Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

DISP LEG HOLDERS

Facility

$66.00

Hospital Charge Code	9916426
Hospital Revenue Code	270
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$64.02
Rate for Payer: AlohaCare Medicaid	$33.00
Rate for Payer: AlohaCare Medicare	$33.00
Rate for Payer: Cash Price	$42.90
Rate for Payer: Devoted Health Medicare	$36.30
Rate for Payer: Hawaii Medical Service Association Medicare	$33.00
Rate for Payer: Hawaii Western Management Group Commercial	$62.70
Rate for Payer: Health Management Network Commercial	$56.10
Rate for Payer: Humana Medicare	$33.00
Rate for Payer: Kaiser Permanente Commercial	$59.40
Rate for Payer: Kaiser Permanente Medicaid	$33.66
Rate for Payer: Kaiser Permanente Medicare	$33.00
Rate for Payer: MDX Hawaii PPO	$64.02
Rate for Payer: Ohana Health Plan Medicaid	$33.00
Rate for Payer: Ohana Health Plan Medicare	$33.00
Rate for Payer: UnitedHealthcare Medicare	$33.00
Rate for Payer: University Health Alliance Commercial	$48.11

DISP. SUCTION IRRIGATOR STRYKER

Facility

$217.00

Hospital Charge Code	10109438
Hospital Revenue Code	272
Min. Negotiated Rate	$184.45
Max. Negotiated Rate	$210.49
Rate for Payer: Cash Price	$141.05
Rate for Payer: Health Management Network Commercial	$184.45
Rate for Payer: Kaiser Permanente Commercial	$195.30
Rate for Payer: MDX Hawaii PPO	$210.49

DISP. SUCTION IRRIGATOR STRYKER

Facility

$217.00

Hospital Charge Code	10109438
Hospital Revenue Code	272
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$210.49
Rate for Payer: AlohaCare Medicaid	$108.50
Rate for Payer: AlohaCare Medicare	$108.50
Rate for Payer: Cash Price	$141.05
Rate for Payer: Devoted Health Medicare	$119.35
Rate for Payer: Hawaii Medical Service Association Medicare	$108.50
Rate for Payer: Hawaii Western Management Group Commercial	$206.15
Rate for Payer: Health Management Network Commercial	$184.45
Rate for Payer: Humana Medicare	$108.50
Rate for Payer: Kaiser Permanente Commercial	$195.30
Rate for Payer: Kaiser Permanente Medicaid	$110.67
Rate for Payer: Kaiser Permanente Medicare	$108.50
Rate for Payer: MDX Hawaii PPO	$210.49
Rate for Payer: Ohana Health Plan Medicaid	$108.50
Rate for Payer: Ohana Health Plan Medicare	$108.50
Rate for Payer: UnitedHealthcare Medicare	$108.50
Rate for Payer: University Health Alliance Commercial	$158.17

DISP. SUCTION IRRIGATOR TIP STRYKER

Facility

$107.00

Hospital Charge Code	10109436
Hospital Revenue Code	272
Min. Negotiated Rate	$53.50
Max. Negotiated Rate	$103.79
Rate for Payer: AlohaCare Medicaid	$53.50
Rate for Payer: AlohaCare Medicare	$53.50
Rate for Payer: Cash Price	$69.55
Rate for Payer: Devoted Health Medicare	$58.85
Rate for Payer: Hawaii Medical Service Association Medicare	$53.50
Rate for Payer: Hawaii Western Management Group Commercial	$101.65
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Humana Medicare	$53.50
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: Kaiser Permanente Medicaid	$54.57
Rate for Payer: Kaiser Permanente Medicare	$53.50
Rate for Payer: MDX Hawaii PPO	$103.79
Rate for Payer: Ohana Health Plan Medicaid	$53.50
Rate for Payer: Ohana Health Plan Medicare	$53.50
Rate for Payer: UnitedHealthcare Medicare	$53.50
Rate for Payer: University Health Alliance Commercial	$77.99

DISP. SUCTION IRRIGATOR TIP STRYKER

Facility

$107.00

Hospital Charge Code	10109436
Hospital Revenue Code	272
Min. Negotiated Rate	$90.95
Max. Negotiated Rate	$103.79
Rate for Payer: Cash Price	$69.55
Rate for Payer: Health Management Network Commercial	$90.95
Rate for Payer: Kaiser Permanente Commercial	$96.30
Rate for Payer: MDX Hawaii PPO	$103.79

DISSECTOR, SPACEMAKER HERNIA BILATERAL 10MM-12MM

Facility

$1,629.00

Service Code	HCPCS C1727
Hospital Charge Code	8274225
Hospital Revenue Code	272
Min. Negotiated Rate	$1,384.65
Max. Negotiated Rate	$1,580.13
Rate for Payer: Cash Price	$1,058.85
Rate for Payer: Health Management Network Commercial	$1,384.65
Rate for Payer: Kaiser Permanente Commercial	$1,466.10
Rate for Payer: MDX Hawaii PPO	$1,580.13

DISSECTOR, SPACEMAKER HERNIA BILATERAL 10MM-12MM

Facility

$1,629.00

Service Code	HCPCS C1727
Hospital Charge Code	8274225
Hospital Revenue Code	272
Min. Negotiated Rate	$814.50
Max. Negotiated Rate	$1,580.13
Rate for Payer: AlohaCare Medicaid	$814.50
Rate for Payer: AlohaCare Medicare	$814.50
Rate for Payer: Cash Price	$1,058.85
Rate for Payer: Devoted Health Medicare	$895.95
Rate for Payer: Hawaii Medical Service Association Medicare	$814.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,547.55
Rate for Payer: Health Management Network Commercial	$1,384.65
Rate for Payer: Humana Medicare	$814.50
Rate for Payer: Kaiser Permanente Commercial	$1,466.10
Rate for Payer: Kaiser Permanente Medicaid	$830.79
Rate for Payer: Kaiser Permanente Medicare	$814.50
Rate for Payer: MDX Hawaii PPO	$1,580.13
Rate for Payer: Ohana Health Plan Medicaid	$814.50
Rate for Payer: Ohana Health Plan Medicare	$814.50
Rate for Payer: UnitedHealthcare Medicare	$814.50
Rate for Payer: University Health Alliance Commercial	$1,187.38

DISTAL CLAVICLE PLATE, 10 HOLE, LEFT, STERILE

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Charge Code	12983765
Hospital Revenue Code	278
Min. Negotiated Rate	$1,339.50
Max. Negotiated Rate	$2,598.63
Rate for Payer: AlohaCare Medicaid	$1,339.50
Rate for Payer: AlohaCare Medicare	$1,339.50
Rate for Payer: Cash Price	$1,741.35
Rate for Payer: Devoted Health Medicare	$1,473.45
Rate for Payer: Hawaii Medical Service Association Medicare	$1,339.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Humana Medicare	$1,339.50
Rate for Payer: Kaiser Permanente Commercial	$2,411.10
Rate for Payer: Kaiser Permanente Medicaid	$1,366.29
Rate for Payer: Kaiser Permanente Medicare	$1,339.50
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: Ohana Health Plan Medicaid	$1,339.50
Rate for Payer: Ohana Health Plan Medicare	$1,339.50
Rate for Payer: UnitedHealthcare Medicare	$1,339.50
Rate for Payer: University Health Alliance Commercial	$1,500.24

DISTAL CLAVICLE PLATE, 10 HOLE, LEFT, STERILE

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Charge Code	12983765
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.24
Max. Negotiated Rate	$2,598.63
Rate for Payer: Cash Price	$1,741.35
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Kaiser Permanente Commercial	$2,411.10
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: University Health Alliance Commercial	$1,500.24

DISTAL CLAVICLE PLATE, 10 HOLE, RIGHT STERILE

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Charge Code	12983761
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.24
Max. Negotiated Rate	$2,598.63
Rate for Payer: Cash Price	$1,741.35
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Kaiser Permanente Commercial	$2,411.10
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: University Health Alliance Commercial	$1,500.24

DISTAL CLAVICLE PLATE, 10 HOLE, RIGHT STERILE

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Charge Code	12983761
Hospital Revenue Code	278
Min. Negotiated Rate	$1,339.50
Max. Negotiated Rate	$2,598.63
Rate for Payer: AlohaCare Medicaid	$1,339.50
Rate for Payer: AlohaCare Medicare	$1,339.50
Rate for Payer: Cash Price	$1,741.35
Rate for Payer: Devoted Health Medicare	$1,473.45
Rate for Payer: Hawaii Medical Service Association Medicare	$1,339.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Humana Medicare	$1,339.50
Rate for Payer: Kaiser Permanente Commercial	$2,411.10
Rate for Payer: Kaiser Permanente Medicaid	$1,366.29
Rate for Payer: Kaiser Permanente Medicare	$1,339.50
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: Ohana Health Plan Medicaid	$1,339.50
Rate for Payer: Ohana Health Plan Medicare	$1,339.50
Rate for Payer: UnitedHealthcare Medicare	$1,339.50
Rate for Payer: University Health Alliance Commercial	$1,500.24

DISTAL CLAVICLE PLATE, 22 DEG, LEFT, STERILE

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Charge Code	12983762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.24
Max. Negotiated Rate	$2,598.63
Rate for Payer: Cash Price	$1,741.35
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Kaiser Permanente Commercial	$2,411.10
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: University Health Alliance Commercial	$1,500.24

DISTAL CLAVICLE PLATE, 22 DEG, LEFT, STERILE

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Charge Code	12983762
Hospital Revenue Code	278
Min. Negotiated Rate	$1,339.50
Max. Negotiated Rate	$2,598.63
Rate for Payer: AlohaCare Medicaid	$1,339.50
Rate for Payer: AlohaCare Medicare	$1,339.50
Rate for Payer: Cash Price	$1,741.35
Rate for Payer: Devoted Health Medicare	$1,473.45
Rate for Payer: Hawaii Medical Service Association Medicare	$1,339.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Humana Medicare	$1,339.50
Rate for Payer: Kaiser Permanente Commercial	$2,411.10
Rate for Payer: Kaiser Permanente Medicaid	$1,366.29
Rate for Payer: Kaiser Permanente Medicare	$1,339.50
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: Ohana Health Plan Medicaid	$1,339.50
Rate for Payer: Ohana Health Plan Medicare	$1,339.50
Rate for Payer: UnitedHealthcare Medicare	$1,339.50
Rate for Payer: University Health Alliance Commercial	$1,500.24

DISTAL CLAVICLE PLATE, 22 DEG, RIGHT STERILE

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Charge Code	12983763
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.24
Max. Negotiated Rate	$2,598.63
Rate for Payer: Cash Price	$1,741.35
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Kaiser Permanente Commercial	$2,411.10
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: University Health Alliance Commercial	$1,500.24

DISTAL CLAVICLE PLATE, 22 DEG, RIGHT STERILE

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Charge Code	12983763
Hospital Revenue Code	278
Min. Negotiated Rate	$1,339.50
Max. Negotiated Rate	$2,598.63
Rate for Payer: AlohaCare Medicaid	$1,339.50
Rate for Payer: AlohaCare Medicare	$1,339.50
Rate for Payer: Cash Price	$1,741.35
Rate for Payer: Devoted Health Medicare	$1,473.45
Rate for Payer: Hawaii Medical Service Association Medicare	$1,339.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Humana Medicare	$1,339.50
Rate for Payer: Kaiser Permanente Commercial	$2,411.10
Rate for Payer: Kaiser Permanente Medicaid	$1,366.29
Rate for Payer: Kaiser Permanente Medicare	$1,339.50
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: Ohana Health Plan Medicaid	$1,339.50
Rate for Payer: Ohana Health Plan Medicare	$1,339.50
Rate for Payer: UnitedHealthcare Medicare	$1,339.50
Rate for Payer: University Health Alliance Commercial	$1,500.24

DISTAL RADIUS PLATE 2.4MM VOLAR LEFT NARROW

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043796
Hospital Revenue Code	278
Min. Negotiated Rate	$3,750.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: AlohaCare Medicaid	$3,750.00
Rate for Payer: AlohaCare Medicare	$3,750.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Devoted Health Medicare	$4,125.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,750.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Humana Medicare	$3,750.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: Kaiser Permanente Medicaid	$3,825.00
Rate for Payer: Kaiser Permanente Medicare	$3,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: Ohana Health Plan Medicaid	$3,750.00
Rate for Payer: Ohana Health Plan Medicare	$3,750.00
Rate for Payer: UnitedHealthcare Medicare	$3,750.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR LEFT NARROW

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043796
Hospital Revenue Code	278
Min. Negotiated Rate	$4,200.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR LEFT STANDARD

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043800
Hospital Revenue Code	278
Min. Negotiated Rate	$3,750.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: AlohaCare Medicaid	$3,750.00
Rate for Payer: AlohaCare Medicare	$3,750.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Devoted Health Medicare	$4,125.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,750.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Humana Medicare	$3,750.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: Kaiser Permanente Medicaid	$3,825.00
Rate for Payer: Kaiser Permanente Medicare	$3,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: Ohana Health Plan Medicaid	$3,750.00
Rate for Payer: Ohana Health Plan Medicare	$3,750.00
Rate for Payer: UnitedHealthcare Medicare	$3,750.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR LEFT STANDARD

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043800
Hospital Revenue Code	278
Min. Negotiated Rate	$4,200.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR RIGHT NARROW

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043797
Hospital Revenue Code	278
Min. Negotiated Rate	$4,200.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR RIGHT NARROW

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043797
Hospital Revenue Code	278
Min. Negotiated Rate	$3,750.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: AlohaCare Medicaid	$3,750.00
Rate for Payer: AlohaCare Medicare	$3,750.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Devoted Health Medicare	$4,125.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,750.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Humana Medicare	$3,750.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: Kaiser Permanente Medicaid	$3,825.00
Rate for Payer: Kaiser Permanente Medicare	$3,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: Ohana Health Plan Medicaid	$3,750.00
Rate for Payer: Ohana Health Plan Medicare	$3,750.00
Rate for Payer: UnitedHealthcare Medicare	$3,750.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR RIGHT STANDARD

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043799
Hospital Revenue Code	278
Min. Negotiated Rate	$4,200.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR RIGHT STANDARD

Facility

$7,500.00

Service Code	HCPCS C1713
Hospital Charge Code	13043799
Hospital Revenue Code	278
Min. Negotiated Rate	$3,750.00
Max. Negotiated Rate	$7,275.00
Rate for Payer: AlohaCare Medicaid	$3,750.00
Rate for Payer: AlohaCare Medicare	$3,750.00
Rate for Payer: Cash Price	$4,875.00
Rate for Payer: Devoted Health Medicare	$4,125.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,750.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,250.00
Rate for Payer: Health Management Network Commercial	$6,375.00
Rate for Payer: Humana Medicare	$3,750.00
Rate for Payer: Kaiser Permanente Commercial	$6,750.00
Rate for Payer: Kaiser Permanente Medicaid	$3,825.00
Rate for Payer: Kaiser Permanente Medicare	$3,750.00
Rate for Payer: MDX Hawaii PPO	$7,275.00
Rate for Payer: Ohana Health Plan Medicaid	$3,750.00
Rate for Payer: Ohana Health Plan Medicare	$3,750.00
Rate for Payer: UnitedHealthcare Medicare	$3,750.00
Rate for Payer: University Health Alliance Commercial	$4,200.00

DISTAL RADIUS PLATE 2.4MM VOLAR TEMPLATES

Facility

$563.00

Service Code	HCPCS C1713
Hospital Charge Code	13043798
Hospital Revenue Code	278
Min. Negotiated Rate	$315.28
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$365.95
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: University Health Alliance Commercial	$315.28

DISTAL RADIUS PLATE 2.4MM VOLAR TEMPLATES

Facility

$563.00

Service Code	HCPCS C1713
Hospital Charge Code	13043798
Hospital Revenue Code	278
Min. Negotiated Rate	$281.50
Max. Negotiated Rate	$546.11
Rate for Payer: AlohaCare Medicaid	$281.50
Rate for Payer: AlohaCare Medicare	$281.50
Rate for Payer: Cash Price	$365.95
Rate for Payer: Devoted Health Medicare	$309.65
Rate for Payer: Hawaii Medical Service Association Medicare	$281.50
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Humana Medicare	$281.50
Rate for Payer: Kaiser Permanente Commercial	$506.70
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: Kaiser Permanente Medicare	$281.50
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: Ohana Health Plan Medicaid	$281.50
Rate for Payer: Ohana Health Plan Medicare	$281.50
Rate for Payer: UnitedHealthcare Medicare	$281.50
Rate for Payer: University Health Alliance Commercial	$315.28

Know your out-of-pocket cost for care.

All Charges