Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Hip Vivacit E DM Bearing 28X40mm 110031010 [3642806]

Facility

$10,953.00

Service Code	HCPCS C1776
Hospital Charge Code	3642806
Hospital Revenue Code	278
Min. Negotiated Rate	$5,586.03
Max. Negotiated Rate	$10,624.41
Rate for Payer: Cash Price	$7,119.45
Rate for Payer: Hawaii Western Management Group Commercial	$7,667.10
Rate for Payer: Health Management Network Commercial	$9,310.05
Rate for Payer: Kaiser Permanente Commercial	$6,900.39
Rate for Payer: Kaiser Permanente Medicaid	$5,586.03
Rate for Payer: MDX Hawaii PPO	$10,624.41
Rate for Payer: University Health Alliance Commercial	$6,133.68

Total Hip Vivacit E DM Bearing 28X40mm 110031010 [3642806]

Facility

$10,953.00

Service Code	HCPCS C1776
Hospital Charge Code	3642806
Hospital Revenue Code	278
Min. Negotiated Rate	$6,133.68
Max. Negotiated Rate	$10,624.41
Rate for Payer: Cash Price	$7,119.45
Rate for Payer: Hawaii Western Management Group Commercial	$7,667.10
Rate for Payer: Health Management Network Commercial	$9,310.05
Rate for Payer: MDX Hawaii PPO	$10,624.41
Rate for Payer: University Health Alliance Commercial	$6,133.68

Total Hip Vivacit E DM Bearing 28X44mm 110031012 [3642215]

Facility

$5,353.00

Service Code	HCPCS C1776
Hospital Charge Code	3642215
Hospital Revenue Code	278
Min. Negotiated Rate	$2,997.68
Max. Negotiated Rate	$5,192.41
Rate for Payer: Cash Price	$3,479.45
Rate for Payer: Hawaii Western Management Group Commercial	$3,747.10
Rate for Payer: Health Management Network Commercial	$4,550.05
Rate for Payer: MDX Hawaii PPO	$5,192.41
Rate for Payer: University Health Alliance Commercial	$2,997.68

Total Hip Vivacit E DM Bearing 28X44mm 110031012 [3642215]

Facility

$5,353.00

Service Code	HCPCS C1776
Hospital Charge Code	3642215
Hospital Revenue Code	278
Min. Negotiated Rate	$2,730.03
Max. Negotiated Rate	$5,192.41
Rate for Payer: Cash Price	$3,479.45
Rate for Payer: Hawaii Western Management Group Commercial	$3,747.10
Rate for Payer: Health Management Network Commercial	$4,550.05
Rate for Payer: Kaiser Permanente Commercial	$3,372.39
Rate for Payer: Kaiser Permanente Medicaid	$2,730.03
Rate for Payer: MDX Hawaii PPO	$5,192.41
Rate for Payer: University Health Alliance Commercial	$2,997.68

Total Hip Vivacit E DM Bearing 28X46mm 110031013 [3642946]

Facility

$5,353.00

Service Code	HCPCS C1776
Hospital Charge Code	3642946
Hospital Revenue Code	278
Min. Negotiated Rate	$2,730.03
Max. Negotiated Rate	$5,192.41
Rate for Payer: Cash Price	$3,479.45
Rate for Payer: Hawaii Western Management Group Commercial	$3,747.10
Rate for Payer: Health Management Network Commercial	$4,550.05
Rate for Payer: Kaiser Permanente Commercial	$3,372.39
Rate for Payer: Kaiser Permanente Medicaid	$2,730.03
Rate for Payer: MDX Hawaii PPO	$5,192.41
Rate for Payer: University Health Alliance Commercial	$2,997.68

Total Hip Vivacit E DM Bearing 28X46mm 110031013 [3642946]

Facility

$5,353.00

Service Code	HCPCS C1776
Hospital Charge Code	3642946
Hospital Revenue Code	278
Min. Negotiated Rate	$2,997.68
Max. Negotiated Rate	$5,192.41
Rate for Payer: Cash Price	$3,479.45
Rate for Payer: Hawaii Western Management Group Commercial	$3,747.10
Rate for Payer: Health Management Network Commercial	$4,550.05
Rate for Payer: MDX Hawaii PPO	$5,192.41
Rate for Payer: University Health Alliance Commercial	$2,997.68

Total Knee All Poly Patella Ve 35mmx9.0mm 42-5402-000-35 [3643818]

Facility

$2,753.00

Service Code	HCPCS C1776
Hospital Charge Code	3643818
Hospital Revenue Code	278
Min. Negotiated Rate	$1,541.68
Max. Negotiated Rate	$2,670.41
Rate for Payer: Cash Price	$1,789.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,927.10
Rate for Payer: Health Management Network Commercial	$2,340.05
Rate for Payer: MDX Hawaii PPO	$2,670.41
Rate for Payer: University Health Alliance Commercial	$1,541.68

Total Knee All Poly Patella Ve 35mmx9.0mm 42-5402-000-35 [3643818]

Facility

$2,753.00

Service Code	HCPCS C1776
Hospital Charge Code	3643818
Hospital Revenue Code	278
Min. Negotiated Rate	$1,404.03
Max. Negotiated Rate	$2,670.41
Rate for Payer: Cash Price	$1,789.45
Rate for Payer: Hawaii Western Management Group Commercial	$1,927.10
Rate for Payer: Health Management Network Commercial	$2,340.05
Rate for Payer: Kaiser Permanente Commercial	$1,734.39
Rate for Payer: Kaiser Permanente Medicaid	$1,404.03
Rate for Payer: MDX Hawaii PPO	$2,670.41
Rate for Payer: University Health Alliance Commercial	$1,541.68

Total Knee DJO Empowr Femur Sz7 Rt 242-02-107 [3644316]

Facility

$14,488.00

Service Code	HCPCS C1776
Hospital Charge Code	3644316
Hospital Revenue Code	278
Min. Negotiated Rate	$8,113.28
Max. Negotiated Rate	$14,053.36
Rate for Payer: Cash Price	$9,417.20
Rate for Payer: Hawaii Western Management Group Commercial	$10,141.60
Rate for Payer: Health Management Network Commercial	$12,314.80
Rate for Payer: MDX Hawaii PPO	$14,053.36
Rate for Payer: University Health Alliance Commercial	$8,113.28

Total Knee DJO Empowr Femur Sz7 Rt 242-02-107 [3644316]

Facility

$14,488.00

Service Code	HCPCS C1776
Hospital Charge Code	3644316
Hospital Revenue Code	278
Min. Negotiated Rate	$7,388.88
Max. Negotiated Rate	$14,053.36
Rate for Payer: Cash Price	$9,417.20
Rate for Payer: Hawaii Western Management Group Commercial	$10,141.60
Rate for Payer: Health Management Network Commercial	$12,314.80
Rate for Payer: Kaiser Permanente Commercial	$9,127.44
Rate for Payer: Kaiser Permanente Medicaid	$7,388.88
Rate for Payer: MDX Hawaii PPO	$14,053.36
Rate for Payer: University Health Alliance Commercial	$8,113.28

Total Knee DJO Empowr Straight Fluted Bone Pin 800-02-505 [3644318]

Facility

$1,401.49

Hospital Charge Code	3644318
Hospital Revenue Code	272
Min. Negotiated Rate	$714.76
Max. Negotiated Rate	$1,359.45
Rate for Payer: Cash Price	$910.97
Rate for Payer: Hawaii Western Management Group Commercial	$1,331.42
Rate for Payer: Health Management Network Commercial	$1,191.27
Rate for Payer: Kaiser Permanente Commercial	$882.94
Rate for Payer: Kaiser Permanente Medicaid	$714.76
Rate for Payer: MDX Hawaii PPO	$1,359.45
Rate for Payer: University Health Alliance Commercial	$1,021.55

Total Knee DJO Empowr Straight Fluted Bone Pin 800-02-505 [3644318]

Facility

$1,401.49

Hospital Charge Code	3644318
Hospital Revenue Code	272
Min. Negotiated Rate	$1,191.27
Max. Negotiated Rate	$1,359.45
Rate for Payer: Cash Price	$910.97
Rate for Payer: Health Management Network Commercial	$1,191.27
Rate for Payer: MDX Hawaii PPO	$1,359.45

Total Knee DJO Empowr Tibia Sz8 Rt 353-02-108 [3644315]

Facility

$10,862.00

Service Code	HCPCS C1776
Hospital Charge Code	3644315
Hospital Revenue Code	278
Min. Negotiated Rate	$5,539.62
Max. Negotiated Rate	$10,536.14
Rate for Payer: Cash Price	$7,060.30
Rate for Payer: Hawaii Western Management Group Commercial	$7,603.40
Rate for Payer: Health Management Network Commercial	$9,232.70
Rate for Payer: Kaiser Permanente Commercial	$6,843.06
Rate for Payer: Kaiser Permanente Medicaid	$5,539.62
Rate for Payer: MDX Hawaii PPO	$10,536.14
Rate for Payer: University Health Alliance Commercial	$6,082.72

Total Knee DJO Empowr Tibia Sz8 Rt 353-02-108 [3644315]

Facility

$10,862.00

Service Code	HCPCS C1776
Hospital Charge Code	3644315
Hospital Revenue Code	278
Min. Negotiated Rate	$6,082.72
Max. Negotiated Rate	$10,536.14
Rate for Payer: Cash Price	$7,060.30
Rate for Payer: Hawaii Western Management Group Commercial	$7,603.40
Rate for Payer: Health Management Network Commercial	$9,232.70
Rate for Payer: MDX Hawaii PPO	$10,536.14
Rate for Payer: University Health Alliance Commercial	$6,082.72

Total Knee DJO Empowr VVC Tibial Insert Sz 8 12mm 346-12-708 [3644317]

Facility

$10,974.00

Service Code	HCPCS C1776
Hospital Charge Code	3644317
Hospital Revenue Code	278
Min. Negotiated Rate	$5,596.74
Max. Negotiated Rate	$10,644.78
Rate for Payer: Cash Price	$7,133.10
Rate for Payer: Hawaii Western Management Group Commercial	$7,681.80
Rate for Payer: Health Management Network Commercial	$9,327.90
Rate for Payer: Kaiser Permanente Commercial	$6,913.62
Rate for Payer: Kaiser Permanente Medicaid	$5,596.74
Rate for Payer: MDX Hawaii PPO	$10,644.78
Rate for Payer: University Health Alliance Commercial	$6,145.44

Total Knee DJO Empowr VVC Tibial Insert Sz 8 12mm 346-12-708 [3644317]

Facility

$10,974.00

Service Code	HCPCS C1776
Hospital Charge Code	3644317
Hospital Revenue Code	278
Min. Negotiated Rate	$6,145.44
Max. Negotiated Rate	$10,644.78
Rate for Payer: Cash Price	$7,133.10
Rate for Payer: Hawaii Western Management Group Commercial	$7,681.80
Rate for Payer: Health Management Network Commercial	$9,327.90
Rate for Payer: MDX Hawaii PPO	$10,644.78
Rate for Payer: University Health Alliance Commercial	$6,145.44

Total Knee Empowr 3D Femur LT Sz 5 243-01-105 [3644375]

Facility

$19,356.50

Service Code	HCPCS C1776
Hospital Charge Code	3644375
Hospital Revenue Code	278
Min. Negotiated Rate	$9,871.82
Max. Negotiated Rate	$18,775.81
Rate for Payer: Cash Price	$12,581.72
Rate for Payer: Hawaii Western Management Group Commercial	$13,549.55
Rate for Payer: Health Management Network Commercial	$16,453.03
Rate for Payer: Kaiser Permanente Commercial	$12,194.59
Rate for Payer: Kaiser Permanente Medicaid	$9,871.82
Rate for Payer: MDX Hawaii PPO	$18,775.81
Rate for Payer: University Health Alliance Commercial	$10,839.64

Total Knee Empowr 3D Femur LT Sz 5 243-01-105 [3644375]

Facility

$19,356.50

Service Code	HCPCS C1776
Hospital Charge Code	3644375
Hospital Revenue Code	278
Min. Negotiated Rate	$10,839.64
Max. Negotiated Rate	$18,775.81
Rate for Payer: Cash Price	$12,581.72
Rate for Payer: Hawaii Western Management Group Commercial	$13,549.55
Rate for Payer: Health Management Network Commercial	$16,453.03
Rate for Payer: MDX Hawaii PPO	$18,775.81
Rate for Payer: University Health Alliance Commercial	$10,839.64

Total Knee Empowr 3D Tibial Insert Sz 5 19mm 341-19-705 [3644376]

Facility

$8,149.50

Service Code	HCPCS C1776
Hospital Charge Code	3644376
Hospital Revenue Code	278
Min. Negotiated Rate	$4,563.72
Max. Negotiated Rate	$7,905.02
Rate for Payer: Cash Price	$5,297.18
Rate for Payer: Hawaii Western Management Group Commercial	$5,704.65
Rate for Payer: Health Management Network Commercial	$6,927.07
Rate for Payer: MDX Hawaii PPO	$7,905.02
Rate for Payer: University Health Alliance Commercial	$4,563.72

Total Knee Empowr 3D Tibial Insert Sz 5 19mm 341-19-705 [3644376]

Facility

$8,149.50

Service Code	HCPCS C1776
Hospital Charge Code	3644376
Hospital Revenue Code	278
Min. Negotiated Rate	$4,156.24
Max. Negotiated Rate	$7,905.02
Rate for Payer: Cash Price	$5,297.18
Rate for Payer: Hawaii Western Management Group Commercial	$5,704.65
Rate for Payer: Health Management Network Commercial	$6,927.07
Rate for Payer: Kaiser Permanente Commercial	$5,134.19
Rate for Payer: Kaiser Permanente Medicaid	$4,156.24
Rate for Payer: MDX Hawaii PPO	$7,905.02
Rate for Payer: University Health Alliance Commercial	$4,563.72

Total Knee Empowr Tibia Minus LT Sz 5 353-03-105 [3644374]

Facility

$10,862.00

Service Code	HCPCS C1776
Hospital Charge Code	3644374
Hospital Revenue Code	278
Min. Negotiated Rate	$6,082.72
Max. Negotiated Rate	$10,536.14
Rate for Payer: Cash Price	$7,060.30
Rate for Payer: Hawaii Western Management Group Commercial	$7,603.40
Rate for Payer: Health Management Network Commercial	$9,232.70
Rate for Payer: MDX Hawaii PPO	$10,536.14
Rate for Payer: University Health Alliance Commercial	$6,082.72

Total Knee Empowr Tibia Minus LT Sz 5 353-03-105 [3644374]

Facility

$10,862.00

Service Code	HCPCS C1776
Hospital Charge Code	3644374
Hospital Revenue Code	278
Min. Negotiated Rate	$5,539.62
Max. Negotiated Rate	$10,536.14
Rate for Payer: Cash Price	$7,060.30
Rate for Payer: Hawaii Western Management Group Commercial	$7,603.40
Rate for Payer: Health Management Network Commercial	$9,232.70
Rate for Payer: Kaiser Permanente Commercial	$6,843.06
Rate for Payer: Kaiser Permanente Medicaid	$5,539.62
Rate for Payer: MDX Hawaii PPO	$10,536.14
Rate for Payer: University Health Alliance Commercial	$6,082.72

Total Knee MIS Headed Screw 33MM 00598304033 [3627424A]

Facility

$658.25

Service Code	HCPCS C1713
Hospital Charge Code	3627424A
Hospital Revenue Code	278
Min. Negotiated Rate	$335.71
Max. Negotiated Rate	$638.50
Rate for Payer: Cash Price	$427.86
Rate for Payer: Hawaii Western Management Group Commercial	$460.77
Rate for Payer: Health Management Network Commercial	$559.51
Rate for Payer: Kaiser Permanente Commercial	$414.70
Rate for Payer: Kaiser Permanente Medicaid	$335.71
Rate for Payer: MDX Hawaii PPO	$638.50
Rate for Payer: University Health Alliance Commercial	$368.62

Total Knee MIS Headed Screw 33MM 00598304033 [3627424A]

Facility

$658.25

Service Code	HCPCS C1713
Hospital Charge Code	3627424A
Hospital Revenue Code	278
Min. Negotiated Rate	$368.62
Max. Negotiated Rate	$638.50
Rate for Payer: Cash Price	$427.86
Rate for Payer: Hawaii Western Management Group Commercial	$460.77
Rate for Payer: Health Management Network Commercial	$559.51
Rate for Payer: MDX Hawaii PPO	$638.50
Rate for Payer: University Health Alliance Commercial	$368.62

Total Knee MIS Headed Screw 48MM 00598304048 [3627424]

Facility

$658.25

Service Code	HCPCS C1713
Hospital Charge Code	3627424
Hospital Revenue Code	278
Min. Negotiated Rate	$335.71
Max. Negotiated Rate	$638.50
Rate for Payer: Cash Price	$427.86
Rate for Payer: Hawaii Western Management Group Commercial	$460.77
Rate for Payer: Health Management Network Commercial	$559.51
Rate for Payer: Kaiser Permanente Commercial	$414.70
Rate for Payer: Kaiser Permanente Medicaid	$335.71
Rate for Payer: MDX Hawaii PPO	$638.50
Rate for Payer: University Health Alliance Commercial	$368.62

Know your out-of-pocket cost for care.

All Charges