Samuel Mahelona Memorial Hospital

All Charges

Charge

Type

Setting

Price

topiramate 100 mg tablet [HHSC]

Facility

$39.87

Service Code	NDC 68084034401
Hospital Charge Code	2500827
Hospital Revenue Code	250
Min. Negotiated Rate	$33.89
Max. Negotiated Rate	$38.67
Rate for Payer: Cash Price	$25.92
Rate for Payer: Health Management Network Commercial	$33.89
Rate for Payer: Kaiser Permanente Commercial	$35.88
Rate for Payer: MDX Hawaii PPO	$38.67

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

topiramate 100 mg tablet [HHSC]

Facility

$39.87

Service Code	NDC 68084034401
Hospital Charge Code	2500827
Hospital Revenue Code	250
Min. Negotiated Rate	$19.93
Max. Negotiated Rate	$38.67
Rate for Payer: AlohaCare Medicaid	$19.93
Rate for Payer: AlohaCare Medicare	$19.93
Rate for Payer: Cash Price	$25.92
Rate for Payer: Devoted Health Medicare	$21.93
Rate for Payer: Hawaii Medical Service Association Medicare	$19.93
Rate for Payer: Hawaii Western Management Group Commercial	$37.88
Rate for Payer: Health Management Network Commercial	$33.89
Rate for Payer: Humana Medicare	$19.93
Rate for Payer: Kaiser Permanente Commercial	$35.88
Rate for Payer: Kaiser Permanente Medicaid	$20.33
Rate for Payer: Kaiser Permanente Medicare	$19.93
Rate for Payer: MDX Hawaii PPO	$38.67
Rate for Payer: Ohana Health Plan Medicaid	$19.93
Rate for Payer: Ohana Health Plan Medicare	$19.93
Rate for Payer: UnitedHealthcare Medicaid	$23.92
Rate for Payer: UnitedHealthcare Medicare	$19.93
Rate for Payer: University Health Alliance Commercial	$29.06

topiramate 25 mg tablet [HHSC]

Facility

$11.68

Service Code	NDC 68084034201
Hospital Charge Code	2500828
Hospital Revenue Code	250
Min. Negotiated Rate	$5.84
Max. Negotiated Rate	$11.33
Rate for Payer: AlohaCare Medicaid	$5.84
Rate for Payer: AlohaCare Medicare	$5.84
Rate for Payer: Cash Price	$7.59
Rate for Payer: Devoted Health Medicare	$6.42
Rate for Payer: Hawaii Medical Service Association Medicare	$5.84
Rate for Payer: Hawaii Western Management Group Commercial	$11.10
Rate for Payer: Health Management Network Commercial	$9.93
Rate for Payer: Humana Medicare	$5.84
Rate for Payer: Kaiser Permanente Commercial	$10.51
Rate for Payer: Kaiser Permanente Medicaid	$5.96
Rate for Payer: Kaiser Permanente Medicare	$5.84
Rate for Payer: MDX Hawaii PPO	$11.33
Rate for Payer: Ohana Health Plan Medicaid	$5.84
Rate for Payer: Ohana Health Plan Medicare	$5.84
Rate for Payer: UnitedHealthcare Medicaid	$7.01
Rate for Payer: UnitedHealthcare Medicare	$5.84
Rate for Payer: University Health Alliance Commercial	$8.51

topiramate 25 mg tablet [HHSC]

Facility

$11.68

Service Code	NDC 68084034201
Hospital Charge Code	2500828
Hospital Revenue Code	250
Min. Negotiated Rate	$9.93
Max. Negotiated Rate	$11.33
Rate for Payer: Cash Price	$7.59
Rate for Payer: Health Management Network Commercial	$9.93
Rate for Payer: Kaiser Permanente Commercial	$10.51
Rate for Payer: MDX Hawaii PPO	$11.33

topiramate 25 mg tablet [HHSC]

Facility

$14.20

Service Code	NDC 68382013814
Hospital Charge Code	2500828
Hospital Revenue Code	250
Min. Negotiated Rate	$7.10
Max. Negotiated Rate	$13.77
Rate for Payer: AlohaCare Medicaid	$7.10
Rate for Payer: AlohaCare Medicare	$7.10
Rate for Payer: Cash Price	$9.23
Rate for Payer: Devoted Health Medicare	$7.81
Rate for Payer: Hawaii Medical Service Association Medicare	$7.10
Rate for Payer: Hawaii Western Management Group Commercial	$13.49
Rate for Payer: Health Management Network Commercial	$12.07
Rate for Payer: Humana Medicare	$7.10
Rate for Payer: Kaiser Permanente Commercial	$12.78
Rate for Payer: Kaiser Permanente Medicaid	$7.24
Rate for Payer: Kaiser Permanente Medicare	$7.10
Rate for Payer: MDX Hawaii PPO	$13.77
Rate for Payer: Ohana Health Plan Medicaid	$7.10
Rate for Payer: Ohana Health Plan Medicare	$7.10
Rate for Payer: UnitedHealthcare Medicaid	$8.52
Rate for Payer: UnitedHealthcare Medicare	$7.10
Rate for Payer: University Health Alliance Commercial	$10.35

topiramate 25 mg tablet [HHSC]

Facility

$14.20

Service Code	NDC 68382013814
Hospital Charge Code	2500828
Hospital Revenue Code	250
Min. Negotiated Rate	$12.07
Max. Negotiated Rate	$13.77
Rate for Payer: Cash Price	$9.23
Rate for Payer: Health Management Network Commercial	$12.07
Rate for Payer: Kaiser Permanente Commercial	$12.78
Rate for Payer: MDX Hawaii PPO	$13.77

Topiramate FSI

Facility

$138.00

Service Code	HCPCS 80201
Hospital Charge Code	8118061
Hospital Revenue Code	301
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$133.86
Rate for Payer: Cash Price	$89.70
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Kaiser Permanente Commercial	$124.20
Rate for Payer: MDX Hawaii PPO	$133.86

Topiramate FSI

Facility

$138.00

Service Code	HCPCS 80201
Hospital Charge Code	8118061
Hospital Revenue Code	301
Min. Negotiated Rate	$11.92
Max. Negotiated Rate	$133.86
Rate for Payer: AlohaCare Medicaid	$69.00
Rate for Payer: AlohaCare Medicare	$69.00
Rate for Payer: Cash Price	$89.70
Rate for Payer: Cash Price	$89.70
Rate for Payer: Devoted Health Medicare	$75.90
Rate for Payer: Hawaii Medical Service Association ABD	$16.48
Rate for Payer: Hawaii Medical Service Association Commercial	$14.90
Rate for Payer: Hawaii Medical Service Association Medicare	$69.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17.30
Rate for Payer: Hawaii Western Management Group Commercial	$11.92
Rate for Payer: Health Management Network Commercial	$117.30
Rate for Payer: Humana Medicare	$69.00
Rate for Payer: Kaiser Permanente Commercial	$124.20
Rate for Payer: Kaiser Permanente Medicaid	$70.38
Rate for Payer: Kaiser Permanente Medicare	$69.00
Rate for Payer: MDX Hawaii PPO	$133.86
Rate for Payer: Ohana Health Plan Medicaid	$69.00
Rate for Payer: Ohana Health Plan Medicare	$69.00
Rate for Payer: UnitedHealthcare Medicaid	$16.48
Rate for Payer: UnitedHealthcare Medicare	$69.00
Rate for Payer: University Health Alliance Commercial	$30.82

Total CO2 iSTAT

Facility

$55.00

Service Code	HCPCS 82374 QW
Hospital Charge Code	8293269
Hospital Revenue Code	301
Min. Negotiated Rate	$46.75
Max. Negotiated Rate	$53.35
Rate for Payer: Cash Price	$35.75
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: MDX Hawaii PPO	$53.35

Total CO2 iSTAT

Facility

$55.00

Service Code	HCPCS 82374 QW
Hospital Charge Code	8293269
Hospital Revenue Code	301
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$53.35
Rate for Payer: AlohaCare Medicaid	$27.50
Rate for Payer: AlohaCare Medicare	$27.50
Rate for Payer: Cash Price	$35.75
Rate for Payer: Cash Price	$35.75
Rate for Payer: Devoted Health Medicare	$30.25
Rate for Payer: Hawaii Medical Service Association ABD	$6.76
Rate for Payer: Hawaii Medical Service Association Commercial	$6.10
Rate for Payer: Hawaii Medical Service Association Medicare	$27.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.10
Rate for Payer: Hawaii Western Management Group Commercial	$4.88
Rate for Payer: Health Management Network Commercial	$46.75
Rate for Payer: Humana Medicare	$27.50
Rate for Payer: Kaiser Permanente Commercial	$49.50
Rate for Payer: Kaiser Permanente Medicaid	$28.05
Rate for Payer: Kaiser Permanente Medicare	$27.50
Rate for Payer: MDX Hawaii PPO	$53.35
Rate for Payer: Ohana Health Plan Medicaid	$27.50
Rate for Payer: Ohana Health Plan Medicare	$27.50
Rate for Payer: UnitedHealthcare Medicaid	$6.76
Rate for Payer: UnitedHealthcare Medicare	$27.50
Rate for Payer: University Health Alliance Commercial	$12.64

Total Protein, Body Fluid FSI

Facility

$63.00

Service Code	HCPCS 84157
Hospital Charge Code	8228929
Hospital Revenue Code	301
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

Total Protein, Body Fluid FSI

Facility

$63.00

Service Code	HCPCS 84157
Hospital Charge Code	8228929
Hospital Revenue Code	301
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$34.65
Rate for Payer: Hawaii Medical Service Association ABD	$3.69
Rate for Payer: Hawaii Medical Service Association Commercial	$5.00
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.06
Rate for Payer: Hawaii Western Management Group Commercial	$4.00
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicaid	$3.69
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$9.47

Total Protein Creatinine w/Ratio Urine Random FSI

Facility

$269.00

Service Code	HCPCS 82570
Hospital Charge Code	8118062
Hospital Revenue Code	300
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$260.93
Rate for Payer: AlohaCare Medicaid	$134.50
Rate for Payer: AlohaCare Medicare	$134.50
Rate for Payer: Cash Price	$174.85
Rate for Payer: Cash Price	$174.85
Rate for Payer: Devoted Health Medicare	$147.95
Rate for Payer: Hawaii Medical Service Association ABD	$7.15
Rate for Payer: Hawaii Medical Service Association Commercial	$6.47
Rate for Payer: Hawaii Medical Service Association Medicare	$134.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7.51
Rate for Payer: Hawaii Western Management Group Commercial	$5.18
Rate for Payer: Health Management Network Commercial	$228.65
Rate for Payer: Humana Medicare	$134.50
Rate for Payer: Kaiser Permanente Commercial	$242.10
Rate for Payer: Kaiser Permanente Medicaid	$137.19
Rate for Payer: Kaiser Permanente Medicare	$134.50
Rate for Payer: MDX Hawaii PPO	$260.93
Rate for Payer: Ohana Health Plan Medicaid	$134.50
Rate for Payer: Ohana Health Plan Medicare	$134.50
Rate for Payer: UnitedHealthcare Medicaid	$7.15
Rate for Payer: UnitedHealthcare Medicare	$134.50
Rate for Payer: University Health Alliance Commercial	$13.38

Total Protein Creatinine w/Ratio Urine Random FSI

Facility

$269.00

Service Code	HCPCS 82570
Hospital Charge Code	8118062
Hospital Revenue Code	300
Min. Negotiated Rate	$228.65
Max. Negotiated Rate	$260.93
Rate for Payer: Cash Price	$174.85
Rate for Payer: Health Management Network Commercial	$228.65
Rate for Payer: Kaiser Permanente Commercial	$242.10
Rate for Payer: MDX Hawaii PPO	$260.93

Total Protein, CSF FSI

Facility

$63.00

Service Code	HCPCS 84157
Hospital Charge Code	8228928
Hospital Revenue Code	301
Min. Negotiated Rate	$3.69
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$34.65
Rate for Payer: Hawaii Medical Service Association ABD	$3.69
Rate for Payer: Hawaii Medical Service Association Commercial	$5.00
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.06
Rate for Payer: Hawaii Western Management Group Commercial	$4.00
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicaid	$3.69
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$9.47

Total Protein, CSF FSI

Facility

$63.00

Service Code	HCPCS 84157
Hospital Charge Code	8228928
Hospital Revenue Code	301
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

Total Protein FSI

Facility

$63.00

Service Code	HCPCS 84155
Hospital Charge Code	8228927
Hospital Revenue Code	301
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$61.11
Rate for Payer: AlohaCare Medicaid	$31.50
Rate for Payer: AlohaCare Medicare	$31.50
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Devoted Health Medicare	$34.65
Rate for Payer: Hawaii Medical Service Association ABD	$5.06
Rate for Payer: Hawaii Medical Service Association Commercial	$4.59
Rate for Payer: Hawaii Medical Service Association Medicare	$31.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5.31
Rate for Payer: Hawaii Western Management Group Commercial	$3.67
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Humana Medicare	$31.50
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: Kaiser Permanente Medicaid	$32.13
Rate for Payer: Kaiser Permanente Medicare	$31.50
Rate for Payer: MDX Hawaii PPO	$61.11
Rate for Payer: Ohana Health Plan Medicaid	$31.50
Rate for Payer: Ohana Health Plan Medicare	$31.50
Rate for Payer: UnitedHealthcare Medicaid	$5.06
Rate for Payer: UnitedHealthcare Medicare	$31.50
Rate for Payer: University Health Alliance Commercial	$9.47

Total Protein FSI

Facility

$63.00

Service Code	HCPCS 84155
Hospital Charge Code	8228927
Hospital Revenue Code	301
Min. Negotiated Rate	$53.55
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$40.95
Rate for Payer: Health Management Network Commercial	$53.55
Rate for Payer: Kaiser Permanente Commercial	$56.70
Rate for Payer: MDX Hawaii PPO	$61.11

Total Testosterone FSI

Facility

$294.00

Service Code	HCPCS 84403
Hospital Charge Code	8118063
Hospital Revenue Code	301
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$285.18
Rate for Payer: Cash Price	$191.10
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Kaiser Permanente Commercial	$264.60
Rate for Payer: MDX Hawaii PPO	$285.18

Total Testosterone FSI

Facility

$294.00

Service Code	HCPCS 84403
Hospital Charge Code	8118063
Hospital Revenue Code	301
Min. Negotiated Rate	$25.81
Max. Negotiated Rate	$285.18
Rate for Payer: AlohaCare Medicaid	$147.00
Rate for Payer: AlohaCare Medicare	$147.00
Rate for Payer: Cash Price	$191.10
Rate for Payer: Cash Price	$191.10
Rate for Payer: Devoted Health Medicare	$161.70
Rate for Payer: Hawaii Medical Service Association ABD	$35.68
Rate for Payer: Hawaii Medical Service Association Commercial	$32.26
Rate for Payer: Hawaii Medical Service Association Medicare	$147.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$37.46
Rate for Payer: Hawaii Western Management Group Commercial	$25.81
Rate for Payer: Health Management Network Commercial	$249.90
Rate for Payer: Humana Medicare	$147.00
Rate for Payer: Kaiser Permanente Commercial	$264.60
Rate for Payer: Kaiser Permanente Medicaid	$149.94
Rate for Payer: Kaiser Permanente Medicare	$147.00
Rate for Payer: MDX Hawaii PPO	$285.18
Rate for Payer: Ohana Health Plan Medicaid	$147.00
Rate for Payer: Ohana Health Plan Medicare	$147.00
Rate for Payer: UnitedHealthcare Medicaid	$35.68
Rate for Payer: UnitedHealthcare Medicare	$147.00
Rate for Payer: University Health Alliance Commercial	$66.75

Toxigenic C diff RTPCR FSI

Facility

$440.00

Service Code	HCPCS 87493
Hospital Charge Code	9381907
Hospital Revenue Code	306
Min. Negotiated Rate	$37.27
Max. Negotiated Rate	$426.80
Rate for Payer: AlohaCare Medicaid	$220.00
Rate for Payer: AlohaCare Medicare	$220.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Cash Price	$286.00
Rate for Payer: Devoted Health Medicare	$242.00
Rate for Payer: Hawaii Medical Service Association ABD	$50.27
Rate for Payer: Hawaii Medical Service Association Commercial	$46.59
Rate for Payer: Hawaii Medical Service Association Medicare	$220.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$50.93
Rate for Payer: Hawaii Western Management Group Commercial	$37.27
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Humana Medicare	$220.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: Kaiser Permanente Medicaid	$224.40
Rate for Payer: Kaiser Permanente Medicare	$220.00
Rate for Payer: MDX Hawaii PPO	$426.80
Rate for Payer: Ohana Health Plan Medicaid	$220.00
Rate for Payer: Ohana Health Plan Medicare	$220.00
Rate for Payer: UnitedHealthcare Medicaid	$50.27
Rate for Payer: UnitedHealthcare Medicare	$220.00
Rate for Payer: University Health Alliance Commercial	$93.00

Toxigenic C diff RTPCR FSI

Facility

$440.00

Service Code	HCPCS 87493
Hospital Charge Code	9381907
Hospital Revenue Code	306
Min. Negotiated Rate	$374.00
Max. Negotiated Rate	$426.80
Rate for Payer: Cash Price	$286.00
Rate for Payer: Health Management Network Commercial	$374.00
Rate for Payer: Kaiser Permanente Commercial	$396.00
Rate for Payer: MDX Hawaii PPO	$426.80

Toxoplasma Ab IgM

Facility

$109.00

Service Code	HCPCS 86778
Hospital Charge Code	8208547
Hospital Revenue Code	302
Min. Negotiated Rate	$92.65
Max. Negotiated Rate	$105.73
Rate for Payer: Cash Price	$70.85
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: MDX Hawaii PPO	$105.73

Toxoplasma Ab IgM

Facility

$109.00

Service Code	HCPCS 86778
Hospital Charge Code	8208547
Hospital Revenue Code	302
Min. Negotiated Rate	$14.41
Max. Negotiated Rate	$105.73
Rate for Payer: AlohaCare Medicaid	$54.50
Rate for Payer: AlohaCare Medicare	$54.50
Rate for Payer: Cash Price	$70.85
Rate for Payer: Cash Price	$70.85
Rate for Payer: Devoted Health Medicare	$59.95
Rate for Payer: Hawaii Medical Service Association ABD	$19.90
Rate for Payer: Hawaii Medical Service Association Commercial	$18.01
Rate for Payer: Hawaii Medical Service Association Medicare	$54.50
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.90
Rate for Payer: Hawaii Western Management Group Commercial	$14.41
Rate for Payer: Health Management Network Commercial	$92.65
Rate for Payer: Humana Medicare	$54.50
Rate for Payer: Kaiser Permanente Commercial	$98.10
Rate for Payer: Kaiser Permanente Medicaid	$55.59
Rate for Payer: Kaiser Permanente Medicare	$54.50
Rate for Payer: MDX Hawaii PPO	$105.73
Rate for Payer: Ohana Health Plan Medicaid	$54.50
Rate for Payer: Ohana Health Plan Medicare	$54.50
Rate for Payer: UnitedHealthcare Medicaid	$19.90
Rate for Payer: UnitedHealthcare Medicare	$54.50
Rate for Payer: University Health Alliance Commercial	$37.22

Know your out-of-pocket cost for care.

All Charges