Kona Community Hospital

All Charges

Charge

Type

Setting

Price

CYCLOPENTOLATE 1 % OPHT DROP

Facility

$87.56

Service Code	NDC 61314039601
Hospital Revenue Code	250
Min. Negotiated Rate	$44.66
Max. Negotiated Rate	$84.93
Rate for Payer: Cash Price	$56.91
Rate for Payer: Hawaii Western Management Group Commercial	$83.18
Rate for Payer: Health Management Network Commercial	$74.43
Rate for Payer: Kaiser Permanente Commercial	$55.16
Rate for Payer: Kaiser Permanente Medicaid	$44.66
Rate for Payer: MDX Hawaii PPO	$84.93
Rate for Payer: UnitedHealthcare Medicaid	$52.54
Rate for Payer: University Health Alliance Commercial	$63.82

CYCLOPENTOLATE 1 % OPHT DROP

Facility

$164.69

Service Code	NDC 00065039602
Hospital Revenue Code	250
Min. Negotiated Rate	$83.99
Max. Negotiated Rate	$159.75
Rate for Payer: Cash Price	$107.05
Rate for Payer: Hawaii Western Management Group Commercial	$156.46
Rate for Payer: Health Management Network Commercial	$139.99
Rate for Payer: Kaiser Permanente Commercial	$103.75
Rate for Payer: Kaiser Permanente Medicaid	$83.99
Rate for Payer: MDX Hawaii PPO	$159.75
Rate for Payer: UnitedHealthcare Medicaid	$98.81
Rate for Payer: University Health Alliance Commercial	$120.04

CYCLOPHOSPHAMIDE 100 MG

Professional

Both

$65.00

Service Code	HCPCS J9070
Min. Negotiated Rate	$55.25
Max. Negotiated Rate	$79.11
Rate for Payer: Cash Price	$42.25
Rate for Payer: Cash Price	$42.25
Rate for Payer: Hawaii Western Management Group Commercial	$79.11
Rate for Payer: Health Management Network Commercial	$55.25

CYCLOPHOSPHAMIDE 1 GRAM IV RECON.SOLN.

Facility

$1,214.65

Service Code	HCPCS J9075
Hospital Revenue Code	636
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1,178.21
Rate for Payer: AlohaCare Medicaid	$0.77
Rate for Payer: AlohaCare Medicare	$0.77
Rate for Payer: Cash Price	$789.52
Rate for Payer: Cash Price	$789.52
Rate for Payer: Devoted Health Medicare	$0.85
Rate for Payer: Hawaii Medical Service Association ABD	$0.62
Rate for Payer: Hawaii Medical Service Association Commercial	$0.96
Rate for Payer: Hawaii Medical Service Association Medicare	$0.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.62
Rate for Payer: Hawaii Western Management Group Commercial	$1,153.92
Rate for Payer: Health Management Network Commercial	$1,032.45
Rate for Payer: Humana Medicare	$0.77
Rate for Payer: Kaiser Permanente Commercial	$765.23
Rate for Payer: Kaiser Permanente Medicaid	$619.47
Rate for Payer: Kaiser Permanente Medicare	$0.77
Rate for Payer: MDX Hawaii PPO	$1,178.21
Rate for Payer: Ohana Health Plan Medicaid	$0.85
Rate for Payer: Ohana Health Plan Medicare	$0.77
Rate for Payer: UnitedHealthcare Medicaid	$728.79
Rate for Payer: UnitedHealthcare Medicare	$0.77
Rate for Payer: University Health Alliance Commercial	$885.36

CYCLOPHOSPHAMIDE 1 GRAM IV RECON.SOLN.

Facility

$1,214.65

Service Code	HCPCS J9075
Hospital Revenue Code	250
Min. Negotiated Rate	$1,032.45
Max. Negotiated Rate	$1,178.21
Rate for Payer: Cash Price	$789.52
Rate for Payer: Health Management Network Commercial	$1,032.45
Rate for Payer: MDX Hawaii PPO	$1,178.21

CYCLOPHOSPHAMIDE 500 MG IV RECON.SOLN.

Facility

$1,095.38

Service Code	HCPCS J9074
Hospital Revenue Code	636
Min. Negotiated Rate	$3.65
Max. Negotiated Rate	$1,062.52
Rate for Payer: AlohaCare Medicaid	$3.65
Rate for Payer: AlohaCare Medicare	$3.65
Rate for Payer: Cash Price	$712.00
Rate for Payer: Cash Price	$712.00
Rate for Payer: Devoted Health Medicare	$4.01
Rate for Payer: Hawaii Medical Service Association ABD	$4.21
Rate for Payer: Hawaii Medical Service Association Commercial	$4.56
Rate for Payer: Hawaii Medical Service Association Medicare	$3.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4.21
Rate for Payer: Hawaii Western Management Group Commercial	$1,040.61
Rate for Payer: Health Management Network Commercial	$931.07
Rate for Payer: Humana Medicare	$3.65
Rate for Payer: Kaiser Permanente Commercial	$690.09
Rate for Payer: Kaiser Permanente Medicaid	$558.64
Rate for Payer: Kaiser Permanente Medicare	$3.65
Rate for Payer: MDX Hawaii PPO	$1,062.52
Rate for Payer: Ohana Health Plan Medicaid	$4.01
Rate for Payer: Ohana Health Plan Medicare	$3.65
Rate for Payer: UnitedHealthcare Medicaid	$657.23
Rate for Payer: UnitedHealthcare Medicare	$3.65
Rate for Payer: University Health Alliance Commercial	$798.42

CYCLOPHOSPHAMIDE 500 MG IV RECON.SOLN.

Facility

$1,095.38

Service Code	HCPCS J9074
Hospital Revenue Code	250
Min. Negotiated Rate	$931.07
Max. Negotiated Rate	$1,062.52
Rate for Payer: Cash Price	$712.00
Rate for Payer: Health Management Network Commercial	$931.07
Rate for Payer: MDX Hawaii PPO	$1,062.52

CYPROHEPTADINE 4 MG PO TABLET

Facility

$5.89

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$5.71
Rate for Payer: Cash Price	$3.83
Rate for Payer: Hawaii Western Management Group Commercial	$5.60
Rate for Payer: Health Management Network Commercial	$5.01
Rate for Payer: Kaiser Permanente Commercial	$3.71
Rate for Payer: Kaiser Permanente Medicaid	$3.00
Rate for Payer: MDX Hawaii PPO	$5.71
Rate for Payer: UnitedHealthcare Medicaid	$3.53
Rate for Payer: University Health Alliance Commercial	$4.29

CYPROHEPTADINE 4 MG PO TABLET

Facility

$5.89

Service Code	HCPCS A9270
Hospital Revenue Code	250
Min. Negotiated Rate	$5.01
Max. Negotiated Rate	$5.71
Rate for Payer: Cash Price	$3.83
Rate for Payer: Health Management Network Commercial	$5.01
Rate for Payer: MDX Hawaii PPO	$5.71

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$6,425.98

Service Code	APR-DRG 1311
Min. Negotiated Rate	$6,425.98
Max. Negotiated Rate	$6,425.98
Rate for Payer: AlohaCare Medicaid	$6,425.98
Rate for Payer: Hawaii Medical Service Association ABD	$6,425.98
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,425.98
Rate for Payer: Kaiser Permanente Medicaid	$6,425.98
Rate for Payer: Ohana Health Plan Medicaid	$6,425.98
Rate for Payer: UnitedHealthcare Medicaid	$6,425.98

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$9,176.33

Service Code	APR-DRG 1312
Min. Negotiated Rate	$9,176.33
Max. Negotiated Rate	$9,176.33
Rate for Payer: AlohaCare Medicaid	$9,176.33
Rate for Payer: Hawaii Medical Service Association ABD	$9,176.33
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,176.33
Rate for Payer: Kaiser Permanente Medicaid	$9,176.33
Rate for Payer: Ohana Health Plan Medicaid	$9,176.33
Rate for Payer: UnitedHealthcare Medicaid	$9,176.33

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$12,651.37

Service Code	APR-DRG 1313
Min. Negotiated Rate	$12,651.37
Max. Negotiated Rate	$12,651.37
Rate for Payer: AlohaCare Medicaid	$12,651.37
Rate for Payer: Hawaii Medical Service Association ABD	$12,651.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,651.37
Rate for Payer: Kaiser Permanente Medicaid	$12,651.37
Rate for Payer: Ohana Health Plan Medicaid	$12,651.37
Rate for Payer: UnitedHealthcare Medicaid	$12,651.37

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$17,089.25

Service Code	APR-DRG 1314
Min. Negotiated Rate	$17,089.25
Max. Negotiated Rate	$17,089.25
Rate for Payer: AlohaCare Medicaid	$17,089.25
Rate for Payer: Hawaii Medical Service Association ABD	$17,089.25
Rate for Payer: Hawaii Medical Service Association Non-ABD	$17,089.25
Rate for Payer: Kaiser Permanente Medicaid	$17,089.25
Rate for Payer: Ohana Health Plan Medicaid	$17,089.25
Rate for Payer: UnitedHealthcare Medicaid	$17,089.25

CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL NECK RESECTION

Facility

$10,679.55

Service Code	CPT 51050
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$6,334.13
Rate for Payer: AlohaCare Medicare	$6,334.13
Rate for Payer: Devoted Health Medicare	$6,967.54
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$6,334.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,334.13
Rate for Payer: Ohana Health Plan Medicaid	$6,967.54
Rate for Payer: Ohana Health Plan Medicare	$6,334.13
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,334.13
Rate for Payer: University Health Alliance Commercial	$10,679.55

CYSTOURETHROSCOPY (SEPARATE PROCEDURE)

Facility

$2,837.00

Service Code	CPT 52000
Hospital Revenue Code	360
Min. Negotiated Rate	$340.18
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$823.75
Rate for Payer: AlohaCare Medicare	$823.75
Rate for Payer: Devoted Health Medicare	$906.12
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	$823.75
Rate for Payer: Hawaii Medical Service Association Non-ABD	$407.95
Rate for Payer: Humana Medicare	$823.75
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$823.75
Rate for Payer: Ohana Health Plan Medicaid	$906.12
Rate for Payer: Ohana Health Plan Medicare	$823.75
Rate for Payer: UnitedHealthcare Medicaid	$340.18
Rate for Payer: UnitedHealthcare Medicare	$823.75

CYSTOURETHROSCOPY, WITH BIOPSY(S)

Facility

$9,416.00

Service Code	CPT 52204
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$5,160.40

CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE

Facility

$9,416.00

Service Code	CPT 52281
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$5,160.40

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S)

Facility

$14,715.00

Service Code	CPT 52240
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$6,334.13
Rate for Payer: AlohaCare Medicare	$6,334.13
Rate for Payer: Devoted Health Medicare	$6,967.54
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$6,334.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,334.13
Rate for Payer: Ohana Health Plan Medicaid	$6,967.54
Rate for Payer: Ohana Health Plan Medicare	$6,334.13
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,334.13
Rate for Payer: University Health Alliance Commercial	$6,743.44

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)

Facility

$14,715.00

Service Code	CPT 52235
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$6,743.44

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM)

Facility

$14,715.00

Service Code	CPT 52234
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$14,715.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$5,160.40

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY

Facility

$9,416.00

Service Code	CPT 52224
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$5,160.40

CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER

Facility

$9,416.00

Service Code	CPT 52287
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$6,743.44

CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE)

Facility

$9,416.00

Service Code	CPT 52332
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$9,416.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$5,160.40

CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY OR FULGURATION

Facility

$10,679.55

Service Code	CPT 52250
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$4,164.22
Rate for Payer: AlohaCare Medicare	$4,164.22
Rate for Payer: Devoted Health Medicare	$4,580.64
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$6,183.00
Rate for Payer: Hawaii Medical Service Association Medicare	$4,164.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$4,164.22
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$4,164.22
Rate for Payer: Ohana Health Plan Medicaid	$4,580.64
Rate for Payer: Ohana Health Plan Medicare	$4,164.22
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$4,164.22
Rate for Payer: University Health Alliance Commercial	$10,679.55

CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED

Facility

$7,917.66

Service Code	CPT 52284
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$7,917.66
Rate for Payer: AlohaCare Medicaid	$6,334.13
Rate for Payer: AlohaCare Medicare	$6,334.13
Rate for Payer: Devoted Health Medicare	$6,967.54
Rate for Payer: Hawaii Medical Service Association Commercial	$7,917.66
Rate for Payer: Hawaii Medical Service Association Medicare	$6,334.13
Rate for Payer: Humana Medicare	$6,334.13
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$6,334.13
Rate for Payer: Ohana Health Plan Medicaid	$6,967.54
Rate for Payer: Ohana Health Plan Medicare	$6,334.13
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$6,334.13

Know your out-of-pocket cost for care.

All Charges