Kauai Veterans Memorial Hospital

All Charges

Charge

Type

Setting

Price

TINE PLATE, 2.7MM, 6 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13000861
Hospital Revenue Code	278
Min. Negotiated Rate	$1,054.48
Max. Negotiated Rate	$1,826.51
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: University Health Alliance Commercial	$1,054.48

TINE PLATE, 2.7MM, 6 HOLE

Facility

$1,883.00

Service Code	HCPCS C1713
Hospital Charge Code	13000861
Hospital Revenue Code	278
Min. Negotiated Rate	$941.50
Max. Negotiated Rate	$1,826.51
Rate for Payer: AlohaCare Medicaid	$941.50
Rate for Payer: AlohaCare Medicare	$941.50
Rate for Payer: Cash Price	$1,223.95
Rate for Payer: Devoted Health Medicare	$1,035.65
Rate for Payer: Hawaii Medical Service Association Medicare	$941.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,318.10
Rate for Payer: Health Management Network Commercial	$1,600.55
Rate for Payer: Humana Medicare	$941.50
Rate for Payer: Kaiser Permanente Commercial	$1,694.70
Rate for Payer: Kaiser Permanente Medicaid	$960.33
Rate for Payer: Kaiser Permanente Medicare	$941.50
Rate for Payer: MDX Hawaii PPO	$1,826.51
Rate for Payer: Ohana Health Plan Medicaid	$941.50
Rate for Payer: Ohana Health Plan Medicare	$941.50
Rate for Payer: UnitedHealthcare Medicare	$941.50
Rate for Payer: University Health Alliance Commercial	$1,054.48

TIP INTRAUTERINE MANIPULATOR 6.7MMX 10 CM

Facility

$261.00

Hospital Charge Code	9716417
Hospital Revenue Code	272
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$253.17
Rate for Payer: AlohaCare Medicaid	$130.50
Rate for Payer: AlohaCare Medicare	$130.50
Rate for Payer: Cash Price	$169.65
Rate for Payer: Devoted Health Medicare	$143.55
Rate for Payer: Hawaii Medical Service Association Medicare	$130.50
Rate for Payer: Hawaii Western Management Group Commercial	$247.95
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Humana Medicare	$130.50
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: Kaiser Permanente Medicaid	$133.11
Rate for Payer: Kaiser Permanente Medicare	$130.50
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: Ohana Health Plan Medicaid	$130.50
Rate for Payer: Ohana Health Plan Medicare	$130.50
Rate for Payer: UnitedHealthcare Medicare	$130.50
Rate for Payer: University Health Alliance Commercial	$190.24

TIP INTRAUTERINE MANIPULATOR 6.7MMX 10 CM

Facility

$261.00

Hospital Charge Code	9716417
Hospital Revenue Code	272
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$253.17
Rate for Payer: Cash Price	$169.65
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: MDX Hawaii PPO	$253.17

TIP INTRAUTERINE MANIPULATOR 6.7MMX 12 CM ORANGE RUMI II SYSTEM

Facility

$261.00

Hospital Charge Code	9716418
Hospital Revenue Code	272
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$253.17
Rate for Payer: AlohaCare Medicaid	$130.50
Rate for Payer: AlohaCare Medicare	$130.50
Rate for Payer: Cash Price	$169.65
Rate for Payer: Devoted Health Medicare	$143.55
Rate for Payer: Hawaii Medical Service Association Medicare	$130.50
Rate for Payer: Hawaii Western Management Group Commercial	$247.95
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Humana Medicare	$130.50
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: Kaiser Permanente Medicaid	$133.11
Rate for Payer: Kaiser Permanente Medicare	$130.50
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: Ohana Health Plan Medicaid	$130.50
Rate for Payer: Ohana Health Plan Medicare	$130.50
Rate for Payer: UnitedHealthcare Medicare	$130.50
Rate for Payer: University Health Alliance Commercial	$190.24

TIP INTRAUTERINE MANIPULATOR 6.7MMX 12 CM ORANGE RUMI II SYSTEM

Facility

$261.00

Hospital Charge Code	9716418
Hospital Revenue Code	272
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$253.17
Rate for Payer: Cash Price	$169.65
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: MDX Hawaii PPO	$253.17

TIP INTRAUTERINE MANIPULATOR 6.7MM X 6 CM

Facility

$261.00

Hospital Charge Code	9716415
Hospital Revenue Code	272
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$253.17
Rate for Payer: Cash Price	$169.65
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: MDX Hawaii PPO	$253.17

TIP INTRAUTERINE MANIPULATOR 6.7MM X 6 CM

Facility

$261.00

Hospital Charge Code	9716415
Hospital Revenue Code	272
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$253.17
Rate for Payer: AlohaCare Medicaid	$130.50
Rate for Payer: AlohaCare Medicare	$130.50
Rate for Payer: Cash Price	$169.65
Rate for Payer: Devoted Health Medicare	$143.55
Rate for Payer: Hawaii Medical Service Association Medicare	$130.50
Rate for Payer: Hawaii Western Management Group Commercial	$247.95
Rate for Payer: Health Management Network Commercial	$221.85
Rate for Payer: Humana Medicare	$130.50
Rate for Payer: Kaiser Permanente Commercial	$234.90
Rate for Payer: Kaiser Permanente Medicaid	$133.11
Rate for Payer: Kaiser Permanente Medicare	$130.50
Rate for Payer: MDX Hawaii PPO	$253.17
Rate for Payer: Ohana Health Plan Medicaid	$130.50
Rate for Payer: Ohana Health Plan Medicare	$130.50
Rate for Payer: UnitedHealthcare Medicare	$130.50
Rate for Payer: University Health Alliance Commercial	$190.24

TIP INTRAUTERINE MANIPULATOR 6.7MM X 8 CM

Facility

$288.00

Hospital Charge Code	9716416
Hospital Revenue Code	272
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$187.20
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: MDX Hawaii PPO	$279.36

TIP INTRAUTERINE MANIPULATOR 6.7MM X 8 CM

Facility

$288.00

Hospital Charge Code	9716416
Hospital Revenue Code	272
Min. Negotiated Rate	$144.00
Max. Negotiated Rate	$279.36
Rate for Payer: AlohaCare Medicaid	$144.00
Rate for Payer: AlohaCare Medicare	$144.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Devoted Health Medicare	$158.40
Rate for Payer: Hawaii Medical Service Association Medicare	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$273.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Humana Medicare	$144.00
Rate for Payer: Kaiser Permanente Commercial	$259.20
Rate for Payer: Kaiser Permanente Medicaid	$146.88
Rate for Payer: Kaiser Permanente Medicare	$144.00
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: Ohana Health Plan Medicaid	$144.00
Rate for Payer: Ohana Health Plan Medicare	$144.00
Rate for Payer: UnitedHealthcare Medicare	$144.00
Rate for Payer: University Health Alliance Commercial	$209.92

TIP UTERINE MANIPULATOR 3.75CM

Facility

$356.00

Hospital Charge Code	9715513
Hospital Revenue Code	272
Min. Negotiated Rate	$302.60
Max. Negotiated Rate	$345.32
Rate for Payer: Cash Price	$231.40
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

TIP UTERINE MANIPULATOR 3.75CM

Facility

$356.00

Hospital Charge Code	9715513
Hospital Revenue Code	272
Min. Negotiated Rate	$178.00
Max. Negotiated Rate	$345.32
Rate for Payer: AlohaCare Medicaid	$178.00
Rate for Payer: AlohaCare Medicare	$178.00
Rate for Payer: Cash Price	$231.40
Rate for Payer: Devoted Health Medicare	$195.80
Rate for Payer: Hawaii Medical Service Association Medicare	$178.00
Rate for Payer: Hawaii Western Management Group Commercial	$338.20
Rate for Payer: Health Management Network Commercial	$302.60
Rate for Payer: Humana Medicare	$178.00
Rate for Payer: Kaiser Permanente Commercial	$320.40
Rate for Payer: Kaiser Permanente Medicaid	$181.56
Rate for Payer: Kaiser Permanente Medicare	$178.00
Rate for Payer: MDX Hawaii PPO	$345.32
Rate for Payer: Ohana Health Plan Medicaid	$178.00
Rate for Payer: Ohana Health Plan Medicare	$178.00
Rate for Payer: UnitedHealthcare Medicare	$178.00
Rate for Payer: University Health Alliance Commercial	$259.49

Tissue Transglutaminase Antibody IgA, tTG IgA, TG2 IgA, Native tTG, Human RGC Ttg FSI

Facility

$699.00

Service Code	HCPCS 83516
Hospital Charge Code	8118060
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$678.03
Rate for Payer: AlohaCare Medicaid	$349.50
Rate for Payer: AlohaCare Medicare	$349.50
Rate for Payer: Cash Price	$454.35
Rate for Payer: Cash Price	$454.35
Rate for Payer: Devoted Health Medicare	$384.45
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$349.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Humana Medicare	$349.50
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: Kaiser Permanente Medicaid	$356.49
Rate for Payer: Kaiser Permanente Medicare	$349.50
Rate for Payer: MDX Hawaii PPO	$678.03
Rate for Payer: Ohana Health Plan Medicaid	$349.50
Rate for Payer: Ohana Health Plan Medicare	$349.50
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$349.50
Rate for Payer: University Health Alliance Commercial	$29.82

Tissue Transglutaminase Antibody IgA, tTG IgA, TG2 IgA, Native tTG, Human RGC Ttg FSI

Facility

$699.00

Service Code	HCPCS 83516
Hospital Charge Code	8118060
Hospital Revenue Code	301
Min. Negotiated Rate	$594.15
Max. Negotiated Rate	$678.03
Rate for Payer: Cash Price	$454.35
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: MDX Hawaii PPO	$678.03

Tissue transglutaminase IgA Rfx Endomysial IgA Titer FSI

Facility

$699.00

Service Code	HCPCS 83516
Hospital Charge Code	8228926
Hospital Revenue Code	301
Min. Negotiated Rate	$11.53
Max. Negotiated Rate	$678.03
Rate for Payer: AlohaCare Medicaid	$349.50
Rate for Payer: AlohaCare Medicare	$349.50
Rate for Payer: Cash Price	$454.35
Rate for Payer: Cash Price	$454.35
Rate for Payer: Devoted Health Medicare	$384.45
Rate for Payer: Hawaii Medical Service Association ABD	$15.95
Rate for Payer: Hawaii Medical Service Association Commercial	$14.41
Rate for Payer: Hawaii Medical Service Association Medicare	$349.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16.75
Rate for Payer: Hawaii Western Management Group Commercial	$11.53
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Humana Medicare	$349.50
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: Kaiser Permanente Medicaid	$356.49
Rate for Payer: Kaiser Permanente Medicare	$349.50
Rate for Payer: MDX Hawaii PPO	$678.03
Rate for Payer: Ohana Health Plan Medicaid	$349.50
Rate for Payer: Ohana Health Plan Medicare	$349.50
Rate for Payer: UnitedHealthcare Medicaid	$15.95
Rate for Payer: UnitedHealthcare Medicare	$349.50
Rate for Payer: University Health Alliance Commercial	$29.82

Tissue transglutaminase IgA Rfx Endomysial IgA Titer FSI

Facility

$699.00

Service Code	HCPCS 83516
Hospital Charge Code	8228926
Hospital Revenue Code	301
Min. Negotiated Rate	$594.15
Max. Negotiated Rate	$678.03
Rate for Payer: Cash Price	$454.35
Rate for Payer: Health Management Network Commercial	$594.15
Rate for Payer: Kaiser Permanente Commercial	$629.10
Rate for Payer: MDX Hawaii PPO	$678.03

TLSO FLEX TRNK SC TO SCAP SPN PRFAB

Facility

$2,761.00

Service Code	HCPCS L0456
Hospital Charge Code	10046949
Hospital Revenue Code	274
Min. Negotiated Rate	$1,546.16
Max. Negotiated Rate	$2,678.17
Rate for Payer: Cash Price	$1,794.65
Rate for Payer: Hawaii Western Management Group Commercial	$1,932.70
Rate for Payer: Health Management Network Commercial	$2,346.85
Rate for Payer: Kaiser Permanente Commercial	$2,484.90
Rate for Payer: MDX Hawaii PPO	$2,678.17
Rate for Payer: University Health Alliance Commercial	$1,546.16

TLSO FLEX TRNK SC TO SCAP SPN PRFAB

Facility

$2,761.00

Service Code	HCPCS L0456
Hospital Charge Code	10046949
Hospital Revenue Code	274
Min. Negotiated Rate	$468.91
Max. Negotiated Rate	$2,678.17
Rate for Payer: AlohaCare Medicaid	$1,380.50
Rate for Payer: AlohaCare Medicare	$1,380.50
Rate for Payer: Cash Price	$1,794.65
Rate for Payer: Cash Price	$1,794.65
Rate for Payer: Devoted Health Medicare	$1,518.55
Rate for Payer: Hawaii Medical Service Association Medicare	$1,380.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,932.70
Rate for Payer: Health Management Network Commercial	$2,346.85
Rate for Payer: Humana Medicare	$1,380.50
Rate for Payer: Kaiser Permanente Commercial	$2,484.90
Rate for Payer: Kaiser Permanente Medicaid	$1,408.11
Rate for Payer: Kaiser Permanente Medicare	$1,380.50
Rate for Payer: MDX Hawaii PPO	$2,678.17
Rate for Payer: Ohana Health Plan Medicaid	$1,380.50
Rate for Payer: Ohana Health Plan Medicare	$1,380.50
Rate for Payer: UnitedHealthcare Medicaid	$468.91
Rate for Payer: UnitedHealthcare Medicare	$1,380.50
Rate for Payer: University Health Alliance Commercial	$1,546.16

TLSO TRIPLANER HYPREXT RIGD FRME

Facility

$2,475.00

Service Code	HCPCS L0635
Hospital Charge Code	10046947
Hospital Revenue Code	274
Min. Negotiated Rate	$844.18
Max. Negotiated Rate	$2,400.75
Rate for Payer: AlohaCare Medicaid	$1,237.50
Rate for Payer: AlohaCare Medicare	$1,237.50
Rate for Payer: Cash Price	$1,608.75
Rate for Payer: Cash Price	$1,608.75
Rate for Payer: Devoted Health Medicare	$1,361.25
Rate for Payer: Hawaii Medical Service Association Medicare	$1,237.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,732.50
Rate for Payer: Health Management Network Commercial	$2,103.75
Rate for Payer: Humana Medicare	$1,237.50
Rate for Payer: Kaiser Permanente Commercial	$2,227.50
Rate for Payer: Kaiser Permanente Medicaid	$1,262.25
Rate for Payer: Kaiser Permanente Medicare	$1,237.50
Rate for Payer: MDX Hawaii PPO	$2,400.75
Rate for Payer: Ohana Health Plan Medicaid	$1,237.50
Rate for Payer: Ohana Health Plan Medicare	$1,237.50
Rate for Payer: UnitedHealthcare Medicaid	$844.18
Rate for Payer: UnitedHealthcare Medicare	$1,237.50
Rate for Payer: University Health Alliance Commercial	$1,386.00

TLSO TRIPLANER HYPREXT RIGD FRME

Facility

$2,475.00

Service Code	HCPCS L0635
Hospital Charge Code	10046947
Hospital Revenue Code	274
Min. Negotiated Rate	$1,386.00
Max. Negotiated Rate	$2,400.75
Rate for Payer: Cash Price	$1,608.75
Rate for Payer: Hawaii Western Management Group Commercial	$1,732.50
Rate for Payer: Health Management Network Commercial	$2,103.75
Rate for Payer: Kaiser Permanente Commercial	$2,227.50
Rate for Payer: MDX Hawaii PPO	$2,400.75
Rate for Payer: University Health Alliance Commercial	$1,386.00

TLSO TRIPLANR 3 SHELL ANT-STERNL

Facility

$3,299.00

Service Code	HCPCS L0484
Hospital Charge Code	11435328
Hospital Revenue Code	278
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$3,200.03
Rate for Payer: AlohaCare Medicaid	$1,649.50
Rate for Payer: AlohaCare Medicare	$1,649.50
Rate for Payer: Cash Price	$2,144.35
Rate for Payer: Cash Price	$2,144.35
Rate for Payer: Devoted Health Medicare	$1,814.45
Rate for Payer: Hawaii Medical Service Association Medicare	$1,649.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,309.30
Rate for Payer: Health Management Network Commercial	$2,804.15
Rate for Payer: Humana Medicare	$1,649.50
Rate for Payer: Kaiser Permanente Commercial	$2,969.10
Rate for Payer: Kaiser Permanente Medicaid	$1,682.49
Rate for Payer: Kaiser Permanente Medicare	$1,649.50
Rate for Payer: MDX Hawaii PPO	$3,200.03
Rate for Payer: Ohana Health Plan Medicaid	$1,649.50
Rate for Payer: Ohana Health Plan Medicare	$1,649.50
Rate for Payer: UnitedHealthcare Medicaid	$1.00
Rate for Payer: UnitedHealthcare Medicare	$1,649.50
Rate for Payer: University Health Alliance Commercial	$1,847.44

TLSO TRIPLANR 3 SHELL ANT-STERNL

Facility

$3,299.00

Service Code	HCPCS L0484
Hospital Charge Code	11435328
Hospital Revenue Code	278
Min. Negotiated Rate	$1,847.44
Max. Negotiated Rate	$3,200.03
Rate for Payer: Cash Price	$2,144.35
Rate for Payer: Hawaii Western Management Group Commercial	$2,309.30
Rate for Payer: Health Management Network Commercial	$2,804.15
Rate for Payer: Kaiser Permanente Commercial	$2,969.10
Rate for Payer: MDX Hawaii PPO	$3,200.03
Rate for Payer: University Health Alliance Commercial	$1,847.44

TLSO TRIPLANR 4 SHELL ANT-STERNL

Facility

$3,927.00

Service Code	HCPCS L0464
Hospital Charge Code	10120415
Hospital Revenue Code	274
Min. Negotiated Rate	$2,199.12
Max. Negotiated Rate	$3,809.19
Rate for Payer: Cash Price	$2,552.55
Rate for Payer: Hawaii Western Management Group Commercial	$2,748.90
Rate for Payer: Health Management Network Commercial	$3,337.95
Rate for Payer: Kaiser Permanente Commercial	$3,534.30
Rate for Payer: MDX Hawaii PPO	$3,809.19
Rate for Payer: University Health Alliance Commercial	$2,199.12

TLSO TRIPLANR 4 SHELL ANT-STERNL

Facility

$3,927.00

Service Code	HCPCS L0464
Hospital Charge Code	10120415
Hospital Revenue Code	274
Min. Negotiated Rate	$700.78
Max. Negotiated Rate	$3,809.19
Rate for Payer: AlohaCare Medicaid	$1,963.50
Rate for Payer: AlohaCare Medicare	$1,963.50
Rate for Payer: Cash Price	$2,552.55
Rate for Payer: Cash Price	$2,552.55
Rate for Payer: Devoted Health Medicare	$2,159.85
Rate for Payer: Hawaii Medical Service Association Medicare	$1,963.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,748.90
Rate for Payer: Health Management Network Commercial	$3,337.95
Rate for Payer: Humana Medicare	$1,963.50
Rate for Payer: Kaiser Permanente Commercial	$3,534.30
Rate for Payer: Kaiser Permanente Medicaid	$2,002.77
Rate for Payer: Kaiser Permanente Medicare	$1,963.50
Rate for Payer: MDX Hawaii PPO	$3,809.19
Rate for Payer: Ohana Health Plan Medicaid	$1,963.50
Rate for Payer: Ohana Health Plan Medicare	$1,963.50
Rate for Payer: UnitedHealthcare Medicaid	$700.78
Rate for Payer: UnitedHealthcare Medicare	$1,963.50
Rate for Payer: University Health Alliance Commercial	$2,199.12

tobra-dex 0.3-0.1% ophth susp 2.5ml [HHSC]

Facility

$352.94

Service Code	NDC 61314064725
Hospital Charge Code	2500225
Hospital Revenue Code	250
Min. Negotiated Rate	$176.47
Max. Negotiated Rate	$342.35
Rate for Payer: AlohaCare Medicaid	$176.47
Rate for Payer: AlohaCare Medicare	$176.47
Rate for Payer: Cash Price	$229.41
Rate for Payer: Devoted Health Medicare	$194.12
Rate for Payer: Hawaii Medical Service Association Medicare	$176.47
Rate for Payer: Hawaii Western Management Group Commercial	$335.29
Rate for Payer: Health Management Network Commercial	$300.00
Rate for Payer: Humana Medicare	$176.47
Rate for Payer: Kaiser Permanente Commercial	$317.65
Rate for Payer: Kaiser Permanente Medicaid	$180.00
Rate for Payer: Kaiser Permanente Medicare	$176.47
Rate for Payer: MDX Hawaii PPO	$342.35
Rate for Payer: Ohana Health Plan Medicaid	$176.47
Rate for Payer: Ohana Health Plan Medicare	$176.47
Rate for Payer: UnitedHealthcare Medicaid	$211.76
Rate for Payer: UnitedHealthcare Medicare	$176.47
Rate for Payer: University Health Alliance Commercial	$257.26

Know your out-of-pocket cost for care.

All Charges