Kahuku Medical Center

All Charges

Charge

Type

Setting

Price

carvedilol 12.5 mg Tab [KMC]

Facility

$3.00

Service Code	NDC 00904730761
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

carvedilol 20 mg oral Cap, ER [KMC]

Facility

$20.26

Service Code	NDC 00007337113
Hospital Revenue Code	250
Min. Negotiated Rate	$17.22
Max. Negotiated Rate	$19.65
Rate for Payer: Cash Price	$13.17
Rate for Payer: Health Management Network Commercial	$17.22
Rate for Payer: Kaiser Permanente Commercial	$18.23
Rate for Payer: MDX Hawaii PPO	$19.65

carvedilol 20 mg oral Cap, ER [KMC]

Facility

$20.26

Service Code	NDC 00007337113
Hospital Revenue Code	250
Min. Negotiated Rate	$8.51
Max. Negotiated Rate	$19.65
Rate for Payer: AlohaCare Medicaid	$10.13
Rate for Payer: AlohaCare Medicare	$8.51
Rate for Payer: Cash Price	$13.17
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$18.64
Rate for Payer: Devoted Health Medicare	$8.51
Rate for Payer: Hawaii Medical Service Association Medicare	$8.51
Rate for Payer: Hawaii Western Management Group Commercial	$19.25
Rate for Payer: Health Management Network Commercial	$17.22
Rate for Payer: Humana Medicare	$8.51
Rate for Payer: Kaiser Permanente Commercial	$18.23
Rate for Payer: Kaiser Permanente Medicaid	$10.33
Rate for Payer: Kaiser Permanente Medicare	$8.51
Rate for Payer: MDX Hawaii PPO	$19.65
Rate for Payer: Ohana Health Plan Medicaid	$8.51
Rate for Payer: Ohana Health Plan Medicare	$8.51
Rate for Payer: UnitedHealthcare Medicaid	$12.16
Rate for Payer: UnitedHealthcare Medicare	$8.51
Rate for Payer: University Health Alliance Commercial	$14.77

carvedilol 25 mg Tab [KMC]

Facility

$8.55

Service Code	NDC 72888003701
Hospital Revenue Code	250
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$8.29
Rate for Payer: AlohaCare Medicaid	$4.28
Rate for Payer: AlohaCare Medicare	$3.59
Rate for Payer: Cash Price	$5.56
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.87
Rate for Payer: Devoted Health Medicare	$3.59
Rate for Payer: Hawaii Medical Service Association Medicare	$3.59
Rate for Payer: Hawaii Western Management Group Commercial	$8.12
Rate for Payer: Health Management Network Commercial	$7.27
Rate for Payer: Humana Medicare	$3.59
Rate for Payer: Kaiser Permanente Commercial	$7.70
Rate for Payer: Kaiser Permanente Medicaid	$4.36
Rate for Payer: Kaiser Permanente Medicare	$3.59
Rate for Payer: MDX Hawaii PPO	$8.29
Rate for Payer: Ohana Health Plan Medicaid	$3.59
Rate for Payer: Ohana Health Plan Medicare	$3.59
Rate for Payer: UnitedHealthcare Medicaid	$5.13
Rate for Payer: UnitedHealthcare Medicare	$3.59
Rate for Payer: University Health Alliance Commercial	$6.23

carvedilol 25 mg Tab [KMC]

Facility

$8.55

Service Code	NDC 72888003701
Hospital Revenue Code	250
Min. Negotiated Rate	$7.27
Max. Negotiated Rate	$8.29
Rate for Payer: Cash Price	$5.56
Rate for Payer: Health Management Network Commercial	$7.27
Rate for Payer: Kaiser Permanente Commercial	$7.70
Rate for Payer: MDX Hawaii PPO	$8.29

carvedilol 3.125 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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

carvedilol 3.125 mg Tab [KMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Revenue Code	637
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 Medicare	$1.26
Rate for Payer: University Health Alliance Commercial	$2.19

carvedilol 40 mg oral Cap, ER [KMC]

Facility

$20.26

Service Code	NDC 00007337213
Hospital Revenue Code	250
Min. Negotiated Rate	$17.22
Max. Negotiated Rate	$19.65
Rate for Payer: Cash Price	$13.17
Rate for Payer: Health Management Network Commercial	$17.22
Rate for Payer: Kaiser Permanente Commercial	$18.23
Rate for Payer: MDX Hawaii PPO	$19.65

carvedilol 40 mg oral Cap, ER [KMC]

Facility

$20.26

Service Code	NDC 00007337213
Hospital Revenue Code	250
Min. Negotiated Rate	$8.51
Max. Negotiated Rate	$19.65
Rate for Payer: AlohaCare Medicaid	$10.13
Rate for Payer: AlohaCare Medicare	$8.51
Rate for Payer: Cash Price	$13.17
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$18.64
Rate for Payer: Devoted Health Medicare	$8.51
Rate for Payer: Hawaii Medical Service Association Medicare	$8.51
Rate for Payer: Hawaii Western Management Group Commercial	$19.25
Rate for Payer: Health Management Network Commercial	$17.22
Rate for Payer: Humana Medicare	$8.51
Rate for Payer: Kaiser Permanente Commercial	$18.23
Rate for Payer: Kaiser Permanente Medicaid	$10.33
Rate for Payer: Kaiser Permanente Medicare	$8.51
Rate for Payer: MDX Hawaii PPO	$19.65
Rate for Payer: Ohana Health Plan Medicaid	$8.51
Rate for Payer: Ohana Health Plan Medicare	$8.51
Rate for Payer: UnitedHealthcare Medicaid	$12.16
Rate for Payer: UnitedHealthcare Medicare	$8.51
Rate for Payer: University Health Alliance Commercial	$14.77

carvedilol 6.25 mg Tab [KMC]

Facility

$7.80

Service Code	NDC 68084085401
Hospital Revenue Code	250
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$7.57
Rate for Payer: AlohaCare Medicaid	$3.90
Rate for Payer: AlohaCare Medicare	$3.28
Rate for Payer: Cash Price	$5.07
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$7.18
Rate for Payer: Devoted Health Medicare	$3.28
Rate for Payer: Hawaii Medical Service Association Medicare	$3.28
Rate for Payer: Hawaii Western Management Group Commercial	$7.41
Rate for Payer: Health Management Network Commercial	$6.63
Rate for Payer: Humana Medicare	$3.28
Rate for Payer: Kaiser Permanente Commercial	$7.02
Rate for Payer: Kaiser Permanente Medicaid	$3.98
Rate for Payer: Kaiser Permanente Medicare	$3.28
Rate for Payer: MDX Hawaii PPO	$7.57
Rate for Payer: Ohana Health Plan Medicaid	$3.28
Rate for Payer: Ohana Health Plan Medicare	$3.28
Rate for Payer: UnitedHealthcare Medicaid	$4.68
Rate for Payer: UnitedHealthcare Medicare	$3.28
Rate for Payer: University Health Alliance Commercial	$5.69

carvedilol 6.25 mg Tab [KMC]

Facility

$7.80

Service Code	NDC 68084085401
Hospital Revenue Code	250
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$7.57
Rate for Payer: Cash Price	$5.07
Rate for Payer: Health Management Network Commercial	$6.63
Rate for Payer: Kaiser Permanente Commercial	$7.02
Rate for Payer: MDX Hawaii PPO	$7.57

carvedilol 80 mg ER capsule [KMC]

Facility

$39.64

Service Code	NDC 60505368103
Hospital Revenue Code	250
Min. Negotiated Rate	$33.69
Max. Negotiated Rate	$38.45
Rate for Payer: Cash Price	$25.77
Rate for Payer: Health Management Network Commercial	$33.69
Rate for Payer: Kaiser Permanente Commercial	$35.68
Rate for Payer: MDX Hawaii PPO	$38.45

carvedilol 80 mg ER capsule [KMC]

Facility

$39.64

Service Code	NDC 60505368103
Hospital Revenue Code	250
Min. Negotiated Rate	$16.65
Max. Negotiated Rate	$38.45
Rate for Payer: AlohaCare Medicaid	$19.82
Rate for Payer: AlohaCare Medicare	$16.65
Rate for Payer: Cash Price	$25.77
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$36.47
Rate for Payer: Devoted Health Medicare	$16.65
Rate for Payer: Hawaii Medical Service Association Medicare	$16.65
Rate for Payer: Hawaii Western Management Group Commercial	$37.66
Rate for Payer: Health Management Network Commercial	$33.69
Rate for Payer: Humana Medicare	$16.65
Rate for Payer: Kaiser Permanente Commercial	$35.68
Rate for Payer: Kaiser Permanente Medicaid	$20.22
Rate for Payer: Kaiser Permanente Medicare	$16.65
Rate for Payer: MDX Hawaii PPO	$38.45
Rate for Payer: Ohana Health Plan Medicaid	$16.65
Rate for Payer: Ohana Health Plan Medicare	$16.65
Rate for Payer: UnitedHealthcare Medicaid	$23.78
Rate for Payer: UnitedHealthcare Medicare	$16.65
Rate for Payer: University Health Alliance Commercial	$28.89

CA SCREEN;PELVIC/BREAST EXAM

Professional

Both

$107.00

Service Code	HCPCS G0101
Hospital Revenue Code	521
Min. Negotiated Rate	$24.78
Max. Negotiated Rate	$290.48
Rate for Payer: AlohaCare Medicaid	$27.76
Rate for Payer: AlohaCare Medicare	$24.78
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$24.78
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$290.48
Rate for Payer: Hawaii Medical Service Association Medicare	$152.00
Rate for Payer: Hawaii Medical Service Association Medicare	$273.13
Rate for Payer: Hawaii Western Management Group Commercial	$36.20
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$152.00
Rate for Payer: Kaiser Permanente Commercial	$29.74
Rate for Payer: Kaiser Permanente Commercial	$273.13
Rate for Payer: Kaiser Permanente Medicaid	$290.48
Rate for Payer: Kaiser Permanente Medicare	$152.00
Rate for Payer: Kaiser Permanente Medicare	$273.13
Rate for Payer: Ohana Health Plan Medicaid	$27.76
Rate for Payer: Ohana Health Plan Medicare	$24.78
Rate for Payer: UnitedHealthcare Medicaid	$290.48
Rate for Payer: UnitedHealthcare Medicare	$152.00
Rate for Payer: UnitedHealthcare Medicare	$273.13

CAST APP LEG LONG-THIGHS/TOES Charge

Facility

$708.00

Service Code	HCPCS 29345
Hospital Charge Code	440293450
Hospital Revenue Code	450
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: MDX Hawaii PPO	$686.76

CAST APP LEG LONG-THIGHS/TOES Charge

Facility

$708.00

Service Code	HCPCS 29345
Hospital Charge Code	440293450
Hospital Revenue Code	450
Min. Negotiated Rate	$297.36
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$354.00
Rate for Payer: AlohaCare Medicare	$297.36
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$651.36
Rate for Payer: Devoted Health Medicare	$297.36
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$297.36
Rate for Payer: Hawaii Western Management Group Commercial	$672.60
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$297.36
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$297.36
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$297.36
Rate for Payer: Ohana Health Plan Medicare	$297.36
Rate for Payer: UnitedHealthcare Medicare	$297.36
Rate for Payer: University Health Alliance Commercial	$516.06

CAST APPLICATION, SHORT ARM CHARGE

Facility

$708.00

Service Code	HCPCS 29075
Hospital Charge Code	440290750
Hospital Revenue Code	450
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$686.76
Rate for Payer: Cash Price	$460.20
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: MDX Hawaii PPO	$686.76

CAST APPLICATION, SHORT ARM CHARGE

Facility

$708.00

Service Code	HCPCS 29075
Hospital Charge Code	440290750
Hospital Revenue Code	450
Min. Negotiated Rate	$297.36
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$354.00
Rate for Payer: AlohaCare Medicare	$297.36
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Cash Price	$460.20
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$651.36
Rate for Payer: Devoted Health Medicare	$297.36
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$297.36
Rate for Payer: Hawaii Western Management Group Commercial	$672.60
Rate for Payer: Health Management Network Commercial	$601.80
Rate for Payer: Humana Medicare	$297.36
Rate for Payer: Kaiser Permanente Commercial	$637.20
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$297.36
Rate for Payer: MDX Hawaii PPO	$686.76
Rate for Payer: Ohana Health Plan Medicaid	$297.36
Rate for Payer: Ohana Health Plan Medicare	$297.36
Rate for Payer: UnitedHealthcare Medicare	$297.36
Rate for Payer: University Health Alliance Commercial	$516.06

CAST REMOVAL CHARGE

Facility

$513.00

Service Code	HCPCS 29705
Hospital Charge Code	440297050
Hospital Revenue Code	450
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$333.45
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: MDX Hawaii PPO	$497.61

CAST REMOVAL CHARGE

Facility

$513.00

Service Code	HCPCS 29705
Hospital Charge Code	440297050
Hospital Revenue Code	450
Min. Negotiated Rate	$215.46
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$256.50
Rate for Payer: AlohaCare Medicare	$215.46
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$471.96
Rate for Payer: Devoted Health Medicare	$215.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$215.46
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$215.46
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$215.46
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$215.46
Rate for Payer: Ohana Health Plan Medicare	$215.46
Rate for Payer: UnitedHealthcare Medicare	$215.46
Rate for Payer: University Health Alliance Commercial	$373.93

CAST REMOVAL, SHORT ARM/LEG CHARGE

Facility

$513.00

Service Code	HCPCS 29700
Hospital Charge Code	440297000
Hospital Revenue Code	450
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$333.45
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: MDX Hawaii PPO	$497.61

CAST REMOVAL, SHORT ARM/LEG CHARGE

Facility

$513.00

Service Code	HCPCS 29700
Hospital Charge Code	440297000
Hospital Revenue Code	450
Min. Negotiated Rate	$215.46
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$256.50
Rate for Payer: AlohaCare Medicare	$215.46
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$471.96
Rate for Payer: Devoted Health Medicare	$215.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$215.46
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$215.46
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$215.46
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$215.46
Rate for Payer: Ohana Health Plan Medicare	$215.46
Rate for Payer: UnitedHealthcare Medicare	$215.46
Rate for Payer: University Health Alliance Commercial	$373.93

CAST WINDOWING Charge

Facility

$513.00

Service Code	HCPCS 29730
Hospital Charge Code	440297300
Hospital Revenue Code	450
Min. Negotiated Rate	$215.46
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$256.50
Rate for Payer: AlohaCare Medicare	$215.46
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Cash Price	$333.45
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$471.96
Rate for Payer: Devoted Health Medicare	$215.46
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$417.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$215.46
Rate for Payer: Hawaii Western Management Group Commercial	$487.35
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Humana Medicare	$215.46
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$215.46
Rate for Payer: MDX Hawaii PPO	$497.61
Rate for Payer: Ohana Health Plan Medicaid	$215.46
Rate for Payer: Ohana Health Plan Medicare	$215.46
Rate for Payer: UnitedHealthcare Medicare	$215.46
Rate for Payer: University Health Alliance Commercial	$373.93

CAST WINDOWING Charge

Facility

$513.00

Service Code	HCPCS 29730
Hospital Charge Code	440297300
Hospital Revenue Code	450
Min. Negotiated Rate	$436.05
Max. Negotiated Rate	$497.61
Rate for Payer: Cash Price	$333.45
Rate for Payer: Health Management Network Commercial	$436.05
Rate for Payer: Kaiser Permanente Commercial	$461.70
Rate for Payer: MDX Hawaii PPO	$497.61

Catheter Tip Culture DLS

Facility

$178.00

Service Code	HCPCS 87071
Hospital Charge Code	422870715
Hospital Revenue Code	306
Min. Negotiated Rate	$7.91
Max. Negotiated Rate	$172.66
Rate for Payer: AlohaCare Medicaid	$89.00
Rate for Payer: AlohaCare Medicare	$74.76
Rate for Payer: Cash Price	$115.70
Rate for Payer: Cash Price	$115.70
Rate for Payer: Deseret Mutual Benefit Administrators Commercial	$163.76
Rate for Payer: Devoted Health Medicare	$74.76
Rate for Payer: Hawaii Medical Service Association ABD/Non-ABD	$7.91
Rate for Payer: Hawaii Medical Service Association Commercial	$12.36
Rate for Payer: Hawaii Medical Service Association Medicare	$74.76
Rate for Payer: Hawaii Western Management Group Commercial	$9.89
Rate for Payer: Health Management Network Commercial	$151.30
Rate for Payer: Humana Medicare	$74.76
Rate for Payer: Kaiser Permanente Commercial	$160.20
Rate for Payer: Kaiser Permanente Medicaid	$90.78
Rate for Payer: Kaiser Permanente Medicare	$74.76
Rate for Payer: MDX Hawaii PPO	$172.66
Rate for Payer: Ohana Health Plan Medicaid	$74.76
Rate for Payer: Ohana Health Plan Medicare	$74.76
Rate for Payer: UnitedHealthcare Medicaid	$7.91
Rate for Payer: UnitedHealthcare Medicare	$74.76
Rate for Payer: University Health Alliance Commercial	$24.38

Know your out-of-pocket cost for care.

All Charges