Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Knee Psn Asf Mc Ve 14mm Lt 4-5 Cd 42-5121-003-14 [3643979]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3643979
Hospital Revenue Code	278
Min. Negotiated Rate	$1,862.00
Max. Negotiated Rate	$3,225.25
Rate for Payer: Cash Price	$2,161.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,327.50
Rate for Payer: Health Management Network Commercial	$2,826.25
Rate for Payer: MDX Hawaii PPO	$3,225.25
Rate for Payer: University Health Alliance Commercial	$1,862.00

Total Knee Psn Asf Mc Ve 14mm Lt 4-5 Cd 42-5121-003-14 [3643979]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3643979
Hospital Revenue Code	278
Min. Negotiated Rate	$1,695.75
Max. Negotiated Rate	$3,225.25
Rate for Payer: Cash Price	$2,161.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,327.50
Rate for Payer: Health Management Network Commercial	$2,826.25
Rate for Payer: Kaiser Permanente Commercial	$2,094.75
Rate for Payer: Kaiser Permanente Medicaid	$1,695.75
Rate for Payer: MDX Hawaii PPO	$3,225.25
Rate for Payer: University Health Alliance Commercial	$1,862.00

Total Knee PSN ASF MC VE 14mm Lt 6-7 EF 42-5121-007-14 [3644778]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3644778
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 14mm Lt 6-7 EF 42-5121-007-14 [3644778]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3644778
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 14mm Lt 8-11 GH 42-5121-009-14 [3645372]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3645372
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 14mm Lt 8-11 GH 42-5121-009-14 [3645372]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3645372
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 16mm Rt 6-7 Cd 42-5221-004-16 [3643893]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3643893
Hospital Revenue Code	278
Min. Negotiated Rate	$1,862.00
Max. Negotiated Rate	$3,225.25
Rate for Payer: Cash Price	$2,161.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,327.50
Rate for Payer: Health Management Network Commercial	$2,826.25
Rate for Payer: MDX Hawaii PPO	$3,225.25
Rate for Payer: University Health Alliance Commercial	$1,862.00

Total Knee Psn Asf Mc Ve 16mm Rt 6-7 Cd 42-5221-004-16 [3643893]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3643893
Hospital Revenue Code	278
Min. Negotiated Rate	$1,695.75
Max. Negotiated Rate	$3,225.25
Rate for Payer: Cash Price	$2,161.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,327.50
Rate for Payer: Health Management Network Commercial	$2,826.25
Rate for Payer: Kaiser Permanente Commercial	$2,094.75
Rate for Payer: Kaiser Permanente Medicaid	$1,695.75
Rate for Payer: MDX Hawaii PPO	$3,225.25
Rate for Payer: University Health Alliance Commercial	$1,862.00

Total Knee PSN ASF ME VE 14mm Rt 8-11 EF 42-5221-008-14 [3644998]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3644998
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 ME VE 14mm Rt 8-11 EF 42-5221-008-14 [3644998]

Facility

$4,778.00

Service Code	HCPCS C1776
Hospital Charge Code	3644998
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 UC 10mm Rt 3-7 CD 42-5212-004-10 [3641555]

Facility

$6,238.50

Service Code	HCPCS C1776
Hospital Charge Code	3641555
Hospital Revenue Code	278
Min. Negotiated Rate	$3,181.64
Max. Negotiated Rate	$6,051.35
Rate for Payer: Cash Price	$4,055.02
Rate for Payer: Hawaii Western Management Group Commercial	$4,366.95
Rate for Payer: Health Management Network Commercial	$5,302.73
Rate for Payer: Kaiser Permanente Commercial	$3,930.26
Rate for Payer: Kaiser Permanente Medicaid	$3,181.64
Rate for Payer: MDX Hawaii PPO	$6,051.35
Rate for Payer: University Health Alliance Commercial	$3,493.56

Total Knee PSN ASF UC 10mm Rt 3-7 CD 42-5212-004-10 [3641555]

Facility

$6,238.50

Service Code	HCPCS C1776
Hospital Charge Code	3641555
Hospital Revenue Code	278
Min. Negotiated Rate	$3,493.56
Max. Negotiated Rate	$6,051.35
Rate for Payer: Cash Price	$4,055.02
Rate for Payer: Hawaii Western Management Group Commercial	$4,366.95
Rate for Payer: Health Management Network Commercial	$5,302.73
Rate for Payer: MDX Hawaii PPO	$6,051.35
Rate for Payer: University Health Alliance Commercial	$3,493.56

Total Knee Psn Asf Uc 10mm Ve Lt 4-11 Ef [3643639]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3643639
Hospital Revenue Code	278
Min. Negotiated Rate	$1,862.00
Max. Negotiated Rate	$3,225.25
Rate for Payer: Cash Price	$2,161.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,327.50
Rate for Payer: Health Management Network Commercial	$2,826.25
Rate for Payer: MDX Hawaii PPO	$3,225.25
Rate for Payer: University Health Alliance Commercial	$1,862.00

Total Knee Psn Asf Uc 10mm Ve Lt 4-11 Ef [3643639]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3643639
Hospital Revenue Code	278
Min. Negotiated Rate	$1,695.75
Max. Negotiated Rate	$3,225.25
Rate for Payer: Cash Price	$2,161.25
Rate for Payer: Hawaii Western Management Group Commercial	$2,327.50
Rate for Payer: Health Management Network Commercial	$2,826.25
Rate for Payer: Kaiser Permanente Commercial	$2,094.75
Rate for Payer: Kaiser Permanente Medicaid	$1,695.75
Rate for Payer: MDX Hawaii PPO	$3,225.25
Rate for Payer: University Health Alliance Commercial	$1,862.00

Total Knee Psn Cr Pps Ccr Nrw Sz9 Rt 42-5080-066-02 [3643513]

Facility

$10,603.00

Service Code	HCPCS C1776
Hospital Charge Code	3643513
Hospital Revenue Code	278
Min. Negotiated Rate	$5,937.68
Max. Negotiated Rate	$10,284.91
Rate for Payer: Cash Price	$6,891.95
Rate for Payer: Hawaii Western Management Group Commercial	$7,422.10
Rate for Payer: Health Management Network Commercial	$9,012.55
Rate for Payer: MDX Hawaii PPO	$10,284.91
Rate for Payer: University Health Alliance Commercial	$5,937.68

Total Knee Psn Cr Pps Ccr Nrw Sz9 Rt 42-5080-066-02 [3643513]

Facility

$10,603.00

Service Code	HCPCS C1776
Hospital Charge Code	3643513
Hospital Revenue Code	278
Min. Negotiated Rate	$5,407.53
Max. Negotiated Rate	$10,284.91
Rate for Payer: Cash Price	$6,891.95
Rate for Payer: Hawaii Western Management Group Commercial	$7,422.10
Rate for Payer: Health Management Network Commercial	$9,012.55
Rate for Payer: Kaiser Permanente Commercial	$6,679.89
Rate for Payer: Kaiser Permanente Medicaid	$5,407.53
Rate for Payer: MDX Hawaii PPO	$10,284.91
Rate for Payer: University Health Alliance Commercial	$5,937.68

Total Knee PSN FEM CR CMT CCR NRW Sz 11 LT 42502007001 [3642506]

Facility

$5,375.00

Service Code	HCPCS C1776
Hospital Charge Code	3642506
Hospital Revenue Code	278
Min. Negotiated Rate	$3,010.00
Max. Negotiated Rate	$5,213.75
Rate for Payer: Cash Price	$3,493.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,762.50
Rate for Payer: Health Management Network Commercial	$4,568.75
Rate for Payer: MDX Hawaii PPO	$5,213.75
Rate for Payer: University Health Alliance Commercial	$3,010.00

Total Knee PSN FEM CR CMT CCR NRW Sz 11 LT 42502007001 [3642506]

Facility

$5,375.00

Service Code	HCPCS C1776
Hospital Charge Code	3642506
Hospital Revenue Code	278
Min. Negotiated Rate	$2,741.25
Max. Negotiated Rate	$5,213.75
Rate for Payer: Cash Price	$3,493.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,762.50
Rate for Payer: Health Management Network Commercial	$4,568.75
Rate for Payer: Kaiser Permanente Commercial	$3,386.25
Rate for Payer: Kaiser Permanente Medicaid	$2,741.25
Rate for Payer: MDX Hawaii PPO	$5,213.75
Rate for Payer: University Health Alliance Commercial	$3,010.00

Total Knee PSN FEM CR CMT CCR NRW Sz7 RT 42-5020-062-02 [3640835]

Facility

$8,678.00

Service Code	HCPCS C1776
Hospital Charge Code	3640835
Hospital Revenue Code	278
Min. Negotiated Rate	$4,425.78
Max. Negotiated Rate	$8,417.66
Rate for Payer: Cash Price	$5,640.70
Rate for Payer: Hawaii Western Management Group Commercial	$6,074.60
Rate for Payer: Health Management Network Commercial	$7,376.30
Rate for Payer: Kaiser Permanente Commercial	$5,467.14
Rate for Payer: Kaiser Permanente Medicaid	$4,425.78
Rate for Payer: MDX Hawaii PPO	$8,417.66
Rate for Payer: University Health Alliance Commercial	$4,859.68

Total Knee PSN FEM CR CMT CCR NRW Sz7 RT 42-5020-062-02 [3640835]

Facility

$8,678.00

Service Code	HCPCS C1776
Hospital Charge Code	3640835
Hospital Revenue Code	278
Min. Negotiated Rate	$4,859.68
Max. Negotiated Rate	$8,417.66
Rate for Payer: Cash Price	$5,640.70
Rate for Payer: Hawaii Western Management Group Commercial	$6,074.60
Rate for Payer: Health Management Network Commercial	$7,376.30
Rate for Payer: MDX Hawaii PPO	$8,417.66
Rate for Payer: University Health Alliance Commercial	$4,859.68

Total Knee PSN FEM CR CMT CCR NRW Sz8 RT 42-5020-064-02 [3642998]

Facility

$8,678.00

Service Code	HCPCS C1776
Hospital Charge Code	3642998
Hospital Revenue Code	278
Min. Negotiated Rate	$4,859.68
Max. Negotiated Rate	$8,417.66
Rate for Payer: Cash Price	$5,640.70
Rate for Payer: Hawaii Western Management Group Commercial	$6,074.60
Rate for Payer: Health Management Network Commercial	$7,376.30
Rate for Payer: MDX Hawaii PPO	$8,417.66
Rate for Payer: University Health Alliance Commercial	$4,859.68

Total Knee PSN FEM CR CMT CCR NRW Sz8 RT 42-5020-064-02 [3642998]

Facility

$8,678.00

Service Code	HCPCS C1776
Hospital Charge Code	3642998
Hospital Revenue Code	278
Min. Negotiated Rate	$4,425.78
Max. Negotiated Rate	$8,417.66
Rate for Payer: Cash Price	$5,640.70
Rate for Payer: Hawaii Western Management Group Commercial	$6,074.60
Rate for Payer: Health Management Network Commercial	$7,376.30
Rate for Payer: Kaiser Permanente Commercial	$5,467.14
Rate for Payer: Kaiser Permanente Medicaid	$4,425.78
Rate for Payer: MDX Hawaii PPO	$8,417.66
Rate for Payer: University Health Alliance Commercial	$4,859.68

Total Knee PSN FEM CR CMT CCR STD Sz11 RT 42502607002 [3641926]

Facility

$5,375.00

Service Code	HCPCS C1776
Hospital Charge Code	3641926
Hospital Revenue Code	278
Min. Negotiated Rate	$2,741.25
Max. Negotiated Rate	$5,213.75
Rate for Payer: Cash Price	$3,493.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,762.50
Rate for Payer: Health Management Network Commercial	$4,568.75
Rate for Payer: Kaiser Permanente Commercial	$3,386.25
Rate for Payer: Kaiser Permanente Medicaid	$2,741.25
Rate for Payer: MDX Hawaii PPO	$5,213.75
Rate for Payer: University Health Alliance Commercial	$3,010.00

Total Knee PSN FEM CR CMT CCR STD Sz11 RT 42502607002 [3641926]

Facility

$5,375.00

Service Code	HCPCS C1776
Hospital Charge Code	3641926
Hospital Revenue Code	278
Min. Negotiated Rate	$3,010.00
Max. Negotiated Rate	$5,213.75
Rate for Payer: Cash Price	$3,493.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,762.50
Rate for Payer: Health Management Network Commercial	$4,568.75
Rate for Payer: MDX Hawaii PPO	$5,213.75
Rate for Payer: University Health Alliance Commercial	$3,010.00

Total Knee PSN FEM CR CMT CCR STD Sz5 RT 42502605802 [3641095]

Facility

$5,375.00

Service Code	HCPCS C1776
Hospital Charge Code	3641095
Hospital Revenue Code	278
Min. Negotiated Rate	$3,010.00
Max. Negotiated Rate	$5,213.75
Rate for Payer: Cash Price	$3,493.75
Rate for Payer: Hawaii Western Management Group Commercial	$3,762.50
Rate for Payer: Health Management Network Commercial	$4,568.75
Rate for Payer: MDX Hawaii PPO	$5,213.75
Rate for Payer: University Health Alliance Commercial	$3,010.00

Know your out-of-pocket cost for care.

All Charges