Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

buprenorphine SL 8 mg tablet [HHSC]

Facility

$23.35

Service Code	HCPCS J0571
Hospital Charge Code	2500127
Hospital Revenue Code	250
Min. Negotiated Rate	$19.85
Max. Negotiated Rate	$22.65
Rate for Payer: Cash Price	$15.18
Rate for Payer: Cash Price	$33.07
Rate for Payer: Cash Price	$32.63
Rate for Payer: Cash Price	$10.48
Rate for Payer: Health Management Network Commercial	$42.67
Rate for Payer: Health Management Network Commercial	$13.70
Rate for Payer: Health Management Network Commercial	$19.85
Rate for Payer: Health Management Network Commercial	$43.25
Rate for Payer: Kaiser Permanente Commercial	$21.02
Rate for Payer: Kaiser Permanente Commercial	$45.18
Rate for Payer: Kaiser Permanente Commercial	$14.51
Rate for Payer: Kaiser Permanente Commercial	$45.79
Rate for Payer: MDX Hawaii PPO	$49.35
Rate for Payer: MDX Hawaii PPO	$22.65
Rate for Payer: MDX Hawaii PPO	$15.64
Rate for Payer: MDX Hawaii PPO	$48.69

busPIRone 10 mg tablet [HHSC]

Facility

$7.48

Service Code	NDC 68382018101
Hospital Charge Code	2500130
Hospital Revenue Code	250
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$7.26
Rate for Payer: AlohaCare Medicaid	$3.74
Rate for Payer: AlohaCare Medicare	$3.74
Rate for Payer: Cash Price	$4.86
Rate for Payer: Devoted Health Medicare	$4.11
Rate for Payer: Hawaii Medical Service Association Medicare	$3.74
Rate for Payer: Hawaii Western Management Group Commercial	$7.11
Rate for Payer: Health Management Network Commercial	$6.36
Rate for Payer: Humana Medicare	$3.74
Rate for Payer: Kaiser Permanente Commercial	$6.73
Rate for Payer: Kaiser Permanente Medicaid	$3.81
Rate for Payer: Kaiser Permanente Medicare	$3.74
Rate for Payer: MDX Hawaii PPO	$7.26
Rate for Payer: Ohana Health Plan Medicaid	$3.74
Rate for Payer: Ohana Health Plan Medicare	$3.74
Rate for Payer: UnitedHealthcare Medicaid	$4.49
Rate for Payer: UnitedHealthcare Medicare	$3.74
Rate for Payer: University Health Alliance Commercial	$5.45

busPIRone 10 mg tablet [HHSC]

Facility

$7.48

Service Code	NDC 64380074206
Hospital Charge Code	2500130
Hospital Revenue Code	250
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$7.26
Rate for Payer: AlohaCare Medicaid	$3.74
Rate for Payer: AlohaCare Medicare	$3.74
Rate for Payer: Cash Price	$4.86
Rate for Payer: Devoted Health Medicare	$4.11
Rate for Payer: Hawaii Medical Service Association Medicare	$3.74
Rate for Payer: Hawaii Western Management Group Commercial	$7.11
Rate for Payer: Health Management Network Commercial	$6.36
Rate for Payer: Humana Medicare	$3.74
Rate for Payer: Kaiser Permanente Commercial	$6.73
Rate for Payer: Kaiser Permanente Medicaid	$3.81
Rate for Payer: Kaiser Permanente Medicare	$3.74
Rate for Payer: MDX Hawaii PPO	$7.26
Rate for Payer: Ohana Health Plan Medicaid	$3.74
Rate for Payer: Ohana Health Plan Medicare	$3.74
Rate for Payer: UnitedHealthcare Medicaid	$4.49
Rate for Payer: UnitedHealthcare Medicare	$3.74
Rate for Payer: University Health Alliance Commercial	$5.45

busPIRone 10 mg tablet [HHSC]

Facility

$7.48

Service Code	NDC 68382018101
Hospital Charge Code	2500130
Hospital Revenue Code	250
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$7.26
Rate for Payer: Cash Price	$4.86
Rate for Payer: Health Management Network Commercial	$6.36
Rate for Payer: Kaiser Permanente Commercial	$6.73
Rate for Payer: MDX Hawaii PPO	$7.26

busPIRone 10 mg tablet [HHSC]

Facility

$7.48

Service Code	NDC 64380074206
Hospital Charge Code	2500130
Hospital Revenue Code	250
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$7.26
Rate for Payer: Cash Price	$4.86
Rate for Payer: Health Management Network Commercial	$6.36
Rate for Payer: Kaiser Permanente Commercial	$6.73
Rate for Payer: MDX Hawaii PPO	$7.26

busPIRone 10 mg tablet [HHSC]

Facility

$7.48

Service Code	NDC 51079098620
Hospital Charge Code	2500130
Hospital Revenue Code	250
Min. Negotiated Rate	$6.36
Max. Negotiated Rate	$7.26
Rate for Payer: Cash Price	$4.86
Rate for Payer: Health Management Network Commercial	$6.36
Rate for Payer: Kaiser Permanente Commercial	$6.73
Rate for Payer: MDX Hawaii PPO	$7.26

busPIRone 10 mg tablet [HHSC]

Facility

$7.48

Service Code	NDC 51079098620
Hospital Charge Code	2500130
Hospital Revenue Code	250
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$7.26
Rate for Payer: AlohaCare Medicaid	$3.74
Rate for Payer: AlohaCare Medicare	$3.74
Rate for Payer: Cash Price	$4.86
Rate for Payer: Devoted Health Medicare	$4.11
Rate for Payer: Hawaii Medical Service Association Medicare	$3.74
Rate for Payer: Hawaii Western Management Group Commercial	$7.11
Rate for Payer: Health Management Network Commercial	$6.36
Rate for Payer: Humana Medicare	$3.74
Rate for Payer: Kaiser Permanente Commercial	$6.73
Rate for Payer: Kaiser Permanente Medicaid	$3.81
Rate for Payer: Kaiser Permanente Medicare	$3.74
Rate for Payer: MDX Hawaii PPO	$7.26
Rate for Payer: Ohana Health Plan Medicaid	$3.74
Rate for Payer: Ohana Health Plan Medicare	$3.74
Rate for Payer: UnitedHealthcare Medicaid	$4.49
Rate for Payer: UnitedHealthcare Medicare	$3.74
Rate for Payer: University Health Alliance Commercial	$5.45

butorphanol 1 mg/mL vial [HHSC]

Facility

$26.62

Service Code	HCPCS J0595
Hospital Charge Code	2500132
Hospital Revenue Code	636
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$25.82
Rate for Payer: AlohaCare Medicaid	$13.31
Rate for Payer: AlohaCare Medicare	$13.31
Rate for Payer: Cash Price	$17.30
Rate for Payer: Cash Price	$17.30
Rate for Payer: Devoted Health Medicare	$14.64
Rate for Payer: Hawaii Medical Service Association ABD	$5.05
Rate for Payer: Hawaii Medical Service Association Medicare	$13.31
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.05
Rate for Payer: Hawaii Western Management Group Commercial	$25.29
Rate for Payer: Health Management Network Commercial	$22.63
Rate for Payer: Humana Medicare	$13.31
Rate for Payer: Kaiser Permanente Commercial	$23.96
Rate for Payer: Kaiser Permanente Medicaid	$13.58
Rate for Payer: Kaiser Permanente Medicare	$13.31
Rate for Payer: MDX Hawaii PPO	$25.82
Rate for Payer: Ohana Health Plan Medicaid	$13.31
Rate for Payer: Ohana Health Plan Medicare	$13.31
Rate for Payer: UnitedHealthcare Medicaid	$15.97
Rate for Payer: UnitedHealthcare Medicare	$13.31
Rate for Payer: University Health Alliance Commercial	$19.40

butorphanol 1 mg/mL vial [HHSC]

Facility

$26.62

Service Code	HCPCS J0595
Hospital Charge Code	2500132
Hospital Revenue Code	250
Min. Negotiated Rate	$22.63
Max. Negotiated Rate	$25.82
Rate for Payer: Cash Price	$17.30
Rate for Payer: Health Management Network Commercial	$22.63
Rate for Payer: Kaiser Permanente Commercial	$23.96
Rate for Payer: MDX Hawaii PPO	$25.82

C8921 TTE w or wo Fol w Contr Compl Charge

Facility

$2,589.00

Service Code	HCPCS C8921
Hospital Charge Code	8220672
Hospital Revenue Code	483
Min. Negotiated Rate	$592.55
Max. Negotiated Rate	$2,511.33
Rate for Payer: AlohaCare Medicaid	$1,294.50
Rate for Payer: AlohaCare Medicare	$1,294.50
Rate for Payer: Cash Price	$1,682.85
Rate for Payer: Cash Price	$1,682.85
Rate for Payer: Devoted Health Medicare	$1,423.95
Rate for Payer: Hawaii Medical Service Association Commercial	$1,001.12
Rate for Payer: Hawaii Medical Service Association Medicare	$1,294.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,459.55
Rate for Payer: Health Management Network Commercial	$2,200.65
Rate for Payer: Humana Medicare	$1,294.50
Rate for Payer: Kaiser Permanente Commercial	$2,330.10
Rate for Payer: Kaiser Permanente Medicaid	$1,320.39
Rate for Payer: Kaiser Permanente Medicare	$1,294.50
Rate for Payer: MDX Hawaii PPO	$2,511.33
Rate for Payer: Ohana Health Plan Medicaid	$1,294.50
Rate for Payer: Ohana Health Plan Medicare	$1,294.50
Rate for Payer: UnitedHealthcare Medicaid	$592.55
Rate for Payer: UnitedHealthcare Medicare	$1,294.50
Rate for Payer: University Health Alliance Commercial	$1,887.12

C8921 TTE w or wo Fol w Contr Compl Charge

Facility

$2,589.00

Service Code	HCPCS C8921
Hospital Charge Code	8220672
Hospital Revenue Code	483
Min. Negotiated Rate	$2,200.65
Max. Negotiated Rate	$2,511.33
Rate for Payer: Cash Price	$1,682.85
Rate for Payer: Health Management Network Commercial	$2,200.65
Rate for Payer: Kaiser Permanente Commercial	$2,330.10
Rate for Payer: MDX Hawaii PPO	$2,511.33

C8957 Prolonged IV Inf Req Pump Charge

Facility

$588.00

Service Code	HCPCS C8957
Hospital Charge Code	8220036
Hospital Revenue Code	940
Min. Negotiated Rate	$499.80
Max. Negotiated Rate	$570.36
Rate for Payer: Cash Price	$382.20
Rate for Payer: Health Management Network Commercial	$499.80
Rate for Payer: Kaiser Permanente Commercial	$529.20
Rate for Payer: MDX Hawaii PPO	$570.36

C8957 Prolonged IV Inf Req Pump Charge

Facility

$588.00

Service Code	HCPCS C8957
Hospital Charge Code	8220036
Hospital Revenue Code	940
Min. Negotiated Rate	$248.77
Max. Negotiated Rate	$570.36
Rate for Payer: AlohaCare Medicaid	$294.00
Rate for Payer: AlohaCare Medicare	$294.00
Rate for Payer: Cash Price	$382.20
Rate for Payer: Cash Price	$382.20
Rate for Payer: Devoted Health Medicare	$323.40
Rate for Payer: Hawaii Medical Service Association Commercial	$271.64
Rate for Payer: Hawaii Medical Service Association Medicare	$294.00
Rate for Payer: Hawaii Western Management Group Commercial	$558.60
Rate for Payer: Health Management Network Commercial	$499.80
Rate for Payer: Humana Medicare	$294.00
Rate for Payer: Kaiser Permanente Commercial	$529.20
Rate for Payer: Kaiser Permanente Medicaid	$299.88
Rate for Payer: Kaiser Permanente Medicare	$294.00
Rate for Payer: MDX Hawaii PPO	$570.36
Rate for Payer: Ohana Health Plan Medicaid	$294.00
Rate for Payer: Ohana Health Plan Medicare	$294.00
Rate for Payer: UnitedHealthcare Medicaid	$248.77
Rate for Payer: UnitedHealthcare Medicare	$294.00
Rate for Payer: University Health Alliance Commercial	$428.59

CAGE PLATE, 2.0MM, 2X5 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	12970968
Hospital Revenue Code	278
Min. Negotiated Rate	$731.00
Max. Negotiated Rate	$1,418.14
Rate for Payer: AlohaCare Medicaid	$731.00
Rate for Payer: AlohaCare Medicare	$731.00
Rate for Payer: Cash Price	$950.30
Rate for Payer: Devoted Health Medicare	$804.10
Rate for Payer: Hawaii Medical Service Association Medicare	$731.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,023.40
Rate for Payer: Health Management Network Commercial	$1,242.70
Rate for Payer: Humana Medicare	$731.00
Rate for Payer: Kaiser Permanente Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Medicaid	$745.62
Rate for Payer: Kaiser Permanente Medicare	$731.00
Rate for Payer: MDX Hawaii PPO	$1,418.14
Rate for Payer: Ohana Health Plan Medicaid	$731.00
Rate for Payer: Ohana Health Plan Medicare	$731.00
Rate for Payer: UnitedHealthcare Medicare	$731.00
Rate for Payer: University Health Alliance Commercial	$818.72

CAGE PLATE, 2.0MM, 2X5 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	12970968
Hospital Revenue Code	278
Min. Negotiated Rate	$818.72
Max. Negotiated Rate	$1,418.14
Rate for Payer: Cash Price	$950.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,023.40
Rate for Payer: Health Management Network Commercial	$1,242.70
Rate for Payer: Kaiser Permanente Commercial	$1,315.80
Rate for Payer: MDX Hawaii PPO	$1,418.14
Rate for Payer: University Health Alliance Commercial	$818.72

CAGE PLATE, 2.4MM, 2X5 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	12970971
Hospital Revenue Code	278
Min. Negotiated Rate	$818.72
Max. Negotiated Rate	$1,418.14
Rate for Payer: Cash Price	$950.30
Rate for Payer: Hawaii Western Management Group Commercial	$1,023.40
Rate for Payer: Health Management Network Commercial	$1,242.70
Rate for Payer: Kaiser Permanente Commercial	$1,315.80
Rate for Payer: MDX Hawaii PPO	$1,418.14
Rate for Payer: University Health Alliance Commercial	$818.72

CAGE PLATE, 2.4MM, 2X5 HOLE

Facility

$1,462.00

Service Code	HCPCS C1713
Hospital Charge Code	12970971
Hospital Revenue Code	278
Min. Negotiated Rate	$731.00
Max. Negotiated Rate	$1,418.14
Rate for Payer: AlohaCare Medicaid	$731.00
Rate for Payer: AlohaCare Medicare	$731.00
Rate for Payer: Cash Price	$950.30
Rate for Payer: Devoted Health Medicare	$804.10
Rate for Payer: Hawaii Medical Service Association Medicare	$731.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,023.40
Rate for Payer: Health Management Network Commercial	$1,242.70
Rate for Payer: Humana Medicare	$731.00
Rate for Payer: Kaiser Permanente Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Medicaid	$745.62
Rate for Payer: Kaiser Permanente Medicare	$731.00
Rate for Payer: MDX Hawaii PPO	$1,418.14
Rate for Payer: Ohana Health Plan Medicaid	$731.00
Rate for Payer: Ohana Health Plan Medicare	$731.00
Rate for Payer: UnitedHealthcare Medicare	$731.00
Rate for Payer: University Health Alliance Commercial	$818.72

calamine-zinc 8%-8% topical susp [HHSC]

Facility

$13.07

Service Code	HCPCS A9150
Hospital Charge Code	2501033
Hospital Revenue Code	250
Min. Negotiated Rate	$11.11
Max. Negotiated Rate	$12.68
Rate for Payer: Cash Price	$8.50
Rate for Payer: Cash Price	$6.58
Rate for Payer: Health Management Network Commercial	$8.60
Rate for Payer: Health Management Network Commercial	$11.11
Rate for Payer: Kaiser Permanente Commercial	$9.11
Rate for Payer: Kaiser Permanente Commercial	$11.76
Rate for Payer: MDX Hawaii PPO	$12.68
Rate for Payer: MDX Hawaii PPO	$9.82

calamine-zinc 8%-8% topical susp [HHSC]

Facility

$13.07

Service Code	HCPCS A9150
Hospital Charge Code	2501033
Hospital Revenue Code	637
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$12.68
Rate for Payer: AlohaCare Medicaid	$6.54
Rate for Payer: AlohaCare Medicaid	$5.06
Rate for Payer: AlohaCare Medicare	$5.06
Rate for Payer: AlohaCare Medicare	$6.54
Rate for Payer: Cash Price	$6.58
Rate for Payer: Cash Price	$8.50
Rate for Payer: Devoted Health Medicare	$5.57
Rate for Payer: Devoted Health Medicare	$7.19
Rate for Payer: Hawaii Medical Service Association Medicare	$6.54
Rate for Payer: Hawaii Medical Service Association Medicare	$5.06
Rate for Payer: Hawaii Western Management Group Commercial	$12.42
Rate for Payer: Hawaii Western Management Group Commercial	$9.61
Rate for Payer: Health Management Network Commercial	$8.60
Rate for Payer: Health Management Network Commercial	$11.11
Rate for Payer: Humana Medicare	$5.06
Rate for Payer: Humana Medicare	$6.54
Rate for Payer: Kaiser Permanente Commercial	$9.11
Rate for Payer: Kaiser Permanente Commercial	$11.76
Rate for Payer: Kaiser Permanente Medicaid	$5.16
Rate for Payer: Kaiser Permanente Medicaid	$6.67
Rate for Payer: Kaiser Permanente Medicare	$6.54
Rate for Payer: Kaiser Permanente Medicare	$5.06
Rate for Payer: MDX Hawaii PPO	$12.68
Rate for Payer: MDX Hawaii PPO	$9.82
Rate for Payer: Ohana Health Plan Medicaid	$5.06
Rate for Payer: Ohana Health Plan Medicaid	$6.54
Rate for Payer: Ohana Health Plan Medicare	$5.06
Rate for Payer: Ohana Health Plan Medicare	$6.54
Rate for Payer: UnitedHealthcare Medicare	$5.06
Rate for Payer: UnitedHealthcare Medicare	$6.54
Rate for Payer: University Health Alliance Commercial	$7.38
Rate for Payer: University Health Alliance Commercial	$9.53

calcitriol 0.25 mcg capsule [HHSC]

Facility

$6.72

Service Code	NDC 64380072306
Hospital Charge Code	2500133
Hospital Revenue Code	250
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$6.52
Rate for Payer: AlohaCare Medicaid	$3.36
Rate for Payer: AlohaCare Medicare	$3.36
Rate for Payer: Cash Price	$4.37
Rate for Payer: Devoted Health Medicare	$3.70
Rate for Payer: Hawaii Medical Service Association Medicare	$3.36
Rate for Payer: Hawaii Western Management Group Commercial	$6.38
Rate for Payer: Health Management Network Commercial	$5.71
Rate for Payer: Humana Medicare	$3.36
Rate for Payer: Kaiser Permanente Commercial	$6.05
Rate for Payer: Kaiser Permanente Medicaid	$3.43
Rate for Payer: Kaiser Permanente Medicare	$3.36
Rate for Payer: MDX Hawaii PPO	$6.52
Rate for Payer: Ohana Health Plan Medicaid	$3.36
Rate for Payer: Ohana Health Plan Medicare	$3.36
Rate for Payer: UnitedHealthcare Medicaid	$4.03
Rate for Payer: UnitedHealthcare Medicare	$3.36
Rate for Payer: University Health Alliance Commercial	$4.90

calcitriol 0.25 mcg capsule [HHSC]

Facility

$6.72

Service Code	NDC 64380072306
Hospital Charge Code	2500133
Hospital Revenue Code	250
Min. Negotiated Rate	$5.71
Max. Negotiated Rate	$6.52
Rate for Payer: Cash Price	$4.37
Rate for Payer: Health Management Network Commercial	$5.71
Rate for Payer: Kaiser Permanente Commercial	$6.05
Rate for Payer: MDX Hawaii PPO	$6.52

calcitriol 0.25 mcg capsule [HHSC]

Facility

$4.26

Service Code	NDC 60687034501
Hospital Charge Code	2500133
Hospital Revenue Code	250
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$4.13
Rate for Payer: AlohaCare Medicaid	$2.13
Rate for Payer: AlohaCare Medicare	$2.13
Rate for Payer: Cash Price	$2.77
Rate for Payer: Devoted Health Medicare	$2.34
Rate for Payer: Hawaii Medical Service Association Medicare	$2.13
Rate for Payer: Hawaii Western Management Group Commercial	$4.05
Rate for Payer: Health Management Network Commercial	$3.62
Rate for Payer: Humana Medicare	$2.13
Rate for Payer: Kaiser Permanente Commercial	$3.83
Rate for Payer: Kaiser Permanente Medicaid	$2.17
Rate for Payer: Kaiser Permanente Medicare	$2.13
Rate for Payer: MDX Hawaii PPO	$4.13
Rate for Payer: Ohana Health Plan Medicaid	$2.13
Rate for Payer: Ohana Health Plan Medicare	$2.13
Rate for Payer: UnitedHealthcare Medicaid	$2.56
Rate for Payer: UnitedHealthcare Medicare	$2.13
Rate for Payer: University Health Alliance Commercial	$3.11

calcitriol 0.25 mcg capsule [HHSC]

Facility

$4.26

Service Code	NDC 60687034501
Hospital Charge Code	2500133
Hospital Revenue Code	250
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$4.13
Rate for Payer: Cash Price	$2.77
Rate for Payer: Health Management Network Commercial	$3.62
Rate for Payer: Kaiser Permanente Commercial	$3.83
Rate for Payer: MDX Hawaii PPO	$4.13

calcium acetate 667 mg capsule [HHSC]

Facility

$8.06

Service Code	NDC 68084047901
Hospital Charge Code	2500134
Hospital Revenue Code	250
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$7.82
Rate for Payer: Cash Price	$5.24
Rate for Payer: Health Management Network Commercial	$6.85
Rate for Payer: Kaiser Permanente Commercial	$7.25
Rate for Payer: MDX Hawaii PPO	$7.82

calcium acetate 667 mg capsule [HHSC]

Facility

$8.06

Service Code	NDC 68084047901
Hospital Charge Code	2500134
Hospital Revenue Code	250
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$7.82
Rate for Payer: AlohaCare Medicaid	$4.03
Rate for Payer: AlohaCare Medicare	$4.03
Rate for Payer: Cash Price	$5.24
Rate for Payer: Devoted Health Medicare	$4.43
Rate for Payer: Hawaii Medical Service Association Medicare	$4.03
Rate for Payer: Hawaii Western Management Group Commercial	$7.66
Rate for Payer: Health Management Network Commercial	$6.85
Rate for Payer: Humana Medicare	$4.03
Rate for Payer: Kaiser Permanente Commercial	$7.25
Rate for Payer: Kaiser Permanente Medicaid	$4.11
Rate for Payer: Kaiser Permanente Medicare	$4.03
Rate for Payer: MDX Hawaii PPO	$7.82
Rate for Payer: Ohana Health Plan Medicaid	$4.03
Rate for Payer: Ohana Health Plan Medicare	$4.03
Rate for Payer: UnitedHealthcare Medicaid	$4.84
Rate for Payer: UnitedHealthcare Medicare	$4.03
Rate for Payer: University Health Alliance Commercial	$5.87

Know your out-of-pocket cost for care.

All Charges