Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

Bordatella pertussis/parapertussis DNA FSI

Facility

$758.00

Service Code	HCPCS 87798
Hospital Charge Code	8228845
Hospital Revenue Code	300
Min. Negotiated Rate	$644.30
Max. Negotiated Rate	$735.26
Rate for Payer: Cash Price	$492.70
Rate for Payer: Health Management Network Commercial	$644.30
Rate for Payer: Kaiser Permanente Commercial	$682.20
Rate for Payer: MDX Hawaii PPO	$735.26

Bordetella pertussis DNA FSI

Facility

$86.00

Service Code	HCPCS 86140
Hospital Charge Code	8117865
Hospital Revenue Code	306
Min. Negotiated Rate	$73.10
Max. Negotiated Rate	$83.42
Rate for Payer: Cash Price	$55.90
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Kaiser Permanente Commercial	$77.40
Rate for Payer: MDX Hawaii PPO	$83.42

Bordetella pertussis DNA FSI

Facility

$86.00

Service Code	HCPCS 86140
Hospital Charge Code	8117865
Hospital Revenue Code	306
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$83.42
Rate for Payer: AlohaCare Medicaid	$43.00
Rate for Payer: AlohaCare Medicare	$43.00
Rate for Payer: Cash Price	$55.90
Rate for Payer: Cash Price	$55.90
Rate for Payer: Devoted Health Medicare	$47.30
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$43.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$73.10
Rate for Payer: Humana Medicare	$43.00
Rate for Payer: Kaiser Permanente Commercial	$77.40
Rate for Payer: Kaiser Permanente Medicaid	$43.86
Rate for Payer: Kaiser Permanente Medicare	$43.00
Rate for Payer: MDX Hawaii PPO	$83.42
Rate for Payer: Ohana Health Plan Medicaid	$43.00
Rate for Payer: Ohana Health Plan Medicare	$43.00
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$43.00
Rate for Payer: University Health Alliance Commercial	$13.38

B. pertussis IgA Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916507
Hospital Revenue Code	302
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$98.15
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: MDX Hawaii PPO	$146.47

B. pertussis IgA Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916507
Hospital Revenue Code	302
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$146.47
Rate for Payer: AlohaCare Medicaid	$75.50
Rate for Payer: AlohaCare Medicare	$75.50
Rate for Payer: Cash Price	$98.15
Rate for Payer: Cash Price	$98.15
Rate for Payer: Devoted Health Medicare	$83.05
Rate for Payer: Hawaii Medical Service Association ABD	$11.06
Rate for Payer: Hawaii Medical Service Association Commercial	$16.49
Rate for Payer: Hawaii Medical Service Association Medicare	$75.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.22
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Humana Medicare	$75.50
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: Kaiser Permanente Medicare	$75.50
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: Ohana Health Plan Medicaid	$75.50
Rate for Payer: Ohana Health Plan Medicare	$75.50
Rate for Payer: UnitedHealthcare Medicaid	$11.06
Rate for Payer: UnitedHealthcare Medicare	$75.50
Rate for Payer: University Health Alliance Commercial	$34.10

B. pertussis IgG, IgM, IgA with Rfx Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916508
Hospital Revenue Code	302
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$98.15
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: MDX Hawaii PPO	$146.47

B. pertussis IgG, IgM, IgA with Rfx Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916508
Hospital Revenue Code	302
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$146.47
Rate for Payer: AlohaCare Medicaid	$75.50
Rate for Payer: AlohaCare Medicare	$75.50
Rate for Payer: Cash Price	$98.15
Rate for Payer: Cash Price	$98.15
Rate for Payer: Devoted Health Medicare	$83.05
Rate for Payer: Hawaii Medical Service Association ABD	$11.06
Rate for Payer: Hawaii Medical Service Association Commercial	$16.49
Rate for Payer: Hawaii Medical Service Association Medicare	$75.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.22
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Humana Medicare	$75.50
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: Kaiser Permanente Medicare	$75.50
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: Ohana Health Plan Medicaid	$75.50
Rate for Payer: Ohana Health Plan Medicare	$75.50
Rate for Payer: UnitedHealthcare Medicaid	$11.06
Rate for Payer: UnitedHealthcare Medicare	$75.50
Rate for Payer: University Health Alliance Commercial	$34.10

B. pertussis IgG Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9902025
Hospital Revenue Code	302
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$146.47
Rate for Payer: AlohaCare Medicaid	$75.50
Rate for Payer: AlohaCare Medicare	$75.50
Rate for Payer: Cash Price	$98.15
Rate for Payer: Cash Price	$98.15
Rate for Payer: Devoted Health Medicare	$83.05
Rate for Payer: Hawaii Medical Service Association ABD	$11.06
Rate for Payer: Hawaii Medical Service Association Commercial	$16.49
Rate for Payer: Hawaii Medical Service Association Medicare	$75.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.22
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Humana Medicare	$75.50
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: Kaiser Permanente Medicare	$75.50
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: Ohana Health Plan Medicaid	$75.50
Rate for Payer: Ohana Health Plan Medicare	$75.50
Rate for Payer: UnitedHealthcare Medicaid	$11.06
Rate for Payer: UnitedHealthcare Medicare	$75.50
Rate for Payer: University Health Alliance Commercial	$34.10

B. pertussis IgG Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9902025
Hospital Revenue Code	302
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$98.15
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: MDX Hawaii PPO	$146.47

B. pertussis IgG Reflex Immunoblot FSI

Facility

$78.00

Service Code	HCPCS 86615
Hospital Charge Code	9902024
Hospital Revenue Code	302
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$75.66
Rate for Payer: AlohaCare Medicaid	$39.00
Rate for Payer: AlohaCare Medicare	$39.00
Rate for Payer: Cash Price	$50.70
Rate for Payer: Cash Price	$50.70
Rate for Payer: Devoted Health Medicare	$42.90
Rate for Payer: Hawaii Medical Service Association ABD	$11.06
Rate for Payer: Hawaii Medical Service Association Commercial	$16.49
Rate for Payer: Hawaii Medical Service Association Medicare	$39.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.22
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Humana Medicare	$39.00
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: Kaiser Permanente Medicaid	$39.78
Rate for Payer: Kaiser Permanente Medicare	$39.00
Rate for Payer: MDX Hawaii PPO	$75.66
Rate for Payer: Ohana Health Plan Medicaid	$39.00
Rate for Payer: Ohana Health Plan Medicare	$39.00
Rate for Payer: UnitedHealthcare Medicaid	$11.06
Rate for Payer: UnitedHealthcare Medicare	$39.00
Rate for Payer: University Health Alliance Commercial	$34.10

B. pertussis IgG Reflex Immunoblot FSI

Facility

$78.00

Service Code	HCPCS 86615
Hospital Charge Code	9902024
Hospital Revenue Code	302
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$75.66
Rate for Payer: Cash Price	$50.70
Rate for Payer: Health Management Network Commercial	$66.30
Rate for Payer: Kaiser Permanente Commercial	$70.20
Rate for Payer: MDX Hawaii PPO	$75.66

B. pertussis IgM Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916506
Hospital Revenue Code	302
Min. Negotiated Rate	$11.06
Max. Negotiated Rate	$146.47
Rate for Payer: AlohaCare Medicaid	$75.50
Rate for Payer: AlohaCare Medicare	$75.50
Rate for Payer: Cash Price	$98.15
Rate for Payer: Cash Price	$98.15
Rate for Payer: Devoted Health Medicare	$83.05
Rate for Payer: Hawaii Medical Service Association ABD	$11.06
Rate for Payer: Hawaii Medical Service Association Commercial	$16.49
Rate for Payer: Hawaii Medical Service Association Medicare	$75.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18.22
Rate for Payer: Hawaii Western Management Group Commercial	$13.19
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Humana Medicare	$75.50
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: Kaiser Permanente Medicaid	$77.01
Rate for Payer: Kaiser Permanente Medicare	$75.50
Rate for Payer: MDX Hawaii PPO	$146.47
Rate for Payer: Ohana Health Plan Medicaid	$75.50
Rate for Payer: Ohana Health Plan Medicare	$75.50
Rate for Payer: UnitedHealthcare Medicaid	$11.06
Rate for Payer: UnitedHealthcare Medicare	$75.50
Rate for Payer: University Health Alliance Commercial	$34.10

B. pertussis IgM Immunoblot FSI

Facility

$151.00

Service Code	HCPCS 86615
Hospital Charge Code	9916506
Hospital Revenue Code	302
Min. Negotiated Rate	$128.35
Max. Negotiated Rate	$146.47
Rate for Payer: Cash Price	$98.15
Rate for Payer: Health Management Network Commercial	$128.35
Rate for Payer: Kaiser Permanente Commercial	$135.90
Rate for Payer: MDX Hawaii PPO	$146.47

BRACE CLAVICLE ADL XLGE

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8266934
Hospital Revenue Code	274
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$27.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Hawaii Medical Service Association Medicare	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$27.00
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$27.00
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$27.00
Rate for Payer: Ohana Health Plan Medicare	$27.00
Rate for Payer: UnitedHealthcare Medicaid	$41.53
Rate for Payer: UnitedHealthcare Medicare	$27.00
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE CLAVICLE ADL XLGE

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8266934
Hospital Revenue Code	274
Min. Negotiated Rate	$30.24
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE CLAVICLE ADULT LGE

Facility

$56.00

Service Code	HCPCS L3650
Hospital Charge Code	8267012
Hospital Revenue Code	274
Min. Negotiated Rate	$31.36
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$36.40
Rate for Payer: Hawaii Western Management Group Commercial	$39.20
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: University Health Alliance Commercial	$31.36

BRACE CLAVICLE ADULT LGE

Facility

$56.00

Service Code	HCPCS L3650
Hospital Charge Code	8267012
Hospital Revenue Code	274
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$54.32
Rate for Payer: AlohaCare Medicaid	$28.00
Rate for Payer: AlohaCare Medicare	$28.00
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.80
Rate for Payer: Hawaii Medical Service Association Medicare	$28.00
Rate for Payer: Hawaii Western Management Group Commercial	$39.20
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Humana Medicare	$28.00
Rate for Payer: Kaiser Permanente Commercial	$50.40
Rate for Payer: Kaiser Permanente Medicaid	$28.56
Rate for Payer: Kaiser Permanente Medicare	$28.00
Rate for Payer: MDX Hawaii PPO	$54.32
Rate for Payer: Ohana Health Plan Medicaid	$28.00
Rate for Payer: Ohana Health Plan Medicare	$28.00
Rate for Payer: UnitedHealthcare Medicaid	$41.53
Rate for Payer: UnitedHealthcare Medicare	$28.00
Rate for Payer: University Health Alliance Commercial	$31.36

BRACE CLAVICLE ADULT MED

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8267011
Hospital Revenue Code	274
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$27.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Hawaii Medical Service Association Medicare	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$27.00
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$27.00
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$27.00
Rate for Payer: Ohana Health Plan Medicare	$27.00
Rate for Payer: UnitedHealthcare Medicaid	$41.53
Rate for Payer: UnitedHealthcare Medicare	$27.00
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE CLAVICLE ADULT MED

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8267011
Hospital Revenue Code	274
Min. Negotiated Rate	$30.24
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE CLAVICLE ADULT SML

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8266869
Hospital Revenue Code	274
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$52.38
Rate for Payer: AlohaCare Medicaid	$27.00
Rate for Payer: AlohaCare Medicare	$27.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Hawaii Medical Service Association Medicare	$27.00
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Humana Medicare	$27.00
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: Kaiser Permanente Medicaid	$27.54
Rate for Payer: Kaiser Permanente Medicare	$27.00
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: Ohana Health Plan Medicaid	$27.00
Rate for Payer: Ohana Health Plan Medicare	$27.00
Rate for Payer: UnitedHealthcare Medicaid	$41.53
Rate for Payer: UnitedHealthcare Medicare	$27.00
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE CLAVICLE ADULT SML

Facility

$54.00

Service Code	HCPCS L3650
Hospital Charge Code	8266869
Hospital Revenue Code	274
Min. Negotiated Rate	$30.24
Max. Negotiated Rate	$52.38
Rate for Payer: Cash Price	$35.10
Rate for Payer: Hawaii Western Management Group Commercial	$37.80
Rate for Payer: Health Management Network Commercial	$45.90
Rate for Payer: Kaiser Permanente Commercial	$48.60
Rate for Payer: MDX Hawaii PPO	$52.38
Rate for Payer: University Health Alliance Commercial	$30.24

BRACE LUMB ORTHO RIGID A&P PANEL PREFAB

Facility

$1,651.00

Service Code	HCPCS L0627
Hospital Charge Code	9568326
Hospital Revenue Code	274
Min. Negotiated Rate	$924.56
Max. Negotiated Rate	$1,601.47
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.70
Rate for Payer: Health Management Network Commercial	$1,403.35
Rate for Payer: Kaiser Permanente Commercial	$1,485.90
Rate for Payer: MDX Hawaii PPO	$1,601.47
Rate for Payer: University Health Alliance Commercial	$924.56

BRACE LUMB ORTHO RIGID A&P PANEL PREFAB

Facility

$1,651.00

Service Code	HCPCS L0627
Hospital Charge Code	9568326
Hospital Revenue Code	274
Min. Negotiated Rate	$193.79
Max. Negotiated Rate	$1,601.47
Rate for Payer: AlohaCare Medicaid	$825.50
Rate for Payer: AlohaCare Medicare	$825.50
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Cash Price	$1,073.15
Rate for Payer: Devoted Health Medicare	$908.05
Rate for Payer: Hawaii Medical Service Association Medicare	$825.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.70
Rate for Payer: Health Management Network Commercial	$1,403.35
Rate for Payer: Humana Medicare	$825.50
Rate for Payer: Kaiser Permanente Commercial	$1,485.90
Rate for Payer: Kaiser Permanente Medicaid	$842.01
Rate for Payer: Kaiser Permanente Medicare	$825.50
Rate for Payer: MDX Hawaii PPO	$1,601.47
Rate for Payer: Ohana Health Plan Medicaid	$825.50
Rate for Payer: Ohana Health Plan Medicare	$825.50
Rate for Payer: UnitedHealthcare Medicaid	$193.79
Rate for Payer: UnitedHealthcare Medicare	$825.50
Rate for Payer: University Health Alliance Commercial	$924.56

BRACE TLSO FLEX TRUNK

Facility

$2,262.00

Service Code	HCPCS L0456
Hospital Charge Code	9533608
Hospital Revenue Code	274
Min. Negotiated Rate	$1,266.72
Max. Negotiated Rate	$2,194.14
Rate for Payer: Cash Price	$1,470.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,583.40
Rate for Payer: Health Management Network Commercial	$1,922.70
Rate for Payer: Kaiser Permanente Commercial	$2,035.80
Rate for Payer: MDX Hawaii PPO	$2,194.14
Rate for Payer: University Health Alliance Commercial	$1,266.72

BRACE TLSO FLEX TRUNK

Facility

$2,262.00

Service Code	HCPCS L0456
Hospital Charge Code	9533608
Hospital Revenue Code	274
Min. Negotiated Rate	$468.91
Max. Negotiated Rate	$2,194.14
Rate for Payer: AlohaCare Medicaid	$1,131.00
Rate for Payer: AlohaCare Medicare	$1,131.00
Rate for Payer: Cash Price	$1,470.30
Rate for Payer: Cash Price	$1,470.30
Rate for Payer: Devoted Health Medicare	$1,244.10
Rate for Payer: Hawaii Medical Service Association Medicare	$1,131.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,583.40
Rate for Payer: Health Management Network Commercial	$1,922.70
Rate for Payer: Humana Medicare	$1,131.00
Rate for Payer: Kaiser Permanente Commercial	$2,035.80
Rate for Payer: Kaiser Permanente Medicaid	$1,153.62
Rate for Payer: Kaiser Permanente Medicare	$1,131.00
Rate for Payer: MDX Hawaii PPO	$2,194.14
Rate for Payer: Ohana Health Plan Medicaid	$1,131.00
Rate for Payer: Ohana Health Plan Medicare	$1,131.00
Rate for Payer: UnitedHealthcare Medicaid	$468.91
Rate for Payer: UnitedHealthcare Medicare	$1,131.00
Rate for Payer: University Health Alliance Commercial	$1,266.72

Know your out-of-pocket cost for care.

All Charges