Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

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	$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 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 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

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	$300.00
Max. Negotiated Rate	$342.35
Rate for Payer: Cash Price	$229.41
Rate for Payer: Health Management Network Commercial	$300.00
Rate for Payer: Kaiser Permanente Commercial	$317.65
Rate for Payer: MDX Hawaii PPO	$342.35

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

Facility

$208.42

Service Code	NDC 00574403125
Hospital Charge Code	2500225
Hospital Revenue Code	250
Min. Negotiated Rate	$104.21
Max. Negotiated Rate	$202.17
Rate for Payer: AlohaCare Medicaid	$104.21
Rate for Payer: AlohaCare Medicare	$104.21
Rate for Payer: Cash Price	$135.47
Rate for Payer: Devoted Health Medicare	$114.63
Rate for Payer: Hawaii Medical Service Association Medicare	$104.21
Rate for Payer: Hawaii Western Management Group Commercial	$198.00
Rate for Payer: Health Management Network Commercial	$177.16
Rate for Payer: Humana Medicare	$104.21
Rate for Payer: Kaiser Permanente Commercial	$187.58
Rate for Payer: Kaiser Permanente Medicaid	$106.29
Rate for Payer: Kaiser Permanente Medicare	$104.21
Rate for Payer: MDX Hawaii PPO	$202.17
Rate for Payer: Ohana Health Plan Medicaid	$104.21
Rate for Payer: Ohana Health Plan Medicare	$104.21
Rate for Payer: UnitedHealthcare Medicaid	$125.05
Rate for Payer: UnitedHealthcare Medicare	$104.21
Rate for Payer: University Health Alliance Commercial	$151.92

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

Facility

$309.20

Service Code	NDC 24208029525
Hospital Charge Code	2500225
Hospital Revenue Code	250
Min. Negotiated Rate	$154.60
Max. Negotiated Rate	$299.92
Rate for Payer: AlohaCare Medicaid	$154.60
Rate for Payer: AlohaCare Medicare	$154.60
Rate for Payer: Cash Price	$200.98
Rate for Payer: Devoted Health Medicare	$170.06
Rate for Payer: Hawaii Medical Service Association Medicare	$154.60
Rate for Payer: Hawaii Western Management Group Commercial	$293.74
Rate for Payer: Health Management Network Commercial	$262.82
Rate for Payer: Humana Medicare	$154.60
Rate for Payer: Kaiser Permanente Commercial	$278.28
Rate for Payer: Kaiser Permanente Medicaid	$157.69
Rate for Payer: Kaiser Permanente Medicare	$154.60
Rate for Payer: MDX Hawaii PPO	$299.92
Rate for Payer: Ohana Health Plan Medicaid	$154.60
Rate for Payer: Ohana Health Plan Medicare	$154.60
Rate for Payer: UnitedHealthcare Medicaid	$185.52
Rate for Payer: UnitedHealthcare Medicare	$154.60
Rate for Payer: University Health Alliance Commercial	$225.38

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

Facility

$208.42

Service Code	NDC 00574403125
Hospital Charge Code	2500225
Hospital Revenue Code	250
Min. Negotiated Rate	$177.16
Max. Negotiated Rate	$202.17
Rate for Payer: Cash Price	$135.47
Rate for Payer: Health Management Network Commercial	$177.16
Rate for Payer: Kaiser Permanente Commercial	$187.58
Rate for Payer: MDX Hawaii PPO	$202.17

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

Facility

$309.20

Service Code	NDC 24208029525
Hospital Charge Code	2500225
Hospital Revenue Code	250
Min. Negotiated Rate	$262.82
Max. Negotiated Rate	$299.92
Rate for Payer: Cash Price	$200.98
Rate for Payer: Health Management Network Commercial	$262.82
Rate for Payer: Kaiser Permanente Commercial	$278.28
Rate for Payer: MDX Hawaii PPO	$299.92

tobramycin 0.3% ophth drop [HHSC]

Facility

$77.09

Service Code	NDC 24208029005
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$65.53
Max. Negotiated Rate	$74.78
Rate for Payer: Cash Price	$50.11
Rate for Payer: Health Management Network Commercial	$65.53
Rate for Payer: Kaiser Permanente Commercial	$69.38
Rate for Payer: MDX Hawaii PPO	$74.78

tobramycin 0.3% ophth drop [HHSC]

Facility

$77.09

Service Code	NDC 24208029005
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$38.55
Max. Negotiated Rate	$74.78
Rate for Payer: AlohaCare Medicaid	$38.55
Rate for Payer: AlohaCare Medicare	$38.55
Rate for Payer: Cash Price	$50.11
Rate for Payer: Devoted Health Medicare	$42.40
Rate for Payer: Hawaii Medical Service Association Medicare	$38.55
Rate for Payer: Hawaii Western Management Group Commercial	$73.24
Rate for Payer: Health Management Network Commercial	$65.53
Rate for Payer: Humana Medicare	$38.55
Rate for Payer: Kaiser Permanente Commercial	$69.38
Rate for Payer: Kaiser Permanente Medicaid	$39.32
Rate for Payer: Kaiser Permanente Medicare	$38.55
Rate for Payer: MDX Hawaii PPO	$74.78
Rate for Payer: Ohana Health Plan Medicaid	$38.55
Rate for Payer: Ohana Health Plan Medicare	$38.55
Rate for Payer: UnitedHealthcare Medicaid	$46.25
Rate for Payer: UnitedHealthcare Medicare	$38.55
Rate for Payer: University Health Alliance Commercial	$56.19

tobramycin 0.3% ophth drop [HHSC]

Facility

$160.27

Service Code	NDC 61314064305
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$80.14
Max. Negotiated Rate	$155.46
Rate for Payer: AlohaCare Medicaid	$80.14
Rate for Payer: AlohaCare Medicare	$80.14
Rate for Payer: Cash Price	$104.18
Rate for Payer: Devoted Health Medicare	$88.15
Rate for Payer: Hawaii Medical Service Association Medicare	$80.14
Rate for Payer: Hawaii Western Management Group Commercial	$152.26
Rate for Payer: Health Management Network Commercial	$136.23
Rate for Payer: Humana Medicare	$80.14
Rate for Payer: Kaiser Permanente Commercial	$144.24
Rate for Payer: Kaiser Permanente Medicaid	$81.74
Rate for Payer: Kaiser Permanente Medicare	$80.14
Rate for Payer: MDX Hawaii PPO	$155.46
Rate for Payer: Ohana Health Plan Medicaid	$80.14
Rate for Payer: Ohana Health Plan Medicare	$80.14
Rate for Payer: UnitedHealthcare Medicaid	$96.16
Rate for Payer: UnitedHealthcare Medicare	$80.14
Rate for Payer: University Health Alliance Commercial	$116.82

tobramycin 0.3% ophth drop [HHSC]

Facility

$160.27

Service Code	NDC 61314064305
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$136.23
Max. Negotiated Rate	$155.46
Rate for Payer: Cash Price	$104.18
Rate for Payer: Health Management Network Commercial	$136.23
Rate for Payer: Kaiser Permanente Commercial	$144.24
Rate for Payer: MDX Hawaii PPO	$155.46

tobramycin 0.3% ophth drop [HHSC]

Facility

$79.01

Service Code	NDC 17478029010
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$39.51
Max. Negotiated Rate	$76.64
Rate for Payer: AlohaCare Medicaid	$39.51
Rate for Payer: AlohaCare Medicare	$39.51
Rate for Payer: Cash Price	$51.36
Rate for Payer: Devoted Health Medicare	$43.46
Rate for Payer: Hawaii Medical Service Association Medicare	$39.51
Rate for Payer: Hawaii Western Management Group Commercial	$75.06
Rate for Payer: Health Management Network Commercial	$67.16
Rate for Payer: Humana Medicare	$39.51
Rate for Payer: Kaiser Permanente Commercial	$71.11
Rate for Payer: Kaiser Permanente Medicaid	$40.30
Rate for Payer: Kaiser Permanente Medicare	$39.51
Rate for Payer: MDX Hawaii PPO	$76.64
Rate for Payer: Ohana Health Plan Medicaid	$39.51
Rate for Payer: Ohana Health Plan Medicare	$39.51
Rate for Payer: UnitedHealthcare Medicaid	$47.41
Rate for Payer: UnitedHealthcare Medicare	$39.51
Rate for Payer: University Health Alliance Commercial	$57.59

tobramycin 0.3% ophth drop [HHSC]

Facility

$40.12

Service Code	NDC 70069013101
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$20.06
Max. Negotiated Rate	$38.92
Rate for Payer: AlohaCare Medicaid	$20.06
Rate for Payer: AlohaCare Medicare	$20.06
Rate for Payer: Cash Price	$26.08
Rate for Payer: Devoted Health Medicare	$22.07
Rate for Payer: Hawaii Medical Service Association Medicare	$20.06
Rate for Payer: Hawaii Western Management Group Commercial	$38.11
Rate for Payer: Health Management Network Commercial	$34.10
Rate for Payer: Humana Medicare	$20.06
Rate for Payer: Kaiser Permanente Commercial	$36.11
Rate for Payer: Kaiser Permanente Medicaid	$20.46
Rate for Payer: Kaiser Permanente Medicare	$20.06
Rate for Payer: MDX Hawaii PPO	$38.92
Rate for Payer: Ohana Health Plan Medicaid	$20.06
Rate for Payer: Ohana Health Plan Medicare	$20.06
Rate for Payer: UnitedHealthcare Medicaid	$24.07
Rate for Payer: UnitedHealthcare Medicare	$20.06
Rate for Payer: University Health Alliance Commercial	$29.24

tobramycin 0.3% ophth drop [HHSC]

Facility

$79.01

Service Code	NDC 17478029010
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$67.16
Max. Negotiated Rate	$76.64
Rate for Payer: Cash Price	$51.36
Rate for Payer: Health Management Network Commercial	$67.16
Rate for Payer: Kaiser Permanente Commercial	$71.11
Rate for Payer: MDX Hawaii PPO	$76.64

tobramycin 0.3% ophth drop [HHSC]

Facility

$40.12

Service Code	NDC 70069013101
Hospital Charge Code	2500826
Hospital Revenue Code	250
Min. Negotiated Rate	$34.10
Max. Negotiated Rate	$38.92
Rate for Payer: Cash Price	$26.08
Rate for Payer: Health Management Network Commercial	$34.10
Rate for Payer: Kaiser Permanente Commercial	$36.11
Rate for Payer: MDX Hawaii PPO	$38.92

topiramate 100 mg tablet [HHSC]

Facility

$43.59

Service Code	NDC 68382014014
Hospital Charge Code	2500827
Hospital Revenue Code	250
Min. Negotiated Rate	$21.80
Max. Negotiated Rate	$42.28
Rate for Payer: AlohaCare Medicaid	$21.80
Rate for Payer: AlohaCare Medicare	$21.80
Rate for Payer: Cash Price	$28.33
Rate for Payer: Devoted Health Medicare	$23.97
Rate for Payer: Hawaii Medical Service Association Medicare	$21.80
Rate for Payer: Hawaii Western Management Group Commercial	$41.41
Rate for Payer: Health Management Network Commercial	$37.05
Rate for Payer: Humana Medicare	$21.80
Rate for Payer: Kaiser Permanente Commercial	$39.23
Rate for Payer: Kaiser Permanente Medicaid	$22.23
Rate for Payer: Kaiser Permanente Medicare	$21.80
Rate for Payer: MDX Hawaii PPO	$42.28
Rate for Payer: Ohana Health Plan Medicaid	$21.80
Rate for Payer: Ohana Health Plan Medicare	$21.80
Rate for Payer: UnitedHealthcare Medicaid	$26.15
Rate for Payer: UnitedHealthcare Medicare	$21.80
Rate for Payer: University Health Alliance Commercial	$31.77

Know your out-of-pocket cost for care.

All Charges