Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

US Breast Left Complete

Facility

$322.00

Service Code	HCPCS 76641
Hospital Charge Code	424766410
Hospital Revenue Code	402
Min. Negotiated Rate	$273.70
Max. Negotiated Rate	$312.34
Rate for Payer: Cash Price	$209.30
Rate for Payer: Health Management Network Commercial	$273.70
Rate for Payer: Kaiser Permanente Commercial	$289.80
Rate for Payer: MDX Hawaii PPO	$312.34

US Breast Left Limited

Facility

$246.00

Service Code	HCPCS 76642
Hospital Charge Code	424766420
Hospital Revenue Code	402
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$159.90
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62

US Breast Left Limited

Facility

$246.00

Service Code	HCPCS 76642
Hospital Charge Code	424766420
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$238.62
Rate for Payer: AlohaCare Medicaid	$123.00
Rate for Payer: AlohaCare Medicare	$103.32
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$226.32
Rate for Payer: Devoted Health Medicare	$103.32
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$103.32
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Humana Medicare	$103.32
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: Kaiser Permanente Medicaid	$125.46
Rate for Payer: Kaiser Permanente Medicare	$103.32
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: Ohana Health Plan Medicaid	$103.32
Rate for Payer: Ohana Health Plan Medicare	$103.32
Rate for Payer: UnitedHealthcare Medicaid	$55.91
Rate for Payer: UnitedHealthcare Medicare	$103.32
Rate for Payer: University Health Alliance Commercial	$182.63

US Breast Right

Facility

$352.00

Service Code	HCPCS 76445
Hospital Charge Code	424764450
Hospital Revenue Code	402
Min. Negotiated Rate	$147.84
Max. Negotiated Rate	$341.44
Rate for Payer: AlohaCare Medicaid	$176.00
Rate for Payer: AlohaCare Medicare	$147.84
Rate for Payer: Cash Price	$228.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$323.84
Rate for Payer: Devoted Health Medicare	$147.84
Rate for Payer: Hawaii Medical Service Association Medicare	$147.84
Rate for Payer: Hawaii Western Management Group Commercial	$334.40
Rate for Payer: Health Management Network Commercial	$299.20
Rate for Payer: Humana Medicare	$147.84
Rate for Payer: Kaiser Permanente Commercial	$316.80
Rate for Payer: Kaiser Permanente Medicaid	$179.52
Rate for Payer: Kaiser Permanente Medicare	$147.84
Rate for Payer: MDX Hawaii PPO	$341.44
Rate for Payer: Ohana Health Plan Medicaid	$147.84
Rate for Payer: Ohana Health Plan Medicare	$147.84
Rate for Payer: UnitedHealthcare Medicare	$147.84
Rate for Payer: University Health Alliance Commercial	$256.57

US Breast Right

Facility

$352.00

Service Code	HCPCS 76445
Hospital Charge Code	424764450
Hospital Revenue Code	402
Min. Negotiated Rate	$299.20
Max. Negotiated Rate	$341.44
Rate for Payer: Cash Price	$228.80
Rate for Payer: Health Management Network Commercial	$299.20
Rate for Payer: Kaiser Permanente Commercial	$316.80
Rate for Payer: MDX Hawaii PPO	$341.44

US Breast Right Complete

Facility

$322.00

Service Code	HCPCS 76641
Hospital Charge Code	424766410
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$312.34
Rate for Payer: AlohaCare Medicaid	$161.00
Rate for Payer: AlohaCare Medicare	$135.24
Rate for Payer: Cash Price	$209.30
Rate for Payer: Cash Price	$209.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$296.24
Rate for Payer: Devoted Health Medicare	$135.24
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$135.24
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$273.70
Rate for Payer: Humana Medicare	$135.24
Rate for Payer: Kaiser Permanente Commercial	$289.80
Rate for Payer: Kaiser Permanente Medicaid	$164.22
Rate for Payer: Kaiser Permanente Medicare	$135.24
Rate for Payer: MDX Hawaii PPO	$312.34
Rate for Payer: Ohana Health Plan Medicaid	$135.24
Rate for Payer: Ohana Health Plan Medicare	$135.24
Rate for Payer: UnitedHealthcare Medicaid	$67.92
Rate for Payer: UnitedHealthcare Medicare	$135.24
Rate for Payer: University Health Alliance Commercial	$223.66

US Breast Right Complete

Facility

$322.00

Service Code	HCPCS 76641
Hospital Charge Code	424766410
Hospital Revenue Code	402
Min. Negotiated Rate	$273.70
Max. Negotiated Rate	$312.34
Rate for Payer: Cash Price	$209.30
Rate for Payer: Health Management Network Commercial	$273.70
Rate for Payer: Kaiser Permanente Commercial	$289.80
Rate for Payer: MDX Hawaii PPO	$312.34

US Breast Right Limited

Facility

$246.00

Service Code	HCPCS 76642
Hospital Charge Code	424766420
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$238.62
Rate for Payer: AlohaCare Medicaid	$123.00
Rate for Payer: AlohaCare Medicare	$103.32
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$226.32
Rate for Payer: Devoted Health Medicare	$103.32
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Commercial	$128.51
Rate for Payer: Hawaii Medical Service Association Medicare	$103.32
Rate for Payer: Hawaii Western Management Group Commercial	$102.81
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Humana Medicare	$103.32
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: Kaiser Permanente Medicaid	$125.46
Rate for Payer: Kaiser Permanente Medicare	$103.32
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: Ohana Health Plan Medicaid	$103.32
Rate for Payer: Ohana Health Plan Medicare	$103.32
Rate for Payer: UnitedHealthcare Medicaid	$55.91
Rate for Payer: UnitedHealthcare Medicare	$103.32
Rate for Payer: University Health Alliance Commercial	$182.63

US Breast Right Limited

Facility

$246.00

Service Code	HCPCS 76642
Hospital Charge Code	424766420
Hospital Revenue Code	402
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$159.90
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$221.40
Rate for Payer: MDX Hawaii PPO	$238.62

US BREAST UNI OR BI

Facility

$462.00

Service Code	HCPCS 76641
Hospital Charge Code	424766410
Hospital Revenue Code	402
Min. Negotiated Rate	$34.94
Max. Negotiated Rate	$448.14
Rate for Payer: AlohaCare Medicaid	$231.00
Rate for Payer: AlohaCare Medicare	$194.04
Rate for Payer: Cash Price	$300.30
Rate for Payer: Cash Price	$300.30
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$425.04
Rate for Payer: Devoted Health Medicare	$194.04
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$34.94
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$194.04
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$392.70
Rate for Payer: Humana Medicare	$194.04
Rate for Payer: Kaiser Permanente Commercial	$415.80
Rate for Payer: Kaiser Permanente Medicaid	$235.62
Rate for Payer: Kaiser Permanente Medicare	$194.04
Rate for Payer: MDX Hawaii PPO	$448.14
Rate for Payer: Ohana Health Plan Medicaid	$194.04
Rate for Payer: Ohana Health Plan Medicare	$194.04
Rate for Payer: UnitedHealthcare Medicaid	$67.92
Rate for Payer: UnitedHealthcare Medicare	$194.04
Rate for Payer: University Health Alliance Commercial	$223.66

US BREAST UNI OR BI

Facility

$462.00

Service Code	HCPCS 76641
Hospital Charge Code	424766410
Hospital Revenue Code	402
Min. Negotiated Rate	$392.70
Max. Negotiated Rate	$448.14
Rate for Payer: Cash Price	$300.30
Rate for Payer: Health Management Network Commercial	$392.70
Rate for Payer: Kaiser Permanente Commercial	$415.80
Rate for Payer: MDX Hawaii PPO	$448.14

US Carotid Duplex Bilateral

Facility

$737.00

Service Code	HCPCS 93880
Hospital Charge Code	424938800
Hospital Revenue Code	921
Min. Negotiated Rate	$626.45
Max. Negotiated Rate	$714.89
Rate for Payer: Cash Price	$479.05
Rate for Payer: Health Management Network Commercial	$626.45
Rate for Payer: Kaiser Permanente Commercial	$663.30
Rate for Payer: MDX Hawaii PPO	$714.89

US Carotid Duplex Bilateral

Facility

$737.00

Service Code	HCPCS 93880
Hospital Charge Code	424938800
Hospital Revenue Code	921
Min. Negotiated Rate	$142.03
Max. Negotiated Rate	$714.89
Rate for Payer: AlohaCare Medicaid	$368.50
Rate for Payer: AlohaCare Medicare	$309.54
Rate for Payer: Cash Price	$479.05
Rate for Payer: Cash Price	$479.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$678.04
Rate for Payer: Devoted Health Medicare	$309.54
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$142.03
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Medicare	$309.54
Rate for Payer: Hawaii Western Management Group Commercial	$700.15
Rate for Payer: Health Management Network Commercial	$626.45
Rate for Payer: Humana Medicare	$309.54
Rate for Payer: Kaiser Permanente Commercial	$663.30
Rate for Payer: Kaiser Permanente Medicaid	$375.87
Rate for Payer: Kaiser Permanente Medicare	$309.54
Rate for Payer: MDX Hawaii PPO	$714.89
Rate for Payer: Ohana Health Plan Medicaid	$309.54
Rate for Payer: Ohana Health Plan Medicare	$309.54
Rate for Payer: UnitedHealthcare Medicaid	$142.03
Rate for Payer: UnitedHealthcare Medicare	$309.54
Rate for Payer: University Health Alliance Commercial	$537.20

US Carotid Duplex Left

Facility

$471.00

Service Code	HCPCS 93882
Hospital Charge Code	424938820
Hospital Revenue Code	921
Min. Negotiated Rate	$89.14
Max. Negotiated Rate	$456.87
Rate for Payer: AlohaCare Medicaid	$235.50
Rate for Payer: AlohaCare Medicare	$197.82
Rate for Payer: Cash Price	$306.15
Rate for Payer: Cash Price	$306.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$433.32
Rate for Payer: Devoted Health Medicare	$197.82
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$89.14
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$197.82
Rate for Payer: Hawaii Western Management Group Commercial	$447.45
Rate for Payer: Health Management Network Commercial	$400.35
Rate for Payer: Humana Medicare	$197.82
Rate for Payer: Kaiser Permanente Commercial	$423.90
Rate for Payer: Kaiser Permanente Medicaid	$240.21
Rate for Payer: Kaiser Permanente Medicare	$197.82
Rate for Payer: MDX Hawaii PPO	$456.87
Rate for Payer: Ohana Health Plan Medicaid	$197.82
Rate for Payer: Ohana Health Plan Medicare	$197.82
Rate for Payer: UnitedHealthcare Medicaid	$89.14
Rate for Payer: UnitedHealthcare Medicare	$197.82
Rate for Payer: University Health Alliance Commercial	$343.31

US Carotid Duplex Left

Facility

$471.00

Service Code	HCPCS 93882
Hospital Charge Code	424938820
Hospital Revenue Code	921
Min. Negotiated Rate	$400.35
Max. Negotiated Rate	$456.87
Rate for Payer: Cash Price	$306.15
Rate for Payer: Health Management Network Commercial	$400.35
Rate for Payer: Kaiser Permanente Commercial	$423.90
Rate for Payer: MDX Hawaii PPO	$456.87

US Carotid Duplex Right

Facility

$471.00

Service Code	HCPCS 93882
Hospital Charge Code	424938820
Hospital Revenue Code	921
Min. Negotiated Rate	$400.35
Max. Negotiated Rate	$456.87
Rate for Payer: Cash Price	$306.15
Rate for Payer: Health Management Network Commercial	$400.35
Rate for Payer: Kaiser Permanente Commercial	$423.90
Rate for Payer: MDX Hawaii PPO	$456.87

US Carotid Duplex Right

Facility

$471.00

Service Code	HCPCS 93882
Hospital Charge Code	424938820
Hospital Revenue Code	921
Min. Negotiated Rate	$89.14
Max. Negotiated Rate	$456.87
Rate for Payer: AlohaCare Medicaid	$235.50
Rate for Payer: AlohaCare Medicare	$197.82
Rate for Payer: Cash Price	$306.15
Rate for Payer: Cash Price	$306.15
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$433.32
Rate for Payer: Devoted Health Medicare	$197.82
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$89.14
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$197.82
Rate for Payer: Hawaii Western Management Group Commercial	$447.45
Rate for Payer: Health Management Network Commercial	$400.35
Rate for Payer: Humana Medicare	$197.82
Rate for Payer: Kaiser Permanente Commercial	$423.90
Rate for Payer: Kaiser Permanente Medicaid	$240.21
Rate for Payer: Kaiser Permanente Medicare	$197.82
Rate for Payer: MDX Hawaii PPO	$456.87
Rate for Payer: Ohana Health Plan Medicaid	$197.82
Rate for Payer: Ohana Health Plan Medicare	$197.82
Rate for Payer: UnitedHealthcare Medicaid	$89.14
Rate for Payer: UnitedHealthcare Medicare	$197.82
Rate for Payer: University Health Alliance Commercial	$343.31

US CHEST

Facility

$1,461.00

Service Code	HCPCS 76604
Hospital Charge Code	424766040
Hospital Revenue Code	402
Min. Negotiated Rate	$1,241.85
Max. Negotiated Rate	$1,417.17
Rate for Payer: Cash Price	$949.65
Rate for Payer: Health Management Network Commercial	$1,241.85
Rate for Payer: Kaiser Permanente Commercial	$1,314.90
Rate for Payer: MDX Hawaii PPO	$1,417.17

US CHEST

Facility

$1,461.00

Service Code	HCPCS 76604
Hospital Charge Code	424766040
Hospital Revenue Code	402
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$1,417.17
Rate for Payer: AlohaCare Medicaid	$730.50
Rate for Payer: AlohaCare Medicare	$613.62
Rate for Payer: Cash Price	$949.65
Rate for Payer: Cash Price	$949.65
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$1,344.12
Rate for Payer: Devoted Health Medicare	$613.62
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$42.98
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$613.62
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$1,241.85
Rate for Payer: Humana Medicare	$613.62
Rate for Payer: Kaiser Permanente Commercial	$1,314.90
Rate for Payer: Kaiser Permanente Medicaid	$745.11
Rate for Payer: Kaiser Permanente Medicare	$613.62
Rate for Payer: MDX Hawaii PPO	$1,417.17
Rate for Payer: Ohana Health Plan Medicaid	$613.62
Rate for Payer: Ohana Health Plan Medicare	$613.62
Rate for Payer: UnitedHealthcare Medicaid	$42.98
Rate for Payer: UnitedHealthcare Medicare	$613.62
Rate for Payer: University Health Alliance Commercial	$171.44

US Echocardiography, transthoracic

Facility

$608.00

Service Code	HCPCS 93306
Hospital Charge Code	424930060
Hospital Revenue Code	483
Min. Negotiated Rate	$516.80
Max. Negotiated Rate	$589.76
Rate for Payer: Cash Price	$395.20
Rate for Payer: Health Management Network Commercial	$516.80
Rate for Payer: Kaiser Permanente Commercial	$547.20
Rate for Payer: MDX Hawaii PPO	$589.76

US Echocardiography, transthoracic

Facility

$608.00

Service Code	HCPCS 93306
Hospital Charge Code	424930060
Hospital Revenue Code	483
Min. Negotiated Rate	$132.88
Max. Negotiated Rate	$806.88
Rate for Payer: AlohaCare Medicaid	$304.00
Rate for Payer: AlohaCare Medicare	$255.36
Rate for Payer: Cash Price	$395.20
Rate for Payer: Cash Price	$395.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$559.36
Rate for Payer: Devoted Health Medicare	$255.36
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$132.88
Rate for Payer: Hawaii Medical Service Association Commercial	$806.88
Rate for Payer: Hawaii Medical Service Association Medicare	$255.36
Rate for Payer: Hawaii Western Management Group Commercial	$577.60
Rate for Payer: Health Management Network Commercial	$516.80
Rate for Payer: Humana Medicare	$255.36
Rate for Payer: Kaiser Permanente Commercial	$547.20
Rate for Payer: Kaiser Permanente Medicaid	$310.08
Rate for Payer: Kaiser Permanente Medicare	$255.36
Rate for Payer: MDX Hawaii PPO	$589.76
Rate for Payer: Ohana Health Plan Medicaid	$255.36
Rate for Payer: Ohana Health Plan Medicare	$255.36
Rate for Payer: UnitedHealthcare Medicaid	$132.88
Rate for Payer: UnitedHealthcare Medicare	$255.36
Rate for Payer: University Health Alliance Commercial	$443.17

US Echocardiography,transthoracic,follow-up or limited study

Facility

$357.00

Service Code	HCPCS 93308
Hospital Charge Code	424933080
Hospital Revenue Code	483
Min. Negotiated Rate	$64.51
Max. Negotiated Rate	$352.34
Rate for Payer: AlohaCare Medicaid	$178.50
Rate for Payer: AlohaCare Medicare	$149.94
Rate for Payer: Cash Price	$232.05
Rate for Payer: Cash Price	$232.05
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$328.44
Rate for Payer: Devoted Health Medicare	$149.94
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$64.51
Rate for Payer: Hawaii Medical Service Association Commercial	$352.34
Rate for Payer: Hawaii Medical Service Association Medicare	$149.94
Rate for Payer: Hawaii Western Management Group Commercial	$339.15
Rate for Payer: Health Management Network Commercial	$303.45
Rate for Payer: Humana Medicare	$149.94
Rate for Payer: Kaiser Permanente Commercial	$321.30
Rate for Payer: Kaiser Permanente Medicaid	$182.07
Rate for Payer: Kaiser Permanente Medicare	$149.94
Rate for Payer: MDX Hawaii PPO	$346.29
Rate for Payer: Ohana Health Plan Medicaid	$149.94
Rate for Payer: Ohana Health Plan Medicare	$149.94
Rate for Payer: UnitedHealthcare Medicaid	$64.51
Rate for Payer: UnitedHealthcare Medicare	$149.94
Rate for Payer: University Health Alliance Commercial	$260.22

US Echocardiography,transthoracic,follow-up or limited study

Facility

$357.00

Service Code	HCPCS 93308
Hospital Charge Code	424933080
Hospital Revenue Code	483
Min. Negotiated Rate	$303.45
Max. Negotiated Rate	$346.29
Rate for Payer: Cash Price	$232.05
Rate for Payer: Health Management Network Commercial	$303.45
Rate for Payer: Kaiser Permanente Commercial	$321.30
Rate for Payer: MDX Hawaii PPO	$346.29

U/S-EXT. NON-VASCULAR

Facility

$689.00

Service Code	HCPCS 76881
Hospital Charge Code	424768810
Hospital Revenue Code	402
Min. Negotiated Rate	$585.65
Max. Negotiated Rate	$668.33
Rate for Payer: Cash Price	$447.85
Rate for Payer: Health Management Network Commercial	$585.65
Rate for Payer: Kaiser Permanente Commercial	$620.10
Rate for Payer: MDX Hawaii PPO	$668.33

U/S-EXT. NON-VASCULAR

Facility

$689.00

Service Code	HCPCS 76881
Hospital Charge Code	424768810
Hospital Revenue Code	402
Min. Negotiated Rate	$61.93
Max. Negotiated Rate	$668.33
Rate for Payer: AlohaCare Medicaid	$344.50
Rate for Payer: AlohaCare Medicare	$289.38
Rate for Payer: Cash Price	$447.85
Rate for Payer: Cash Price	$447.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$633.88
Rate for Payer: Devoted Health Medicare	$289.38
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$61.93
Rate for Payer: Hawaii Medical Service Association Commercial	$154.38
Rate for Payer: Hawaii Medical Service Association Medicare	$289.38
Rate for Payer: Hawaii Western Management Group Commercial	$123.50
Rate for Payer: Health Management Network Commercial	$585.65
Rate for Payer: Humana Medicare	$289.38
Rate for Payer: Kaiser Permanente Commercial	$620.10
Rate for Payer: Kaiser Permanente Medicaid	$351.39
Rate for Payer: Kaiser Permanente Medicare	$289.38
Rate for Payer: MDX Hawaii PPO	$668.33
Rate for Payer: Ohana Health Plan Medicaid	$289.38
Rate for Payer: Ohana Health Plan Medicare	$289.38
Rate for Payer: UnitedHealthcare Medicaid	$61.93
Rate for Payer: UnitedHealthcare Medicare	$289.38
Rate for Payer: University Health Alliance Commercial	$246.33

Know your out-of-pocket cost for care.

All Charges