Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Arthroscopy Blade 4.0Mm Tomcat 0375-545-000 [3600276]

Facility

$410.94

Hospital Charge Code	3600276
Hospital Revenue Code	272
Min. Negotiated Rate	$349.30
Max. Negotiated Rate	$398.61
Rate for Payer: Cash Price	$267.11
Rate for Payer: Health Management Network Commercial	$349.30
Rate for Payer: MDX Hawaii PPO	$398.61

Arthroscopy Blade 5.0Mm Barrel Bur 375951100 [3600528]

Facility

$429.06

Hospital Charge Code	3600528
Hospital Revenue Code	272
Min. Negotiated Rate	$364.70
Max. Negotiated Rate	$416.19
Rate for Payer: Cash Price	$278.89
Rate for Payer: Health Management Network Commercial	$364.70
Rate for Payer: MDX Hawaii PPO	$416.19

Arthroscopy Blade 5.0Mm Barrel Bur 375951100 [3600528]

Facility

$429.06

Hospital Charge Code	3600528
Hospital Revenue Code	272
Min. Negotiated Rate	$218.82
Max. Negotiated Rate	$416.19
Rate for Payer: Cash Price	$278.89
Rate for Payer: Hawaii Western Management Group Commercial	$407.61
Rate for Payer: Health Management Network Commercial	$364.70
Rate for Payer: Kaiser Permanente Commercial	$270.31
Rate for Payer: Kaiser Permanente Medicaid	$218.82
Rate for Payer: MDX Hawaii PPO	$416.19
Rate for Payer: University Health Alliance Commercial	$312.74

ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE

Facility

$14,715.00

Service Code	CPT 29838
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY)

Facility

$10,679.55

Service Code	CPT 29877
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$10,679.55

ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT OSTEOCHONDRITIS DISSECANS LESION WITH INTERNAL FIXATION

Facility

$9,429.30

Service Code	CPT 29887
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,429.30
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL AUTOGRAFT(S) (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF THE AUTOGRAFT[S])

Facility

$14,715.00

Service Code	CPT 29866
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09

ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE)

Facility

$10,679.55

Service Code	CPT 29875
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$10,679.55

ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, 2 OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL)

Facility

$10,679.55

Service Code	CPT 29876
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$10,679.55

ARTHROSCOPY, KNEE, SURGICAL; WITH LATERAL RELEASE

Facility

$9,416.00

Service Code	CPT 29873
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED

Facility

$10,679.55

Service Code	CPT 29880
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$10,679.55

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S), WHEN PERFORMED

Facility

$10,679.55

Service Code	CPT 29881
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$10,679.55

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND LATERAL)

Facility

$9,416.00

Service Code	CPT 29883
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$9,416.00
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$849.21
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

Arthroscopy Pump Tubing Arthrex AR-6410 [3600282]

Facility

$673.21

Hospital Charge Code	3600282
Hospital Revenue Code	272
Min. Negotiated Rate	$343.34
Max. Negotiated Rate	$653.01
Rate for Payer: Cash Price	$437.59
Rate for Payer: Hawaii Western Management Group Commercial	$639.55
Rate for Payer: Health Management Network Commercial	$572.23
Rate for Payer: Kaiser Permanente Commercial	$424.12
Rate for Payer: Kaiser Permanente Medicaid	$343.34
Rate for Payer: MDX Hawaii PPO	$653.01
Rate for Payer: University Health Alliance Commercial	$490.70

Arthroscopy Pump Tubing Arthrex AR-6410 [3600282]

Facility

$673.21

Hospital Charge Code	3600282
Hospital Revenue Code	272
Min. Negotiated Rate	$572.23
Max. Negotiated Rate	$653.01
Rate for Payer: Cash Price	$437.59
Rate for Payer: Health Management Network Commercial	$572.23
Rate for Payer: MDX Hawaii PPO	$653.01

ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS

Facility

$24,500.00

Service Code	CPT 29828
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$24,500.00

ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS

Facility

$24,500.00

Service Code	CPT 29828
Hospital Revenue Code	361
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$24,500.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$24,500.00

ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY

Facility

$14,715.00

Service Code	CPT 29806
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED, 1 OR 2 DISCRETE STRUCTURES (EG, HUMERAL BONE, HUMERAL ARTICULAR CARTILAGE, GLENOID BONE, GLENOID ARTICULAR CARTILAGE, BICEPS TENDON, BICEPS ANCHOR COMPLEX, LABRUM, ARTICULAR CAPSULE, ARTICULAR SIDE OF THE ROTATOR CUFF, BURSAL SIDE OF THE ROTATOR CUFF, SUBACROMIAL BURSA, FOREIGN BODY[IES])

Facility

$14,715.00

Service Code	CPT 29822
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$6,743.44

ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH CORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 29826
Hospital Revenue Code	361
Min. Negotiated Rate	$575.82
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$575.82

Facility

$2,837.00

Service Code	CPT 29826
Hospital Revenue Code	360
Min. Negotiated Rate	$575.82
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$575.82

ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE)

Facility

$14,715.00

Service Code	CPT 29824
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$14,715.00
Rate for Payer: AlohaCare Medicaid	$3,865.36
Rate for Payer: AlohaCare Medicare	$3,865.36
Rate for Payer: Devoted Health Medicare	$4,251.90
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	$3,865.36
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,154.45
Rate for Payer: Humana Medicare	$3,865.36
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,865.36
Rate for Payer: Ohana Health Plan Medicaid	$4,251.90
Rate for Payer: Ohana Health Plan Medicare	$3,865.36
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$3,865.36
Rate for Payer: University Health Alliance Commercial	$11,157.19

ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION

Facility

$9,429.30

Service Code	CPT 29807
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$9,429.30
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
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	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$700.72
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$6,743.44

ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR

Facility

$17,484.00

Service Code	CPT 29827
Hospital Revenue Code	360
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$17,484.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$17,484.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,902.37
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$11,157.19

ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR

Facility

$17,484.00

Service Code	CPT 29827
Hospital Revenue Code	361
Min. Negotiated Rate	$521.33
Max. Negotiated Rate	$17,484.00
Rate for Payer: AlohaCare Medicaid	$8,572.09
Rate for Payer: AlohaCare Medicare	$8,572.09
Rate for Payer: Devoted Health Medicare	$9,429.30
Rate for Payer: Hawaii Medical Service Association ABD	$1,900.00
Rate for Payer: Hawaii Medical Service Association Commercial	$17,484.00
Rate for Payer: Hawaii Medical Service Association Medicare	$8,572.09
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,902.37
Rate for Payer: Humana Medicare	$8,572.09
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$8,572.09
Rate for Payer: Ohana Health Plan Medicaid	$9,429.30
Rate for Payer: Ohana Health Plan Medicare	$8,572.09
Rate for Payer: UnitedHealthcare Medicaid	$521.33
Rate for Payer: UnitedHealthcare Medicare	$8,572.09
Rate for Payer: University Health Alliance Commercial	$11,157.19

Know your out-of-pocket cost for care.

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