Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Hip Shell Bipolar Cup 54mmx28mm Ringloc 11-165232 [3643458]

Facility

$4,049.00

Service Code	HCPCS C1776
Hospital Charge Code	3643458
Hospital Revenue Code	278
Min. Negotiated Rate	$2,267.44
Max. Negotiated Rate	$3,927.53
Rate for Payer: Cash Price	$2,631.85
Rate for Payer: Hawaii Western Management Group Commercial	$2,834.30
Rate for Payer: Health Management Network Commercial	$3,441.65
Rate for Payer: MDX Hawaii PPO	$3,927.53
Rate for Payer: University Health Alliance Commercial	$2,267.44

Hip Shell Bipolar Cup 56mm x 28mm Ringloc 11-165236 [3644260]

Facility

$4,049.00

Service Code	HCPCS C1776
Hospital Charge Code	3644260
Hospital Revenue Code	278
Min. Negotiated Rate	$2,064.99
Max. Negotiated Rate	$3,927.53
Rate for Payer: Cash Price	$2,631.85
Rate for Payer: Hawaii Western Management Group Commercial	$2,834.30
Rate for Payer: Health Management Network Commercial	$3,441.65
Rate for Payer: Kaiser Permanente Commercial	$2,550.87
Rate for Payer: Kaiser Permanente Medicaid	$2,064.99
Rate for Payer: MDX Hawaii PPO	$3,927.53
Rate for Payer: University Health Alliance Commercial	$2,267.44

Hip Shell Bipolar Cup 56mm x 28mm Ringloc 11-165236 [3644260]

Facility

$4,049.00

Service Code	HCPCS C1776
Hospital Charge Code	3644260
Hospital Revenue Code	278
Min. Negotiated Rate	$2,267.44
Max. Negotiated Rate	$3,927.53
Rate for Payer: Cash Price	$2,631.85
Rate for Payer: Hawaii Western Management Group Commercial	$2,834.30
Rate for Payer: Health Management Network Commercial	$3,441.65
Rate for Payer: MDX Hawaii PPO	$3,927.53
Rate for Payer: University Health Alliance Commercial	$2,267.44

Hip Shell Bipolar Cup 57mm x 28mm Ringloc 11-165238 [3644898]

Facility

$4,049.00

Service Code	HCPCS C1776
Hospital Charge Code	3644898
Hospital Revenue Code	278
Min. Negotiated Rate	$2,267.44
Max. Negotiated Rate	$3,927.53
Rate for Payer: Cash Price	$2,631.85
Rate for Payer: Hawaii Western Management Group Commercial	$2,834.30
Rate for Payer: Health Management Network Commercial	$3,441.65
Rate for Payer: MDX Hawaii PPO	$3,927.53
Rate for Payer: University Health Alliance Commercial	$2,267.44

Hip Shell Bipolar Cup 57mm x 28mm Ringloc 11-165238 [3644898]

Facility

$4,049.00

Service Code	HCPCS C1776
Hospital Charge Code	3644898
Hospital Revenue Code	278
Min. Negotiated Rate	$2,064.99
Max. Negotiated Rate	$3,927.53
Rate for Payer: Cash Price	$2,631.85
Rate for Payer: Hawaii Western Management Group Commercial	$2,834.30
Rate for Payer: Health Management Network Commercial	$3,441.65
Rate for Payer: Kaiser Permanente Commercial	$2,550.87
Rate for Payer: Kaiser Permanente Medicaid	$2,064.99
Rate for Payer: MDX Hawaii PPO	$3,927.53
Rate for Payer: University Health Alliance Commercial	$2,267.44

Hip Shell Bipolar Cup 58mm x 28mm Ringloc 11-165240 [3644259]

Facility

$4,049.00

Service Code	HCPCS C1776
Hospital Charge Code	3644259
Hospital Revenue Code	278
Min. Negotiated Rate	$2,064.99
Max. Negotiated Rate	$3,927.53
Rate for Payer: Cash Price	$2,631.85
Rate for Payer: Hawaii Western Management Group Commercial	$2,834.30
Rate for Payer: Health Management Network Commercial	$3,441.65
Rate for Payer: Kaiser Permanente Commercial	$2,550.87
Rate for Payer: Kaiser Permanente Medicaid	$2,064.99
Rate for Payer: MDX Hawaii PPO	$3,927.53
Rate for Payer: University Health Alliance Commercial	$2,267.44

Hip Shell Bipolar Cup 58mm x 28mm Ringloc 11-165240 [3644259]

Facility

$4,049.00

Service Code	HCPCS C1776
Hospital Charge Code	3644259
Hospital Revenue Code	278
Min. Negotiated Rate	$2,267.44
Max. Negotiated Rate	$3,927.53
Rate for Payer: Cash Price	$2,631.85
Rate for Payer: Hawaii Western Management Group Commercial	$2,834.30
Rate for Payer: Health Management Network Commercial	$3,441.65
Rate for Payer: MDX Hawaii PPO	$3,927.53
Rate for Payer: University Health Alliance Commercial	$2,267.44

Hip Shell Bipolar Cup 60mm x 28mm Ringloc 11-165244 [3644037]

Facility

$2,758.00

Service Code	HCPCS C1776
Hospital Charge Code	3644037
Hospital Revenue Code	278
Min. Negotiated Rate	$1,406.58
Max. Negotiated Rate	$2,675.26
Rate for Payer: Cash Price	$1,792.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,930.60
Rate for Payer: Health Management Network Commercial	$2,344.30
Rate for Payer: Kaiser Permanente Commercial	$1,737.54
Rate for Payer: Kaiser Permanente Medicaid	$1,406.58
Rate for Payer: MDX Hawaii PPO	$2,675.26
Rate for Payer: University Health Alliance Commercial	$1,544.48

Hip Shell Bipolar Cup 60mm x 28mm Ringloc 11-165244 [3644037]

Facility

$2,758.00

Service Code	HCPCS C1776
Hospital Charge Code	3644037
Hospital Revenue Code	278
Min. Negotiated Rate	$1,544.48
Max. Negotiated Rate	$2,675.26
Rate for Payer: Cash Price	$1,792.70
Rate for Payer: Hawaii Western Management Group Commercial	$1,930.60
Rate for Payer: Health Management Network Commercial	$2,344.30
Rate for Payer: MDX Hawaii PPO	$2,675.26
Rate for Payer: University Health Alliance Commercial	$1,544.48

Hip Stem Taperfill Lateral Offset Sz 11 425-97-011 [3644551]

Facility

$19,129.00

Service Code	HCPCS C1776
Hospital Charge Code	3644551
Hospital Revenue Code	278
Min. Negotiated Rate	$10,712.24
Max. Negotiated Rate	$18,555.13
Rate for Payer: Cash Price	$12,433.85
Rate for Payer: Hawaii Western Management Group Commercial	$13,390.30
Rate for Payer: Health Management Network Commercial	$16,259.65
Rate for Payer: MDX Hawaii PPO	$18,555.13
Rate for Payer: University Health Alliance Commercial	$10,712.24

Hip Stem Taperfill Lateral Offset Sz 11 425-97-011 [3644551]

Facility

$19,129.00

Service Code	HCPCS C1776
Hospital Charge Code	3644551
Hospital Revenue Code	278
Min. Negotiated Rate	$9,755.79
Max. Negotiated Rate	$18,555.13
Rate for Payer: Cash Price	$12,433.85
Rate for Payer: Hawaii Western Management Group Commercial	$13,390.30
Rate for Payer: Health Management Network Commercial	$16,259.65
Rate for Payer: Kaiser Permanente Commercial	$12,051.27
Rate for Payer: Kaiser Permanente Medicaid	$9,755.79
Rate for Payer: MDX Hawaii PPO	$18,555.13
Rate for Payer: University Health Alliance Commercial	$10,712.24

Hip Stem Taperfill Lateral Offset Sz 13 425-97-013 [3644963]

Facility

$19,223.50

Service Code	HCPCS C1776
Hospital Charge Code	3644963
Hospital Revenue Code	278
Min. Negotiated Rate	$10,765.16
Max. Negotiated Rate	$18,646.79
Rate for Payer: Cash Price	$12,495.28
Rate for Payer: Hawaii Western Management Group Commercial	$13,456.45
Rate for Payer: Health Management Network Commercial	$16,339.98
Rate for Payer: MDX Hawaii PPO	$18,646.79
Rate for Payer: University Health Alliance Commercial	$10,765.16

Hip Stem Taperfill Lateral Offset Sz 13 425-97-013 [3644963]

Facility

$19,223.50

Service Code	HCPCS C1776
Hospital Charge Code	3644963
Hospital Revenue Code	278
Min. Negotiated Rate	$9,803.99
Max. Negotiated Rate	$18,646.79
Rate for Payer: Cash Price	$12,495.28
Rate for Payer: Hawaii Western Management Group Commercial	$13,456.45
Rate for Payer: Health Management Network Commercial	$16,339.98
Rate for Payer: Kaiser Permanente Commercial	$12,110.81
Rate for Payer: Kaiser Permanente Medicaid	$9,803.99
Rate for Payer: MDX Hawaii PPO	$18,646.79
Rate for Payer: University Health Alliance Commercial	$10,765.16

Hip Stem Taperfill Lateral Offset Sz 17 425-97-017 [3644628]

Facility

$19,223.50

Service Code	HCPCS C1776
Hospital Charge Code	3644628
Hospital Revenue Code	278
Min. Negotiated Rate	$10,765.16
Max. Negotiated Rate	$18,646.79
Rate for Payer: Cash Price	$12,495.28
Rate for Payer: Hawaii Western Management Group Commercial	$13,456.45
Rate for Payer: Health Management Network Commercial	$16,339.98
Rate for Payer: MDX Hawaii PPO	$18,646.79
Rate for Payer: University Health Alliance Commercial	$10,765.16

Hip Stem Taperfill Lateral Offset Sz 17 425-97-017 [3644628]

Facility

$19,223.50

Service Code	HCPCS C1776
Hospital Charge Code	3644628
Hospital Revenue Code	278
Min. Negotiated Rate	$9,803.99
Max. Negotiated Rate	$18,646.79
Rate for Payer: Cash Price	$12,495.28
Rate for Payer: Hawaii Western Management Group Commercial	$13,456.45
Rate for Payer: Health Management Network Commercial	$16,339.98
Rate for Payer: Kaiser Permanente Commercial	$12,110.81
Rate for Payer: Kaiser Permanente Medicaid	$9,803.99
Rate for Payer: MDX Hawaii PPO	$18,646.79
Rate for Payer: University Health Alliance Commercial	$10,765.16

Hip Tm Acet Rev Sys Shell 64mm 00-7000-064-20 [3643858]

Facility

$8,250.00

Service Code	HCPCS C1776
Hospital Charge Code	3643858
Hospital Revenue Code	278
Min. Negotiated Rate	$4,620.00
Max. Negotiated Rate	$8,002.50
Rate for Payer: Cash Price	$5,362.50
Rate for Payer: Hawaii Western Management Group Commercial	$5,775.00
Rate for Payer: Health Management Network Commercial	$7,012.50
Rate for Payer: MDX Hawaii PPO	$8,002.50
Rate for Payer: University Health Alliance Commercial	$4,620.00

Hip Tm Acet Rev Sys Shell 64mm 00-7000-064-20 [3643858]

Facility

$8,250.00

Service Code	HCPCS C1776
Hospital Charge Code	3643858
Hospital Revenue Code	278
Min. Negotiated Rate	$4,207.50
Max. Negotiated Rate	$8,002.50
Rate for Payer: Cash Price	$5,362.50
Rate for Payer: Hawaii Western Management Group Commercial	$5,775.00
Rate for Payer: Health Management Network Commercial	$7,012.50
Rate for Payer: Kaiser Permanente Commercial	$5,197.50
Rate for Payer: Kaiser Permanente Medicaid	$4,207.50
Rate for Payer: MDX Hawaii PPO	$8,002.50
Rate for Payer: University Health Alliance Commercial	$4,620.00

Hip Trident X3 0deg Poly Insert 36mm 723-00-36D [3644821]

Facility

$6,186.00

Service Code	HCPCS C1776
Hospital Charge Code	3644821
Hospital Revenue Code	278
Min. Negotiated Rate	$3,154.86
Max. Negotiated Rate	$6,000.42
Rate for Payer: Cash Price	$4,020.90
Rate for Payer: Hawaii Western Management Group Commercial	$4,330.20
Rate for Payer: Health Management Network Commercial	$5,258.10
Rate for Payer: Kaiser Permanente Commercial	$3,897.18
Rate for Payer: Kaiser Permanente Medicaid	$3,154.86
Rate for Payer: MDX Hawaii PPO	$6,000.42
Rate for Payer: University Health Alliance Commercial	$3,464.16

Hip Trident X3 0deg Poly Insert 36mm 723-00-36D [3644821]

Facility

$6,186.00

Service Code	HCPCS C1776
Hospital Charge Code	3644821
Hospital Revenue Code	278
Min. Negotiated Rate	$3,464.16
Max. Negotiated Rate	$6,000.42
Rate for Payer: Cash Price	$4,020.90
Rate for Payer: Hawaii Western Management Group Commercial	$4,330.20
Rate for Payer: Health Management Network Commercial	$5,258.10
Rate for Payer: MDX Hawaii PPO	$6,000.42
Rate for Payer: University Health Alliance Commercial	$3,464.16

HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC

Facility

$105,592.43

Service Code	MSDRG 969
Min. Negotiated Rate	$80,512.03
Max. Negotiated Rate	$105,592.43
Rate for Payer: AlohaCare Medicare	$80,512.03
Rate for Payer: Devoted Health Medicare	$88,563.23
Rate for Payer: Hawaii Medical Service Association Commercial	$100,767.26
Rate for Payer: Hawaii Medical Service Association Medicare	$80,512.03
Rate for Payer: Humana Medicare	$80,512.03
Rate for Payer: Kaiser Permanente Commercial	$105,592.43
Rate for Payer: Kaiser Permanente Medicare	$80,512.03
Rate for Payer: Ohana Health Plan Medicare	$80,512.03
Rate for Payer: UnitedHealthcare Medicare	$80,512.03

HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC

Facility

$100,767.26

Service Code	MSDRG 970
Min. Negotiated Rate	$34,689.10
Max. Negotiated Rate	$100,767.26
Rate for Payer: AlohaCare Medicare	$34,689.10
Rate for Payer: Devoted Health Medicare	$38,158.01
Rate for Payer: Hawaii Medical Service Association Commercial	$100,767.26
Rate for Payer: Hawaii Medical Service Association Medicare	$34,689.10
Rate for Payer: Humana Medicare	$34,689.10
Rate for Payer: Kaiser Permanente Commercial	$45,495.15
Rate for Payer: Kaiser Permanente Medicare	$34,689.10
Rate for Payer: Ohana Health Plan Medicare	$34,689.10
Rate for Payer: UnitedHealthcare Medicare	$34,689.10

HIV WITH MAJOR RELATED CONDITION WITH CC

Facility

$58,628.22

Service Code	MSDRG 975
Min. Negotiated Rate	$17,032.84
Max. Negotiated Rate	$58,628.22
Rate for Payer: AlohaCare Medicare	$17,032.84
Rate for Payer: Devoted Health Medicare	$18,736.12
Rate for Payer: Hawaii Medical Service Association Commercial	$58,628.22
Rate for Payer: Hawaii Medical Service Association Medicare	$17,032.84
Rate for Payer: Humana Medicare	$17,032.84
Rate for Payer: Kaiser Permanente Commercial	$22,338.75
Rate for Payer: Kaiser Permanente Medicare	$17,032.84
Rate for Payer: Ohana Health Plan Medicare	$17,032.84
Rate for Payer: UnitedHealthcare Medicare	$17,032.84

HIV WITH MAJOR RELATED CONDITION WITH MCC

Facility

$58,628.22

Service Code	MSDRG 974
Min. Negotiated Rate	$37,958.88
Max. Negotiated Rate	$58,628.22
Rate for Payer: AlohaCare Medicare	$37,958.88
Rate for Payer: Devoted Health Medicare	$41,754.77
Rate for Payer: Hawaii Medical Service Association Commercial	$58,628.22
Rate for Payer: Hawaii Medical Service Association Medicare	$37,958.88
Rate for Payer: Humana Medicare	$37,958.88
Rate for Payer: Kaiser Permanente Commercial	$49,783.50
Rate for Payer: Kaiser Permanente Medicare	$37,958.88
Rate for Payer: Ohana Health Plan Medicare	$37,958.88
Rate for Payer: UnitedHealthcare Medicare	$37,958.88

HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC

Facility

$58,628.22

Service Code	MSDRG 976
Min. Negotiated Rate	$11,872.99
Max. Negotiated Rate	$58,628.22
Rate for Payer: AlohaCare Medicare	$11,872.99
Rate for Payer: Devoted Health Medicare	$13,060.29
Rate for Payer: Hawaii Medical Service Association Commercial	$58,628.22
Rate for Payer: Hawaii Medical Service Association Medicare	$11,872.99
Rate for Payer: Humana Medicare	$11,872.99
Rate for Payer: Kaiser Permanente Commercial	$15,430.12
Rate for Payer: Kaiser Permanente Medicare	$11,872.99
Rate for Payer: Ohana Health Plan Medicare	$11,872.99
Rate for Payer: UnitedHealthcare Medicare	$11,872.99

HIV WITH OR WITHOUT OTHER RELATED CONDITION

Facility

$42,139.04

Service Code	MSDRG 977
Min. Negotiated Rate	$17,068.35
Max. Negotiated Rate	$42,139.04
Rate for Payer: AlohaCare Medicare	$17,068.35
Rate for Payer: Devoted Health Medicare	$18,775.19
Rate for Payer: Hawaii Medical Service Association Commercial	$42,139.04
Rate for Payer: Hawaii Medical Service Association Medicare	$17,068.35
Rate for Payer: Humana Medicare	$17,068.35
Rate for Payer: Kaiser Permanente Commercial	$21,866.10
Rate for Payer: Kaiser Permanente Medicare	$17,068.35
Rate for Payer: Ohana Health Plan Medicare	$17,068.35
Rate for Payer: UnitedHealthcare Medicare	$17,068.35

Know your out-of-pocket cost for care.

All Charges