White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Legionella Pneumophila 1, IgM SO

Facility

$169.00

Service Code	HCPCS 86713
Hospital Charge Code	1701218
Hospital Revenue Code	302
Rate for Payer: Cash Price	$114.92

Legionella Pneumophila 1, IgM SO

Facility

$169.00

Service Code	HCPCS 86713
Hospital Charge Code	1701218
Hospital Revenue Code	302
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$121.68
Rate for Payer: Amerigroup CHIP/Medicaid	$5.97
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$15.30
Rate for Payer: Amerigroup Medicare	$15.30
Rate for Payer: BCBS of TX Blue Advantage	$50.70
Rate for Payer: BCBS of TX Blue Essentials	$60.84
Rate for Payer: BCBS of TX Medicare	$15.30
Rate for Payer: BCBS of TX PPO	$67.60
Rate for Payer: Cash Price	$114.92
Rate for Payer: Cash Price	$114.92
Rate for Payer: Cigna Medicaid	$121.68
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Employer Direct Commercial	$15.30
Rate for Payer: Humana Medicare/TRICARE	$15.30
Rate for Payer: Molina CHIP/Medicaid	$121.68
Rate for Payer: Molina Dual Medicare/Medicaid	$15.30
Rate for Payer: Molina Medicare	$15.30
Rate for Payer: Multiplan Auto	$109.85
Rate for Payer: Multiplan Commercial	$109.85
Rate for Payer: Multiplan Workers Comp	$109.85
Rate for Payer: Parkland Medicaid	$121.68
Rate for Payer: Scott and White EPO/PPO	$19.12
Rate for Payer: Scott and White Medicare	$15.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$121.68
Rate for Payer: Superior Health Plan EPO	$15.30
Rate for Payer: Superior Health Plan Medicare	$15.30
Rate for Payer: Universal American Dual Medicare/Medicaid	$15.30
Rate for Payer: Universal American Medicare	$15.30
Rate for Payer: Wellcare Medicare	$15.30
Rate for Payer: Wellmed Medicare	$15.30

LENEVA INJECTABLE ADIPOSE MATRIX 1.5 CC

Facility

$5,339.04

Service Code	HCPCS Q4151
Hospital Charge Code	993870
Hospital Revenue Code	278
Min. Negotiated Rate	$125.01
Max. Negotiated Rate	$3,844.11
Rate for Payer: Amerigroup CHIP/Medicaid	$480.51
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$125.01
Rate for Payer: Amerigroup Medicare	$125.01
Rate for Payer: BCBS of TX Blue Advantage	$1,601.71
Rate for Payer: BCBS of TX Blue Essentials	$1,922.05
Rate for Payer: BCBS of TX Medicare	$125.01
Rate for Payer: BCBS of TX PPO	$2,135.62
Rate for Payer: Cash Price	$3,630.55
Rate for Payer: Cash Price	$3,630.55
Rate for Payer: Cash Price	$3,630.55
Rate for Payer: Cigna Commercial	$264.25
Rate for Payer: Cigna Medicaid	$3,844.11
Rate for Payer: Cigna Medicare	$125.01
Rate for Payer: Employer Direct Commercial	$125.01
Rate for Payer: Humana Medicare/TRICARE	$125.01
Rate for Payer: Molina CHIP/Medicaid	$3,844.11
Rate for Payer: Molina Dual Medicare/Medicaid	$125.01
Rate for Payer: Molina Medicare	$125.01
Rate for Payer: Multiplan Auto	$2,669.52
Rate for Payer: Multiplan Commercial	$2,669.52
Rate for Payer: Multiplan Workers Comp	$2,669.52
Rate for Payer: Parkland Medicaid	$3,844.11
Rate for Payer: Scott and White EPO/PPO	$2,669.52
Rate for Payer: Scott and White Medicare	$125.01
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,844.11
Rate for Payer: Superior Health Plan EPO	$125.01
Rate for Payer: Superior Health Plan Medicare	$125.01
Rate for Payer: Universal American Dual Medicare/Medicaid	$125.01
Rate for Payer: Universal American Medicare	$125.01
Rate for Payer: Wellcare Medicare	$125.01
Rate for Payer: Wellmed Medicare	$125.01

LENEVA INJECTABLE ADIPOSE MATRIX 1.5 CC

Facility

$5,339.04

Service Code	HCPCS Q4151
Hospital Charge Code	993870
Hospital Revenue Code	278
Min. Negotiated Rate	$1,334.76
Max. Negotiated Rate	$2,669.52
Rate for Payer: Cash Price	$3,630.55
Rate for Payer: Cigna Commercial	$1,334.76
Rate for Payer: Multiplan Auto	$2,669.52
Rate for Payer: Multiplan Commercial	$2,669.52
Rate for Payer: Multiplan Workers Comp	$2,669.52
Rate for Payer: Scott and White EPO/PPO	$2,669.52

Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each

Facility

$12,336.12

Service Code	HCPCS 27686
Hospital Charge Code	991327
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cash Price	$8,388.56
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$8,882.01
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$8,882.01
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$8,882.01
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$8,882.01
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each

Facility

$12,336.12

Service Code	HCPCS 27686
Hospital Charge Code	991327
Hospital Revenue Code	360
Rate for Payer: Cash Price	$8,388.56

Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure)

Facility

$7,783.60

Service Code	HCPCS 27685
Hospital Charge Code	9900436
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cash Price	$5,292.85
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicaid	$5,604.19
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina CHIP/Medicaid	$5,604.19
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$5,604.19
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5,604.19
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure)

Facility

$10,000.00

Service Code	CPT 27685
Hospital Charge Code	36027685
Hospital Revenue Code	360
Min. Negotiated Rate	$1,088.27
Max. Negotiated Rate	$10,000.00
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Amerigroup Medicare	$3,286.91
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$3,286.91
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,947.94
Rate for Payer: Cigna Medicare	$3,286.91
Rate for Payer: Employer Direct Commercial	$3,286.91
Rate for Payer: Humana Medicare/TRICARE	$3,286.91
Rate for Payer: Molina Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Molina Medicare	$3,286.91
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Scott and White EPO/PPO	$5,476.44
Rate for Payer: Scott and White Medicare	$3,286.91
Rate for Payer: Superior Health Plan EPO	$3,286.91
Rate for Payer: Superior Health Plan Medicare	$3,286.91
Rate for Payer: Universal American Dual Medicare/Medicaid	$3,286.91
Rate for Payer: Universal American Medicare	$3,286.91
Rate for Payer: Wellcare Medicare	$3,286.91
Rate for Payer: Wellmed Medicare	$3,286.91

Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure)

Facility

$7,783.60

Service Code	HCPCS 27685
Hospital Charge Code	9900436
Hospital Revenue Code	360
Rate for Payer: Cash Price	$5,292.85

LENS MORGAN -- DHF

Facility

$648.34

Service Code	HCPCS A4649
Hospital Charge Code	80326200
Hospital Revenue Code	270
Rate for Payer: Cash Price	$440.87

LENS MORGAN -- DHF

Facility

$648.34

Service Code	HCPCS A4649
Hospital Charge Code	80326200
Hospital Revenue Code	270
Min. Negotiated Rate	$58.35
Max. Negotiated Rate	$466.80
Rate for Payer: Amerigroup CHIP/Medicaid	$58.35
Rate for Payer: BCBS of TX Blue Advantage	$194.50
Rate for Payer: BCBS of TX Blue Essentials	$233.40
Rate for Payer: BCBS of TX PPO	$259.34
Rate for Payer: Cash Price	$440.87
Rate for Payer: Cigna Medicaid	$466.80
Rate for Payer: Molina CHIP/Medicaid	$466.80
Rate for Payer: Multiplan Auto	$421.42
Rate for Payer: Multiplan Commercial	$421.42
Rate for Payer: Multiplan Workers Comp	$421.42
Rate for Payer: Parkland Medicaid	$466.80
Rate for Payer: Scott and White EPO/PPO	$324.17
Rate for Payer: Superior Health Plan CHIP/Medicaid	$466.80
Rate for Payer: Superior Health Plan EPO	$88.17

levalbuterol 1.25 mg/3 mL Inh Soln 3 mL

Facility

$8.00

Service Code	HCPCS J7614
Hospital Charge Code	77658601
Hospital Revenue Code	636
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$1.68
Rate for Payer: BCBS of TX Blue Essentials	$2.02
Rate for Payer: BCBS of TX PPO	$2.24
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

levalbuterol 1.25 mg/3 mL Inh Soln 3 mL

Facility

$8.00

Service Code	HCPCS J7614
Hospital Charge Code	7447369
Hospital Revenue Code	636
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$5.76
Rate for Payer: Amerigroup CHIP/Medicaid	$0.72
Rate for Payer: BCBS of TX Blue Advantage	$1.68
Rate for Payer: BCBS of TX Blue Essentials	$2.02
Rate for Payer: BCBS of TX PPO	$2.24
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Medicaid	$5.76
Rate for Payer: Molina CHIP/Medicaid	$5.76
Rate for Payer: Multiplan Auto	$5.20
Rate for Payer: Multiplan Commercial	$5.20
Rate for Payer: Multiplan Workers Comp	$5.20
Rate for Payer: Parkland Medicaid	$5.76
Rate for Payer: Scott and White EPO/PPO	$4.00
Rate for Payer: Superior Health Plan CHIP/Medicaid	$5.76
Rate for Payer: Superior Health Plan EPO	$1.09

levalbuterol 1.25 mg/3 mL Inh Soln 3 mL

Facility

$8.00

Service Code	HCPCS J7614
Hospital Charge Code	7447369
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

levalbuterol 1.25 mg/3 mL Inh Soln 3 mL

Facility

$8.00

Service Code	HCPCS J7614
Hospital Charge Code	77658601
Hospital Revenue Code	636
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$4.00
Rate for Payer: Cash Price	$5.44
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: Scott and White EPO/PPO	$4.00

levETIRAcetam 100 mg/mL IV Soln 5 mL

Facility

$128.17

Service Code	HCPCS J1953
Hospital Charge Code	77658709
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

levETIRAcetam 100 mg/mL IV Soln 5 mL

Facility

$128.17

Service Code	HCPCS J1953
Hospital Charge Code	77658709
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.16
Rate for Payer: BCBS of TX Blue Essentials	$0.19
Rate for Payer: BCBS of TX PPO	$0.21
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

levETIRAcetam 100 mg/mL Oral Soln 5 mL

Facility

$30.10

Service Code	HCPCS J3490
Hospital Charge Code	77658817
Hospital Revenue Code	250
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$21.67
Rate for Payer: Amerigroup CHIP/Medicaid	$2.71
Rate for Payer: BCBS of TX Blue Advantage	$9.03
Rate for Payer: BCBS of TX Blue Essentials	$10.84
Rate for Payer: BCBS of TX PPO	$12.04
Rate for Payer: Cash Price	$20.47
Rate for Payer: Cigna Medicaid	$21.67
Rate for Payer: Molina CHIP/Medicaid	$21.67
Rate for Payer: Multiplan Auto	$19.57
Rate for Payer: Multiplan Commercial	$19.57
Rate for Payer: Multiplan Workers Comp	$19.57
Rate for Payer: Parkland Medicaid	$21.67
Rate for Payer: Scott and White EPO/PPO	$15.05
Rate for Payer: Superior Health Plan CHIP/Medicaid	$21.67
Rate for Payer: Superior Health Plan EPO	$4.09

levETIRAcetam 100 mg/mL Oral Soln 5 mL

Facility

$30.10

Service Code	HCPCS J3490
Hospital Charge Code	77658817
Hospital Revenue Code	250
Rate for Payer: Cash Price	$20.47

levETIRAcetam 500 mg/NaCl 0.82% 100 mL

Facility

$128.17

Service Code	HCPCS J1953
Hospital Charge Code	77659241
Hospital Revenue Code	636
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$64.08
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Commercial	$32.04
Rate for Payer: Scott and White EPO/PPO	$64.08

levETIRAcetam 500 mg/NaCl 0.82% 100 mL

Facility

$128.17

Service Code	HCPCS J1953
Hospital Charge Code	77659241
Hospital Revenue Code	636
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$92.28
Rate for Payer: Amerigroup CHIP/Medicaid	$11.54
Rate for Payer: BCBS of TX Blue Advantage	$0.16
Rate for Payer: BCBS of TX Blue Essentials	$0.19
Rate for Payer: BCBS of TX PPO	$0.21
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cash Price	$87.16
Rate for Payer: Cigna Medicaid	$92.28
Rate for Payer: Molina CHIP/Medicaid	$92.28
Rate for Payer: Multiplan Auto	$83.31
Rate for Payer: Multiplan Commercial	$83.31
Rate for Payer: Multiplan Workers Comp	$83.31
Rate for Payer: Parkland Medicaid	$92.28
Rate for Payer: Scott and White EPO/PPO	$64.08
Rate for Payer: Superior Health Plan CHIP/Medicaid	$92.28
Rate for Payer: Superior Health Plan EPO	$17.43

levETIRAcetam 500 mg Tab

Facility

$15.30

Service Code	HCPCS J3490
Hospital Charge Code	77659186
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.40

levETIRAcetam 500 mg Tab

Facility

$15.30

Service Code	HCPCS J3490
Hospital Charge Code	77659186
Hospital Revenue Code	250
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$11.02
Rate for Payer: Amerigroup CHIP/Medicaid	$1.38
Rate for Payer: BCBS of TX Blue Advantage	$4.59
Rate for Payer: BCBS of TX Blue Essentials	$5.51
Rate for Payer: BCBS of TX PPO	$6.12
Rate for Payer: Cash Price	$10.40
Rate for Payer: Cigna Medicaid	$11.02
Rate for Payer: Molina CHIP/Medicaid	$11.02
Rate for Payer: Multiplan Auto	$9.95
Rate for Payer: Multiplan Commercial	$9.95
Rate for Payer: Multiplan Workers Comp	$9.95
Rate for Payer: Parkland Medicaid	$11.02
Rate for Payer: Scott and White EPO/PPO	$7.65
Rate for Payer: Superior Health Plan CHIP/Medicaid	$11.02
Rate for Payer: Superior Health Plan EPO	$2.08

Levetiracetam Lvl

Facility

$160.00

Service Code	HCPCS 80177
Hospital Charge Code	9094974
Hospital Revenue Code	301
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$115.20
Rate for Payer: Amerigroup CHIP/Medicaid	$5.17
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$13.25
Rate for Payer: Amerigroup Medicare	$13.25
Rate for Payer: BCBS of TX Blue Advantage	$48.00
Rate for Payer: BCBS of TX Blue Essentials	$57.60
Rate for Payer: BCBS of TX Medicare	$13.25
Rate for Payer: BCBS of TX PPO	$64.00
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cigna Medicaid	$115.20
Rate for Payer: Cigna Medicare	$13.25
Rate for Payer: Employer Direct Commercial	$13.25
Rate for Payer: Humana Medicare/TRICARE	$13.25
Rate for Payer: Molina CHIP/Medicaid	$115.20
Rate for Payer: Molina Dual Medicare/Medicaid	$13.25
Rate for Payer: Molina Medicare	$13.25
Rate for Payer: Multiplan Auto	$104.00
Rate for Payer: Multiplan Commercial	$104.00
Rate for Payer: Multiplan Workers Comp	$104.00
Rate for Payer: Parkland Medicaid	$115.20
Rate for Payer: Scott and White EPO/PPO	$16.56
Rate for Payer: Scott and White Medicare	$13.25
Rate for Payer: Superior Health Plan CHIP/Medicaid	$115.20
Rate for Payer: Superior Health Plan EPO	$13.25
Rate for Payer: Superior Health Plan Medicare	$13.25
Rate for Payer: Universal American Dual Medicare/Medicaid	$13.25
Rate for Payer: Universal American Medicare	$13.25
Rate for Payer: Wellcare Medicare	$13.25
Rate for Payer: Wellmed Medicare	$13.25

Levetiracetam Lvl

Facility

$160.00

Service Code	HCPCS 80177
Hospital Charge Code	9094974
Hospital Revenue Code	301
Rate for Payer: Cash Price	$108.80

Know your out-of-pocket cost for care.

All Charges