Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

PT Wound VAC >50 Units

Facility

$1,541.00

Service Code	HCPCS 97608 RT,52
Hospital Charge Code	10659800
Hospital Revenue Code	420
Min. Negotiated Rate	$1,309.85
Max. Negotiated Rate	$1,494.77
Rate for Payer: Cash Price	$1,001.65
Rate for Payer: Health Management Network Commercial	$1,309.85
Rate for Payer: Kaiser Permanente Commercial	$1,386.90
Rate for Payer: MDX Hawaii PPO	$1,494.77

PULMONARY EDEMA AND RESPIRATORY FAILURE

Facility

$45,602.65

Service Code	MSDRG 189
Min. Negotiated Rate	$45,602.65
Max. Negotiated Rate	$45,602.65
Rate for Payer: Hawaii Medical Service Association Commercial	$45,602.65

PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE

Facility

$30,954.81

Service Code	MSDRG 175
Min. Negotiated Rate	$30,954.81
Max. Negotiated Rate	$30,954.81
Rate for Payer: Hawaii Medical Service Association Commercial	$30,954.81

PULMONARY EMBOLISM WITHOUT MCC

Facility

$30,954.81

Service Code	MSDRG 176
Min. Negotiated Rate	$30,954.81
Max. Negotiated Rate	$30,954.81
Rate for Payer: Hawaii Medical Service Association Commercial	$30,954.81

PULMONARY REHAB WITH EXERCISE CHARGE

Facility

$481.00

Service Code	HCPCS 94625
Hospital Charge Code	8243393
Hospital Revenue Code	420
Min. Negotiated Rate	$408.85
Max. Negotiated Rate	$466.57
Rate for Payer: Cash Price	$312.65
Rate for Payer: Health Management Network Commercial	$408.85
Rate for Payer: Kaiser Permanente Commercial	$432.90
Rate for Payer: MDX Hawaii PPO	$466.57

PULMONARY REHAB WITH EXERCISE CHARGE

Facility

$481.00

Service Code	HCPCS 94625
Hospital Charge Code	8243393
Hospital Revenue Code	420
Min. Negotiated Rate	$18.47
Max. Negotiated Rate	$466.57
Rate for Payer: AlohaCare Medicaid	$240.50
Rate for Payer: AlohaCare Medicare	$240.50
Rate for Payer: Cash Price	$312.65
Rate for Payer: Cash Price	$312.65
Rate for Payer: Devoted Health Medicare	$264.55
Rate for Payer: Hawaii Medical Service Association Commercial	$75.34
Rate for Payer: Hawaii Medical Service Association Medicare	$240.50
Rate for Payer: Hawaii Western Management Group Commercial	$456.95
Rate for Payer: Health Management Network Commercial	$408.85
Rate for Payer: Humana Medicare	$240.50
Rate for Payer: Kaiser Permanente Commercial	$432.90
Rate for Payer: Kaiser Permanente Medicaid	$245.31
Rate for Payer: Kaiser Permanente Medicare	$240.50
Rate for Payer: MDX Hawaii PPO	$466.57
Rate for Payer: Ohana Health Plan Medicaid	$240.50
Rate for Payer: Ohana Health Plan Medicare	$240.50
Rate for Payer: UnitedHealthcare Medicaid	$18.47
Rate for Payer: UnitedHealthcare Medicare	$240.50
Rate for Payer: University Health Alliance Commercial	$269.36

PULMONARY STRESS TEST CHARGE

Facility

$811.00

Service Code	HCPCS 94618
Hospital Charge Code	8243394
Hospital Revenue Code	460
Min. Negotiated Rate	$7.81
Max. Negotiated Rate	$786.67
Rate for Payer: AlohaCare Medicaid	$405.50
Rate for Payer: AlohaCare Medicare	$405.50
Rate for Payer: Cash Price	$527.15
Rate for Payer: Cash Price	$527.15
Rate for Payer: Devoted Health Medicare	$446.05
Rate for Payer: Hawaii Medical Service Association ABD	$7.81
Rate for Payer: Hawaii Medical Service Association Commercial	$169.91
Rate for Payer: Hawaii Medical Service Association Medicare	$405.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$11.23
Rate for Payer: Hawaii Western Management Group Commercial	$770.45
Rate for Payer: Health Management Network Commercial	$689.35
Rate for Payer: Humana Medicare	$405.50
Rate for Payer: Kaiser Permanente Commercial	$729.90
Rate for Payer: Kaiser Permanente Medicaid	$413.61
Rate for Payer: Kaiser Permanente Medicare	$405.50
Rate for Payer: MDX Hawaii PPO	$786.67
Rate for Payer: Ohana Health Plan Medicaid	$405.50
Rate for Payer: Ohana Health Plan Medicare	$405.50
Rate for Payer: UnitedHealthcare Medicaid	$36.04
Rate for Payer: UnitedHealthcare Medicare	$405.50
Rate for Payer: University Health Alliance Commercial	$454.16

PULMONARY STRESS TEST CHARGE

Facility

$811.00

Service Code	HCPCS 94618
Hospital Charge Code	8243394
Hospital Revenue Code	460
Min. Negotiated Rate	$689.35
Max. Negotiated Rate	$786.67
Rate for Payer: Cash Price	$527.15
Rate for Payer: Health Management Network Commercial	$689.35
Rate for Payer: Kaiser Permanente Commercial	$729.90
Rate for Payer: MDX Hawaii PPO	$786.67

PULSE OXIMETRY CONTINUOUS CHARGE

Facility

$600.00

Service Code	HCPCS 94762
Hospital Charge Code	8243405
Hospital Revenue Code	410
Min. Negotiated Rate	$19.84
Max. Negotiated Rate	$582.00
Rate for Payer: AlohaCare Medicaid	$300.00
Rate for Payer: AlohaCare Medicare	$300.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Devoted Health Medicare	$330.00
Rate for Payer: Hawaii Medical Service Association Commercial	$164.32
Rate for Payer: Hawaii Medical Service Association Medicare	$300.00
Rate for Payer: Hawaii Western Management Group Commercial	$570.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Humana Medicare	$300.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: Kaiser Permanente Medicare	$300.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: Ohana Health Plan Medicaid	$300.00
Rate for Payer: Ohana Health Plan Medicare	$300.00
Rate for Payer: UnitedHealthcare Medicaid	$19.84
Rate for Payer: UnitedHealthcare Medicare	$300.00
Rate for Payer: University Health Alliance Commercial	$336.00

PULSE OXIMETRY CONTINUOUS CHARGE

Facility

$600.00

Service Code	HCPCS 94762
Hospital Charge Code	8243405
Hospital Revenue Code	410
Min. Negotiated Rate	$510.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$540.00
Rate for Payer: MDX Hawaii PPO	$582.00

PULSE OXIMETRY MULTIPLE CHARGE

Facility

$158.00

Service Code	HCPCS 94761
Hospital Charge Code	8243404
Hospital Revenue Code	460
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$153.26
Rate for Payer: AlohaCare Medicaid	$79.00
Rate for Payer: AlohaCare Medicare	$79.00
Rate for Payer: Cash Price	$102.70
Rate for Payer: Cash Price	$102.70
Rate for Payer: Devoted Health Medicare	$86.90
Rate for Payer: Hawaii Medical Service Association Medicare	$79.00
Rate for Payer: Hawaii Western Management Group Commercial	$150.10
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Humana Medicare	$79.00
Rate for Payer: Kaiser Permanente Commercial	$142.20
Rate for Payer: Kaiser Permanente Medicaid	$80.58
Rate for Payer: Kaiser Permanente Medicare	$79.00
Rate for Payer: MDX Hawaii PPO	$153.26
Rate for Payer: Ohana Health Plan Medicaid	$79.00
Rate for Payer: Ohana Health Plan Medicare	$79.00
Rate for Payer: UnitedHealthcare Medicaid	$4.77
Rate for Payer: UnitedHealthcare Medicare	$79.00
Rate for Payer: University Health Alliance Commercial	$88.48

PULSE OXIMETRY MULTIPLE CHARGE

Facility

$158.00

Service Code	HCPCS 94761
Hospital Charge Code	8243404
Hospital Revenue Code	460
Min. Negotiated Rate	$134.30
Max. Negotiated Rate	$153.26
Rate for Payer: Cash Price	$102.70
Rate for Payer: Health Management Network Commercial	$134.30
Rate for Payer: Kaiser Permanente Commercial	$142.20
Rate for Payer: MDX Hawaii PPO	$153.26

PULSE OXIMETRY SINGLE CHARGE

Facility

$56.00

Service Code	HCPCS 94760
Hospital Charge Code	8243403
Hospital Revenue Code	460
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$28.00
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.80
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Western Management Group Commercial	$53.20
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$28.00
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$2.29
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$31.36

PULSE OXIMETRY SINGLE CHARGE

Facility

$56.00

Service Code	HCPCS 94760
Hospital Charge Code	8243403
Hospital Revenue Code	460
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32

pyrantel 50 mg/mL (base) susp [HHSC]

Facility

$45.33

Service Code	NDC 23513061801
Hospital Charge Code	2500713
Hospital Revenue Code	250
Min. Negotiated Rate	$38.53
Max. Negotiated Rate	$43.97
Rate for Payer: Cash Price	$29.46
Rate for Payer: Health Management Network Commercial	$38.53
Rate for Payer: Kaiser Permanente Commercial	$40.80
Rate for Payer: MDX Hawaii PPO	$43.97

pyrantel 50 mg/mL (base) susp [HHSC]

Facility

$45.33

Service Code	NDC 10956061801
Hospital Charge Code	2500713
Hospital Revenue Code	250
Min. Negotiated Rate	$22.66
Max. Negotiated Rate	$43.97
Rate for Payer: AlohaCare Medicaid	$22.66
Rate for Payer: AlohaCare Medicare	$22.66
Rate for Payer: Cash Price	$29.46
Rate for Payer: Devoted Health Medicare	$24.93
Rate for Payer: Hawaii Medical Service Association Medicare	$22.66
Rate for Payer: Hawaii Western Management Group Commercial	$43.06
Rate for Payer: Health Management Network Commercial	$38.53
Rate for Payer: Humana Medicare	$22.66
Rate for Payer: Kaiser Permanente Commercial	$40.80
Rate for Payer: Kaiser Permanente Medicaid	$23.12
Rate for Payer: Kaiser Permanente Medicare	$22.66
Rate for Payer: MDX Hawaii PPO	$43.97
Rate for Payer: Ohana Health Plan Medicaid	$22.66
Rate for Payer: Ohana Health Plan Medicare	$22.66
Rate for Payer: UnitedHealthcare Medicaid	$27.20
Rate for Payer: UnitedHealthcare Medicare	$22.66
Rate for Payer: University Health Alliance Commercial	$33.04

pyrantel 50 mg/mL (base) susp [HHSC]

Facility

$45.33

Service Code	NDC 10956061801
Hospital Charge Code	2500713
Hospital Revenue Code	250
Min. Negotiated Rate	$38.53
Max. Negotiated Rate	$43.97
Rate for Payer: Cash Price	$29.46
Rate for Payer: Health Management Network Commercial	$38.53
Rate for Payer: Kaiser Permanente Commercial	$40.80
Rate for Payer: MDX Hawaii PPO	$43.97

pyrantel 50 mg/mL (base) susp [HHSC]

Facility

$45.33

Service Code	NDC 23513061801
Hospital Charge Code	2500713
Hospital Revenue Code	250
Min. Negotiated Rate	$22.66
Max. Negotiated Rate	$43.97
Rate for Payer: AlohaCare Medicaid	$22.66
Rate for Payer: AlohaCare Medicare	$22.66
Rate for Payer: Cash Price	$29.46
Rate for Payer: Devoted Health Medicare	$24.93
Rate for Payer: Hawaii Medical Service Association Medicare	$22.66
Rate for Payer: Hawaii Western Management Group Commercial	$43.06
Rate for Payer: Health Management Network Commercial	$38.53
Rate for Payer: Humana Medicare	$22.66
Rate for Payer: Kaiser Permanente Commercial	$40.80
Rate for Payer: Kaiser Permanente Medicaid	$23.12
Rate for Payer: Kaiser Permanente Medicare	$22.66
Rate for Payer: MDX Hawaii PPO	$43.97
Rate for Payer: Ohana Health Plan Medicaid	$22.66
Rate for Payer: Ohana Health Plan Medicare	$22.66
Rate for Payer: UnitedHealthcare Medicaid	$27.20
Rate for Payer: UnitedHealthcare Medicare	$22.66
Rate for Payer: University Health Alliance Commercial	$33.04

Q0091 Obtaining screen pap smear

Professional

Both

$180.00

Service Code	HCPCS Q0091
Hospital Charge Code	9057787
Hospital Revenue Code	521
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicare	$15.64
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Devoted Health Medicare	$17.20
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$10.00
Rate for Payer: Health Management Network Commercial	$153.00
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$18.77
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Ohana Health Plan Medicare	$15.64
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$339.46
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: University Health Alliance Commercial	$17.91

Q0091 Screening pap smear; obtaining, preparing and conveyance of cervical or vaginal smear to lab

Professional

Both

$194.00

Service Code	HCPCS Q0091
Hospital Charge Code	8040961
Hospital Revenue Code	521
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$434.26
Rate for Payer: AlohaCare Medicare	$15.64
Rate for Payer: Cash Price	$126.10
Rate for Payer: Cash Price	$126.10
Rate for Payer: Cash Price	$126.10
Rate for Payer: Devoted Health Medicare	$17.20
Rate for Payer: Hawaii Medical Service Association ABD	$434.26
Rate for Payer: Hawaii Medical Service Association Medicare	$303.73
Rate for Payer: Hawaii Medical Service Association Medicare	$339.46
Rate for Payer: Hawaii Medical Service Association Medicare	$237.64
Rate for Payer: Hawaii Medical Service Association Medicare	$246.64
Rate for Payer: Hawaii Medical Service Association Medicare	$265.97
Rate for Payer: Hawaii Medical Service Association Medicare	$181.39
Rate for Payer: Hawaii Medical Service Association Medicare	$209.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$434.26
Rate for Payer: Hawaii Western Management Group Commercial	$10.00
Rate for Payer: Health Management Network Commercial	$164.90
Rate for Payer: Kaiser Permanente Commercial	$237.64
Rate for Payer: Kaiser Permanente Commercial	$18.77
Rate for Payer: Kaiser Permanente Commercial	$181.39
Rate for Payer: Kaiser Permanente Commercial	$209.49
Rate for Payer: Kaiser Permanente Commercial	$246.64
Rate for Payer: Kaiser Permanente Commercial	$265.97
Rate for Payer: Kaiser Permanente Commercial	$303.73
Rate for Payer: Kaiser Permanente Commercial	$339.46
Rate for Payer: Kaiser Permanente Medicaid	$434.26
Rate for Payer: Kaiser Permanente Medicare	$339.46
Rate for Payer: Kaiser Permanente Medicare	$265.97
Rate for Payer: Kaiser Permanente Medicare	$303.73
Rate for Payer: Kaiser Permanente Medicare	$181.39
Rate for Payer: Kaiser Permanente Medicare	$209.49
Rate for Payer: Kaiser Permanente Medicare	$237.64
Rate for Payer: Kaiser Permanente Medicare	$246.64
Rate for Payer: Ohana Health Plan Medicare	$15.64
Rate for Payer: UnitedHealthcare Medicaid	$434.26
Rate for Payer: UnitedHealthcare Medicare	$265.97
Rate for Payer: UnitedHealthcare Medicare	$339.46
Rate for Payer: UnitedHealthcare Medicare	$181.39
Rate for Payer: UnitedHealthcare Medicare	$209.49
Rate for Payer: UnitedHealthcare Medicare	$237.64
Rate for Payer: UnitedHealthcare Medicare	$303.73
Rate for Payer: UnitedHealthcare Medicare	$246.64
Rate for Payer: University Health Alliance Commercial	$17.91

Q0162 Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeut

Professional

Both

$91.00

Service Code	HCPCS Q0162
Hospital Charge Code	8100725
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$77.35
Rate for Payer: AlohaCare Medicare	$0.02
Rate for Payer: Cash Price	$59.15
Rate for Payer: Cash Price	$59.15
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$51.15
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: Kaiser Permanente Commercial	$0.02
Rate for Payer: Kaiser Permanente Medicaid	$0.02
Rate for Payer: Kaiser Permanente Medicare	$0.02
Rate for Payer: Ohana Health Plan Medicare	$0.02
Rate for Payer: UnitedHealthcare Medicare	$0.02

Q0222 Bebtelovimab 175 mg

Facility

$0.01

Service Code	HCPCS Q0222
Hospital Charge Code	10529650
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: AlohaCare Medicaid	$0.01
Rate for Payer: AlohaCare Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Hawaii Medical Service Association Medicare	$0.01
Rate for Payer: Hawaii Western Management Group Commercial	$0.01
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Humana Medicare	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.01
Rate for Payer: Kaiser Permanente Medicaid	$0.01
Rate for Payer: Kaiser Permanente Medicare	$0.01
Rate for Payer: MDX Hawaii PPO	$0.01
Rate for Payer: Ohana Health Plan Medicaid	$0.01
Rate for Payer: Ohana Health Plan Medicare	$0.01
Rate for Payer: UnitedHealthcare Medicaid	$0.01
Rate for Payer: UnitedHealthcare Medicare	$0.01
Rate for Payer: University Health Alliance Commercial	$0.01

Q0222 Bebtelovimab 175 mg

Facility

$0.01

Service Code	HCPCS Q0222
Hospital Charge Code	10529650
Hospital Revenue Code	636
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Management Network Commercial	$0.01
Rate for Payer: Kaiser Permanente Commercial	$0.01
Rate for Payer: MDX Hawaii PPO	$0.01

Q2039 Influenza virus vaccine, not otherwise specified

Professional

Both

$50.00

Service Code	HCPCS Q2039
Hospital Charge Code	8127507
Hospital Revenue Code	250
Min. Negotiated Rate	$42.50
Max. Negotiated Rate	$47.57
Rate for Payer: Cash Price	$32.50
Rate for Payer: Cash Price	$32.50
Rate for Payer: Hawaii Western Management Group Commercial	$47.57
Rate for Payer: Health Management Network Commercial	$42.50

QCKFIX SCRW,TI,CANN ST,CANC.,4.0X 50MM

Facility

$346.00

Service Code	HCPCS C1713
Hospital Charge Code	12953319
Hospital Revenue Code	278
Min. Negotiated Rate	$193.76
Max. Negotiated Rate	$335.62
Rate for Payer: Cash Price	$224.90
Rate for Payer: Hawaii Western Management Group Commercial	$242.20
Rate for Payer: Health Management Network Commercial	$294.10
Rate for Payer: Kaiser Permanente Commercial	$311.40
Rate for Payer: MDX Hawaii PPO	$335.62
Rate for Payer: University Health Alliance Commercial	$193.76

Know your out-of-pocket cost for care.

All Charges