PPO	$88.27
Rate for Payer: Ohana Health Plan Medicaid	$13.72
Rate for Payer: Ohana Health Plan Medicare	$12.47
Rate for Payer: UnitedHealthcare Medicaid	$13.60
Rate for Payer: UnitedHealthcare Medicare	$12.47
Rate for Payer: University Health Alliance Commercial	$25.44

HCHG TROPONIN I POC

Facility

$91.00

Service Code	HCPCS 84484
Hospital Charge Code	H3011349
Hospital Revenue Code	301
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$59.15
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: MDX Hawaii PPO	$88.27

HCHG TROPONIN T

Facility

$134.00

Service Code	HCPCS 84484
Hospital Charge Code	H3011614
Hospital Revenue Code	301
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: MDX Hawaii PPO	$129.98

Know your out-of-pocket cost for care.

All Charges