Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

L3760 - EO Adj Lcking Jnts Prefab

Facility

$96.00

Service Code	HCPCS L3760
Hospital Charge Code	8409612
Hospital Revenue Code	274
Min. Negotiated Rate	$53.76
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$62.40
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: University Health Alliance Commercial	$53.76

L3760 - EO Adj Lcking Jnts Prefab

Facility

$96.00

Service Code	HCPCS L3760
Hospital Charge Code	8409612
Hospital Revenue Code	274
Min. Negotiated Rate	$48.00
Max. Negotiated Rate	$214.57
Rate for Payer: AlohaCare Medicaid	$48.00
Rate for Payer: AlohaCare Medicare	$48.00
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Devoted Health Medicare	$52.80
Rate for Payer: Hawaii Medical Service Association Medicare	$48.00
Rate for Payer: Hawaii Western Management Group Commercial	$67.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Humana Medicare	$48.00
Rate for Payer: Kaiser Permanente Commercial	$86.40
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: Kaiser Permanente Medicare	$48.00
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: Ohana Health Plan Medicaid	$48.00
Rate for Payer: Ohana Health Plan Medicare	$48.00
Rate for Payer: UnitedHealthcare Medicaid	$214.57
Rate for Payer: UnitedHealthcare Medicare	$48.00
Rate for Payer: University Health Alliance Commercial	$53.76

L3760 - EO Custom Fab Elbow Splint

Facility

$319.00

Service Code	HCPCS L3760
Hospital Charge Code	8409611
Hospital Revenue Code	274
Min. Negotiated Rate	$178.64
Max. Negotiated Rate	$309.43
Rate for Payer: Cash Price	$207.35
Rate for Payer: Hawaii Western Management Group Commercial	$223.30
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: MDX Hawaii PPO	$309.43
Rate for Payer: University Health Alliance Commercial	$178.64

L3760 - EO Custom Fab Elbow Splint

Facility

$319.00

Service Code	HCPCS L3760
Hospital Charge Code	8409611
Hospital Revenue Code	274
Min. Negotiated Rate	$159.50
Max. Negotiated Rate	$309.43
Rate for Payer: AlohaCare Medicaid	$159.50
Rate for Payer: AlohaCare Medicare	$159.50
Rate for Payer: Cash Price	$207.35
Rate for Payer: Cash Price	$207.35
Rate for Payer: Devoted Health Medicare	$175.45
Rate for Payer: Hawaii Medical Service Association Medicare	$159.50
Rate for Payer: Hawaii Western Management Group Commercial	$223.30
Rate for Payer: Health Management Network Commercial	$271.15
Rate for Payer: Humana Medicare	$159.50
Rate for Payer: Kaiser Permanente Commercial	$287.10
Rate for Payer: Kaiser Permanente Medicaid	$162.69
Rate for Payer: Kaiser Permanente Medicare	$159.50
Rate for Payer: MDX Hawaii PPO	$309.43
Rate for Payer: Ohana Health Plan Medicaid	$159.50
Rate for Payer: Ohana Health Plan Medicare	$159.50
Rate for Payer: UnitedHealthcare Medicaid	$214.57
Rate for Payer: UnitedHealthcare Medicare	$159.50
Rate for Payer: University Health Alliance Commercial	$178.64

L3807 - Splint Aqua Plast Sm

Facility

$45.00

Service Code	HCPCS L3807
Hospital Charge Code	8409605
Hospital Revenue Code	274
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$29.25
Rate for Payer: Hawaii Western Management Group Commercial	$31.50
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: University Health Alliance Commercial	$25.20

L3807 - Splint Aqua Plast Sm

Facility

$45.00

Service Code	HCPCS L3807
Hospital Charge Code	8409605
Hospital Revenue Code	274
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$107.29
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$22.50
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Devoted Health Medicare	$24.75
Rate for Payer: Hawaii Medical Service Association Medicare	$22.50
Rate for Payer: Hawaii Western Management Group Commercial	$31.50
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$22.50
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$22.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$22.50
Rate for Payer: Ohana Health Plan Medicare	$22.50
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$22.50
Rate for Payer: University Health Alliance Commercial	$25.20

L3807 - Splint Aqua Plast Sm/Med

Facility

$45.00

Service Code	HCPCS L3807
Hospital Charge Code	8409606
Hospital Revenue Code	274
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$107.29
Rate for Payer: AlohaCare Medicaid	$22.50
Rate for Payer: AlohaCare Medicare	$22.50
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Devoted Health Medicare	$24.75
Rate for Payer: Hawaii Medical Service Association Medicare	$22.50
Rate for Payer: Hawaii Western Management Group Commercial	$31.50
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Humana Medicare	$22.50
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: Kaiser Permanente Medicaid	$22.95
Rate for Payer: Kaiser Permanente Medicare	$22.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: Ohana Health Plan Medicaid	$22.50
Rate for Payer: Ohana Health Plan Medicare	$22.50
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$22.50
Rate for Payer: University Health Alliance Commercial	$25.20

L3807 - Splint Aqua Plast Sm/Med

Facility

$45.00

Service Code	HCPCS L3807
Hospital Charge Code	8409606
Hospital Revenue Code	274
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$43.65
Rate for Payer: Cash Price	$29.25
Rate for Payer: Hawaii Western Management Group Commercial	$31.50
Rate for Payer: Health Management Network Commercial	$38.25
Rate for Payer: Kaiser Permanente Commercial	$40.50
Rate for Payer: MDX Hawaii PPO	$43.65
Rate for Payer: University Health Alliance Commercial	$25.20

L3807 - WHFO MP Ext Assist

Facility

$32.00

Service Code	HCPCS L3807
Hospital Charge Code	8409598
Hospital Revenue Code	274
Min. Negotiated Rate	$17.92
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$20.80
Rate for Payer: Hawaii Western Management Group Commercial	$22.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: University Health Alliance Commercial	$17.92

L3807 - WHFO MP Ext Assist

Facility

$32.00

Service Code	HCPCS L3807
Hospital Charge Code	8409598
Hospital Revenue Code	274
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$107.29
Rate for Payer: AlohaCare Medicaid	$16.00
Rate for Payer: AlohaCare Medicare	$16.00
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Devoted Health Medicare	$17.60
Rate for Payer: Hawaii Medical Service Association Medicare	$16.00
Rate for Payer: Hawaii Western Management Group Commercial	$22.40
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Humana Medicare	$16.00
Rate for Payer: Kaiser Permanente Commercial	$28.80
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicare	$16.00
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: Ohana Health Plan Medicaid	$16.00
Rate for Payer: Ohana Health Plan Medicare	$16.00
Rate for Payer: UnitedHealthcare Medicaid	$107.29
Rate for Payer: UnitedHealthcare Medicare	$16.00
Rate for Payer: University Health Alliance Commercial	$17.92

L3808 - Splint Aqua Plast Med

Facility

$72.00

Service Code	HCPCS L3808
Hospital Charge Code	8409628
Hospital Revenue Code	274
Min. Negotiated Rate	$18.94
Max. Negotiated Rate	$69.84
Rate for Payer: AlohaCare Medicaid	$36.00
Rate for Payer: AlohaCare Medicare	$36.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cash Price	$46.80
Rate for Payer: Devoted Health Medicare	$39.60
Rate for Payer: Hawaii Medical Service Association Medicare	$36.00
Rate for Payer: Hawaii Western Management Group Commercial	$50.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Humana Medicare	$36.00
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: Kaiser Permanente Medicaid	$36.72
Rate for Payer: Kaiser Permanente Medicare	$36.00
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: Ohana Health Plan Medicaid	$36.00
Rate for Payer: Ohana Health Plan Medicare	$36.00
Rate for Payer: UnitedHealthcare Medicaid	$18.94
Rate for Payer: UnitedHealthcare Medicare	$36.00
Rate for Payer: University Health Alliance Commercial	$40.32

L3808 - Splint Aqua Plast Med

Facility

$72.00

Service Code	HCPCS L3808
Hospital Charge Code	8409628
Hospital Revenue Code	274
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$69.84
Rate for Payer: Cash Price	$46.80
Rate for Payer: Hawaii Western Management Group Commercial	$50.40
Rate for Payer: Health Management Network Commercial	$61.20
Rate for Payer: Kaiser Permanente Commercial	$64.80
Rate for Payer: MDX Hawaii PPO	$69.84
Rate for Payer: University Health Alliance Commercial	$40.32

L3900 - WHFO MP Ext Asst MPStp

Facility

$118.00

Service Code	HCPCS L3900
Hospital Charge Code	8409627
Hospital Revenue Code	274
Min. Negotiated Rate	$59.00
Max. Negotiated Rate	$763.00
Rate for Payer: AlohaCare Medicaid	$59.00
Rate for Payer: AlohaCare Medicare	$59.00
Rate for Payer: Cash Price	$76.70
Rate for Payer: Cash Price	$76.70
Rate for Payer: Devoted Health Medicare	$64.90
Rate for Payer: Hawaii Medical Service Association Medicare	$59.00
Rate for Payer: Hawaii Western Management Group Commercial	$82.60
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Humana Medicare	$59.00
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: Kaiser Permanente Medicaid	$60.18
Rate for Payer: Kaiser Permanente Medicare	$59.00
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: Ohana Health Plan Medicaid	$59.00
Rate for Payer: Ohana Health Plan Medicare	$59.00
Rate for Payer: UnitedHealthcare Medicaid	$763.00
Rate for Payer: UnitedHealthcare Medicare	$59.00
Rate for Payer: University Health Alliance Commercial	$66.08

L3900 - WHFO MP Ext Asst MPStp

Facility

$118.00

Service Code	HCPCS L3900
Hospital Charge Code	8409627
Hospital Revenue Code	274
Min. Negotiated Rate	$66.08
Max. Negotiated Rate	$114.46
Rate for Payer: Cash Price	$76.70
Rate for Payer: Hawaii Western Management Group Commercial	$82.60
Rate for Payer: Health Management Network Commercial	$100.30
Rate for Payer: Kaiser Permanente Commercial	$106.20
Rate for Payer: MDX Hawaii PPO	$114.46
Rate for Payer: University Health Alliance Commercial	$66.08

L3913 - Gel Shell Roylan Thumb

Facility

$103.00

Service Code	HCPCS L3913
Hospital Charge Code	8409609
Hospital Revenue Code	274
Min. Negotiated Rate	$51.50
Max. Negotiated Rate	$116.21
Rate for Payer: AlohaCare Medicaid	$51.50
Rate for Payer: AlohaCare Medicare	$51.50
Rate for Payer: Cash Price	$66.95
Rate for Payer: Cash Price	$66.95
Rate for Payer: Devoted Health Medicare	$56.65
Rate for Payer: Hawaii Medical Service Association Medicare	$51.50
Rate for Payer: Hawaii Western Management Group Commercial	$72.10
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Humana Medicare	$51.50
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: Kaiser Permanente Medicaid	$52.53
Rate for Payer: Kaiser Permanente Medicare	$51.50
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: Ohana Health Plan Medicaid	$51.50
Rate for Payer: Ohana Health Plan Medicare	$51.50
Rate for Payer: UnitedHealthcare Medicaid	$116.21
Rate for Payer: UnitedHealthcare Medicare	$51.50
Rate for Payer: University Health Alliance Commercial	$57.68

L3913 - Gel Shell Roylan Thumb

Facility

$103.00

Service Code	HCPCS L3913
Hospital Charge Code	8409609
Hospital Revenue Code	274
Min. Negotiated Rate	$57.68
Max. Negotiated Rate	$99.91
Rate for Payer: Cash Price	$66.95
Rate for Payer: Hawaii Western Management Group Commercial	$72.10
Rate for Payer: Health Management Network Commercial	$87.55
Rate for Payer: Kaiser Permanente Commercial	$92.70
Rate for Payer: MDX Hawaii PPO	$99.91
Rate for Payer: University Health Alliance Commercial	$57.68

L3919 - Roylan Gel Shell Thumb Md

Facility

$106.00

Service Code	HCPCS L3919
Hospital Charge Code	8409610
Hospital Revenue Code	274
Min. Negotiated Rate	$53.00
Max. Negotiated Rate	$116.21
Rate for Payer: AlohaCare Medicaid	$53.00
Rate for Payer: AlohaCare Medicare	$53.00
Rate for Payer: Cash Price	$68.90
Rate for Payer: Cash Price	$68.90
Rate for Payer: Devoted Health Medicare	$58.30
Rate for Payer: Hawaii Medical Service Association Medicare	$53.00
Rate for Payer: Hawaii Western Management Group Commercial	$74.20
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Humana Medicare	$53.00
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: Kaiser Permanente Medicare	$53.00
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: Ohana Health Plan Medicaid	$53.00
Rate for Payer: Ohana Health Plan Medicare	$53.00
Rate for Payer: UnitedHealthcare Medicaid	$116.21
Rate for Payer: UnitedHealthcare Medicare	$53.00
Rate for Payer: University Health Alliance Commercial	$59.36

L3919 - Roylan Gel Shell Thumb Md

Facility

$106.00

Service Code	HCPCS L3919
Hospital Charge Code	8409610
Hospital Revenue Code	274
Min. Negotiated Rate	$59.36
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$68.90
Rate for Payer: Hawaii Western Management Group Commercial	$74.20
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$95.40
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: University Health Alliance Commercial	$59.36

L3923 - Cushion Fngr Contracture

Facility

$24.00

Service Code	HCPCS L3923
Hospital Charge Code	8409601
Hospital Revenue Code	274
Min. Negotiated Rate	$13.44
Max. Negotiated Rate	$23.28
Rate for Payer: Cash Price	$15.60
Rate for Payer: Hawaii Western Management Group Commercial	$16.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: University Health Alliance Commercial	$13.44

L3923 - Cushion Fngr Contracture

Facility

$24.00

Service Code	HCPCS L3923
Hospital Charge Code	8409601
Hospital Revenue Code	274
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$23.28
Rate for Payer: AlohaCare Medicaid	$12.00
Rate for Payer: AlohaCare Medicare	$12.00
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$15.60
Rate for Payer: Devoted Health Medicare	$13.20
Rate for Payer: Hawaii Medical Service Association Medicare	$12.00
Rate for Payer: Hawaii Western Management Group Commercial	$16.80
Rate for Payer: Health Management Network Commercial	$20.40
Rate for Payer: Humana Medicare	$12.00
Rate for Payer: Kaiser Permanente Commercial	$21.60
Rate for Payer: Kaiser Permanente Medicaid	$12.24
Rate for Payer: Kaiser Permanente Medicare	$12.00
Rate for Payer: MDX Hawaii PPO	$23.28
Rate for Payer: Ohana Health Plan Medicaid	$12.00
Rate for Payer: Ohana Health Plan Medicare	$12.00
Rate for Payer: UnitedHealthcare Medicaid	$16.69
Rate for Payer: UnitedHealthcare Medicare	$12.00
Rate for Payer: University Health Alliance Commercial	$13.44

L3933 - HFO Palm Grip

Facility

$35.00

Service Code	HCPCS L3933
Hospital Charge Code	8409603
Hospital Revenue Code	274
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$33.95
Rate for Payer: Cash Price	$22.75
Rate for Payer: Hawaii Western Management Group Commercial	$24.50
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: MDX Hawaii PPO	$33.95
Rate for Payer: University Health Alliance Commercial	$19.60

L3933 - HFO Palm Grip

Facility

$35.00

Service Code	HCPCS L3933
Hospital Charge Code	8409603
Hospital Revenue Code	274
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$91.55
Rate for Payer: AlohaCare Medicaid	$17.50
Rate for Payer: AlohaCare Medicare	$17.50
Rate for Payer: Cash Price	$22.75
Rate for Payer: Cash Price	$22.75
Rate for Payer: Devoted Health Medicare	$19.25
Rate for Payer: Hawaii Medical Service Association Medicare	$17.50
Rate for Payer: Hawaii Western Management Group Commercial	$24.50
Rate for Payer: Health Management Network Commercial	$29.75
Rate for Payer: Humana Medicare	$17.50
Rate for Payer: Kaiser Permanente Commercial	$31.50
Rate for Payer: Kaiser Permanente Medicaid	$17.85
Rate for Payer: Kaiser Permanente Medicare	$17.50
Rate for Payer: MDX Hawaii PPO	$33.95
Rate for Payer: Ohana Health Plan Medicaid	$17.50
Rate for Payer: Ohana Health Plan Medicare	$17.50
Rate for Payer: UnitedHealthcare Medicaid	$91.55
Rate for Payer: UnitedHealthcare Medicare	$17.50
Rate for Payer: University Health Alliance Commercial	$19.60

labetalol 100 mg/20ml vial [HHSC]

Facility

$22.35

Service Code	NDC 00409226725
Hospital Charge Code	2500444
Hospital Revenue Code	250
Min. Negotiated Rate	$11.18
Max. Negotiated Rate	$21.68
Rate for Payer: AlohaCare Medicaid	$11.18
Rate for Payer: AlohaCare Medicare	$11.18
Rate for Payer: Cash Price	$14.53
Rate for Payer: Devoted Health Medicare	$12.29
Rate for Payer: Hawaii Medical Service Association Medicare	$11.18
Rate for Payer: Hawaii Western Management Group Commercial	$21.23
Rate for Payer: Health Management Network Commercial	$19.00
Rate for Payer: Humana Medicare	$11.18
Rate for Payer: Kaiser Permanente Commercial	$20.11
Rate for Payer: Kaiser Permanente Medicaid	$11.40
Rate for Payer: Kaiser Permanente Medicare	$11.18
Rate for Payer: MDX Hawaii PPO	$21.68
Rate for Payer: Ohana Health Plan Medicaid	$11.18
Rate for Payer: Ohana Health Plan Medicare	$11.18
Rate for Payer: UnitedHealthcare Medicaid	$13.41
Rate for Payer: UnitedHealthcare Medicare	$11.18
Rate for Payer: University Health Alliance Commercial	$16.29

labetalol 100 mg/20ml vial [HHSC]

Facility

$14.12

Service Code	NDC 36000032202
Hospital Charge Code	2500444
Hospital Revenue Code	250
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$13.70
Rate for Payer: Cash Price	$9.18
Rate for Payer: Health Management Network Commercial	$12.00
Rate for Payer: Kaiser Permanente Commercial	$12.71
Rate for Payer: MDX Hawaii PPO	$13.70

labetalol 100 mg/20ml vial [HHSC]

Facility

$26.42

Service Code	NDC 00409012525
Hospital Charge Code	2500444
Hospital Revenue Code	250
Min. Negotiated Rate	$13.21
Max. Negotiated Rate	$25.63
Rate for Payer: AlohaCare Medicaid	$13.21
Rate for Payer: AlohaCare Medicare	$13.21
Rate for Payer: Cash Price	$17.17
Rate for Payer: Devoted Health Medicare	$14.53
Rate for Payer: Hawaii Medical Service Association Medicare	$13.21
Rate for Payer: Hawaii Western Management Group Commercial	$25.10
Rate for Payer: Health Management Network Commercial	$22.46
Rate for Payer: Humana Medicare	$13.21
Rate for Payer: Kaiser Permanente Commercial	$23.78
Rate for Payer: Kaiser Permanente Medicaid	$13.47
Rate for Payer: Kaiser Permanente Medicare	$13.21
Rate for Payer: MDX Hawaii PPO	$25.63
Rate for Payer: Ohana Health Plan Medicaid	$13.21
Rate for Payer: Ohana Health Plan Medicare	$13.21
Rate for Payer: UnitedHealthcare Medicaid	$15.85
Rate for Payer: UnitedHealthcare Medicare	$13.21
Rate for Payer: University Health Alliance Commercial	$19.26

Know your out-of-pocket cost for care.

All Charges