Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

DULOXETINE 20 MG CAPSULE,DELAYED RELEASE [39275]

Facility

OP

$21.00

Service Code	NDC 27241009706
Hospital Revenue Code	637
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$20.37
Rate for Payer: AlohaCare Medicaid	$10.50
Rate for Payer: AlohaCare Medicare	$15.96
Rate for Payer: Cash Price	$12.60
Rate for Payer: Devoted Health Medicare	$17.64
Rate for Payer: Hawaii Medical Service Association Medicare	$15.96
Rate for Payer: Hawaii Western Management Group Commercial	$19.95
Rate for Payer: Health Management Network Commercial	$17.85
Rate for Payer: Humana Medicare	$15.96
Rate for Payer: Kaiser Permanente Commercial	$18.90
Rate for Payer: Kaiser Permanente Medicaid	$10.71
Rate for Payer: Kaiser Permanente Medicare	$15.96
Rate for Payer: MDX Hawaii PPO	$20.37
Rate for Payer: Ohana Health Plan Medicaid	$15.96
Rate for Payer: Ohana Health Plan Medicare	$15.96
Rate for Payer: UnitedHealthcare Medicare	$15.96
Rate for Payer: University Health Alliance Commercial	$15.31

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

IP

$24.00

Service Code	NDC 68180029506
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

IP

$24.00

Service Code	NDC 60687073401
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

IP

$24.00

Service Code	NDC 60687073411
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

OP

$24.00

Service Code	NDC 60687073401
Hospital Revenue Code	637
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$18.24
Rate for Payer: Cash Price	$14.40
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Hawaii Medical Service Association Medicare	$18.24
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$18.24
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$18.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$18.24
Rate for Payer: Ohana Health Plan Medicare	$18.24
Rate for Payer: UnitedHealthcare Medicare	$18.24
Rate for Payer: University Health Alliance Commercial	$17.49

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

OP

$24.00

Service Code	NDC 60687073411
Hospital Revenue Code	637
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$18.24
Rate for Payer: Cash Price	$14.40
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Hawaii Medical Service Association Medicare	$18.24
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$18.24
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$18.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$18.24
Rate for Payer: Ohana Health Plan Medicare	$18.24
Rate for Payer: UnitedHealthcare Medicare	$18.24
Rate for Payer: University Health Alliance Commercial	$17.49

DULOXETINE 30 MG CAPSULE,DELAYED RELEASE [39276]

Facility

OP

$24.00

Service Code	NDC 68180029506
Hospital Revenue Code	637
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$18.24
Rate for Payer: Cash Price	$14.40
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Hawaii Medical Service Association Medicare	$18.24
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$18.24
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$18.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$18.24
Rate for Payer: Ohana Health Plan Medicare	$18.24
Rate for Payer: UnitedHealthcare Medicare	$18.24
Rate for Payer: University Health Alliance Commercial	$17.49

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

IP

$24.00

Service Code	NDC 60687074511
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

IP

$24.00

Service Code	NDC 60687074501
Hospital Revenue Code	250
Min. Negotiated Rate	$20.40
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$14.40
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

OP

$24.00

Service Code	NDC 60687074511
Hospital Revenue Code	637
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$18.24
Rate for Payer: Cash Price	$14.40
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Hawaii Medical Service Association Medicare	$18.24
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$18.24
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$18.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$18.24
Rate for Payer: Ohana Health Plan Medicare	$18.24
Rate for Payer: UnitedHealthcare Medicare	$18.24
Rate for Payer: University Health Alliance Commercial	$17.49

DULOXETINE 60 MG CAPSULE,DELAYED RELEASE [39277]

Facility

OP

$24.00

Service Code	NDC 60687074501
Hospital Revenue Code	637
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$18.24
Rate for Payer: Cash Price	$14.40
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Hawaii Medical Service Association Medicare	$18.24
Rate for Payer: Hawaii Western Management Group Commercial	$22.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$18.24
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$18.24
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$18.24
Rate for Payer: Ohana Health Plan Medicare	$18.24
Rate for Payer: UnitedHealthcare Medicare	$18.24
Rate for Payer: University Health Alliance Commercial	$17.49

DURASORB 10CM X 25CM PTM1025

Facility

OP

$5,400.00

Hospital Revenue Code	278
Min. Negotiated Rate	$2,700.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: AlohaCare Medicaid	$2,700.00
Rate for Payer: AlohaCare Medicare	$4,104.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Devoted Health Medicare	$4,536.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,104.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Humana Medicare	$4,104.00
Rate for Payer: Kaiser Permanente Commercial	$4,860.00
Rate for Payer: Kaiser Permanente Medicaid	$2,754.00
Rate for Payer: Kaiser Permanente Medicare	$4,104.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: Ohana Health Plan Medicaid	$4,104.00
Rate for Payer: Ohana Health Plan Medicare	$4,104.00
Rate for Payer: UnitedHealthcare Medicare	$4,104.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

DURASORB 10CM X 25CM PTM1025

Facility

IP

$5,400.00

Hospital Revenue Code	278
Min. Negotiated Rate	$3,024.00
Max. Negotiated Rate	$5,238.00
Rate for Payer: Cash Price	$3,240.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,780.00
Rate for Payer: Health Management Network Commercial	$4,590.00
Rate for Payer: Kaiser Permanente Commercial	$4,860.00
Rate for Payer: MDX Hawaii PPO	$5,238.00
Rate for Payer: University Health Alliance Commercial	$3,024.00

DURASORB SIA 20X25 PTM2025

Facility

IP

$12,800.00

Hospital Revenue Code	278
Min. Negotiated Rate	$7,168.00
Max. Negotiated Rate	$12,416.00
Rate for Payer: Cash Price	$7,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,960.00
Rate for Payer: Health Management Network Commercial	$10,880.00
Rate for Payer: Kaiser Permanente Commercial	$11,520.00
Rate for Payer: MDX Hawaii PPO	$12,416.00
Rate for Payer: University Health Alliance Commercial	$7,168.00

DURASORB SIA 20X25 PTM2025

Facility

OP

$12,800.00

Hospital Revenue Code	278
Min. Negotiated Rate	$6,400.00
Max. Negotiated Rate	$12,416.00
Rate for Payer: AlohaCare Medicaid	$6,400.00
Rate for Payer: AlohaCare Medicare	$9,728.00
Rate for Payer: Cash Price	$7,680.00
Rate for Payer: Devoted Health Medicare	$10,752.00
Rate for Payer: Hawaii Medical Service Association Medicare	$9,728.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,960.00
Rate for Payer: Health Management Network Commercial	$10,880.00
Rate for Payer: Humana Medicare	$9,728.00
Rate for Payer: Kaiser Permanente Commercial	$11,520.00
Rate for Payer: Kaiser Permanente Medicaid	$6,528.00
Rate for Payer: Kaiser Permanente Medicare	$9,728.00
Rate for Payer: MDX Hawaii PPO	$12,416.00
Rate for Payer: Ohana Health Plan Medicaid	$9,728.00
Rate for Payer: Ohana Health Plan Medicare	$9,728.00
Rate for Payer: UnitedHealthcare Medicare	$9,728.00
Rate for Payer: University Health Alliance Commercial	$7,168.00

DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [139352]

Facility

IP

$7,731.00

Service Code	HCPCS J9173
Hospital Revenue Code	250
Min. Negotiated Rate	$6,571.35
Max. Negotiated Rate	$7,499.07
Rate for Payer: Cash Price	$4,638.60
Rate for Payer: Cash Price	$1,113.60
Rate for Payer: Health Management Network Commercial	$1,577.60
Rate for Payer: Health Management Network Commercial	$6,571.35
Rate for Payer: Kaiser Permanente Commercial	$1,670.40
Rate for Payer: Kaiser Permanente Commercial	$6,957.90
Rate for Payer: MDX Hawaii PPO	$7,499.07
Rate for Payer: MDX Hawaii PPO	$1,800.32

DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION [139352]

Facility

OP

$7,731.00

Service Code	HCPCS J9173
Hospital Revenue Code	636
Min. Negotiated Rate	$85.25
Max. Negotiated Rate	$7,499.07
Rate for Payer: AlohaCare Medicaid	$3,865.50
Rate for Payer: AlohaCare Medicaid	$928.00
Rate for Payer: AlohaCare Medicare	$1,410.56
Rate for Payer: AlohaCare Medicare	$5,875.56
Rate for Payer: Cash Price	$4,638.60
Rate for Payer: Cash Price	$1,113.60
Rate for Payer: Cash Price	$1,113.60
Rate for Payer: Cash Price	$4,638.60
Rate for Payer: Devoted Health Medicare	$6,494.04
Rate for Payer: Devoted Health Medicare	$1,559.04
Rate for Payer: Hawaii Medical Service Association ABD	$85.25
Rate for Payer: Hawaii Medical Service Association ABD	$85.25
Rate for Payer: Hawaii Medical Service Association Commercial	$107.69
Rate for Payer: Hawaii Medical Service Association Commercial	$107.69
Rate for Payer: Hawaii Medical Service Association Medicare	$1,410.56
Rate for Payer: Hawaii Medical Service Association Medicare	$5,875.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$85.25
Rate for Payer: Hawaii Western Management Group Commercial	$1,763.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,344.45
Rate for Payer: Health Management Network Commercial	$1,577.60
Rate for Payer: Health Management Network Commercial	$6,571.35
Rate for Payer: Humana Medicare	$5,875.56
Rate for Payer: Humana Medicare	$1,410.56
Rate for Payer: Kaiser Permanente Commercial	$1,670.40
Rate for Payer: Kaiser Permanente Commercial	$6,957.90
Rate for Payer: Kaiser Permanente Medicaid	$946.56
Rate for Payer: Kaiser Permanente Medicaid	$3,942.81
Rate for Payer: Kaiser Permanente Medicare	$1,410.56
Rate for Payer: Kaiser Permanente Medicare	$5,875.56
Rate for Payer: MDX Hawaii PPO	$1,800.32
Rate for Payer: MDX Hawaii PPO	$7,499.07
Rate for Payer: Ohana Health Plan Medicaid	$5,875.56
Rate for Payer: Ohana Health Plan Medicaid	$1,410.56
Rate for Payer: Ohana Health Plan Medicare	$1,410.56
Rate for Payer: Ohana Health Plan Medicare	$5,875.56
Rate for Payer: UnitedHealthcare Medicaid	$1,113.60
Rate for Payer: UnitedHealthcare Medicaid	$4,638.60
Rate for Payer: UnitedHealthcare Medicare	$1,410.56
Rate for Payer: UnitedHealthcare Medicare	$5,875.56
Rate for Payer: University Health Alliance Commercial	$5,635.13
Rate for Payer: University Health Alliance Commercial	$1,352.84

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

OP

$19.00

Service Code	NDC 31722013130
Hospital Revenue Code	637
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$14.44
Rate for Payer: Cash Price	$11.40
Rate for Payer: Devoted Health Medicare	$15.96
Rate for Payer: Hawaii Medical Service Association Medicare	$14.44
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$14.44
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$14.44
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$14.44
Rate for Payer: Ohana Health Plan Medicare	$14.44
Rate for Payer: UnitedHealthcare Medicare	$14.44
Rate for Payer: University Health Alliance Commercial	$13.85

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

IP

$19.00

Service Code	NDC 42806054930
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

IP

$19.00

Service Code	NDC 31722013130
Hospital Revenue Code	250
Min. Negotiated Rate	$16.15
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$11.40
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: MDX Hawaii PPO	$18.43

DUTASTERIDE 0.5 MG CAPSULE [34089]

Facility

OP

$19.00

Service Code	NDC 42806054930
Hospital Revenue Code	637
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$18.43
Rate for Payer: AlohaCare Medicaid	$9.50
Rate for Payer: AlohaCare Medicare	$14.44
Rate for Payer: Cash Price	$11.40
Rate for Payer: Devoted Health Medicare	$15.96
Rate for Payer: Hawaii Medical Service Association Medicare	$14.44
Rate for Payer: Hawaii Western Management Group Commercial	$18.05
Rate for Payer: Health Management Network Commercial	$16.15
Rate for Payer: Humana Medicare	$14.44
Rate for Payer: Kaiser Permanente Commercial	$17.10
Rate for Payer: Kaiser Permanente Medicaid	$9.69
Rate for Payer: Kaiser Permanente Medicare	$14.44
Rate for Payer: MDX Hawaii PPO	$18.43
Rate for Payer: Ohana Health Plan Medicaid	$14.44
Rate for Payer: Ohana Health Plan Medicare	$14.44
Rate for Payer: UnitedHealthcare Medicare	$14.44
Rate for Payer: University Health Alliance Commercial	$13.85

DVR LCK MEDIUM L 131822060

Facility

OP

$3,178.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,589.00
Max. Negotiated Rate	$3,082.66
Rate for Payer: AlohaCare Medicaid	$1,589.00
Rate for Payer: AlohaCare Medicare	$2,415.28
Rate for Payer: Cash Price	$1,906.80
Rate for Payer: Devoted Health Medicare	$2,669.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,415.28
Rate for Payer: Hawaii Western Management Group Commercial	$2,224.60
Rate for Payer: Health Management Network Commercial	$2,701.30
Rate for Payer: Humana Medicare	$2,415.28
Rate for Payer: Kaiser Permanente Commercial	$2,860.20
Rate for Payer: Kaiser Permanente Medicaid	$1,620.78
Rate for Payer: Kaiser Permanente Medicare	$2,415.28
Rate for Payer: MDX Hawaii PPO	$3,082.66
Rate for Payer: Ohana Health Plan Medicaid	$2,415.28
Rate for Payer: Ohana Health Plan Medicare	$2,415.28
Rate for Payer: UnitedHealthcare Medicare	$2,415.28
Rate for Payer: University Health Alliance Commercial	$1,779.68

DVR LCK MEDIUM L 131822060

Facility

IP

$3,178.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,779.68
Max. Negotiated Rate	$3,082.66
Rate for Payer: Cash Price	$1,906.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,224.60
Rate for Payer: Health Management Network Commercial	$2,701.30
Rate for Payer: Kaiser Permanente Commercial	$2,860.20
Rate for Payer: MDX Hawaii PPO	$3,082.66
Rate for Payer: University Health Alliance Commercial	$1,779.68

DVR LCK STANDARD L 131822050

Facility

OP

$2,828.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,414.00
Max. Negotiated Rate	$2,743.16
Rate for Payer: AlohaCare Medicaid	$1,414.00
Rate for Payer: AlohaCare Medicare	$2,149.28
Rate for Payer: Cash Price	$1,696.80
Rate for Payer: Devoted Health Medicare	$2,375.52
Rate for Payer: Hawaii Medical Service Association Medicare	$2,149.28
Rate for Payer: Hawaii Western Management Group Commercial	$1,979.60
Rate for Payer: Health Management Network Commercial	$2,403.80
Rate for Payer: Humana Medicare	$2,149.28
Rate for Payer: Kaiser Permanente Commercial	$2,545.20
Rate for Payer: Kaiser Permanente Medicaid	$1,442.28
Rate for Payer: Kaiser Permanente Medicare	$2,149.28
Rate for Payer: MDX Hawaii PPO	$2,743.16
Rate for Payer: Ohana Health Plan Medicaid	$2,149.28
Rate for Payer: Ohana Health Plan Medicare	$2,149.28
Rate for Payer: UnitedHealthcare Medicare	$2,149.28
Rate for Payer: University Health Alliance Commercial	$1,583.68

DVR LCK STANDARD L 131822050

Facility

IP

$2,828.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,583.68
Max. Negotiated Rate	$2,743.16
Rate for Payer: Cash Price	$1,696.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,979.60
Rate for Payer: Health Management Network Commercial	$2,403.80
Rate for Payer: Kaiser Permanente Commercial	$2,545.20
Rate for Payer: MDX Hawaii PPO	$2,743.16
Rate for Payer: University Health Alliance Commercial	$1,583.68

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