Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

Bill Endomysial Ab IgA Reflex Titer

Facility

$192.00

Service Code	HCPCS 86255
Hospital Charge Code	422862556
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$186.24
Rate for Payer: AlohaCare Medicaid	$96.00
Rate for Payer: AlohaCare Medicare	$80.64
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cash Price	$124.80
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$176.64
Rate for Payer: Devoted Health Medicare	$80.64
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.66
Rate for Payer: Hawaii Medical Service Association Commercial	$15.06
Rate for Payer: Hawaii Medical Service Association Medicare	$80.64
Rate for Payer: Hawaii Western Management Group Commercial	$12.05
Rate for Payer: Health Management Network Commercial	$163.20
Rate for Payer: Humana Medicare	$80.64
Rate for Payer: Kaiser Permanente Commercial	$172.80
Rate for Payer: Kaiser Permanente Medicaid	$97.92
Rate for Payer: Kaiser Permanente Medicare	$80.64
Rate for Payer: MDX Hawaii PPO	$186.24
Rate for Payer: Ohana Health Plan Medicaid	$80.64
Rate for Payer: Ohana Health Plan Medicare	$80.64
Rate for Payer: UnitedHealthcare Medicaid	$16.66
Rate for Payer: UnitedHealthcare Medicare	$80.64
Rate for Payer: University Health Alliance Commercial	$31.15

Bill Gliadin Deamiated Ab IgG/ IgA

Facility

$189.00

Service Code	HCPCS 83516
Hospital Charge Code	422835166
Hospital Revenue Code	300
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$183.33
Rate for Payer: AlohaCare Medicaid	$94.50
Rate for Payer: AlohaCare Medicare	$79.38
Rate for Payer: Cash Price	$122.85
Rate for Payer: Cash Price	$122.85
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$173.88
Rate for Payer: Devoted Health Medicare	$79.38
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$79.38
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Humana Medicare	$79.38
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: Kaiser Permanente Medicaid	$96.39
Rate for Payer: Kaiser Permanente Medicare	$79.38
Rate for Payer: MDX Hawaii PPO	$183.33
Rate for Payer: Ohana Health Plan Medicaid	$79.38
Rate for Payer: Ohana Health Plan Medicare	$79.38
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$79.38
Rate for Payer: University Health Alliance Commercial	$29.82

Bill Gliadin Deamiated Ab IgG/ IgA

Facility

$189.00

Service Code	HCPCS 83516
Hospital Charge Code	422835166
Hospital Revenue Code	300
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$183.33
Rate for Payer: Cash Price	$122.85
Rate for Payer: Health Management Network Commercial	$160.65
Rate for Payer: Kaiser Permanente Commercial	$170.10
Rate for Payer: MDX Hawaii PPO	$183.33

Bill Reticulin IgG screen reflex titer

Facility

$144.00

Service Code	HCPCS 86255
Hospital Charge Code	422862557
Hospital Revenue Code	300
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$139.68
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: MDX Hawaii PPO	$139.68

Bill Reticulin IgG screen reflex titer

Facility

$144.00

Service Code	HCPCS 86255
Hospital Charge Code	422862557
Hospital Revenue Code	300
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$139.68
Rate for Payer: AlohaCare Medicaid	$72.00
Rate for Payer: AlohaCare Medicare	$60.48
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$132.48
Rate for Payer: Devoted Health Medicare	$60.48
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$16.66
Rate for Payer: Hawaii Medical Service Association Commercial	$15.06
Rate for Payer: Hawaii Medical Service Association Medicare	$60.48
Rate for Payer: Hawaii Western Management Group Commercial	$12.05
Rate for Payer: Health Management Network Commercial	$122.40
Rate for Payer: Humana Medicare	$60.48
Rate for Payer: Kaiser Permanente Commercial	$129.60
Rate for Payer: Kaiser Permanente Medicaid	$73.44
Rate for Payer: Kaiser Permanente Medicare	$60.48
Rate for Payer: MDX Hawaii PPO	$139.68
Rate for Payer: Ohana Health Plan Medicaid	$60.48
Rate for Payer: Ohana Health Plan Medicare	$60.48
Rate for Payer: UnitedHealthcare Medicaid	$16.66
Rate for Payer: UnitedHealthcare Medicare	$60.48
Rate for Payer: University Health Alliance Commercial	$31.15

bimatoprost ophthalmic 0.01% Sol [KMC]

Facility

$201.10

Service Code	NDC 00023320503
Hospital Revenue Code	250
Min. Negotiated Rate	$84.46
Max. Negotiated Rate	$195.07
Rate for Payer: AlohaCare Medicaid	$100.55
Rate for Payer: AlohaCare Medicare	$84.46
Rate for Payer: Cash Price	$130.72
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$185.01
Rate for Payer: Devoted Health Medicare	$84.46
Rate for Payer: Hawaii Medical Service Association Medicare	$84.46
Rate for Payer: Hawaii Western Management Group Commercial	$191.04
Rate for Payer: Health Management Network Commercial	$170.94
Rate for Payer: Humana Medicare	$84.46
Rate for Payer: Kaiser Permanente Commercial	$180.99
Rate for Payer: Kaiser Permanente Medicaid	$102.56
Rate for Payer: Kaiser Permanente Medicare	$84.46
Rate for Payer: MDX Hawaii PPO	$195.07
Rate for Payer: Ohana Health Plan Medicaid	$84.46
Rate for Payer: Ohana Health Plan Medicare	$84.46
Rate for Payer: UnitedHealthcare Medicaid	$120.66
Rate for Payer: UnitedHealthcare Medicare	$84.46
Rate for Payer: University Health Alliance Commercial	$146.58

bimatoprost ophthalmic 0.01% Sol [KMC]

Facility

$201.10

Service Code	NDC 00023320503
Hospital Revenue Code	250
Min. Negotiated Rate	$170.94
Max. Negotiated Rate	$195.07
Rate for Payer: Cash Price	$130.72
Rate for Payer: Health Management Network Commercial	$170.94
Rate for Payer: Kaiser Permanente Commercial	$180.99
Rate for Payer: MDX Hawaii PPO	$195.07

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC

Facility

$47,830.64

Service Code	MSDRG 478
Min. Negotiated Rate	$47,830.64
Max. Negotiated Rate	$47,830.64
Rate for Payer: Hawaii Medical Service Association Commercial	$47,830.64

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$47,830.64

Service Code	MSDRG 477
Min. Negotiated Rate	$47,830.64
Max. Negotiated Rate	$47,830.64
Rate for Payer: Hawaii Medical Service Association Commercial	$47,830.64

BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC

Facility

$47,830.64

Service Code	MSDRG 479
Min. Negotiated Rate	$47,830.64
Max. Negotiated Rate	$47,830.64
Rate for Payer: Hawaii Medical Service Association Commercial	$47,830.64

BIOPSY CERVIX SINGLE/MULT/EXCISION OF LESION SPX

Professional

Both

$347.00

Service Code	HCPCS 57500
Hospital Revenue Code	361
Min. Negotiated Rate	$67.34
Max. Negotiated Rate	$294.95
Rate for Payer: AlohaCare Medicaid	$76.57
Rate for Payer: AlohaCare Medicare	$68.58
Rate for Payer: Cash Price	$225.55
Rate for Payer: Cash Price	$225.55
Rate for Payer: Devoted Health Medicare	$68.58
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$76.57
Rate for Payer: Hawaii Medical Service Association Commercial	$117.98
Rate for Payer: Hawaii Medical Service Association Medicare	$68.58
Rate for Payer: Hawaii Western Management Group Commercial	$67.34
Rate for Payer: Health Management Network Commercial	$294.95
Rate for Payer: Kaiser Permanente Commercial	$82.30
Rate for Payer: Kaiser Permanente Medicaid	$82.30
Rate for Payer: Kaiser Permanente Medicare	$82.30
Rate for Payer: Ohana Health Plan Medicaid	$76.57
Rate for Payer: Ohana Health Plan Medicare	$68.58
Rate for Payer: UnitedHealthcare Medicaid	$76.57
Rate for Payer: UnitedHealthcare Medicare	$68.58
Rate for Payer: University Health Alliance Commercial	$94.97

BIOPSY NAIL UNIT SEPARATE PROCEDURE

Professional

Both

$1,165.00

Service Code	HCPCS 11755
Hospital Revenue Code	361
Min. Negotiated Rate	$54.27
Max. Negotiated Rate	$990.25
Rate for Payer: AlohaCare Medicaid	$60.69
Rate for Payer: AlohaCare Medicare	$54.27
Rate for Payer: Cash Price	$757.25
Rate for Payer: Cash Price	$757.25
Rate for Payer: Devoted Health Medicare	$54.27
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$60.69
Rate for Payer: Hawaii Medical Service Association Commercial	$114.15
Rate for Payer: Hawaii Medical Service Association Medicare	$54.27
Rate for Payer: Hawaii Western Management Group Commercial	$67.86
Rate for Payer: Health Management Network Commercial	$990.25
Rate for Payer: Kaiser Permanente Commercial	$65.12
Rate for Payer: Kaiser Permanente Medicaid	$65.12
Rate for Payer: Kaiser Permanente Medicare	$65.12
Rate for Payer: Ohana Health Plan Medicaid	$60.69
Rate for Payer: Ohana Health Plan Medicare	$54.27
Rate for Payer: UnitedHealthcare Medicaid	$60.69
Rate for Payer: UnitedHealthcare Medicare	$54.27
Rate for Payer: University Health Alliance Commercial	$65.87

BIOPSY VULVA/PERINEUM 1 LESION SPX

Professional

Both

$310.00

Service Code	HCPCS 56605
Hospital Revenue Code	361
Min. Negotiated Rate	$50.43
Max. Negotiated Rate	$263.50
Rate for Payer: AlohaCare Medicaid	$58.72
Rate for Payer: AlohaCare Medicare	$50.43
Rate for Payer: Cash Price	$201.50
Rate for Payer: Cash Price	$201.50
Rate for Payer: Devoted Health Medicare	$50.43
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$58.72
Rate for Payer: Hawaii Medical Service Association Commercial	$91.86
Rate for Payer: Hawaii Medical Service Association Medicare	$50.43
Rate for Payer: Hawaii Western Management Group Commercial	$71.50
Rate for Payer: Health Management Network Commercial	$263.50
Rate for Payer: Kaiser Permanente Commercial	$60.52
Rate for Payer: Kaiser Permanente Medicaid	$60.52
Rate for Payer: Kaiser Permanente Medicare	$60.52
Rate for Payer: Ohana Health Plan Medicaid	$58.72
Rate for Payer: Ohana Health Plan Medicare	$50.43
Rate for Payer: UnitedHealthcare Medicaid	$58.72
Rate for Payer: UnitedHealthcare Medicare	$50.43
Rate for Payer: University Health Alliance Commercial	$125.00

BIOPSY VULVA/PERINEUM EACH ADDL LESION

Professional

Both

$119.00

Service Code	HCPCS 56606
Hospital Revenue Code	361
Min. Negotiated Rate	$24.71
Max. Negotiated Rate	$101.15
Rate for Payer: AlohaCare Medicaid	$28.79
Rate for Payer: AlohaCare Medicare	$24.71
Rate for Payer: Cash Price	$77.35
Rate for Payer: Cash Price	$77.35
Rate for Payer: Devoted Health Medicare	$24.71
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$28.79
Rate for Payer: Hawaii Medical Service Association Commercial	$45.05
Rate for Payer: Hawaii Medical Service Association Medicare	$24.71
Rate for Payer: Hawaii Western Management Group Commercial	$39.26
Rate for Payer: Health Management Network Commercial	$101.15
Rate for Payer: Kaiser Permanente Commercial	$29.65
Rate for Payer: Kaiser Permanente Medicaid	$29.65
Rate for Payer: Kaiser Permanente Medicare	$29.65
Rate for Payer: Ohana Health Plan Medicaid	$28.79
Rate for Payer: Ohana Health Plan Medicare	$24.71
Rate for Payer: UnitedHealthcare Medicaid	$28.79
Rate for Payer: UnitedHealthcare Medicare	$24.71
Rate for Payer: University Health Alliance Commercial	$38.14

biotin 1000 mcg oral tablet [KMC]

Facility

$3.00

Service Code	NDC 74312007961
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

biotin 1000 mcg oral tablet [KMC]

Facility

$3.00

Service Code	NDC 74312007961
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

biotin 5000 mcg Cap [KMC]

Facility

$3.00

Service Code	NDC 74312134302
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

biotin 5000 mcg Cap [KMC]

Facility

$3.00

Service Code	NDC 74312134302
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

bisacodyl 10 mg suppository [KMC]

Facility

$3.00

Service Code	NDC 00574705012
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

bisacodyl 10 mg suppository [KMC]

Facility

$3.00

Service Code	NDC 00574705012
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

bisacodyl 5 mg Oral EC Tab [KMC]

Facility

$3.00

Service Code	NDC 00904674860
Hospital Revenue Code	250
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: MDX Hawaii PPO	$2.91

bisacodyl 5 mg Oral EC Tab [KMC]

Facility

$3.00

Service Code	NDC 00904674860
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

bismuth subsalicylate 262 mg/15 mL Oral Susp [KMC]

Facility

$0.05

Service Code	NDC 00904131309
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Management Network Commercial	$0.04
Rate for Payer: Kaiser Permanente Commercial	$0.05
Rate for Payer: MDX Hawaii PPO	$0.05

bismuth subsalicylate 262 mg/15 mL Oral Susp [KMC]

Facility

$0.05

Service Code	NDC 00904131309
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.05
Rate for Payer: AlohaCare Medicaid	$0.03
Rate for Payer: AlohaCare Medicare	$0.02
Rate for Payer: Cash Price	$0.03
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$0.05
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Hawaii Medical Service Association Medicare	$0.02
Rate for Payer: Hawaii Western Management Group Commercial	$0.05
Rate for Payer: Health Management Network Commercial	$0.04
Rate for Payer: Humana Medicare	$0.02
Rate for Payer: Kaiser Permanente Commercial	$0.05
Rate for Payer: Kaiser Permanente Medicaid	$0.03
Rate for Payer: Kaiser Permanente Medicare	$0.02
Rate for Payer: MDX Hawaii PPO	$0.05
Rate for Payer: Ohana Health Plan Medicaid	$0.02
Rate for Payer: Ohana Health Plan Medicare	$0.02
Rate for Payer: UnitedHealthcare Medicaid	$0.03
Rate for Payer: UnitedHealthcare Medicare	$0.02
Rate for Payer: University Health Alliance Commercial	$0.04

bismuth subsalicylate 262 mg Chew Tab [KMC]

Facility

$3.00

Service Code	NDC 00904720546
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$2.91
Rate for Payer: AlohaCare Medicaid	$1.50
Rate for Payer: AlohaCare Medicare	$1.26
Rate for Payer: Cash Price	$1.95
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$2.76
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Hawaii Medical Service Association Medicare	$1.26
Rate for Payer: Hawaii Western Management Group Commercial	$2.85
Rate for Payer: Health Management Network Commercial	$2.55
Rate for Payer: Humana Medicare	$1.26
Rate for Payer: Kaiser Permanente Commercial	$2.70
Rate for Payer: Kaiser Permanente Medicaid	$1.53
Rate for Payer: Kaiser Permanente Medicare	$1.26
Rate for Payer: MDX Hawaii PPO	$2.91
Rate for Payer: Ohana Health Plan Medicaid	$1.26
Rate for Payer: Ohana Health Plan Medicare	$1.26
Rate for Payer: UnitedHealthcare Medicaid	$1.80
Rate for Payer: UnitedHealthcare Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

Know your out-of-pocket cost for care.

All Charges