Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Shoulder ALT Rev Glenoid Cann Tap 6.5mm 804-06-318 [3644755]

Facility

$3,878.00

Hospital Charge Code	3644755
Hospital Revenue Code	272
Min. Negotiated Rate	$1,977.78
Max. Negotiated Rate	$3,761.66
Rate for Payer: Cash Price	$2,520.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,684.10
Rate for Payer: Health Management Network Commercial	$3,296.30
Rate for Payer: Kaiser Permanente Commercial	$2,443.14
Rate for Payer: Kaiser Permanente Medicaid	$1,977.78
Rate for Payer: MDX Hawaii PPO	$3,761.66
Rate for Payer: University Health Alliance Commercial	$2,826.67

Shoulder ALT Rev Glen W/retain Screw +4 36mm 508-36-107 [3644752]

Facility

$8,548.50

Service Code	HCPCS C1776
Hospital Charge Code	3644752
Hospital Revenue Code	278
Min. Negotiated Rate	$4,787.16
Max. Negotiated Rate	$8,292.05
Rate for Payer: Cash Price	$5,556.52
Rate for Payer: Hawaii Western Management Group Commercial	$5,983.95
Rate for Payer: Health Management Network Commercial	$7,266.23
Rate for Payer: MDX Hawaii PPO	$8,292.05
Rate for Payer: University Health Alliance Commercial	$4,787.16

Shoulder ALT Rev Glen W/retain Screw +4 36mm 508-36-107 [3644752]

Facility

$8,548.50

Service Code	HCPCS C1776
Hospital Charge Code	3644752
Hospital Revenue Code	278
Min. Negotiated Rate	$4,359.73
Max. Negotiated Rate	$8,292.05
Rate for Payer: Cash Price	$5,556.52
Rate for Payer: Hawaii Western Management Group Commercial	$5,983.95
Rate for Payer: Health Management Network Commercial	$7,266.23
Rate for Payer: Kaiser Permanente Commercial	$5,385.56
Rate for Payer: Kaiser Permanente Medicaid	$4,359.73
Rate for Payer: MDX Hawaii PPO	$8,292.05
Rate for Payer: University Health Alliance Commercial	$4,787.16

Shoulder Alt Rev Mod Baseplate w/ Taper Kit 6.5mm Neut 508-65-000 [3645010]

Facility

$11,107.00

Service Code	HCPCS C1776
Hospital Charge Code	3645010
Hospital Revenue Code	278
Min. Negotiated Rate	$5,664.57
Max. Negotiated Rate	$10,773.79
Rate for Payer: Cash Price	$7,219.55
Rate for Payer: Hawaii Western Management Group Commercial	$7,774.90
Rate for Payer: Health Management Network Commercial	$9,440.95
Rate for Payer: Kaiser Permanente Commercial	$6,997.41
Rate for Payer: Kaiser Permanente Medicaid	$5,664.57
Rate for Payer: MDX Hawaii PPO	$10,773.79
Rate for Payer: University Health Alliance Commercial	$6,219.92

Shoulder Alt Rev Mod Baseplate w/ Taper Kit 6.5mm Neut 508-65-000 [3645010]

Facility

$11,107.00

Service Code	HCPCS C1776
Hospital Charge Code	3645010
Hospital Revenue Code	278
Min. Negotiated Rate	$6,219.92
Max. Negotiated Rate	$10,773.79
Rate for Payer: Cash Price	$7,219.55
Rate for Payer: Hawaii Western Management Group Commercial	$7,774.90
Rate for Payer: Health Management Network Commercial	$9,440.95
Rate for Payer: MDX Hawaii PPO	$10,773.79
Rate for Payer: University Health Alliance Commercial	$6,219.92

Shoulder Alt Rev Mod Central Screw 6.5 x 40mm 508-65-040 [3645011]

Facility

$6,578.00

Hospital Charge Code	3645011
Hospital Revenue Code	272
Min. Negotiated Rate	$3,354.78
Max. Negotiated Rate	$6,380.66
Rate for Payer: Cash Price	$4,275.70
Rate for Payer: Hawaii Western Management Group Commercial	$6,249.10
Rate for Payer: Health Management Network Commercial	$5,591.30
Rate for Payer: Kaiser Permanente Commercial	$4,144.14
Rate for Payer: Kaiser Permanente Medicaid	$3,354.78
Rate for Payer: MDX Hawaii PPO	$6,380.66
Rate for Payer: University Health Alliance Commercial	$4,794.70

Shoulder Alt Rev Mod Central Screw 6.5 x 40mm 508-65-040 [3645011]

Facility

$6,578.00

Hospital Charge Code	3645011
Hospital Revenue Code	272
Min. Negotiated Rate	$5,591.30
Max. Negotiated Rate	$6,380.66
Rate for Payer: Cash Price	$4,275.70
Rate for Payer: Health Management Network Commercial	$5,591.30
Rate for Payer: MDX Hawaii PPO	$6,380.66

Shoulder ALT Rev Torx Peripheral Screw 14mm 506-04-114 [3644771]

Facility

$999.87

Hospital Charge Code	3644771
Hospital Revenue Code	272
Min. Negotiated Rate	$509.93
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Hawaii Western Management Group Commercial	$949.88
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: Kaiser Permanente Commercial	$629.92
Rate for Payer: Kaiser Permanente Medicaid	$509.93
Rate for Payer: MDX Hawaii PPO	$969.87
Rate for Payer: University Health Alliance Commercial	$728.81

Shoulder ALT Rev Torx Peripheral Screw 14mm 506-04-114 [3644771]

Facility

$999.87

Hospital Charge Code	3644771
Hospital Revenue Code	272
Min. Negotiated Rate	$849.89
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: MDX Hawaii PPO	$969.87

Shoulder ALT Rev Torx Peripheral Screw 18mm 506-04-118 [3644753]

Facility

$999.87

Hospital Charge Code	3644753
Hospital Revenue Code	272
Min. Negotiated Rate	$509.93
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Hawaii Western Management Group Commercial	$949.88
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: Kaiser Permanente Commercial	$629.92
Rate for Payer: Kaiser Permanente Medicaid	$509.93
Rate for Payer: MDX Hawaii PPO	$969.87
Rate for Payer: University Health Alliance Commercial	$728.81

Shoulder ALT Rev Torx Peripheral Screw 18mm 506-04-118 [3644753]

Facility

$999.87

Hospital Charge Code	3644753
Hospital Revenue Code	272
Min. Negotiated Rate	$849.89
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: MDX Hawaii PPO	$969.87

Shoulder Alt Rev Torx Peripheral Screw 22mm 506-04-122 [3644820]

Facility

$999.87

Hospital Charge Code	3644820
Hospital Revenue Code	272
Min. Negotiated Rate	$509.93
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Hawaii Western Management Group Commercial	$949.88
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: Kaiser Permanente Commercial	$629.92
Rate for Payer: Kaiser Permanente Medicaid	$509.93
Rate for Payer: MDX Hawaii PPO	$969.87
Rate for Payer: University Health Alliance Commercial	$728.81

Shoulder Alt Rev Torx Peripheral Screw 22mm 506-04-122 [3644820]

Facility

$999.87

Hospital Charge Code	3644820
Hospital Revenue Code	272
Min. Negotiated Rate	$849.89
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: MDX Hawaii PPO	$969.87

Shoulder Alt Rev Torx Peripheral Screw 26mm 506-04-126 [3644818]

Facility

$999.87

Hospital Charge Code	3644818
Hospital Revenue Code	272
Min. Negotiated Rate	$509.93
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Hawaii Western Management Group Commercial	$949.88
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: Kaiser Permanente Commercial	$629.92
Rate for Payer: Kaiser Permanente Medicaid	$509.93
Rate for Payer: MDX Hawaii PPO	$969.87
Rate for Payer: University Health Alliance Commercial	$728.81

Shoulder Alt Rev Torx Peripheral Screw 26mm 506-04-126 [3644818]

Facility

$999.87

Hospital Charge Code	3644818
Hospital Revenue Code	272
Min. Negotiated Rate	$849.89
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: MDX Hawaii PPO	$969.87

Shoulder ALT Rev Torx Peripheral Screw 30mm 506-04-130 [3644770]

Facility

$999.87

Hospital Charge Code	3644770
Hospital Revenue Code	272
Min. Negotiated Rate	$509.93
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Hawaii Western Management Group Commercial	$949.88
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: Kaiser Permanente Commercial	$629.92
Rate for Payer: Kaiser Permanente Medicaid	$509.93
Rate for Payer: MDX Hawaii PPO	$969.87
Rate for Payer: University Health Alliance Commercial	$728.81

Shoulder ALT Rev Torx Peripheral Screw 30mm 506-04-130 [3644770]

Facility

$999.87

Hospital Charge Code	3644770
Hospital Revenue Code	272
Min. Negotiated Rate	$849.89
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: MDX Hawaii PPO	$969.87

Shoulder Alt Rev Torx Peripheral Screw 34mm 506-04-134 [3644819]

Facility

$999.87

Hospital Charge Code	3644819
Hospital Revenue Code	272
Min. Negotiated Rate	$509.93
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Hawaii Western Management Group Commercial	$949.88
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: Kaiser Permanente Commercial	$629.92
Rate for Payer: Kaiser Permanente Medicaid	$509.93
Rate for Payer: MDX Hawaii PPO	$969.87
Rate for Payer: University Health Alliance Commercial	$728.81

Shoulder Alt Rev Torx Peripheral Screw 34mm 506-04-134 [3644819]

Facility

$999.87

Hospital Charge Code	3644819
Hospital Revenue Code	272
Min. Negotiated Rate	$849.89
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: MDX Hawaii PPO	$969.87

Shoulder Alt Rev Torx Peripheral Screw 38mm 506-04-138 [3644754]

Facility

$999.87

Hospital Charge Code	3644754
Hospital Revenue Code	272
Min. Negotiated Rate	$849.89
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: MDX Hawaii PPO	$969.87

Shoulder Alt Rev Torx Peripheral Screw 38mm 506-04-138 [3644754]

Facility

$999.87

Hospital Charge Code	3644754
Hospital Revenue Code	272
Min. Negotiated Rate	$509.93
Max. Negotiated Rate	$969.87
Rate for Payer: Cash Price	$649.92
Rate for Payer: Hawaii Western Management Group Commercial	$949.88
Rate for Payer: Health Management Network Commercial	$849.89
Rate for Payer: Kaiser Permanente Commercial	$629.92
Rate for Payer: Kaiser Permanente Medicaid	$509.93
Rate for Payer: MDX Hawaii PPO	$969.87
Rate for Payer: University Health Alliance Commercial	$728.81

SHOULDER & ELBOW JOINT REPLACEMENT

Facility

$9,503.65

Service Code	APR-DRG 3221
Min. Negotiated Rate	$9,503.65
Max. Negotiated Rate	$9,503.65
Rate for Payer: AlohaCare Medicaid	$9,503.65
Rate for Payer: Hawaii Medical Service Association ABD	$9,503.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,503.65
Rate for Payer: Kaiser Permanente Medicaid	$9,503.65
Rate for Payer: Ohana Health Plan Medicaid	$9,503.65
Rate for Payer: UnitedHealthcare Medicaid	$9,503.65

SHOULDER & ELBOW JOINT REPLACEMENT

Facility

$10,330.22

Service Code	APR-DRG 3222
Min. Negotiated Rate	$10,330.22
Max. Negotiated Rate	$10,330.22
Rate for Payer: AlohaCare Medicaid	$10,330.22
Rate for Payer: Hawaii Medical Service Association ABD	$10,330.22
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,330.22
Rate for Payer: Kaiser Permanente Medicaid	$10,330.22
Rate for Payer: Ohana Health Plan Medicaid	$10,330.22
Rate for Payer: UnitedHealthcare Medicaid	$10,330.22

SHOULDER & ELBOW JOINT REPLACEMENT

Facility

$18,327.19

Service Code	APR-DRG 3224
Min. Negotiated Rate	$18,327.19
Max. Negotiated Rate	$18,327.19
Rate for Payer: AlohaCare Medicaid	$18,327.19
Rate for Payer: Hawaii Medical Service Association ABD	$18,327.19
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,327.19
Rate for Payer: Kaiser Permanente Medicaid	$18,327.19
Rate for Payer: Ohana Health Plan Medicaid	$18,327.19
Rate for Payer: UnitedHealthcare Medicaid	$18,327.19

SHOULDER & ELBOW JOINT REPLACEMENT

Facility

$13,043.00

Service Code	APR-DRG 3223
Min. Negotiated Rate	$13,043.00
Max. Negotiated Rate	$13,043.00
Rate for Payer: AlohaCare Medicaid	$13,043.00
Rate for Payer: Hawaii Medical Service Association ABD	$13,043.00
Rate for Payer: Hawaii Medical Service Association Non-ABD	$13,043.00
Rate for Payer: Kaiser Permanente Medicaid	$13,043.00
Rate for Payer: Ohana Health Plan Medicaid	$13,043.00
Rate for Payer: UnitedHealthcare Medicaid	$13,043.00

Know your out-of-pocket cost for care.

All Charges