|
DRILL BIT FAST 2.0 231220204
|
Facility
|
IP
|
$563.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$478.55 |
| Max. Negotiated Rate |
$546.11 |
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Health Management Network Commercial |
$478.55
|
| Rate for Payer: Kaiser Permanente Commercial |
$506.70
|
| Rate for Payer: MDX Hawaii PPO |
$546.11
|
|
|
DRILL BIT FAST 2.0 231220204
|
Facility
|
OP
|
$563.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$174.53 |
| Max. Negotiated Rate |
$546.11 |
| Rate for Payer: AlohaCare Medicaid |
$281.50
|
| Rate for Payer: AlohaCare Medicare |
$174.53
|
| Rate for Payer: Cash Price |
$337.80
|
| Rate for Payer: Devoted Health Medicare |
$191.42
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$174.53
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$534.85
|
| Rate for Payer: Health Management Network Commercial |
$478.55
|
| Rate for Payer: Humana Medicare |
$174.53
|
| Rate for Payer: Kaiser Permanente Commercial |
$506.70
|
| Rate for Payer: Kaiser Permanente Medicaid |
$287.13
|
| Rate for Payer: Kaiser Permanente Medicare |
$174.53
|
| Rate for Payer: MDX Hawaii PPO |
$546.11
|
| Rate for Payer: Ohana Health Plan Medicaid |
$174.53
|
| Rate for Payer: Ohana Health Plan Medicare |
$174.53
|
| Rate for Payer: UnitedHealthcare Medicare |
$174.53
|
| Rate for Payer: University Health Alliance Commercial |
$410.37
|
|
|
DRILL BIT HOLLOW 10.0MM
|
Facility
|
OP
|
$1,610.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$499.10 |
| Max. Negotiated Rate |
$1,561.70 |
| Rate for Payer: AlohaCare Medicaid |
$805.00
|
| Rate for Payer: AlohaCare Medicare |
$499.10
|
| Rate for Payer: Cash Price |
$966.00
|
| Rate for Payer: Devoted Health Medicare |
$547.40
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$499.10
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,529.50
|
| Rate for Payer: Health Management Network Commercial |
$1,368.50
|
| Rate for Payer: Humana Medicare |
$499.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,449.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$821.10
|
| Rate for Payer: Kaiser Permanente Medicare |
$499.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,561.70
|
| Rate for Payer: Ohana Health Plan Medicaid |
$499.10
|
| Rate for Payer: Ohana Health Plan Medicare |
$499.10
|
| Rate for Payer: UnitedHealthcare Medicare |
$499.10
|
| Rate for Payer: University Health Alliance Commercial |
$1,173.53
|
|
|
DRILL BIT HOLLOW 10.0MM
|
Facility
|
IP
|
$1,610.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,368.50 |
| Max. Negotiated Rate |
$1,561.70 |
| Rate for Payer: Cash Price |
$966.00
|
| Rate for Payer: Health Management Network Commercial |
$1,368.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,449.00
|
| Rate for Payer: MDX Hawaii PPO |
$1,561.70
|
|
|
DRILL BIT JC 2.0X85MM 310.20
|
Facility
|
OP
|
$372.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$115.32 |
| Max. Negotiated Rate |
$360.84 |
| Rate for Payer: AlohaCare Medicaid |
$186.00
|
| Rate for Payer: AlohaCare Medicare |
$115.32
|
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Devoted Health Medicare |
$126.48
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$115.32
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$353.40
|
| Rate for Payer: Health Management Network Commercial |
$316.20
|
| Rate for Payer: Humana Medicare |
$115.32
|
| Rate for Payer: Kaiser Permanente Commercial |
$334.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$189.72
|
| Rate for Payer: Kaiser Permanente Medicare |
$115.32
|
| Rate for Payer: MDX Hawaii PPO |
$360.84
|
| Rate for Payer: Ohana Health Plan Medicaid |
$115.32
|
| Rate for Payer: Ohana Health Plan Medicare |
$115.32
|
| Rate for Payer: UnitedHealthcare Medicare |
$115.32
|
| Rate for Payer: University Health Alliance Commercial |
$271.15
|
|
|
DRILL BIT JC 2.0X85MM 310.20
|
Facility
|
IP
|
$372.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$316.20 |
| Max. Negotiated Rate |
$360.84 |
| Rate for Payer: Cash Price |
$223.20
|
| Rate for Payer: Health Management Network Commercial |
$316.20
|
| Rate for Payer: Kaiser Permanente Commercial |
$334.80
|
| Rate for Payer: MDX Hawaii PPO |
$360.84
|
|
|
DRILL BIT JC 2.5MM 4805-95-25
|
Facility
|
OP
|
$882.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$273.42 |
| Max. Negotiated Rate |
$855.54 |
| Rate for Payer: AlohaCare Medicaid |
$441.00
|
| Rate for Payer: AlohaCare Medicare |
$273.42
|
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: Devoted Health Medicare |
$299.88
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$273.42
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$837.90
|
| Rate for Payer: Health Management Network Commercial |
$749.70
|
| Rate for Payer: Humana Medicare |
$273.42
|
| Rate for Payer: Kaiser Permanente Commercial |
$793.80
|
| Rate for Payer: Kaiser Permanente Medicaid |
$449.82
|
| Rate for Payer: Kaiser Permanente Medicare |
$273.42
|
| Rate for Payer: MDX Hawaii PPO |
$855.54
|
| Rate for Payer: Ohana Health Plan Medicaid |
$273.42
|
| Rate for Payer: Ohana Health Plan Medicare |
$273.42
|
| Rate for Payer: UnitedHealthcare Medicare |
$273.42
|
| Rate for Payer: University Health Alliance Commercial |
$642.89
|
|
|
DRILL BIT JC 2.5MM 4805-95-25
|
Facility
|
IP
|
$882.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$749.70 |
| Max. Negotiated Rate |
$855.54 |
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: Health Management Network Commercial |
$749.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$793.80
|
| Rate for Payer: MDX Hawaii PPO |
$855.54
|
|
|
DRILL BIT JC 4.5MM #03.010.089
|
Facility
|
OP
|
$1,584.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$491.04 |
| Max. Negotiated Rate |
$1,536.48 |
| Rate for Payer: AlohaCare Medicaid |
$792.00
|
| Rate for Payer: AlohaCare Medicare |
$491.04
|
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Devoted Health Medicare |
$538.56
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$491.04
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$1,504.80
|
| Rate for Payer: Health Management Network Commercial |
$1,346.40
|
| Rate for Payer: Humana Medicare |
$491.04
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,425.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$807.84
|
| Rate for Payer: Kaiser Permanente Medicare |
$491.04
|
| Rate for Payer: MDX Hawaii PPO |
$1,536.48
|
| Rate for Payer: Ohana Health Plan Medicaid |
$491.04
|
| Rate for Payer: Ohana Health Plan Medicare |
$491.04
|
| Rate for Payer: UnitedHealthcare Medicare |
$491.04
|
| Rate for Payer: University Health Alliance Commercial |
$1,154.58
|
|
|
DRILL BIT JC 4.5MM #03.010.089
|
Facility
|
IP
|
$1,584.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,346.40 |
| Max. Negotiated Rate |
$1,536.48 |
| Rate for Payer: Cash Price |
$950.40
|
| Rate for Payer: Health Management Network Commercial |
$1,346.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$1,425.60
|
| Rate for Payer: MDX Hawaii PPO |
$1,536.48
|
|
|
DRILL BIT L 122 DIA 3.5 703694
|
Facility
|
OP
|
$924.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$286.44 |
| Max. Negotiated Rate |
$896.28 |
| Rate for Payer: AlohaCare Medicaid |
$462.00
|
| Rate for Payer: AlohaCare Medicare |
$286.44
|
| Rate for Payer: Cash Price |
$554.40
|
| Rate for Payer: Devoted Health Medicare |
$314.16
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$286.44
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$877.80
|
| Rate for Payer: Health Management Network Commercial |
$785.40
|
| Rate for Payer: Humana Medicare |
$286.44
|
| Rate for Payer: Kaiser Permanente Commercial |
$831.60
|
| Rate for Payer: Kaiser Permanente Medicaid |
$471.24
|
| Rate for Payer: Kaiser Permanente Medicare |
$286.44
|
| Rate for Payer: MDX Hawaii PPO |
$896.28
|
| Rate for Payer: Ohana Health Plan Medicaid |
$286.44
|
| Rate for Payer: Ohana Health Plan Medicare |
$286.44
|
| Rate for Payer: UnitedHealthcare Medicare |
$286.44
|
| Rate for Payer: University Health Alliance Commercial |
$673.50
|
|
|
DRILL BIT L 122 DIA 3.5 703694
|
Facility
|
IP
|
$924.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$785.40 |
| Max. Negotiated Rate |
$896.28 |
| Rate for Payer: Cash Price |
$554.40
|
| Rate for Payer: Health Management Network Commercial |
$785.40
|
| Rate for Payer: Kaiser Permanente Commercial |
$831.60
|
| Rate for Payer: MDX Hawaii PPO |
$896.28
|
|
|
DRILL BIT LCKNG MED 3.1 705077
|
Facility
|
OP
|
$986.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$305.66 |
| Max. Negotiated Rate |
$956.42 |
| Rate for Payer: AlohaCare Medicaid |
$493.00
|
| Rate for Payer: AlohaCare Medicare |
$305.66
|
| Rate for Payer: Cash Price |
$591.60
|
| Rate for Payer: Devoted Health Medicare |
$335.24
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$305.66
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$936.70
|
| Rate for Payer: Health Management Network Commercial |
$838.10
|
| Rate for Payer: Humana Medicare |
$305.66
|
| Rate for Payer: Kaiser Permanente Commercial |
$887.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$502.86
|
| Rate for Payer: Kaiser Permanente Medicare |
$305.66
|
| Rate for Payer: MDX Hawaii PPO |
$956.42
|
| Rate for Payer: Ohana Health Plan Medicaid |
$305.66
|
| Rate for Payer: Ohana Health Plan Medicare |
$305.66
|
| Rate for Payer: UnitedHealthcare Medicare |
$305.66
|
| Rate for Payer: University Health Alliance Commercial |
$718.70
|
|
|
DRILL BIT LCKNG MED 3.1 705077
|
Facility
|
IP
|
$986.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$838.10 |
| Max. Negotiated Rate |
$956.42 |
| Rate for Payer: Cash Price |
$591.60
|
| Rate for Payer: Health Management Network Commercial |
$838.10
|
| Rate for Payer: Kaiser Permanente Commercial |
$887.40
|
| Rate for Payer: MDX Hawaii PPO |
$956.42
|
|
|
DRILL BIT LCKNG SHR 2.5 705025
|
Facility
|
IP
|
$1,039.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$883.15 |
| Max. Negotiated Rate |
$1,007.83 |
| Rate for Payer: Cash Price |
$623.40
|
| Rate for Payer: Health Management Network Commercial |
$883.15
|
| Rate for Payer: Kaiser Permanente Commercial |
$935.10
|
| Rate for Payer: MDX Hawaii PPO |
$1,007.83
|
|
|
DRILL BIT LCKNG SHR 2.5 705025
|
Facility
|
OP
|
$1,039.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$322.09 |
| Max. Negotiated Rate |
$1,007.83 |
| Rate for Payer: AlohaCare Medicaid |
$519.50
|
| Rate for Payer: AlohaCare Medicare |
$322.09
|
| Rate for Payer: Cash Price |
$623.40
|
| Rate for Payer: Devoted Health Medicare |
$353.26
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$322.09
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$987.05
|
| Rate for Payer: Health Management Network Commercial |
$883.15
|
| Rate for Payer: Humana Medicare |
$322.09
|
| Rate for Payer: Kaiser Permanente Commercial |
$935.10
|
| Rate for Payer: Kaiser Permanente Medicaid |
$529.89
|
| Rate for Payer: Kaiser Permanente Medicare |
$322.09
|
| Rate for Payer: MDX Hawaii PPO |
$1,007.83
|
| Rate for Payer: Ohana Health Plan Medicaid |
$322.09
|
| Rate for Payer: Ohana Health Plan Medicare |
$322.09
|
| Rate for Payer: UnitedHealthcare Medicare |
$322.09
|
| Rate for Payer: University Health Alliance Commercial |
$757.33
|
|
|
DRILL BIT LONG 2.5
|
Facility
|
OP
|
$600.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$186.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: AlohaCare Medicaid |
$300.00
|
| Rate for Payer: AlohaCare Medicare |
$186.00
|
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Devoted Health Medicare |
$204.00
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$186.00
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$570.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Humana Medicare |
$186.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$540.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$306.00
|
| Rate for Payer: Kaiser Permanente Medicare |
$186.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
| Rate for Payer: Ohana Health Plan Medicaid |
$186.00
|
| Rate for Payer: Ohana Health Plan Medicare |
$186.00
|
| Rate for Payer: UnitedHealthcare Medicare |
$186.00
|
| Rate for Payer: University Health Alliance Commercial |
$437.34
|
|
|
DRILL BIT LONG 2.5
|
Facility
|
IP
|
$600.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$510.00 |
| Max. Negotiated Rate |
$582.00 |
| Rate for Payer: Cash Price |
$360.00
|
| Rate for Payer: Health Management Network Commercial |
$510.00
|
| Rate for Payer: Kaiser Permanente Commercial |
$540.00
|
| Rate for Payer: MDX Hawaii PPO |
$582.00
|
|
|
DRILL BIT QC 1.0X160MM 310.401
|
Facility
|
IP
|
$488.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$414.80 |
| Max. Negotiated Rate |
$473.36 |
| Rate for Payer: Cash Price |
$292.80
|
| Rate for Payer: Health Management Network Commercial |
$414.80
|
| Rate for Payer: Kaiser Permanente Commercial |
$439.20
|
| Rate for Payer: MDX Hawaii PPO |
$473.36
|
|
|
DRILL BIT QC 1.0X160MM 310.401
|
Facility
|
OP
|
$488.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$151.28 |
| Max. Negotiated Rate |
$473.36 |
| Rate for Payer: AlohaCare Medicaid |
$244.00
|
| Rate for Payer: AlohaCare Medicare |
$151.28
|
| Rate for Payer: Cash Price |
$292.80
|
| Rate for Payer: Devoted Health Medicare |
$165.92
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$151.28
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$463.60
|
| Rate for Payer: Health Management Network Commercial |
$414.80
|
| Rate for Payer: Humana Medicare |
$151.28
|
| Rate for Payer: Kaiser Permanente Commercial |
$439.20
|
| Rate for Payer: Kaiser Permanente Medicaid |
$248.88
|
| Rate for Payer: Kaiser Permanente Medicare |
$151.28
|
| Rate for Payer: MDX Hawaii PPO |
$473.36
|
| Rate for Payer: Ohana Health Plan Medicaid |
$151.28
|
| Rate for Payer: Ohana Health Plan Medicare |
$151.28
|
| Rate for Payer: UnitedHealthcare Medicare |
$151.28
|
| Rate for Payer: University Health Alliance Commercial |
$355.70
|
|
|
DRILL BIT QC 1.8X110MM 310.509
|
Facility
|
IP
|
$670.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$569.50 |
| Max. Negotiated Rate |
$649.90 |
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Health Management Network Commercial |
$569.50
|
| Rate for Payer: Kaiser Permanente Commercial |
$603.00
|
| Rate for Payer: MDX Hawaii PPO |
$649.90
|
|
|
DRILL BIT QC 1.8X110MM 310.509
|
Facility
|
OP
|
$670.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$207.70 |
| Max. Negotiated Rate |
$649.90 |
| Rate for Payer: AlohaCare Medicaid |
$335.00
|
| Rate for Payer: AlohaCare Medicare |
$207.70
|
| Rate for Payer: Cash Price |
$402.00
|
| Rate for Payer: Devoted Health Medicare |
$227.80
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$207.70
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$636.50
|
| Rate for Payer: Health Management Network Commercial |
$569.50
|
| Rate for Payer: Humana Medicare |
$207.70
|
| Rate for Payer: Kaiser Permanente Commercial |
$603.00
|
| Rate for Payer: Kaiser Permanente Medicaid |
$341.70
|
| Rate for Payer: Kaiser Permanente Medicare |
$207.70
|
| Rate for Payer: MDX Hawaii PPO |
$649.90
|
| Rate for Payer: Ohana Health Plan Medicaid |
$207.70
|
| Rate for Payer: Ohana Health Plan Medicare |
$207.70
|
| Rate for Payer: UnitedHealthcare Medicare |
$207.70
|
| Rate for Payer: University Health Alliance Commercial |
$488.36
|
|
|
DRILL BIT QC 2.0/65MM 310.201
|
Facility
|
OP
|
$356.00
|
|
|
Service Code
|
HCPCS C1769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$110.36 |
| Max. Negotiated Rate |
$345.32 |
| Rate for Payer: AlohaCare Medicaid |
$178.00
|
| Rate for Payer: AlohaCare Medicare |
$110.36
|
| Rate for Payer: Cash Price |
$213.60
|
| Rate for Payer: Devoted Health Medicare |
$121.04
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$110.36
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$338.20
|
| Rate for Payer: Health Management Network Commercial |
$302.60
|
| Rate for Payer: Humana Medicare |
$110.36
|
| Rate for Payer: Kaiser Permanente Commercial |
$320.40
|
| Rate for Payer: Kaiser Permanente Medicaid |
$181.56
|
| Rate for Payer: Kaiser Permanente Medicare |
$110.36
|
| Rate for Payer: MDX Hawaii PPO |
$345.32
|
| Rate for Payer: Ohana Health Plan Medicaid |
$110.36
|
| Rate for Payer: Ohana Health Plan Medicare |
$110.36
|
| Rate for Payer: UnitedHealthcare Medicare |
$110.36
|
| Rate for Payer: University Health Alliance Commercial |
$259.49
|
|
|
DRILL BIT QC 2.0/65MM 310.201
|
Facility
|
IP
|
$356.00
|
|
|
Service Code
|
HCPCS C1769
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$302.60 |
| Max. Negotiated Rate |
$345.32 |
| Rate for Payer: Cash Price |
$213.60
|
| Rate for Payer: Health Management Network Commercial |
$302.60
|
| Rate for Payer: Kaiser Permanente Commercial |
$320.40
|
| Rate for Payer: MDX Hawaii PPO |
$345.32
|
|
|
DRILL BIT QC 2.0X100MM 310.19
|
Facility
|
OP
|
$361.00
|
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$111.91 |
| Max. Negotiated Rate |
$350.17 |
| Rate for Payer: AlohaCare Medicaid |
$180.50
|
| Rate for Payer: AlohaCare Medicare |
$111.91
|
| Rate for Payer: Cash Price |
$216.60
|
| Rate for Payer: Devoted Health Medicare |
$122.74
|
| Rate for Payer: Hawaii Medical Service Association Medicare |
$111.91
|
| Rate for Payer: Hawaii Western Management Group Commercial |
$342.95
|
| Rate for Payer: Health Management Network Commercial |
$306.85
|
| Rate for Payer: Humana Medicare |
$111.91
|
| Rate for Payer: Kaiser Permanente Commercial |
$324.90
|
| Rate for Payer: Kaiser Permanente Medicaid |
$184.11
|
| Rate for Payer: Kaiser Permanente Medicare |
$111.91
|
| Rate for Payer: MDX Hawaii PPO |
$350.17
|
| Rate for Payer: Ohana Health Plan Medicaid |
$111.91
|
| Rate for Payer: Ohana Health Plan Medicare |
$111.91
|
| Rate for Payer: UnitedHealthcare Medicare |
$111.91
|
| Rate for Payer: University Health Alliance Commercial |
$263.13
|
|