Kona Community Hospital

All Charges

Charge

Type

Setting

Price

HCHG RICKETTSIA (TYPHUS FEVER) IGG TITER

Facility

$238.00

Service Code	HCPCS 86757
Hospital Charge Code	H3020970
Hospital Revenue Code	302
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$230.86
Rate for Payer: AlohaCare Medicaid	$19.35
Rate for Payer: AlohaCare Medicare	$19.35
Rate for Payer: Cash Price	$154.70
Rate for Payer: Cash Price	$154.70
Rate for Payer: Devoted Health Medicare	$21.29
Rate for Payer: Hawaii Medical Service Association ABD	$26.75
Rate for Payer: Hawaii Medical Service Association Commercial	$24.19
Rate for Payer: Hawaii Medical Service Association Medicare	$19.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.09
Rate for Payer: Hawaii Western Management Group Commercial	$19.35
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Humana Medicare	$19.35
Rate for Payer: Kaiser Permanente Commercial	$149.94
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: Kaiser Permanente Medicare	$19.35
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: Ohana Health Plan Medicaid	$21.29
Rate for Payer: Ohana Health Plan Medicare	$19.35
Rate for Payer: UnitedHealthcare Medicaid	$26.75
Rate for Payer: UnitedHealthcare Medicare	$19.35
Rate for Payer: University Health Alliance Commercial	$50.04

HCHG RICKETTSIA (TYPHUS FEVER) IGG TITER

Facility

$238.00

Service Code	HCPCS 86757
Hospital Charge Code	H3020970
Hospital Revenue Code	302
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$154.70
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: MDX Hawaii PPO	$230.86

HCHG RICKETTSIA (TYPHUS FEVER) IGM TITER

Facility

$238.00

Service Code	HCPCS 86757
Hospital Charge Code	H3020971
Hospital Revenue Code	302
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$230.86
Rate for Payer: AlohaCare Medicaid	$19.35
Rate for Payer: AlohaCare Medicare	$19.35
Rate for Payer: Cash Price	$154.70
Rate for Payer: Cash Price	$154.70
Rate for Payer: Devoted Health Medicare	$21.29
Rate for Payer: Hawaii Medical Service Association ABD	$26.75
Rate for Payer: Hawaii Medical Service Association Commercial	$24.19
Rate for Payer: Hawaii Medical Service Association Medicare	$19.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.09
Rate for Payer: Hawaii Western Management Group Commercial	$19.35
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: Humana Medicare	$19.35
Rate for Payer: Kaiser Permanente Commercial	$149.94
Rate for Payer: Kaiser Permanente Medicaid	$121.38
Rate for Payer: Kaiser Permanente Medicare	$19.35
Rate for Payer: MDX Hawaii PPO	$230.86
Rate for Payer: Ohana Health Plan Medicaid	$21.29
Rate for Payer: Ohana Health Plan Medicare	$19.35
Rate for Payer: UnitedHealthcare Medicaid	$26.75
Rate for Payer: UnitedHealthcare Medicare	$19.35
Rate for Payer: University Health Alliance Commercial	$50.04

HCHG RICKETTSIA (TYPHUS FEVER) IGM TITER

Facility

$238.00

Service Code	HCPCS 86757
Hospital Charge Code	H3020971
Hospital Revenue Code	302
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$230.86
Rate for Payer: Cash Price	$154.70
Rate for Payer: Health Management Network Commercial	$202.30
Rate for Payer: MDX Hawaii PPO	$230.86

HCHG RISPERIDONE SO

Facility

$353.00

Service Code	HCPCS G0480
Hospital Charge Code	K3010054
Hospital Revenue Code	301
Min. Negotiated Rate	$300.05
Max. Negotiated Rate	$342.41
Rate for Payer: Cash Price	$229.45
Rate for Payer: Health Management Network Commercial	$300.05
Rate for Payer: MDX Hawaii PPO	$342.41

HCHG RISPERIDONE SO

Facility

$353.00

Service Code	HCPCS G0480
Hospital Charge Code	K3010054
Hospital Revenue Code	301
Min. Negotiated Rate	$47.96
Max. Negotiated Rate	$342.41
Rate for Payer: AlohaCare Medicaid	$114.43
Rate for Payer: AlohaCare Medicare	$114.43
Rate for Payer: Cash Price	$229.45
Rate for Payer: Cash Price	$229.45
Rate for Payer: Devoted Health Medicare	$125.87
Rate for Payer: Hawaii Medical Service Association Commercial	$143.04
Rate for Payer: Hawaii Medical Service Association Medicare	$114.43
Rate for Payer: Hawaii Western Management Group Commercial	$335.35
Rate for Payer: Health Management Network Commercial	$300.05
Rate for Payer: Humana Medicare	$114.43
Rate for Payer: Kaiser Permanente Commercial	$222.39
Rate for Payer: Kaiser Permanente Medicaid	$180.03
Rate for Payer: Kaiser Permanente Medicare	$114.43
Rate for Payer: MDX Hawaii PPO	$342.41
Rate for Payer: Ohana Health Plan Medicaid	$125.87
Rate for Payer: Ohana Health Plan Medicare	$114.43
Rate for Payer: UnitedHealthcare Medicaid	$47.96
Rate for Payer: UnitedHealthcare Medicare	$114.43
Rate for Payer: University Health Alliance Commercial	$257.30

HCHG RMVL SUTURES OR STAPLES WO ANESTHESIA

Facility

$263.00

Service Code	HCPCS 15853
Hospital Charge Code	H4501167
Hospital Revenue Code	450
Min. Negotiated Rate	$223.55
Max. Negotiated Rate	$255.11
Rate for Payer: Cash Price	$170.95
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: MDX Hawaii PPO	$255.11

HCHG RMVL SUTURES OR STAPLES WO ANESTHESIA

Facility

$263.00

Service Code	HCPCS 15853
Hospital Charge Code	H4501167
Hospital Revenue Code	450
Min. Negotiated Rate	$165.69
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$170.95
Rate for Payer: Cash Price	$170.95
Rate for Payer: Cash Price	$170.95
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$249.85
Rate for Payer: Health Management Network Commercial	$223.55
Rate for Payer: Kaiser Permanente Commercial	$165.69
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: MDX Hawaii PPO	$255.11
Rate for Payer: University Health Alliance Commercial	$191.70

HCHG RMVL SUTURES & STAPLES WO ANESTHESIA

Facility

$246.00

Service Code	HCPCS 15854
Hospital Charge Code	H4501168
Hospital Revenue Code	450
Min. Negotiated Rate	$209.10
Max. Negotiated Rate	$238.62
Rate for Payer: Cash Price	$159.90
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: MDX Hawaii PPO	$238.62

HCHG RMVL SUTURES & STAPLES WO ANESTHESIA

Facility

$246.00

Service Code	HCPCS 15854
Hospital Charge Code	H4501168
Hospital Revenue Code	450
Min. Negotiated Rate	$154.98
Max. Negotiated Rate	$1,600.00
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$233.70
Rate for Payer: Health Management Network Commercial	$209.10
Rate for Payer: Kaiser Permanente Commercial	$154.98
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: MDX Hawaii PPO	$238.62
Rate for Payer: University Health Alliance Commercial	$179.31

HCHG ROCKY MT SPOTTED FEVER SO

Facility

$318.00

Service Code	HCPCS 86757
Hospital Charge Code	K3020012
Hospital Revenue Code	302
Min. Negotiated Rate	$270.30
Max. Negotiated Rate	$308.46
Rate for Payer: Cash Price	$206.70
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: MDX Hawaii PPO	$308.46

HCHG ROCKY MT SPOTTED FEVER SO

Facility

$318.00

Service Code	HCPCS 86757
Hospital Charge Code	K3020012
Hospital Revenue Code	302
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$308.46
Rate for Payer: AlohaCare Medicaid	$19.35
Rate for Payer: AlohaCare Medicare	$19.35
Rate for Payer: Cash Price	$206.70
Rate for Payer: Cash Price	$206.70
Rate for Payer: Devoted Health Medicare	$21.29
Rate for Payer: Hawaii Medical Service Association ABD	$26.75
Rate for Payer: Hawaii Medical Service Association Commercial	$24.19
Rate for Payer: Hawaii Medical Service Association Medicare	$19.35
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28.09
Rate for Payer: Hawaii Western Management Group Commercial	$19.35
Rate for Payer: Health Management Network Commercial	$270.30
Rate for Payer: Humana Medicare	$19.35
Rate for Payer: Kaiser Permanente Commercial	$200.34
Rate for Payer: Kaiser Permanente Medicaid	$162.18
Rate for Payer: Kaiser Permanente Medicare	$19.35
Rate for Payer: MDX Hawaii PPO	$308.46
Rate for Payer: Ohana Health Plan Medicaid	$21.29
Rate for Payer: Ohana Health Plan Medicare	$19.35
Rate for Payer: UnitedHealthcare Medicaid	$26.75
Rate for Payer: UnitedHealthcare Medicare	$19.35
Rate for Payer: University Health Alliance Commercial	$50.04

HCHG ROHYPNOL SCREEN SO

Facility

$393.00

Service Code	HCPCS 80307
Hospital Charge Code	K3010007
Hospital Revenue Code	301
Min. Negotiated Rate	$334.05
Max. Negotiated Rate	$381.21
Rate for Payer: Cash Price	$255.45
Rate for Payer: Health Management Network Commercial	$334.05
Rate for Payer: MDX Hawaii PPO	$381.21

HCHG ROHYPNOL SCREEN SO

Facility

$393.00

Service Code	HCPCS 80307
Hospital Charge Code	K3010007
Hospital Revenue Code	301
Min. Negotiated Rate	$47.89
Max. Negotiated Rate	$381.21
Rate for Payer: AlohaCare Medicaid	$62.14
Rate for Payer: AlohaCare Medicare	$62.14
Rate for Payer: Cash Price	$255.45
Rate for Payer: Cash Price	$255.45
Rate for Payer: Devoted Health Medicare	$68.35
Rate for Payer: Hawaii Medical Service Association ABD	$59.38
Rate for Payer: Hawaii Medical Service Association Commercial	$77.67
Rate for Payer: Hawaii Medical Service Association Medicare	$62.14
Rate for Payer: Hawaii Medical Service Association Non-ABD	$59.38
Rate for Payer: Hawaii Western Management Group Commercial	$62.14
Rate for Payer: Health Management Network Commercial	$334.05
Rate for Payer: Humana Medicare	$62.14
Rate for Payer: Kaiser Permanente Commercial	$247.59
Rate for Payer: Kaiser Permanente Medicaid	$200.43
Rate for Payer: Kaiser Permanente Medicare	$62.14
Rate for Payer: MDX Hawaii PPO	$381.21
Rate for Payer: Ohana Health Plan Medicaid	$68.35
Rate for Payer: Ohana Health Plan Medicare	$62.14
Rate for Payer: UnitedHealthcare Medicaid	$47.89
Rate for Payer: UnitedHealthcare Medicare	$62.14
Rate for Payer: University Health Alliance Commercial	$147.65

HCHG ROTAVIRUS AG EIA

Facility

$148.00

Service Code	HCPCS 87425
Hospital Charge Code	H3060356
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$143.56
Rate for Payer: AlohaCare Medicaid	$11.98
Rate for Payer: AlohaCare Medicare	$11.98
Rate for Payer: Cash Price	$96.20
Rate for Payer: Cash Price	$96.20
Rate for Payer: Devoted Health Medicare	$13.18
Rate for Payer: Hawaii Medical Service Association ABD	$16.58
Rate for Payer: Hawaii Medical Service Association Commercial	$14.97
Rate for Payer: Hawaii Medical Service Association Medicare	$11.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.41
Rate for Payer: Hawaii Western Management Group Commercial	$11.98
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: Humana Medicare	$11.98
Rate for Payer: Kaiser Permanente Commercial	$93.24
Rate for Payer: Kaiser Permanente Medicaid	$75.48
Rate for Payer: Kaiser Permanente Medicare	$11.98
Rate for Payer: MDX Hawaii PPO	$143.56
Rate for Payer: Ohana Health Plan Medicaid	$13.18
Rate for Payer: Ohana Health Plan Medicare	$11.98
Rate for Payer: UnitedHealthcare Medicaid	$16.58
Rate for Payer: UnitedHealthcare Medicare	$11.98
Rate for Payer: University Health Alliance Commercial	$31.01

HCHG ROTAVIRUS AG EIA

Facility

$148.00

Service Code	HCPCS 87425
Hospital Charge Code	H3060356
Hospital Revenue Code	306
Min. Negotiated Rate	$125.80
Max. Negotiated Rate	$143.56
Rate for Payer: Cash Price	$96.20
Rate for Payer: Health Management Network Commercial	$125.80
Rate for Payer: MDX Hawaii PPO	$143.56

HCHG RPLC GTUBE NO REVJ TRC

Facility

$1,410.00

Service Code	HCPCS 43762
Hospital Charge Code	H4501136
Hospital Revenue Code	450
Min. Negotiated Rate	$1,198.50
Max. Negotiated Rate	$1,367.70
Rate for Payer: Cash Price	$916.50
Rate for Payer: Health Management Network Commercial	$1,198.50
Rate for Payer: MDX Hawaii PPO	$1,367.70

HCHG RPLC GTUBE NO REVJ TRC

Facility

$1,410.00

Service Code	HCPCS 43762
Hospital Charge Code	H4501136
Hospital Revenue Code	450
Min. Negotiated Rate	$295.16
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$295.16
Rate for Payer: AlohaCare Medicare	$295.16
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cash Price	$916.50
Rate for Payer: Devoted Health Medicare	$324.68
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$295.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,339.50
Rate for Payer: Health Management Network Commercial	$1,198.50
Rate for Payer: Humana Medicare	$295.16
Rate for Payer: Kaiser Permanente Commercial	$888.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$295.16
Rate for Payer: MDX Hawaii PPO	$1,367.70
Rate for Payer: Ohana Health Plan Medicaid	$324.68
Rate for Payer: Ohana Health Plan Medicare	$295.16
Rate for Payer: UnitedHealthcare Medicare	$295.16
Rate for Payer: University Health Alliance Commercial	$1,027.75

HCHG RPLC GTUBE NO REVJ TRC

Facility

$1,410.00

Service Code	HCPCS 43762
Hospital Charge Code	H3610690
Hospital Revenue Code	361
Min. Negotiated Rate	$1,198.50
Max. Negotiated Rate	$1,367.70
Rate for Payer: Cash Price	$916.50
Rate for Payer: Health Management Network Commercial	$1,198.50
Rate for Payer: MDX Hawaii PPO	$1,367.70

HCHG RPLC GTUBE NO REVJ TRC

Facility

$1,410.00

Service Code	HCPCS 43762
Hospital Charge Code	H3610690
Hospital Revenue Code	361
Min. Negotiated Rate	$35.99
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$295.16
Rate for Payer: AlohaCare Medicare	$295.16
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cash Price	$916.50
Rate for Payer: Devoted Health Medicare	$324.68
Rate for Payer: Hawaii Medical Service Association Commercial	$368.95
Rate for Payer: Hawaii Medical Service Association Medicare	$295.16
Rate for Payer: Health Management Network Commercial	$1,198.50
Rate for Payer: Humana Medicare	$295.16
Rate for Payer: Kaiser Permanente Commercial	$888.30
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$295.16
Rate for Payer: MDX Hawaii PPO	$1,367.70
Rate for Payer: Ohana Health Plan Medicaid	$324.68
Rate for Payer: Ohana Health Plan Medicare	$295.16
Rate for Payer: UnitedHealthcare Medicaid	$35.99
Rate for Payer: UnitedHealthcare Medicare	$295.16
Rate for Payer: University Health Alliance Commercial	$1,027.75

HCHG RPLC GTUBE REVJ GSTRST TRC

Facility

$1,410.00

Service Code	HCPCS 43763
Hospital Charge Code	H4501137
Hospital Revenue Code	450
Min. Negotiated Rate	$1,198.50
Max. Negotiated Rate	$1,367.70
Rate for Payer: Cash Price	$916.50
Rate for Payer: Health Management Network Commercial	$1,198.50
Rate for Payer: MDX Hawaii PPO	$1,367.70

HCHG RPLC GTUBE REVJ GSTRST TRC

Facility

$1,410.00

Service Code	HCPCS 43763
Hospital Charge Code	H4501137
Hospital Revenue Code	450
Min. Negotiated Rate	$295.16
Max. Negotiated Rate	$1,600.00
Rate for Payer: AlohaCare Medicaid	$295.16
Rate for Payer: AlohaCare Medicare	$295.16
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cash Price	$916.50
Rate for Payer: Cash Price	$916.50
Rate for Payer: Devoted Health Medicare	$324.68
Rate for Payer: Hawaii Medical Service Association ABD	$560.00
Rate for Payer: Hawaii Medical Service Association Commercial	$1,600.00
Rate for Payer: Hawaii Medical Service Association Medicare	$295.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$520.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,339.50
Rate for Payer: Health Management Network Commercial	$1,198.50
Rate for Payer: Humana Medicare	$295.16
Rate for Payer: Kaiser Permanente Commercial	$888.30
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$295.16
Rate for Payer: MDX Hawaii PPO	$1,367.70
Rate for Payer: Ohana Health Plan Medicaid	$324.68
Rate for Payer: Ohana Health Plan Medicare	$295.16
Rate for Payer: UnitedHealthcare Medicare	$295.16
Rate for Payer: University Health Alliance Commercial	$1,027.75

HCHG RPLCMT COMPL PRPH CVC W/O SUBQ PORT/PMP

Facility

$4,880.00

Service Code	HCPCS 36584
Hospital Charge Code	H4501088
Hospital Revenue Code	450
Min. Negotiated Rate	$4,148.00
Max. Negotiated Rate	$4,733.60
Rate for Payer: Cash Price	$3,172.00
Rate for Payer: Health Management Network Commercial	$4,148.00
Rate for Payer: MDX Hawaii PPO	$4,733.60

HCHG RPLCMT COMPL PRPH CVC W/O SUBQ PORT/PMP

Facility

$4,880.00

Service Code	HCPCS 36584
Hospital Charge Code	H4501088
Hospital Revenue Code	450
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$4,733.60
Rate for Payer: AlohaCare Medicaid	$1,859.62
Rate for Payer: AlohaCare Medicare	$1,859.62
Rate for Payer: Cash Price	$3,172.00
Rate for Payer: Cash Price	$3,172.00
Rate for Payer: Cash Price	$3,172.00
Rate for Payer: Devoted Health Medicare	$2,045.58
Rate for Payer: Hawaii Medical Service Association ABD	$393.00
Rate for Payer: Hawaii Medical Service Association Commercial	$2,833.00
Rate for Payer: Hawaii Medical Service Association Medicare	$1,859.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Hawaii Western Management Group Commercial	$4,636.00
Rate for Payer: Health Management Network Commercial	$4,148.00
Rate for Payer: Humana Medicare	$1,859.62
Rate for Payer: Kaiser Permanente Commercial	$3,074.40
Rate for Payer: Kaiser Permanente Medicaid	$937.50
Rate for Payer: Kaiser Permanente Medicare	$1,859.62
Rate for Payer: MDX Hawaii PPO	$4,733.60
Rate for Payer: Ohana Health Plan Medicaid	$2,045.58
Rate for Payer: Ohana Health Plan Medicare	$1,859.62
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$1,859.62
Rate for Payer: University Health Alliance Commercial	$3,557.03

HCHG RP THERAPY IV ADMIN

Facility

$1,547.00

Service Code	HCPCS 79101
Hospital Charge Code	H3420132
Hospital Revenue Code	342
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$1,500.59
Rate for Payer: AlohaCare Medicaid	$275.65
Rate for Payer: AlohaCare Medicare	$275.65
Rate for Payer: Cash Price	$1,005.55
Rate for Payer: Cash Price	$1,005.55
Rate for Payer: Devoted Health Medicare	$303.21
Rate for Payer: Hawaii Medical Service Association ABD	$82.79
Rate for Payer: Hawaii Medical Service Association Commercial	$344.56
Rate for Payer: Hawaii Medical Service Association Medicare	$275.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$91.53
Rate for Payer: Hawaii Western Management Group Commercial	$275.65
Rate for Payer: Health Management Network Commercial	$1,314.95
Rate for Payer: Humana Medicare	$275.65
Rate for Payer: Kaiser Permanente Commercial	$974.61
Rate for Payer: Kaiser Permanente Medicaid	$788.97
Rate for Payer: Kaiser Permanente Medicare	$275.65
Rate for Payer: MDX Hawaii PPO	$1,500.59
Rate for Payer: Ohana Health Plan Medicaid	$303.21
Rate for Payer: Ohana Health Plan Medicare	$275.65
Rate for Payer: UnitedHealthcare Medicaid	$82.79
Rate for Payer: UnitedHealthcare Medicare	$275.65
Rate for Payer: University Health Alliance Commercial	$351.98

Know your out-of-pocket cost for care.

All Charges