Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

G0283 ESTIM UNATTENDED PT

Facility

$69.00

Service Code	HCPCS G0283 GP,59
Hospital Charge Code	8323308
Hospital Revenue Code	420
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

G0283 UNATTENDED ESTIM

Facility

$69.00

Service Code	HCPCS G0283 GP,CQ
Hospital Charge Code	8323309
Hospital Revenue Code	430
Min. Negotiated Rate	$9.73
Max. Negotiated Rate	$66.93
Rate for Payer: AlohaCare Medicaid	$34.50
Rate for Payer: AlohaCare Medicare	$34.50
Rate for Payer: Cash Price	$44.85
Rate for Payer: Cash Price	$44.85
Rate for Payer: Devoted Health Medicare	$37.95
Rate for Payer: Hawaii Medical Service Association Medicare	$34.50
Rate for Payer: Hawaii Western Management Group Commercial	$65.55
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Humana Medicare	$34.50
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: Kaiser Permanente Medicaid	$35.19
Rate for Payer: Kaiser Permanente Medicare	$34.50
Rate for Payer: MDX Hawaii PPO	$66.93
Rate for Payer: Ohana Health Plan Medicaid	$34.50
Rate for Payer: Ohana Health Plan Medicare	$34.50
Rate for Payer: UnitedHealthcare Medicaid	$9.73
Rate for Payer: UnitedHealthcare Medicare	$34.50
Rate for Payer: University Health Alliance Commercial	$50.29

G0283 UNATTENDED ESTIM

Facility

$69.00

Service Code	HCPCS G0283 GP,CQ
Hospital Charge Code	8323309
Hospital Revenue Code	430
Min. Negotiated Rate	$58.65
Max. Negotiated Rate	$66.93
Rate for Payer: Cash Price	$44.85
Rate for Payer: Health Management Network Commercial	$58.65
Rate for Payer: Kaiser Permanente Commercial	$62.10
Rate for Payer: MDX Hawaii PPO	$66.93

G0316 PROLONG HSP INPT, OBSV E&M BEYOND TOTAL TIME OF PRIM SVC, ADD'L 15 MIN, W/WO PAT CONTACT

Professional

Both

$56.00

Service Code	HCPCS G0316
Hospital Charge Code	10602926
Hospital Revenue Code	960
Min. Negotiated Rate	$27.80
Max. Negotiated Rate	$289.59
Rate for Payer: AlohaCare Medicaid	$30.61
Rate for Payer: AlohaCare Medicare	$27.80
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Devoted Health Medicare	$30.58
Rate for Payer: Hawaii Medical Service Association ABD	$30.61
Rate for Payer: Hawaii Medical Service Association Medicare	$27.80
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.61
Rate for Payer: Hawaii Western Management Group Commercial	$289.59
Rate for Payer: Health Management Network Commercial	$47.60
Rate for Payer: Kaiser Permanente Commercial	$30.58
Rate for Payer: Kaiser Permanente Medicaid	$30.58
Rate for Payer: Kaiser Permanente Medicare	$30.58
Rate for Payer: Ohana Health Plan Medicaid	$30.61
Rate for Payer: Ohana Health Plan Medicare	$27.80
Rate for Payer: UnitedHealthcare Medicaid	$30.61
Rate for Payer: UnitedHealthcare Medicare	$27.80
Rate for Payer: University Health Alliance Commercial	$30.12

G0317 PROLONG NF E&M SVC BEYOND TOTAL TIME OF PRIM SVC, ADD'L 15 MIN, W/WO PAT CONTACT

Professional

Both

$59.00

Service Code	HCPCS G0317
Hospital Charge Code	10602927
Hospital Revenue Code	960
Min. Negotiated Rate	$27.22
Max. Negotiated Rate	$315.26
Rate for Payer: AlohaCare Medicaid	$30.61
Rate for Payer: AlohaCare Medicare	$27.22
Rate for Payer: Cash Price	$38.35
Rate for Payer: Cash Price	$38.35
Rate for Payer: Devoted Health Medicare	$29.94
Rate for Payer: Hawaii Medical Service Association ABD	$30.61
Rate for Payer: Hawaii Medical Service Association Medicare	$27.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$30.61
Rate for Payer: Hawaii Western Management Group Commercial	$315.26
Rate for Payer: Health Management Network Commercial	$50.15
Rate for Payer: Kaiser Permanente Commercial	$29.94
Rate for Payer: Kaiser Permanente Medicaid	$29.94
Rate for Payer: Kaiser Permanente Medicare	$29.94
Rate for Payer: Ohana Health Plan Medicaid	$30.61
Rate for Payer: Ohana Health Plan Medicare	$27.22
Rate for Payer: UnitedHealthcare Medicaid	$30.61
Rate for Payer: UnitedHealthcare Medicare	$27.22
Rate for Payer: University Health Alliance Commercial	$29.75

G0396 Alcohol Subs Interv 15to30 Min TechFee

Facility

$141.00

Service Code	HCPCS G0396
Hospital Charge Code	8343987
Hospital Revenue Code	450
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$91.65
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Kaiser Permanente Commercial	$126.90
Rate for Payer: MDX Hawaii PPO	$136.77

G0396 Alcohol Subs Interv 15to30 Min TechFee

Facility

$141.00

Service Code	HCPCS G0396
Hospital Charge Code	8343987
Hospital Revenue Code	450
Min. Negotiated Rate	$70.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$70.50
Rate for Payer: Cash Price	$91.65
Rate for Payer: Cash Price	$91.65
Rate for Payer: Cash Price	$91.65
Rate for Payer: Devoted Health Medicare	$77.55
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$70.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$133.95
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Humana Medicare	$70.50
Rate for Payer: Kaiser Permanente Commercial	$126.90
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$70.50
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: Ohana Health Plan Medicaid	$70.50
Rate for Payer: Ohana Health Plan Medicare	$70.50
Rate for Payer: UnitedHealthcare Medicare	$70.50
Rate for Payer: University Health Alliance Commercial	$102.77

G0397 Alcohol Subs Interv >30 Min TechFee

Facility

$225.00

Service Code	HCPCS G0397
Hospital Charge Code	8343988
Hospital Revenue Code	450
Min. Negotiated Rate	$191.25
Max. Negotiated Rate	$218.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: MDX Hawaii PPO	$218.25

G0397 Alcohol Subs Interv >30 Min TechFee

Facility

$225.00

Service Code	HCPCS G0397
Hospital Charge Code	8343988
Hospital Revenue Code	450
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$525.09
Rate for Payer: AlohaCare Medicare	$112.50
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Cash Price	$146.25
Rate for Payer: Devoted Health Medicare	$123.75
Rate for Payer: Hawaii Medical Service Association ABD	$588.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$112.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$213.75
Rate for Payer: Health Management Network Commercial	$191.25
Rate for Payer: Humana Medicare	$112.50
Rate for Payer: Kaiser Permanente Commercial	$202.50
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$112.50
Rate for Payer: MDX Hawaii PPO	$218.25
Rate for Payer: Ohana Health Plan Medicaid	$112.50
Rate for Payer: Ohana Health Plan Medicare	$112.50
Rate for Payer: UnitedHealthcare Medicare	$112.50
Rate for Payer: University Health Alliance Commercial	$164.00

G0399 Home sleep test (hst) with type iii portable monitor, unattended

Professional

Both

$273.00

Service Code	HCPCS G0399
Hospital Charge Code	8040954
Hospital Revenue Code	960
Min. Negotiated Rate	$186.59
Max. Negotiated Rate	$232.05
Rate for Payer: Cash Price	$177.45
Rate for Payer: Cash Price	$177.45
Rate for Payer: Hawaii Western Management Group Commercial	$186.59
Rate for Payer: Health Management Network Commercial	$232.05

G0451 - Developmental Test Lim

Facility

$146.00

Service Code	HCPCS G0451 GP,CQ
Hospital Charge Code	8409227
Hospital Revenue Code	440
Min. Negotiated Rate	$69.38
Max. Negotiated Rate	$141.62
Rate for Payer: AlohaCare Medicaid	$73.00
Rate for Payer: AlohaCare Medicare	$73.00
Rate for Payer: Cash Price	$94.90
Rate for Payer: Cash Price	$94.90
Rate for Payer: Devoted Health Medicare	$80.30
Rate for Payer: Hawaii Medical Service Association Medicare	$73.00
Rate for Payer: Hawaii Western Management Group Commercial	$138.70
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Humana Medicare	$73.00
Rate for Payer: Kaiser Permanente Commercial	$131.40
Rate for Payer: Kaiser Permanente Medicaid	$74.46
Rate for Payer: Kaiser Permanente Medicare	$73.00
Rate for Payer: MDX Hawaii PPO	$141.62
Rate for Payer: Ohana Health Plan Medicaid	$73.00
Rate for Payer: Ohana Health Plan Medicare	$73.00
Rate for Payer: UnitedHealthcare Medicaid	$69.38
Rate for Payer: UnitedHealthcare Medicare	$73.00
Rate for Payer: University Health Alliance Commercial	$106.42

G0451 - Developmental Test Lim

Facility

$146.00

Service Code	HCPCS G0451 GP,CQ
Hospital Charge Code	8409227
Hospital Revenue Code	440
Min. Negotiated Rate	$124.10
Max. Negotiated Rate	$141.62
Rate for Payer: Cash Price	$94.90
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Kaiser Permanente Commercial	$131.40
Rate for Payer: MDX Hawaii PPO	$141.62

G0463 Other Outpatient Visit 1 Charges

Facility

$255.00

Service Code	HCPCS G0463
Hospital Charge Code	8221508
Hospital Revenue Code	761
Min. Negotiated Rate	$216.75
Max. Negotiated Rate	$247.35
Rate for Payer: Cash Price	$165.75
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: MDX Hawaii PPO	$247.35

G0463 Other Outpatient Visit 1 Charges

Facility

$255.00

Service Code	HCPCS G0463
Hospital Charge Code	8221508
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$247.35
Rate for Payer: AlohaCare Medicaid	$127.50
Rate for Payer: AlohaCare Medicare	$127.50
Rate for Payer: Cash Price	$165.75
Rate for Payer: Cash Price	$165.75
Rate for Payer: Devoted Health Medicare	$140.25
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$127.50
Rate for Payer: Hawaii Western Management Group Commercial	$242.25
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Humana Medicare	$127.50
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: Kaiser Permanente Medicaid	$130.05
Rate for Payer: Kaiser Permanente Medicare	$127.50
Rate for Payer: MDX Hawaii PPO	$247.35
Rate for Payer: Ohana Health Plan Medicaid	$127.50
Rate for Payer: Ohana Health Plan Medicare	$127.50
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$127.50
Rate for Payer: University Health Alliance Commercial	$185.87

G0463 Other Outpatient Visit 2 Charges

Facility

$255.00

Service Code	HCPCS G0463
Hospital Charge Code	8221518
Hospital Revenue Code	761
Min. Negotiated Rate	$216.75
Max. Negotiated Rate	$247.35
Rate for Payer: Cash Price	$165.75
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: MDX Hawaii PPO	$247.35

G0463 Other Outpatient Visit 2 Charges

Facility

$255.00

Service Code	HCPCS G0463
Hospital Charge Code	8221518
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$247.35
Rate for Payer: AlohaCare Medicaid	$127.50
Rate for Payer: AlohaCare Medicare	$127.50
Rate for Payer: Cash Price	$165.75
Rate for Payer: Cash Price	$165.75
Rate for Payer: Devoted Health Medicare	$140.25
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$127.50
Rate for Payer: Hawaii Western Management Group Commercial	$242.25
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Humana Medicare	$127.50
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: Kaiser Permanente Medicaid	$130.05
Rate for Payer: Kaiser Permanente Medicare	$127.50
Rate for Payer: MDX Hawaii PPO	$247.35
Rate for Payer: Ohana Health Plan Medicaid	$127.50
Rate for Payer: Ohana Health Plan Medicare	$127.50
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$127.50
Rate for Payer: University Health Alliance Commercial	$185.87

G0463 Other Outpatient Visit 3 Charges

Facility

$293.00

Service Code	HCPCS G0463
Hospital Charge Code	8221519
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$284.21
Rate for Payer: AlohaCare Medicaid	$146.50
Rate for Payer: AlohaCare Medicare	$146.50
Rate for Payer: Cash Price	$190.45
Rate for Payer: Cash Price	$190.45
Rate for Payer: Devoted Health Medicare	$161.15
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$146.50
Rate for Payer: Hawaii Western Management Group Commercial	$278.35
Rate for Payer: Health Management Network Commercial	$249.05
Rate for Payer: Humana Medicare	$146.50
Rate for Payer: Kaiser Permanente Commercial	$263.70
Rate for Payer: Kaiser Permanente Medicaid	$149.43
Rate for Payer: Kaiser Permanente Medicare	$146.50
Rate for Payer: MDX Hawaii PPO	$284.21
Rate for Payer: Ohana Health Plan Medicaid	$146.50
Rate for Payer: Ohana Health Plan Medicare	$146.50
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$146.50
Rate for Payer: University Health Alliance Commercial	$213.57

G0463 Other Outpatient Visit 3 Charges

Facility

$293.00

Service Code	HCPCS G0463
Hospital Charge Code	8221519
Hospital Revenue Code	761
Min. Negotiated Rate	$249.05
Max. Negotiated Rate	$284.21
Rate for Payer: Cash Price	$190.45
Rate for Payer: Health Management Network Commercial	$249.05
Rate for Payer: Kaiser Permanente Commercial	$263.70
Rate for Payer: MDX Hawaii PPO	$284.21

G0463 Other Outpatient Visit 4 Charges

Facility

$428.00

Service Code	HCPCS G0463
Hospital Charge Code	8221520
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$311.97

G0463 Other Outpatient Visit 4 Charges

Facility

$428.00

Service Code	HCPCS G0463
Hospital Charge Code	8221520
Hospital Revenue Code	761
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

G0463 Other Outpatient Visit 5 Charges

Facility

$428.00

Service Code	HCPCS G0463
Hospital Charge Code	8221521
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$415.16
Rate for Payer: AlohaCare Medicaid	$214.00
Rate for Payer: AlohaCare Medicare	$214.00
Rate for Payer: Cash Price	$278.20
Rate for Payer: Cash Price	$278.20
Rate for Payer: Devoted Health Medicare	$235.40
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$214.00
Rate for Payer: Hawaii Western Management Group Commercial	$406.60
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Humana Medicare	$214.00
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: Kaiser Permanente Medicaid	$218.28
Rate for Payer: Kaiser Permanente Medicare	$214.00
Rate for Payer: MDX Hawaii PPO	$415.16
Rate for Payer: Ohana Health Plan Medicaid	$214.00
Rate for Payer: Ohana Health Plan Medicare	$214.00
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$214.00
Rate for Payer: University Health Alliance Commercial	$311.97

G0463 Other Outpatient Visit 5 Charges

Facility

$428.00

Service Code	HCPCS G0463
Hospital Charge Code	8221521
Hospital Revenue Code	761
Min. Negotiated Rate	$363.80
Max. Negotiated Rate	$415.16
Rate for Payer: Cash Price	$278.20
Rate for Payer: Health Management Network Commercial	$363.80
Rate for Payer: Kaiser Permanente Commercial	$385.20
Rate for Payer: MDX Hawaii PPO	$415.16

G0463 Other Outpatient Visit New 1 Charges

Facility

$255.00

Service Code	HCPCS G0463
Hospital Charge Code	8221522
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$247.35
Rate for Payer: AlohaCare Medicaid	$127.50
Rate for Payer: AlohaCare Medicare	$127.50
Rate for Payer: Cash Price	$165.75
Rate for Payer: Cash Price	$165.75
Rate for Payer: Devoted Health Medicare	$140.25
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$127.50
Rate for Payer: Hawaii Western Management Group Commercial	$242.25
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Humana Medicare	$127.50
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: Kaiser Permanente Medicaid	$130.05
Rate for Payer: Kaiser Permanente Medicare	$127.50
Rate for Payer: MDX Hawaii PPO	$247.35
Rate for Payer: Ohana Health Plan Medicaid	$127.50
Rate for Payer: Ohana Health Plan Medicare	$127.50
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$127.50
Rate for Payer: University Health Alliance Commercial	$185.87

G0463 Other Outpatient Visit New 1 Charges

Facility

$255.00

Service Code	HCPCS G0463
Hospital Charge Code	8221522
Hospital Revenue Code	761
Min. Negotiated Rate	$216.75
Max. Negotiated Rate	$247.35
Rate for Payer: Cash Price	$165.75
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: MDX Hawaii PPO	$247.35

G0463 Other Outpatient Visit New 2 Charges

Facility

$255.00

Service Code	HCPCS G0463
Hospital Charge Code	8221523
Hospital Revenue Code	761
Min. Negotiated Rate	$96.65
Max. Negotiated Rate	$247.35
Rate for Payer: AlohaCare Medicaid	$127.50
Rate for Payer: AlohaCare Medicare	$127.50
Rate for Payer: Cash Price	$165.75
Rate for Payer: Cash Price	$165.75
Rate for Payer: Devoted Health Medicare	$140.25
Rate for Payer: Hawaii Medical Service Association Commercial	$170.03
Rate for Payer: Hawaii Medical Service Association Medicare	$127.50
Rate for Payer: Hawaii Western Management Group Commercial	$242.25
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Humana Medicare	$127.50
Rate for Payer: Kaiser Permanente Commercial	$229.50
Rate for Payer: Kaiser Permanente Medicaid	$130.05
Rate for Payer: Kaiser Permanente Medicare	$127.50
Rate for Payer: MDX Hawaii PPO	$247.35
Rate for Payer: Ohana Health Plan Medicaid	$127.50
Rate for Payer: Ohana Health Plan Medicare	$127.50
Rate for Payer: UnitedHealthcare Medicaid	$96.65
Rate for Payer: UnitedHealthcare Medicare	$127.50
Rate for Payer: University Health Alliance Commercial	$185.87

Know your out-of-pocket cost for care.

All Charges