Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Hip G7 Acet Liner Neutral Vit E 36mm E 30103605 [3642440]

Facility

$5,003.00

Service Code	HCPCS C1776
Hospital Charge Code	3642440
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.53
Max. Negotiated Rate	$4,852.91
Rate for Payer: Cash Price	$3,251.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,502.10
Rate for Payer: Health Management Network Commercial	$4,252.55
Rate for Payer: Kaiser Permanente Commercial	$3,151.89
Rate for Payer: Kaiser Permanente Medicaid	$2,551.53
Rate for Payer: MDX Hawaii PPO	$4,852.91
Rate for Payer: University Health Alliance Commercial	$2,801.68

Total Hip G7 Acet Liner Neutral Vit E 36mm F 30103606 [3642612]

Facility

$5,003.00

Service Code	HCPCS C1776
Hospital Charge Code	3642612
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.53
Max. Negotiated Rate	$4,852.91
Rate for Payer: Cash Price	$3,251.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,502.10
Rate for Payer: Health Management Network Commercial	$4,252.55
Rate for Payer: Kaiser Permanente Commercial	$3,151.89
Rate for Payer: Kaiser Permanente Medicaid	$2,551.53
Rate for Payer: MDX Hawaii PPO	$4,852.91
Rate for Payer: University Health Alliance Commercial	$2,801.68

Total Hip G7 Acet Liner Neutral Vit E 36mm F 30103606 [3642612]

Facility

$5,003.00

Service Code	HCPCS C1776
Hospital Charge Code	3642612
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.68
Max. Negotiated Rate	$4,852.91
Rate for Payer: Cash Price	$3,251.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,502.10
Rate for Payer: Health Management Network Commercial	$4,252.55
Rate for Payer: MDX Hawaii PPO	$4,852.91
Rate for Payer: University Health Alliance Commercial	$2,801.68

Total Hip G7 Acet Liner Neutral Vit E 36mm G 30103607 [3642441]

Facility

$5,003.00

Service Code	HCPCS C1776
Hospital Charge Code	3642441
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.53
Max. Negotiated Rate	$4,852.91
Rate for Payer: Cash Price	$3,251.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,502.10
Rate for Payer: Health Management Network Commercial	$4,252.55
Rate for Payer: Kaiser Permanente Commercial	$3,151.89
Rate for Payer: Kaiser Permanente Medicaid	$2,551.53
Rate for Payer: MDX Hawaii PPO	$4,852.91
Rate for Payer: University Health Alliance Commercial	$2,801.68

Total Hip G7 Acet Liner Neutral Vit E 36mm G 30103607 [3642441]

Facility

$5,003.00

Service Code	HCPCS C1776
Hospital Charge Code	3642441
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.68
Max. Negotiated Rate	$4,852.91
Rate for Payer: Cash Price	$3,251.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,502.10
Rate for Payer: Health Management Network Commercial	$4,252.55
Rate for Payer: MDX Hawaii PPO	$4,852.91
Rate for Payer: University Health Alliance Commercial	$2,801.68

Total Hip G7 Acet Liner Neutral Vit E 40mm G 30104007 [3643971]

Facility

$2,500.00

Service Code	HCPCS C1776
Hospital Charge Code	3643971
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,750.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: Kaiser Permanente Commercial	$1,575.00
Rate for Payer: Kaiser Permanente Medicaid	$1,275.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: University Health Alliance Commercial	$1,400.00

Total Hip G7 Acet Liner Neutral Vit E 40mm G 30104007 [3643971]

Facility

$2,500.00

Service Code	HCPCS C1776
Hospital Charge Code	3643971
Hospital Revenue Code	278
Min. Negotiated Rate	$1,400.00
Max. Negotiated Rate	$2,425.00
Rate for Payer: Cash Price	$1,625.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,750.00
Rate for Payer: Health Management Network Commercial	$2,125.00
Rate for Payer: MDX Hawaii PPO	$2,425.00
Rate for Payer: University Health Alliance Commercial	$1,400.00

Total Hip G7 Dual Mob Acet Liner Neut 40mm Sz D 110024462 [3641363]

Facility

$5,833.75

Service Code	HCPCS C1776
Hospital Charge Code	3641363
Hospital Revenue Code	278
Min. Negotiated Rate	$3,266.90
Max. Negotiated Rate	$5,658.74
Rate for Payer: Cash Price	$3,791.94
Rate for Payer: Hawaii Western Management Group Commercial	$4,083.62
Rate for Payer: Health Management Network Commercial	$4,958.69
Rate for Payer: MDX Hawaii PPO	$5,658.74
Rate for Payer: University Health Alliance Commercial	$3,266.90

Total Hip G7 Dual Mob Acet Liner Neut 40mm Sz D 110024462 [3641363]

Facility

$5,833.75

Service Code	HCPCS C1776
Hospital Charge Code	3641363
Hospital Revenue Code	278
Min. Negotiated Rate	$2,975.21
Max. Negotiated Rate	$5,658.74
Rate for Payer: Cash Price	$3,791.94
Rate for Payer: Hawaii Western Management Group Commercial	$4,083.62
Rate for Payer: Health Management Network Commercial	$4,958.69
Rate for Payer: Kaiser Permanente Commercial	$3,675.26
Rate for Payer: Kaiser Permanente Medicaid	$2,975.21
Rate for Payer: MDX Hawaii PPO	$5,658.74
Rate for Payer: University Health Alliance Commercial	$3,266.90

Total Hip G7 Dual Mobility Acet Liner 38mm C 110024461 [3642128]

Facility

$5,833.75

Service Code	HCPCS C1776
Hospital Charge Code	3642128
Hospital Revenue Code	278
Min. Negotiated Rate	$3,266.90
Max. Negotiated Rate	$5,658.74
Rate for Payer: Cash Price	$3,791.94
Rate for Payer: Hawaii Western Management Group Commercial	$4,083.62
Rate for Payer: Health Management Network Commercial	$4,958.69
Rate for Payer: MDX Hawaii PPO	$5,658.74
Rate for Payer: University Health Alliance Commercial	$3,266.90

Total Hip G7 Dual Mobility Acet Liner 38mm C 110024461 [3642128]

Facility

$5,833.75

Service Code	HCPCS C1776
Hospital Charge Code	3642128
Hospital Revenue Code	278
Min. Negotiated Rate	$2,975.21
Max. Negotiated Rate	$5,658.74
Rate for Payer: Cash Price	$3,791.94
Rate for Payer: Hawaii Western Management Group Commercial	$4,083.62
Rate for Payer: Health Management Network Commercial	$4,958.69
Rate for Payer: Kaiser Permanente Commercial	$3,675.26
Rate for Payer: Kaiser Permanente Medicaid	$2,975.21
Rate for Payer: MDX Hawaii PPO	$5,658.74
Rate for Payer: University Health Alliance Commercial	$3,266.90

Total Hip G7 Dual Mobility Acet Liner 44mm F 110024464 [3642213]

Facility

$7,803.00

Service Code	HCPCS C1776
Hospital Charge Code	3642213
Hospital Revenue Code	278
Min. Negotiated Rate	$4,369.68
Max. Negotiated Rate	$7,568.91
Rate for Payer: Cash Price	$5,071.95
Rate for Payer: Hawaii Western Management Group Commercial	$5,462.10
Rate for Payer: Health Management Network Commercial	$6,632.55
Rate for Payer: MDX Hawaii PPO	$7,568.91
Rate for Payer: University Health Alliance Commercial	$4,369.68

Total Hip G7 Dual Mobility Acet Liner 44mm F 110024464 [3642213]

Facility

$7,803.00

Service Code	HCPCS C1776
Hospital Charge Code	3642213
Hospital Revenue Code	278
Min. Negotiated Rate	$3,979.53
Max. Negotiated Rate	$7,568.91
Rate for Payer: Cash Price	$5,071.95
Rate for Payer: Hawaii Western Management Group Commercial	$5,462.10
Rate for Payer: Health Management Network Commercial	$6,632.55
Rate for Payer: Kaiser Permanente Commercial	$4,915.89
Rate for Payer: Kaiser Permanente Medicaid	$3,979.53
Rate for Payer: MDX Hawaii PPO	$7,568.91
Rate for Payer: University Health Alliance Commercial	$4,369.68

Total Hip G7 Dual Mobility Acet Liner 46mm G 110024465 [3641230]

Facility

$7,803.00

Service Code	HCPCS C1776
Hospital Charge Code	3641230
Hospital Revenue Code	278
Min. Negotiated Rate	$3,979.53
Max. Negotiated Rate	$7,568.91
Rate for Payer: Cash Price	$5,071.95
Rate for Payer: Hawaii Western Management Group Commercial	$5,462.10
Rate for Payer: Health Management Network Commercial	$6,632.55
Rate for Payer: Kaiser Permanente Commercial	$4,915.89
Rate for Payer: Kaiser Permanente Medicaid	$3,979.53
Rate for Payer: MDX Hawaii PPO	$7,568.91
Rate for Payer: University Health Alliance Commercial	$4,369.68

Total Hip G7 Dual Mobility Acet Liner 46mm G 110024465 [3641230]

Facility

$7,803.00

Service Code	HCPCS C1776
Hospital Charge Code	3641230
Hospital Revenue Code	278
Min. Negotiated Rate	$4,369.68
Max. Negotiated Rate	$7,568.91
Rate for Payer: Cash Price	$5,071.95
Rate for Payer: Hawaii Western Management Group Commercial	$5,462.10
Rate for Payer: Health Management Network Commercial	$6,632.55
Rate for Payer: MDX Hawaii PPO	$7,568.91
Rate for Payer: University Health Alliance Commercial	$4,369.68

Total Hip G7 Finned Acet Shell 3H 48mm C 110017101 [3642515]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642515
Hospital Revenue Code	278
Min. Negotiated Rate	$2,675.68
Max. Negotiated Rate	$4,634.66
Rate for Payer: Cash Price	$3,105.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,344.60
Rate for Payer: Health Management Network Commercial	$4,061.30
Rate for Payer: MDX Hawaii PPO	$4,634.66
Rate for Payer: University Health Alliance Commercial	$2,675.68

Total Hip G7 Finned Acet Shell 3H 48mm C 110017101 [3642515]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642515
Hospital Revenue Code	278
Min. Negotiated Rate	$2,436.78
Max. Negotiated Rate	$4,634.66
Rate for Payer: Cash Price	$3,105.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,344.60
Rate for Payer: Health Management Network Commercial	$4,061.30
Rate for Payer: Kaiser Permanente Commercial	$3,010.14
Rate for Payer: Kaiser Permanente Medicaid	$2,436.78
Rate for Payer: MDX Hawaii PPO	$4,634.66
Rate for Payer: University Health Alliance Commercial	$2,675.68

Total Hip G7 Finned Acet Shell 3H 50mm D 110017102 [3642592]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642592
Hospital Revenue Code	278
Min. Negotiated Rate	$2,436.78
Max. Negotiated Rate	$4,634.66
Rate for Payer: Cash Price	$3,105.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,344.60
Rate for Payer: Health Management Network Commercial	$4,061.30
Rate for Payer: Kaiser Permanente Commercial	$3,010.14
Rate for Payer: Kaiser Permanente Medicaid	$2,436.78
Rate for Payer: MDX Hawaii PPO	$4,634.66
Rate for Payer: University Health Alliance Commercial	$2,675.68

Total Hip G7 Finned Acet Shell 3H 50mm D 110017102 [3642592]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642592
Hospital Revenue Code	278
Min. Negotiated Rate	$2,675.68
Max. Negotiated Rate	$4,634.66
Rate for Payer: Cash Price	$3,105.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,344.60
Rate for Payer: Health Management Network Commercial	$4,061.30
Rate for Payer: MDX Hawaii PPO	$4,634.66
Rate for Payer: University Health Alliance Commercial	$2,675.68

Total Hip G7 Finned Acet Shell 3H 52mm E 110017103 [3642632]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642632
Hospital Revenue Code	278
Min. Negotiated Rate	$2,436.78
Max. Negotiated Rate	$4,634.66
Rate for Payer: Cash Price	$3,105.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,344.60
Rate for Payer: Health Management Network Commercial	$4,061.30
Rate for Payer: Kaiser Permanente Commercial	$3,010.14
Rate for Payer: Kaiser Permanente Medicaid	$2,436.78
Rate for Payer: MDX Hawaii PPO	$4,634.66
Rate for Payer: University Health Alliance Commercial	$2,675.68

Total Hip G7 Finned Acet Shell 3H 52mm E 110017103 [3642632]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642632
Hospital Revenue Code	278
Min. Negotiated Rate	$2,675.68
Max. Negotiated Rate	$4,634.66
Rate for Payer: Cash Price	$3,105.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,344.60
Rate for Payer: Health Management Network Commercial	$4,061.30
Rate for Payer: MDX Hawaii PPO	$4,634.66
Rate for Payer: University Health Alliance Commercial	$2,675.68

Total Hip G7 Finned Acet Shell 4H 54mm F 110017104 [3642755]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642755
Hospital Revenue Code	278
Min. Negotiated Rate	$2,436.78
Max. Negotiated Rate	$4,634.66
Rate for Payer: Cash Price	$3,105.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,344.60
Rate for Payer: Health Management Network Commercial	$4,061.30
Rate for Payer: Kaiser Permanente Commercial	$3,010.14
Rate for Payer: Kaiser Permanente Medicaid	$2,436.78
Rate for Payer: MDX Hawaii PPO	$4,634.66
Rate for Payer: University Health Alliance Commercial	$2,675.68

Total Hip G7 Finned Acet Shell 4H 54mm F 110017104 [3642755]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642755
Hospital Revenue Code	278
Min. Negotiated Rate	$2,675.68
Max. Negotiated Rate	$4,634.66
Rate for Payer: Cash Price	$3,105.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,344.60
Rate for Payer: Health Management Network Commercial	$4,061.30
Rate for Payer: MDX Hawaii PPO	$4,634.66
Rate for Payer: University Health Alliance Commercial	$2,675.68

Total Hip G7 Finned Acet Shell 4H 56mm F 110017105 [3642614]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642614
Hospital Revenue Code	278
Min. Negotiated Rate	$2,675.68
Max. Negotiated Rate	$4,634.66
Rate for Payer: Cash Price	$3,105.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,344.60
Rate for Payer: Health Management Network Commercial	$4,061.30
Rate for Payer: MDX Hawaii PPO	$4,634.66
Rate for Payer: University Health Alliance Commercial	$2,675.68

Total Hip G7 Finned Acet Shell 4H 56mm F 110017105 [3642614]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642614
Hospital Revenue Code	278
Min. Negotiated Rate	$2,436.78
Max. Negotiated Rate	$4,634.66
Rate for Payer: Cash Price	$3,105.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,344.60
Rate for Payer: Health Management Network Commercial	$4,061.30
Rate for Payer: Kaiser Permanente Commercial	$3,010.14
Rate for Payer: Kaiser Permanente Medicaid	$2,436.78
Rate for Payer: MDX Hawaii PPO	$4,634.66
Rate for Payer: University Health Alliance Commercial	$2,675.68

Know your out-of-pocket cost for care.

All Charges