Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Knee Psn Fem Ps Cmt Cocr Std Sz 11 Lt [3643599]

Facility

$5,375.00

Service Code	HCPCS C1776
Hospital Charge Code	3643599
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 Ps Cmt Cocr Std Sz 11 Lt [3643599]

Facility

$5,375.00

Service Code	HCPCS C1776
Hospital Charge Code	3643599
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 Ps Cmt Cocr Std Sz11 Rt 42-5006-070-02 [3643601]

Facility

$8,678.00

Service Code	HCPCS C1776
Hospital Charge Code	3643601
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 Ps Cmt Cocr Std Sz11 Rt 42-5006-070-02 [3643601]

Facility

$8,678.00

Service Code	HCPCS C1776
Hospital Charge Code	3643601
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 POR 3 Peg Pat 29 x 9.0mm 42-5405-000-29 [3644418]

Facility

$3,653.00

Service Code	HCPCS C1776
Hospital Charge Code	3644418
Hospital Revenue Code	278
Min. Negotiated Rate	$2,045.68
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,374.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.10
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: University Health Alliance Commercial	$2,045.68

Total Knee PSN POR 3 Peg Pat 29 x 9.0mm 42-5405-000-29 [3644418]

Facility

$3,653.00

Service Code	HCPCS C1776
Hospital Charge Code	3644418
Hospital Revenue Code	278
Min. Negotiated Rate	$1,863.03
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,374.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.10
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: Kaiser Permanente Commercial	$2,301.39
Rate for Payer: Kaiser Permanente Medicaid	$1,863.03
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: University Health Alliance Commercial	$2,045.68

Total Knee PSN POR 3 Peg PAT 32mm x 9.0mm 42-5405-000-32 [3644444]

Facility

$3,653.00

Service Code	HCPCS C1776
Hospital Charge Code	3644444
Hospital Revenue Code	278
Min. Negotiated Rate	$1,863.03
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,374.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.10
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: Kaiser Permanente Commercial	$2,301.39
Rate for Payer: Kaiser Permanente Medicaid	$1,863.03
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: University Health Alliance Commercial	$2,045.68

Total Knee PSN POR 3 Peg PAT 32mm x 9.0mm 42-5405-000-32 [3644444]

Facility

$3,653.00

Service Code	HCPCS C1776
Hospital Charge Code	3644444
Hospital Revenue Code	278
Min. Negotiated Rate	$2,045.68
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,374.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.10
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: University Health Alliance Commercial	$2,045.68

Total Knee PSN POR 3 Peg Pat 35 x 9.5mm 42-5405-000-35 [3644452]

Facility

$3,653.00

Service Code	HCPCS C1776
Hospital Charge Code	3644452
Hospital Revenue Code	278
Min. Negotiated Rate	$1,863.03
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,374.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.10
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: Kaiser Permanente Commercial	$2,301.39
Rate for Payer: Kaiser Permanente Medicaid	$1,863.03
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: University Health Alliance Commercial	$2,045.68

Total Knee PSN POR 3 Peg Pat 35 x 9.5mm 42-5405-000-35 [3644452]

Facility

$3,653.00

Service Code	HCPCS C1776
Hospital Charge Code	3644452
Hospital Revenue Code	278
Min. Negotiated Rate	$2,045.68
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,374.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.10
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: University Health Alliance Commercial	$2,045.68

Total Knee PSN POR 3 Peg Pat 38mm x 10mm 42-5405-000-38 [3644436]

Facility

$3,653.00

Service Code	HCPCS C1776
Hospital Charge Code	3644436
Hospital Revenue Code	278
Min. Negotiated Rate	$1,863.03
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,374.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.10
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: Kaiser Permanente Commercial	$2,301.39
Rate for Payer: Kaiser Permanente Medicaid	$1,863.03
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: University Health Alliance Commercial	$2,045.68

Total Knee PSN POR 3 Peg Pat 38mm x 10mm 42-5405-000-38 [3644436]

Facility

$3,653.00

Service Code	HCPCS C1776
Hospital Charge Code	3644436
Hospital Revenue Code	278
Min. Negotiated Rate	$2,045.68
Max. Negotiated Rate	$3,543.41
Rate for Payer: Cash Price	$2,374.45
Rate for Payer: Hawaii Western Management Group Commercial	$2,557.10
Rate for Payer: Health Management Network Commercial	$3,105.05
Rate for Payer: MDX Hawaii PPO	$3,543.41
Rate for Payer: University Health Alliance Commercial	$2,045.68

Total Knee PSN REV 3mm Offset Stem Ext 12 x 135mm 42-5603-135-12 [3644434]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644434
Hospital Revenue Code	278
Min. Negotiated Rate	$4,436.32
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Total Knee PSN REV 3mm Offset Stem Ext 12 x 135mm 42-5603-135-12 [3644434]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644434
Hospital Revenue Code	278
Min. Negotiated Rate	$4,040.22
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: Kaiser Permanente Commercial	$4,990.86
Rate for Payer: Kaiser Permanente Medicaid	$4,040.22
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Total Knee PSN REV 3mm Offset Stem Ext 15 x 135mm 42-5603-135-15 [3643173]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3643173
Hospital Revenue Code	278
Min. Negotiated Rate	$4,040.22
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: Kaiser Permanente Commercial	$4,990.86
Rate for Payer: Kaiser Permanente Medicaid	$4,040.22
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Total Knee PSN REV 3mm Offset Stem Ext 15 x 135mm 42-5603-135-15 [3643173]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3643173
Hospital Revenue Code	278
Min. Negotiated Rate	$4,436.32
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Total Knee PSN Rev 3mm Offset Stem Ext 20 x 135mm 42-5603-135-20 [3644572]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644572
Hospital Revenue Code	278
Min. Negotiated Rate	$4,040.22
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: Kaiser Permanente Commercial	$4,990.86
Rate for Payer: Kaiser Permanente Medicaid	$4,040.22
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Total Knee PSN Rev 3mm Offset Stem Ext 20 x 135mm 42-5603-135-20 [3644572]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644572
Hospital Revenue Code	278
Min. Negotiated Rate	$4,436.32
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Total Knee PSN REV 6mm Offset Stem Ext 12X135mm 42-5606-135-12 [3643167]

Facility

$7,925.50

Service Code	HCPCS C1776
Hospital Charge Code	3643167
Hospital Revenue Code	278
Min. Negotiated Rate	$4,042.01
Max. Negotiated Rate	$7,687.73
Rate for Payer: Cash Price	$5,151.58
Rate for Payer: Hawaii Western Management Group Commercial	$5,547.85
Rate for Payer: Health Management Network Commercial	$6,736.68
Rate for Payer: Kaiser Permanente Commercial	$4,993.06
Rate for Payer: Kaiser Permanente Medicaid	$4,042.01
Rate for Payer: MDX Hawaii PPO	$7,687.73
Rate for Payer: University Health Alliance Commercial	$4,438.28

Total Knee PSN REV 6mm Offset Stem Ext 12X135mm 42-5606-135-12 [3643167]

Facility

$7,925.50

Service Code	HCPCS C1776
Hospital Charge Code	3643167
Hospital Revenue Code	278
Min. Negotiated Rate	$4,438.28
Max. Negotiated Rate	$7,687.73
Rate for Payer: Cash Price	$5,151.58
Rate for Payer: Hawaii Western Management Group Commercial	$5,547.85
Rate for Payer: Health Management Network Commercial	$6,736.68
Rate for Payer: MDX Hawaii PPO	$7,687.73
Rate for Payer: University Health Alliance Commercial	$4,438.28

Total Knee Psn Rev 6mm Offset Stem Ext 13x135mm 42-5606-135-13 [3643992]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3643992
Hospital Revenue Code	278
Min. Negotiated Rate	$4,040.22
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: Kaiser Permanente Commercial	$4,990.86
Rate for Payer: Kaiser Permanente Medicaid	$4,040.22
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Total Knee Psn Rev 6mm Offset Stem Ext 13x135mm 42-5606-135-13 [3643992]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3643992
Hospital Revenue Code	278
Min. Negotiated Rate	$4,436.32
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Total Knee Psn Rev 6mm Offset Stem Ext 14x135mm 42-5606-135-14 [3643917]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3643917
Hospital Revenue Code	278
Min. Negotiated Rate	$4,436.32
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Total Knee Psn Rev 6mm Offset Stem Ext 14x135mm 42-5606-135-14 [3643917]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3643917
Hospital Revenue Code	278
Min. Negotiated Rate	$4,040.22
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: Kaiser Permanente Commercial	$4,990.86
Rate for Payer: Kaiser Permanente Medicaid	$4,040.22
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Total Knee PSN REV 6mm Offset Stem Ext 22 x 135mm 42-5606-135-22 [3644395]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644395
Hospital Revenue Code	278
Min. Negotiated Rate	$4,436.32
Max. Negotiated Rate	$7,684.34
Rate for Payer: Cash Price	$5,149.30
Rate for Payer: Hawaii Western Management Group Commercial	$5,545.40
Rate for Payer: Health Management Network Commercial	$6,733.70
Rate for Payer: MDX Hawaii PPO	$7,684.34
Rate for Payer: University Health Alliance Commercial	$4,436.32

Know your out-of-pocket cost for care.

All Charges