Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$12.00

Service Code	HCPCS J1596
Hospital Revenue Code	636
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$11.64
Rate for Payer: AlohaCare Medicaid	$6.00
Rate for Payer: AlohaCare Medicaid	$3.50
Rate for Payer: AlohaCare Medicare	$5.32
Rate for Payer: AlohaCare Medicare	$9.12
Rate for Payer: Cash Price	$4.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Devoted Health Medicare	$5.88
Rate for Payer: Hawaii Medical Service Association ABD	$0.43
Rate for Payer: Hawaii Medical Service Association ABD	$0.43
Rate for Payer: Hawaii Medical Service Association Medicare	$5.32
Rate for Payer: Hawaii Medical Service Association Medicare	$9.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.43
Rate for Payer: Hawaii Western Management Group Commercial	$11.40
Rate for Payer: Hawaii Western Management Group Commercial	$6.65
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Humana Medicare	$9.12
Rate for Payer: Humana Medicare	$5.32
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: Kaiser Permanente Medicaid	$3.57
Rate for Payer: Kaiser Permanente Medicaid	$6.12
Rate for Payer: Kaiser Permanente Medicare	$9.12
Rate for Payer: Kaiser Permanente Medicare	$5.32
Rate for Payer: MDX Hawaii PPO	$11.64
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: Ohana Health Plan Medicaid	$5.32
Rate for Payer: Ohana Health Plan Medicaid	$9.12
Rate for Payer: Ohana Health Plan Medicare	$9.12
Rate for Payer: Ohana Health Plan Medicare	$5.32
Rate for Payer: UnitedHealthcare Medicaid	$4.20
Rate for Payer: UnitedHealthcare Medicaid	$7.20
Rate for Payer: UnitedHealthcare Medicare	$9.12
Rate for Payer: UnitedHealthcare Medicare	$5.32
Rate for Payer: University Health Alliance Commercial	$8.75
Rate for Payer: University Health Alliance Commercial	$5.10

GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [3497]

Facility

$12.00

Service Code	HCPCS J1596
Hospital Revenue Code	250
Min. Negotiated Rate	$10.20
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Management Network Commercial	$10.20
Rate for Payer: Health Management Network Commercial	$5.95
Rate for Payer: Kaiser Permanente Commercial	$10.80
Rate for Payer: Kaiser Permanente Commercial	$6.30
Rate for Payer: MDX Hawaii PPO	$6.79
Rate for Payer: MDX Hawaii PPO	$11.64

GORE DRYSEAL SHEATH 12FRX45CM

Facility

$2,271.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,135.50
Max. Negotiated Rate	$2,202.87
Rate for Payer: AlohaCare Medicaid	$1,135.50
Rate for Payer: AlohaCare Medicare	$1,725.96
Rate for Payer: Cash Price	$1,362.60
Rate for Payer: Devoted Health Medicare	$1,907.64
Rate for Payer: Hawaii Medical Service Association Medicare	$1,725.96
Rate for Payer: Hawaii Western Management Group Commercial	$2,157.45
Rate for Payer: Health Management Network Commercial	$1,930.35
Rate for Payer: Humana Medicare	$1,725.96
Rate for Payer: Kaiser Permanente Commercial	$2,043.90
Rate for Payer: Kaiser Permanente Medicaid	$1,158.21
Rate for Payer: Kaiser Permanente Medicare	$1,725.96
Rate for Payer: MDX Hawaii PPO	$2,202.87
Rate for Payer: Ohana Health Plan Medicaid	$1,725.96
Rate for Payer: Ohana Health Plan Medicare	$1,725.96
Rate for Payer: UnitedHealthcare Medicare	$1,725.96
Rate for Payer: University Health Alliance Commercial	$1,655.33

GORE DRYSEAL SHEATH 12FRX45CM

Facility

$2,271.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,930.35
Max. Negotiated Rate	$2,202.87
Rate for Payer: Cash Price	$1,362.60
Rate for Payer: Health Management Network Commercial	$1,930.35
Rate for Payer: Kaiser Permanente Commercial	$2,043.90
Rate for Payer: MDX Hawaii PPO	$2,202.87

GORE DRYSEAL SHEATH 12FX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$2,080.80
Max. Negotiated Rate	$2,374.56
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: Kaiser Permanente Commercial	$2,203.20
Rate for Payer: MDX Hawaii PPO	$2,374.56

GORE DRYSEAL SHEATH 12FX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,374.56
Rate for Payer: AlohaCare Medicaid	$1,224.00
Rate for Payer: AlohaCare Medicare	$1,860.48
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Devoted Health Medicare	$2,056.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,860.48
Rate for Payer: Hawaii Western Management Group Commercial	$2,325.60
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: Humana Medicare	$1,860.48
Rate for Payer: Kaiser Permanente Commercial	$2,203.20
Rate for Payer: Kaiser Permanente Medicaid	$1,248.48
Rate for Payer: Kaiser Permanente Medicare	$1,860.48
Rate for Payer: MDX Hawaii PPO	$2,374.56
Rate for Payer: Ohana Health Plan Medicaid	$1,860.48
Rate for Payer: Ohana Health Plan Medicare	$1,860.48
Rate for Payer: UnitedHealthcare Medicare	$1,860.48
Rate for Payer: University Health Alliance Commercial	$1,784.35

GORE DRYSEAL SHEATH 14FRX33CM

Facility

$1,548.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,315.80
Max. Negotiated Rate	$1,501.56
Rate for Payer: Cash Price	$928.80
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Commercial	$1,393.20
Rate for Payer: MDX Hawaii PPO	$1,501.56

GORE DRYSEAL SHEATH 14FRX33CM

Facility

$1,548.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$774.00
Max. Negotiated Rate	$1,501.56
Rate for Payer: AlohaCare Medicaid	$774.00
Rate for Payer: AlohaCare Medicare	$1,176.48
Rate for Payer: Cash Price	$928.80
Rate for Payer: Devoted Health Medicare	$1,300.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,176.48
Rate for Payer: Hawaii Western Management Group Commercial	$1,470.60
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: Humana Medicare	$1,176.48
Rate for Payer: Kaiser Permanente Commercial	$1,393.20
Rate for Payer: Kaiser Permanente Medicaid	$789.48
Rate for Payer: Kaiser Permanente Medicare	$1,176.48
Rate for Payer: MDX Hawaii PPO	$1,501.56
Rate for Payer: Ohana Health Plan Medicaid	$1,176.48
Rate for Payer: Ohana Health Plan Medicare	$1,176.48
Rate for Payer: UnitedHealthcare Medicare	$1,176.48
Rate for Payer: University Health Alliance Commercial	$1,128.34

GORE DRYSEAL SHEATH 15FRX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,374.56
Rate for Payer: AlohaCare Medicaid	$1,224.00
Rate for Payer: AlohaCare Medicare	$1,860.48
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Devoted Health Medicare	$2,056.32
Rate for Payer: Hawaii Medical Service Association Medicare	$1,860.48
Rate for Payer: Hawaii Western Management Group Commercial	$2,325.60
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: Humana Medicare	$1,860.48
Rate for Payer: Kaiser Permanente Commercial	$2,203.20
Rate for Payer: Kaiser Permanente Medicaid	$1,248.48
Rate for Payer: Kaiser Permanente Medicare	$1,860.48
Rate for Payer: MDX Hawaii PPO	$2,374.56
Rate for Payer: Ohana Health Plan Medicaid	$1,860.48
Rate for Payer: Ohana Health Plan Medicare	$1,860.48
Rate for Payer: UnitedHealthcare Medicare	$1,860.48
Rate for Payer: University Health Alliance Commercial	$1,784.35

GORE DRYSEAL SHEATH 15FRX33CM

Facility

$2,448.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$2,080.80
Max. Negotiated Rate	$2,374.56
Rate for Payer: Cash Price	$1,468.80
Rate for Payer: Health Management Network Commercial	$2,080.80
Rate for Payer: Kaiser Permanente Commercial	$2,203.20
Rate for Payer: MDX Hawaii PPO	$2,374.56

GORE DRYSEAL SHEATH 16FRX33CM

Facility

$2,400.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: AlohaCare Medicaid	$1,200.00
Rate for Payer: AlohaCare Medicare	$1,824.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Devoted Health Medicare	$2,016.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,824.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,280.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Humana Medicare	$1,824.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: Kaiser Permanente Medicare	$1,824.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: Ohana Health Plan Medicaid	$1,824.00
Rate for Payer: Ohana Health Plan Medicare	$1,824.00
Rate for Payer: UnitedHealthcare Medicare	$1,824.00
Rate for Payer: University Health Alliance Commercial	$1,749.36

GORE DRYSEAL SHEATH 16FRX33CM

Facility

$2,400.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$2,160.00
Rate for Payer: MDX Hawaii PPO	$2,328.00

GORE DRYSEAL SHEATH 18FRX28CM

Facility

$1,155.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$981.75
Max. Negotiated Rate	$1,120.35
Rate for Payer: Cash Price	$693.00
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: MDX Hawaii PPO	$1,120.35

GORE DRYSEAL SHEATH 18FRX28CM

Facility

$1,155.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$577.50
Max. Negotiated Rate	$1,120.35
Rate for Payer: AlohaCare Medicaid	$577.50
Rate for Payer: AlohaCare Medicare	$877.80
Rate for Payer: Cash Price	$693.00
Rate for Payer: Devoted Health Medicare	$970.20
Rate for Payer: Hawaii Medical Service Association Medicare	$877.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,097.25
Rate for Payer: Health Management Network Commercial	$981.75
Rate for Payer: Humana Medicare	$877.80
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$589.05
Rate for Payer: Kaiser Permanente Medicare	$877.80
Rate for Payer: MDX Hawaii PPO	$1,120.35
Rate for Payer: Ohana Health Plan Medicaid	$877.80
Rate for Payer: Ohana Health Plan Medicare	$877.80
Rate for Payer: UnitedHealthcare Medicare	$877.80
Rate for Payer: University Health Alliance Commercial	$841.88

GORE DRYSEAL SHEATH 18FRX33CM

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,870.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: MDX Hawaii PPO	$2,134.00

GORE DRYSEAL SHEATH 18FRX33CM

Facility

$2,200.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$1,100.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: AlohaCare Medicaid	$1,100.00
Rate for Payer: AlohaCare Medicare	$1,672.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Devoted Health Medicare	$1,848.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,672.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,090.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Humana Medicare	$1,672.00
Rate for Payer: Kaiser Permanente Commercial	$1,980.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: Kaiser Permanente Medicare	$1,672.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: Ohana Health Plan Medicaid	$1,672.00
Rate for Payer: Ohana Health Plan Medicare	$1,672.00
Rate for Payer: UnitedHealthcare Medicare	$1,672.00
Rate for Payer: University Health Alliance Commercial	$1,603.58

GORE ERLY CANN GRFT ECH470045A

Facility

$2,960.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,657.60
Max. Negotiated Rate	$2,871.20
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,072.00
Rate for Payer: Health Management Network Commercial	$2,516.00
Rate for Payer: Kaiser Permanente Commercial	$2,664.00
Rate for Payer: MDX Hawaii PPO	$2,871.20
Rate for Payer: University Health Alliance Commercial	$1,657.60

GORE ERLY CANN GRFT ECH470045A

Facility

$2,960.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,480.00
Max. Negotiated Rate	$2,871.20
Rate for Payer: AlohaCare Medicaid	$1,480.00
Rate for Payer: AlohaCare Medicare	$2,249.60
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Devoted Health Medicare	$2,486.40
Rate for Payer: Hawaii Medical Service Association Medicare	$2,249.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,072.00
Rate for Payer: Health Management Network Commercial	$2,516.00
Rate for Payer: Humana Medicare	$2,249.60
Rate for Payer: Kaiser Permanente Commercial	$2,664.00
Rate for Payer: Kaiser Permanente Medicaid	$1,509.60
Rate for Payer: Kaiser Permanente Medicare	$2,249.60
Rate for Payer: MDX Hawaii PPO	$2,871.20
Rate for Payer: Ohana Health Plan Medicaid	$2,249.60
Rate for Payer: Ohana Health Plan Medicare	$2,249.60
Rate for Payer: UnitedHealthcare Medicare	$2,249.60
Rate for Payer: University Health Alliance Commercial	$1,657.60

GORE GRAFT 12X50CM SBT1202D

Facility

$2,892.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,619.52
Max. Negotiated Rate	$2,805.24
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: Kaiser Permanente Commercial	$2,602.80
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: University Health Alliance Commercial	$1,619.52

GORE GRAFT 12X50CM SBT1202D

Facility

$2,892.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,446.00
Max. Negotiated Rate	$2,805.24
Rate for Payer: AlohaCare Medicaid	$1,446.00
Rate for Payer: AlohaCare Medicare	$2,197.92
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Devoted Health Medicare	$2,429.28
Rate for Payer: Hawaii Medical Service Association Medicare	$2,197.92
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: Humana Medicare	$2,197.92
Rate for Payer: Kaiser Permanente Commercial	$2,602.80
Rate for Payer: Kaiser Permanente Medicaid	$1,474.92
Rate for Payer: Kaiser Permanente Medicare	$2,197.92
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: Ohana Health Plan Medicaid	$2,197.92
Rate for Payer: Ohana Health Plan Medicare	$2,197.92
Rate for Payer: UnitedHealthcare Medicare	$2,197.92
Rate for Payer: University Health Alliance Commercial	$1,619.52

GORE INTERING 4-7X45 IRS47045L

Facility

$1,947.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$973.50
Max. Negotiated Rate	$1,888.59
Rate for Payer: AlohaCare Medicaid	$973.50
Rate for Payer: AlohaCare Medicare	$1,479.72
Rate for Payer: Cash Price	$1,168.20
Rate for Payer: Devoted Health Medicare	$1,635.48
Rate for Payer: Hawaii Medical Service Association Medicare	$1,479.72
Rate for Payer: Hawaii Western Management Group Commercial	$1,362.90
Rate for Payer: Health Management Network Commercial	$1,654.95
Rate for Payer: Humana Medicare	$1,479.72
Rate for Payer: Kaiser Permanente Commercial	$1,752.30
Rate for Payer: Kaiser Permanente Medicaid	$992.97
Rate for Payer: Kaiser Permanente Medicare	$1,479.72
Rate for Payer: MDX Hawaii PPO	$1,888.59
Rate for Payer: Ohana Health Plan Medicaid	$1,479.72
Rate for Payer: Ohana Health Plan Medicare	$1,479.72
Rate for Payer: UnitedHealthcare Medicare	$1,479.72
Rate for Payer: University Health Alliance Commercial	$1,090.32

GORE INTERING 4-7X45 IRS47045L

Facility

$1,947.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,090.32
Max. Negotiated Rate	$1,888.59
Rate for Payer: Cash Price	$1,168.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,362.90
Rate for Payer: Health Management Network Commercial	$1,654.95
Rate for Payer: Kaiser Permanente Commercial	$1,752.30
Rate for Payer: MDX Hawaii PPO	$1,888.59
Rate for Payer: University Health Alliance Commercial	$1,090.32

GORE PROPATEN 4-7X45 H470045A

Facility

$2,744.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,372.00
Max. Negotiated Rate	$2,661.68
Rate for Payer: AlohaCare Medicaid	$1,372.00
Rate for Payer: AlohaCare Medicare	$2,085.44
Rate for Payer: Cash Price	$1,646.40
Rate for Payer: Devoted Health Medicare	$2,304.96
Rate for Payer: Hawaii Medical Service Association Medicare	$2,085.44
Rate for Payer: Hawaii Western Management Group Commercial	$1,920.80
Rate for Payer: Health Management Network Commercial	$2,332.40
Rate for Payer: Humana Medicare	$2,085.44
Rate for Payer: Kaiser Permanente Commercial	$2,469.60
Rate for Payer: Kaiser Permanente Medicaid	$1,399.44
Rate for Payer: Kaiser Permanente Medicare	$2,085.44
Rate for Payer: MDX Hawaii PPO	$2,661.68
Rate for Payer: Ohana Health Plan Medicaid	$2,085.44
Rate for Payer: Ohana Health Plan Medicare	$2,085.44
Rate for Payer: UnitedHealthcare Medicare	$2,085.44
Rate for Payer: University Health Alliance Commercial	$1,536.64

GORE PROPATEN 4-7X45 H470045A

Facility

$2,744.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$1,536.64
Max. Negotiated Rate	$2,661.68
Rate for Payer: Cash Price	$1,646.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,920.80
Rate for Payer: Health Management Network Commercial	$2,332.40
Rate for Payer: Kaiser Permanente Commercial	$2,469.60
Rate for Payer: MDX Hawaii PPO	$2,661.68
Rate for Payer: University Health Alliance Commercial	$1,536.64

GORE STRETCH 7X10 S0701

Facility

$668.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$334.00
Max. Negotiated Rate	$647.96
Rate for Payer: AlohaCare Medicaid	$334.00
Rate for Payer: AlohaCare Medicare	$507.68
Rate for Payer: Cash Price	$400.80
Rate for Payer: Devoted Health Medicare	$561.12
Rate for Payer: Hawaii Medical Service Association Medicare	$507.68
Rate for Payer: Hawaii Western Management Group Commercial	$467.60
Rate for Payer: Health Management Network Commercial	$567.80
Rate for Payer: Humana Medicare	$507.68
Rate for Payer: Kaiser Permanente Commercial	$601.20
Rate for Payer: Kaiser Permanente Medicaid	$340.68
Rate for Payer: Kaiser Permanente Medicare	$507.68
Rate for Payer: MDX Hawaii PPO	$647.96
Rate for Payer: Ohana Health Plan Medicaid	$507.68
Rate for Payer: Ohana Health Plan Medicare	$507.68
Rate for Payer: UnitedHealthcare Medicare	$507.68
Rate for Payer: University Health Alliance Commercial	$374.08

Know your out-of-pocket cost for care.

All Charges