Honoka'a Hospital and Skilled Nursing Facility

All Charges

Charge

Type

Setting

Price

BREAST HSC+ 10721-215MP

Facility

$2,850.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,425.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: AlohaCare Medicaid	$1,425.00
Rate for Payer: AlohaCare Medicare	$2,166.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Devoted Health Medicare	$2,394.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Humana Medicare	$2,166.00
Rate for Payer: Kaiser Permanente Commercial	$2,565.00
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: Kaiser Permanente Medicare	$2,166.00
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: Ohana Health Plan Medicaid	$2,166.00
Rate for Payer: Ohana Health Plan Medicare	$2,166.00
Rate for Payer: UnitedHealthcare Medicare	$2,166.00
Rate for Payer: University Health Alliance Commercial	$1,596.00

BREAST IMPLANT SZ10621-305MP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

BREAST IMPLANT SZ10621-305MP

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$169.75
Rate for Payer: AlohaCare Medicaid	$87.50
Rate for Payer: AlohaCare Medicare	$133.00
Rate for Payer: Cash Price	$105.00
Rate for Payer: Devoted Health Medicare	$147.00
Rate for Payer: Hawaii Medical Service Association Medicare	$133.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Humana Medicare	$133.00
Rate for Payer: Kaiser Permanente Commercial	$157.50
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: Kaiser Permanente Medicare	$133.00
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: Ohana Health Plan Medicaid	$133.00
Rate for Payer: Ohana Health Plan Medicare	$133.00
Rate for Payer: UnitedHealthcare Medicare	$133.00
Rate for Payer: University Health Alliance Commercial	$98.00

BREAST SILICONE GS10610-190LP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$422.00
Max. Negotiated Rate	$818.68
Rate for Payer: AlohaCare Medicaid	$422.00
Rate for Payer: AlohaCare Medicare	$641.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Devoted Health Medicare	$708.96
Rate for Payer: Hawaii Medical Service Association Medicare	$641.44
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Humana Medicare	$641.44
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: Kaiser Permanente Medicare	$641.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: Ohana Health Plan Medicaid	$641.44
Rate for Payer: Ohana Health Plan Medicare	$641.44
Rate for Payer: UnitedHealthcare Medicare	$641.44
Rate for Payer: University Health Alliance Commercial	$472.64

BREAST SILICONE GS10610-190LP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$759.60
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

BREAST TISSUE ALLOX2-FH14SE

Facility

$3,750.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$2,100.00
Max. Negotiated Rate	$3,637.50
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: Kaiser Permanente Commercial	$3,375.00
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: University Health Alliance Commercial	$2,100.00

BREAST TISSUE ALLOX2-FH14SE

Facility

$3,750.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$1,875.00
Max. Negotiated Rate	$3,637.50
Rate for Payer: AlohaCare Medicaid	$1,875.00
Rate for Payer: AlohaCare Medicare	$2,850.00
Rate for Payer: Cash Price	$2,250.00
Rate for Payer: Devoted Health Medicare	$3,150.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,850.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.00
Rate for Payer: Health Management Network Commercial	$3,187.50
Rate for Payer: Humana Medicare	$2,850.00
Rate for Payer: Kaiser Permanente Commercial	$3,375.00
Rate for Payer: Kaiser Permanente Medicaid	$1,912.50
Rate for Payer: Kaiser Permanente Medicare	$2,850.00
Rate for Payer: MDX Hawaii PPO	$3,637.50
Rate for Payer: Ohana Health Plan Medicaid	$2,850.00
Rate for Payer: Ohana Health Plan Medicare	$2,850.00
Rate for Payer: UnitedHealthcare Medicare	$2,850.00
Rate for Payer: University Health Alliance Commercial	$2,100.00

BRENTUXIMAB VEDOTIN 50 MG/10ML IV (WET SOLR VIAL) [430111348]

Facility

$15,711.00

Service Code	HCPCS J9042
Hospital Revenue Code	636
Min. Negotiated Rate	$258.52
Max. Negotiated Rate	$15,239.67
Rate for Payer: AlohaCare Medicaid	$7,855.50
Rate for Payer: AlohaCare Medicare	$11,940.36
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Devoted Health Medicare	$13,197.24
Rate for Payer: Hawaii Medical Service Association ABD	$258.52
Rate for Payer: Hawaii Medical Service Association Commercial	$335.91
Rate for Payer: Hawaii Medical Service Association Medicare	$11,940.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$258.52
Rate for Payer: Hawaii Western Management Group Commercial	$14,925.45
Rate for Payer: Health Management Network Commercial	$13,354.35
Rate for Payer: Humana Medicare	$11,940.36
Rate for Payer: Kaiser Permanente Commercial	$14,139.90
Rate for Payer: Kaiser Permanente Medicaid	$8,012.61
Rate for Payer: Kaiser Permanente Medicare	$11,940.36
Rate for Payer: MDX Hawaii PPO	$15,239.67
Rate for Payer: Ohana Health Plan Medicaid	$11,940.36
Rate for Payer: Ohana Health Plan Medicare	$11,940.36
Rate for Payer: UnitedHealthcare Medicaid	$9,426.60
Rate for Payer: UnitedHealthcare Medicare	$11,940.36
Rate for Payer: University Health Alliance Commercial	$11,451.75

BRENTUXIMAB VEDOTIN 50 MG/10ML IV (WET SOLR VIAL) [430111348]

Facility

$15,711.00

Service Code	HCPCS J9042
Hospital Revenue Code	250
Min. Negotiated Rate	$13,354.35
Max. Negotiated Rate	$15,239.67
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Health Management Network Commercial	$13,354.35
Rate for Payer: Kaiser Permanente Commercial	$14,139.90
Rate for Payer: MDX Hawaii PPO	$15,239.67

BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [111348]

Facility

$15,711.00

Service Code	HCPCS J9042
Hospital Revenue Code	250
Min. Negotiated Rate	$13,354.35
Max. Negotiated Rate	$15,239.67
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Cash Price	$9,718.80
Rate for Payer: Health Management Network Commercial	$13,354.35
Rate for Payer: Health Management Network Commercial	$13,768.30
Rate for Payer: Kaiser Permanente Commercial	$14,139.90
Rate for Payer: Kaiser Permanente Commercial	$14,578.20
Rate for Payer: MDX Hawaii PPO	$15,712.06
Rate for Payer: MDX Hawaii PPO	$15,239.67

BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [111348]

Facility

$15,711.00

Service Code	HCPCS J9042
Hospital Revenue Code	636
Min. Negotiated Rate	$258.52
Max. Negotiated Rate	$15,239.67
Rate for Payer: AlohaCare Medicaid	$7,855.50
Rate for Payer: AlohaCare Medicaid	$8,099.00
Rate for Payer: AlohaCare Medicare	$12,310.48
Rate for Payer: AlohaCare Medicare	$11,940.36
Rate for Payer: Cash Price	$9,718.80
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Cash Price	$9,718.80
Rate for Payer: Cash Price	$9,426.60
Rate for Payer: Devoted Health Medicare	$13,197.24
Rate for Payer: Devoted Health Medicare	$13,606.32
Rate for Payer: Hawaii Medical Service Association ABD	$258.52
Rate for Payer: Hawaii Medical Service Association ABD	$258.52
Rate for Payer: Hawaii Medical Service Association Commercial	$335.91
Rate for Payer: Hawaii Medical Service Association Commercial	$335.91
Rate for Payer: Hawaii Medical Service Association Medicare	$12,310.48
Rate for Payer: Hawaii Medical Service Association Medicare	$11,940.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$258.52
Rate for Payer: Hawaii Medical Service Association Non-ABD	$258.52
Rate for Payer: Hawaii Western Management Group Commercial	$14,925.45
Rate for Payer: Hawaii Western Management Group Commercial	$15,388.10
Rate for Payer: Health Management Network Commercial	$13,768.30
Rate for Payer: Health Management Network Commercial	$13,354.35
Rate for Payer: Humana Medicare	$11,940.36
Rate for Payer: Humana Medicare	$12,310.48
Rate for Payer: Kaiser Permanente Commercial	$14,139.90
Rate for Payer: Kaiser Permanente Commercial	$14,578.20
Rate for Payer: Kaiser Permanente Medicaid	$8,260.98
Rate for Payer: Kaiser Permanente Medicaid	$8,012.61
Rate for Payer: Kaiser Permanente Medicare	$11,940.36
Rate for Payer: Kaiser Permanente Medicare	$12,310.48
Rate for Payer: MDX Hawaii PPO	$15,239.67
Rate for Payer: MDX Hawaii PPO	$15,712.06
Rate for Payer: Ohana Health Plan Medicaid	$12,310.48
Rate for Payer: Ohana Health Plan Medicaid	$11,940.36
Rate for Payer: Ohana Health Plan Medicare	$11,940.36
Rate for Payer: Ohana Health Plan Medicare	$12,310.48
Rate for Payer: UnitedHealthcare Medicaid	$9,718.80
Rate for Payer: UnitedHealthcare Medicaid	$9,426.60
Rate for Payer: UnitedHealthcare Medicare	$11,940.36
Rate for Payer: UnitedHealthcare Medicare	$12,310.48
Rate for Payer: University Health Alliance Commercial	$11,451.75
Rate for Payer: University Health Alliance Commercial	$11,806.72

BRIDGE PLATE BRGP

Facility

$3,720.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,083.20
Max. Negotiated Rate	$3,608.40
Rate for Payer: Cash Price	$2,232.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,604.00
Rate for Payer: Health Management Network Commercial	$3,162.00
Rate for Payer: Kaiser Permanente Commercial	$3,348.00
Rate for Payer: MDX Hawaii PPO	$3,608.40
Rate for Payer: University Health Alliance Commercial	$2,083.20

BRIDGE PLATE BRGP

Facility

$3,720.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,860.00
Max. Negotiated Rate	$3,608.40
Rate for Payer: AlohaCare Medicaid	$1,860.00
Rate for Payer: AlohaCare Medicare	$2,827.20
Rate for Payer: Cash Price	$2,232.00
Rate for Payer: Devoted Health Medicare	$3,124.80
Rate for Payer: Hawaii Medical Service Association Medicare	$2,827.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,604.00
Rate for Payer: Health Management Network Commercial	$3,162.00
Rate for Payer: Humana Medicare	$2,827.20
Rate for Payer: Kaiser Permanente Commercial	$3,348.00
Rate for Payer: Kaiser Permanente Medicaid	$1,897.20
Rate for Payer: Kaiser Permanente Medicare	$2,827.20
Rate for Payer: MDX Hawaii PPO	$3,608.40
Rate for Payer: Ohana Health Plan Medicaid	$2,827.20
Rate for Payer: Ohana Health Plan Medicare	$2,827.20
Rate for Payer: UnitedHealthcare Medicare	$2,827.20
Rate for Payer: University Health Alliance Commercial	$2,083.20

BRITE TIP INTRODUCER 10X11

Facility

$540.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$459.00
Max. Negotiated Rate	$523.80
Rate for Payer: Cash Price	$324.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Kaiser Permanente Commercial	$486.00
Rate for Payer: MDX Hawaii PPO	$523.80

BRITE TIP INTRODUCER 10X11

Facility

$540.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$270.00
Max. Negotiated Rate	$523.80
Rate for Payer: AlohaCare Medicaid	$270.00
Rate for Payer: AlohaCare Medicare	$410.40
Rate for Payer: Cash Price	$324.00
Rate for Payer: Devoted Health Medicare	$453.60
Rate for Payer: Hawaii Medical Service Association Medicare	$410.40
Rate for Payer: Hawaii Western Management Group Commercial	$513.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: Humana Medicare	$410.40
Rate for Payer: Kaiser Permanente Commercial	$486.00
Rate for Payer: Kaiser Permanente Medicaid	$275.40
Rate for Payer: Kaiser Permanente Medicare	$410.40
Rate for Payer: MDX Hawaii PPO	$523.80
Rate for Payer: Ohana Health Plan Medicaid	$410.40
Rate for Payer: Ohana Health Plan Medicare	$410.40
Rate for Payer: UnitedHealthcare Medicare	$410.40
Rate for Payer: University Health Alliance Commercial	$393.61

BRITE TIP INTRODUCER 10X23

Facility

$604.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$513.40
Max. Negotiated Rate	$585.88
Rate for Payer: Cash Price	$362.40
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: MDX Hawaii PPO	$585.88

BRITE TIP INTRODUCER 10X23

Facility

$604.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$302.00
Max. Negotiated Rate	$585.88
Rate for Payer: AlohaCare Medicaid	$302.00
Rate for Payer: AlohaCare Medicare	$459.04
Rate for Payer: Cash Price	$362.40
Rate for Payer: Devoted Health Medicare	$507.36
Rate for Payer: Hawaii Medical Service Association Medicare	$459.04
Rate for Payer: Hawaii Western Management Group Commercial	$573.80
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Humana Medicare	$459.04
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: Kaiser Permanente Medicaid	$308.04
Rate for Payer: Kaiser Permanente Medicare	$459.04
Rate for Payer: MDX Hawaii PPO	$585.88
Rate for Payer: Ohana Health Plan Medicaid	$459.04
Rate for Payer: Ohana Health Plan Medicare	$459.04
Rate for Payer: UnitedHealthcare Medicare	$459.04
Rate for Payer: University Health Alliance Commercial	$440.26

BRITE TIP INTRODUCER 4X23

Facility

$604.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$513.40
Max. Negotiated Rate	$585.88
Rate for Payer: Cash Price	$362.40
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: MDX Hawaii PPO	$585.88

BRITE TIP INTRODUCER 4X23

Facility

$604.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$302.00
Max. Negotiated Rate	$585.88
Rate for Payer: AlohaCare Medicaid	$302.00
Rate for Payer: AlohaCare Medicare	$459.04
Rate for Payer: Cash Price	$362.40
Rate for Payer: Devoted Health Medicare	$507.36
Rate for Payer: Hawaii Medical Service Association Medicare	$459.04
Rate for Payer: Hawaii Western Management Group Commercial	$573.80
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Humana Medicare	$459.04
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: Kaiser Permanente Medicaid	$308.04
Rate for Payer: Kaiser Permanente Medicare	$459.04
Rate for Payer: MDX Hawaii PPO	$585.88
Rate for Payer: Ohana Health Plan Medicaid	$459.04
Rate for Payer: Ohana Health Plan Medicare	$459.04
Rate for Payer: UnitedHealthcare Medicare	$459.04
Rate for Payer: University Health Alliance Commercial	$440.26

BRITE TIP INTRODUCER 5X11

Facility

$140.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: MDX Hawaii PPO	$135.80

BRITE TIP INTRODUCER 5X11

Facility

$140.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$135.80
Rate for Payer: AlohaCare Medicaid	$70.00
Rate for Payer: AlohaCare Medicare	$106.40
Rate for Payer: Cash Price	$84.00
Rate for Payer: Devoted Health Medicare	$117.60
Rate for Payer: Hawaii Medical Service Association Medicare	$106.40
Rate for Payer: Hawaii Western Management Group Commercial	$133.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Humana Medicare	$106.40
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: Kaiser Permanente Medicare	$106.40
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: Ohana Health Plan Medicaid	$106.40
Rate for Payer: Ohana Health Plan Medicare	$106.40
Rate for Payer: UnitedHealthcare Medicare	$106.40
Rate for Payer: University Health Alliance Commercial	$102.05

BRITE TIP INTRODUCER 5X23

Facility

$604.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$302.00
Max. Negotiated Rate	$585.88
Rate for Payer: AlohaCare Medicaid	$302.00
Rate for Payer: AlohaCare Medicare	$459.04
Rate for Payer: Cash Price	$362.40
Rate for Payer: Devoted Health Medicare	$507.36
Rate for Payer: Hawaii Medical Service Association Medicare	$459.04
Rate for Payer: Hawaii Western Management Group Commercial	$573.80
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Humana Medicare	$459.04
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: Kaiser Permanente Medicaid	$308.04
Rate for Payer: Kaiser Permanente Medicare	$459.04
Rate for Payer: MDX Hawaii PPO	$585.88
Rate for Payer: Ohana Health Plan Medicaid	$459.04
Rate for Payer: Ohana Health Plan Medicare	$459.04
Rate for Payer: UnitedHealthcare Medicare	$459.04
Rate for Payer: University Health Alliance Commercial	$440.26

BRITE TIP INTRODUCER 5X23

Facility

$604.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$513.40
Max. Negotiated Rate	$585.88
Rate for Payer: Cash Price	$362.40
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: MDX Hawaii PPO	$585.88

BRITE TIP INTRODUCER 6X11

Facility

$604.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$513.40
Max. Negotiated Rate	$585.88
Rate for Payer: Cash Price	$362.40
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: MDX Hawaii PPO	$585.88

BRITE TIP INTRODUCER 6X11

Facility

$604.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$302.00
Max. Negotiated Rate	$585.88
Rate for Payer: AlohaCare Medicaid	$302.00
Rate for Payer: AlohaCare Medicare	$459.04
Rate for Payer: Cash Price	$362.40
Rate for Payer: Devoted Health Medicare	$507.36
Rate for Payer: Hawaii Medical Service Association Medicare	$459.04
Rate for Payer: Hawaii Western Management Group Commercial	$573.80
Rate for Payer: Health Management Network Commercial	$513.40
Rate for Payer: Humana Medicare	$459.04
Rate for Payer: Kaiser Permanente Commercial	$543.60
Rate for Payer: Kaiser Permanente Medicaid	$308.04
Rate for Payer: Kaiser Permanente Medicare	$459.04
Rate for Payer: MDX Hawaii PPO	$585.88
Rate for Payer: Ohana Health Plan Medicaid	$459.04
Rate for Payer: Ohana Health Plan Medicare	$459.04
Rate for Payer: UnitedHealthcare Medicare	$459.04
Rate for Payer: University Health Alliance Commercial	$440.26

Know your out-of-pocket cost for care.

All Charges