Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Knee PSN ALL Poly Pat PLY 35mmX9.0mm 42540000035 [3642601]

Facility

$1,443.75

Service Code	HCPCS C1776
Hospital Charge Code	3642601
Hospital Revenue Code	278
Min. Negotiated Rate	$736.31
Max. Negotiated Rate	$1,400.44
Rate for Payer: Cash Price	$938.44
Rate for Payer: Hawaii Western Management Group Commercial	$1,010.62
Rate for Payer: Health Management Network Commercial	$1,227.19
Rate for Payer: Kaiser Permanente Commercial	$909.56
Rate for Payer: Kaiser Permanente Medicaid	$736.31
Rate for Payer: MDX Hawaii PPO	$1,400.44
Rate for Payer: University Health Alliance Commercial	$808.50

Total Knee PSN ALL Poly Pat PLY 35mmX9.0mm 42540000035 [3642601]

Facility

$1,443.75

Service Code	HCPCS C1776
Hospital Charge Code	3642601
Hospital Revenue Code	278
Min. Negotiated Rate	$808.50
Max. Negotiated Rate	$1,400.44
Rate for Payer: Cash Price	$938.44
Rate for Payer: Hawaii Western Management Group Commercial	$1,010.62
Rate for Payer: Health Management Network Commercial	$1,227.19
Rate for Payer: MDX Hawaii PPO	$1,400.44
Rate for Payer: University Health Alliance Commercial	$808.50

Total Knee PSN All Poly Pat Ve 38mm x 9.5mm 42-5402-000-38 [3644849]

Facility

$2,753.00

Service Code	HCPCS C1776
Hospital Charge Code	3644849
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 PSN All Poly Pat Ve 38mm x 9.5mm 42-5402-000-38 [3644849]

Facility

$2,753.00

Service Code	HCPCS C1776
Hospital Charge Code	3644849
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 PSN ASF CPS 10mm VE L 6-9 CD 42-5126-005-10 [3644435]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644435
Hospital Revenue Code	278
Min. Negotiated Rate	$3,256.61
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: Kaiser Permanente Commercial	$4,022.86
Rate for Payer: Kaiser Permanente Medicaid	$3,256.61
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF CPS 10mm VE L 6-9 CD 42-5126-005-10 [3644435]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644435
Hospital Revenue Code	278
Min. Negotiated Rate	$3,575.88
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF CPS 12mm VE Rt 10-12 GH 42-5226-010-12 [3644574]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644574
Hospital Revenue Code	278
Min. Negotiated Rate	$3,256.61
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: Kaiser Permanente Commercial	$4,022.86
Rate for Payer: Kaiser Permanente Medicaid	$3,256.61
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF CPS 12mm VE Rt 10-12 GH 42-5226-010-12 [3644574]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644574
Hospital Revenue Code	278
Min. Negotiated Rate	$3,575.88
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF CPS 14mm VE L 10-12 GH 42-5126-010-14 [3644390]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644390
Hospital Revenue Code	278
Min. Negotiated Rate	$3,575.88
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF CPS 14mm VE L 10-12 GH 42-5126-010-14 [3644390]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644390
Hospital Revenue Code	278
Min. Negotiated Rate	$3,256.61
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: Kaiser Permanente Commercial	$4,022.86
Rate for Payer: Kaiser Permanente Medicaid	$3,256.61
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF CPS 14mm VE L 6-9 EF 42-5126-007-14 [3644804]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644804
Hospital Revenue Code	278
Min. Negotiated Rate	$3,256.61
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: Kaiser Permanente Commercial	$4,022.86
Rate for Payer: Kaiser Permanente Medicaid	$3,256.61
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF CPS 14mm VE L 6-9 EF 42-5126-007-14 [3644804]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644804
Hospital Revenue Code	278
Min. Negotiated Rate	$3,575.88
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF CPS VE 10mm Rt 3-5 CD 42-5226-004-10 [3644408]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644408
Hospital Revenue Code	278
Min. Negotiated Rate	$3,256.61
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: Kaiser Permanente Commercial	$4,022.86
Rate for Payer: Kaiser Permanente Medicaid	$3,256.61
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF CPS VE 10mm Rt 3-5 CD 42-5226-004-10 [3644408]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644408
Hospital Revenue Code	278
Min. Negotiated Rate	$3,575.88
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee Psn Asf Cps Ve 10mm Rt 6-9 Cd 42-5226-005-10 [3643915]

Facility

$3,670.00

Service Code	HCPCS C1776
Hospital Charge Code	3643915
Hospital Revenue Code	278
Min. Negotiated Rate	$2,055.20
Max. Negotiated Rate	$3,559.90
Rate for Payer: Cash Price	$2,385.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,569.00
Rate for Payer: Health Management Network Commercial	$3,119.50
Rate for Payer: MDX Hawaii PPO	$3,559.90
Rate for Payer: University Health Alliance Commercial	$2,055.20

Total Knee Psn Asf Cps Ve 10mm Rt 6-9 Cd 42-5226-005-10 [3643915]

Facility

$3,670.00

Service Code	HCPCS C1776
Hospital Charge Code	3643915
Hospital Revenue Code	278
Min. Negotiated Rate	$1,871.70
Max. Negotiated Rate	$3,559.90
Rate for Payer: Cash Price	$2,385.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,569.00
Rate for Payer: Health Management Network Commercial	$3,119.50
Rate for Payer: Kaiser Permanente Commercial	$2,312.10
Rate for Payer: Kaiser Permanente Medicaid	$1,871.70
Rate for Payer: MDX Hawaii PPO	$3,559.90
Rate for Payer: University Health Alliance Commercial	$2,055.20

Total Knee PSN ASF CPS VE 10mm Rt 6-9 Ef 42-5226-007-10 [3644455]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644455
Hospital Revenue Code	278
Min. Negotiated Rate	$3,256.61
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: Kaiser Permanente Commercial	$4,022.86
Rate for Payer: Kaiser Permanente Medicaid	$3,256.61
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF CPS VE 10mm Rt 6-9 Ef 42-5226-007-10 [3644455]

Facility

$6,385.50

Service Code	HCPCS C1776
Hospital Charge Code	3644455
Hospital Revenue Code	278
Min. Negotiated Rate	$3,575.88
Max. Negotiated Rate	$6,193.94
Rate for Payer: Cash Price	$4,150.58
Rate for Payer: Hawaii Western Management Group Commercial	$4,469.85
Rate for Payer: Health Management Network Commercial	$5,427.68
Rate for Payer: MDX Hawaii PPO	$6,193.94
Rate for Payer: University Health Alliance Commercial	$3,575.88

Total Knee PSN ASF MC VE 10mm LT 12 GH 42-5121-010-10 [3643034]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3643034
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 Knee PSN ASF MC VE 10mm LT 12 GH 42-5121-010-10 [3643034]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3643034
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 Knee PSN ASF MC VE 10mm Lt 4-05 Ef 42-5121-006-10 [3644261]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3644261
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 Knee PSN ASF MC VE 10mm Lt 4-05 Ef 42-5121-006-10 [3644261]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3644261
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 Knee PSN ASF MC VE 10mm LT 4-5 CD 42-5121-003-10 [3642756]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642756
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 Knee PSN ASF MC VE 10mm LT 4-5 CD 42-5121-003-10 [3642756]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3642756
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 Knee PSN ASF MC VE 10mm LT 6-7 CD 42-5121-004-10 [3643052]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3643052
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