Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Knee PSN REV Fem Post Aug Sz 55mm 42-5568-058-05 [3644409]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644409
Hospital Revenue Code	278
Min. Negotiated Rate	$3,193.68
Max. Negotiated Rate	$5,531.91
Rate for Payer: Cash Price	$3,706.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,992.10
Rate for Payer: Health Management Network Commercial	$4,847.55
Rate for Payer: MDX Hawaii PPO	$5,531.91
Rate for Payer: University Health Alliance Commercial	$3,193.68

Total Knee PSN REV Fem Post Aug Sz 55mm 42-5568-058-05 [3644409]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644409
Hospital Revenue Code	278
Min. Negotiated Rate	$2,908.53
Max. Negotiated Rate	$5,531.91
Rate for Payer: Cash Price	$3,706.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,992.10
Rate for Payer: Health Management Network Commercial	$4,847.55
Rate for Payer: Kaiser Permanente Commercial	$3,592.89
Rate for Payer: Kaiser Permanente Medicaid	$2,908.53
Rate for Payer: MDX Hawaii PPO	$5,531.91
Rate for Payer: University Health Alliance Commercial	$3,193.68

Total Knee PSN REV Fem Post Aug Sz 75mm 42-5568-062-05 [3644363]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644363
Hospital Revenue Code	278
Min. Negotiated Rate	$3,193.68
Max. Negotiated Rate	$5,531.91
Rate for Payer: Cash Price	$3,706.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,992.10
Rate for Payer: Health Management Network Commercial	$4,847.55
Rate for Payer: MDX Hawaii PPO	$5,531.91
Rate for Payer: University Health Alliance Commercial	$3,193.68

Total Knee PSN REV Fem Post Aug Sz 75mm 42-5568-062-05 [3644363]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644363
Hospital Revenue Code	278
Min. Negotiated Rate	$2,908.53
Max. Negotiated Rate	$5,531.91
Rate for Payer: Cash Price	$3,706.95
Rate for Payer: Hawaii Western Management Group Commercial	$3,992.10
Rate for Payer: Health Management Network Commercial	$4,847.55
Rate for Payer: Kaiser Permanente Commercial	$3,592.89
Rate for Payer: Kaiser Permanente Medicaid	$2,908.53
Rate for Payer: MDX Hawaii PPO	$5,531.91
Rate for Payer: University Health Alliance Commercial	$3,193.68

Total Knee PSN REV Straight Spline Stem Ext 11 x 135mm 42-5601-135-11 [3644410]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644410
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 Straight Spline Stem Ext 11 x 135mm 42-5601-135-11 [3644410]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644410
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 Straight Spline Stem Ext 15 x 135mm 42-5601-135-15 [3644172]

Facility

$7,953.50

Service Code	HCPCS C1776
Hospital Charge Code	3644172
Hospital Revenue Code	278
Min. Negotiated Rate	$4,453.96
Max. Negotiated Rate	$7,714.90
Rate for Payer: Cash Price	$5,169.78
Rate for Payer: Hawaii Western Management Group Commercial	$5,567.45
Rate for Payer: Health Management Network Commercial	$6,760.48
Rate for Payer: MDX Hawaii PPO	$7,714.90
Rate for Payer: University Health Alliance Commercial	$4,453.96

Total Knee Psn Rev Straight Spline Stem Ext 15 x 135mm 42-5601-135-15 [3644172]

Facility

$7,953.50

Service Code	HCPCS C1776
Hospital Charge Code	3644172
Hospital Revenue Code	278
Min. Negotiated Rate	$4,056.28
Max. Negotiated Rate	$7,714.90
Rate for Payer: Cash Price	$5,169.78
Rate for Payer: Hawaii Western Management Group Commercial	$5,567.45
Rate for Payer: Health Management Network Commercial	$6,760.48
Rate for Payer: Kaiser Permanente Commercial	$5,010.70
Rate for Payer: Kaiser Permanente Medicaid	$4,056.28
Rate for Payer: MDX Hawaii PPO	$7,714.90
Rate for Payer: University Health Alliance Commercial	$4,453.96

Total Knee PSN REV Straight Spline Stem Ext 16X135mm 42-5601-135-16 [3642030]

Facility

$7,953.50

Service Code	HCPCS C1776
Hospital Charge Code	3642030
Hospital Revenue Code	278
Min. Negotiated Rate	$4,453.96
Max. Negotiated Rate	$7,714.90
Rate for Payer: Cash Price	$5,169.78
Rate for Payer: Hawaii Western Management Group Commercial	$5,567.45
Rate for Payer: Health Management Network Commercial	$6,760.48
Rate for Payer: MDX Hawaii PPO	$7,714.90
Rate for Payer: University Health Alliance Commercial	$4,453.96

Total Knee PSN REV Straight Spline Stem Ext 16X135mm 42-5601-135-16 [3642030]

Facility

$7,953.50

Service Code	HCPCS C1776
Hospital Charge Code	3642030
Hospital Revenue Code	278
Min. Negotiated Rate	$4,056.28
Max. Negotiated Rate	$7,714.90
Rate for Payer: Cash Price	$5,169.78
Rate for Payer: Hawaii Western Management Group Commercial	$5,567.45
Rate for Payer: Health Management Network Commercial	$6,760.48
Rate for Payer: Kaiser Permanente Commercial	$5,010.70
Rate for Payer: Kaiser Permanente Medicaid	$4,056.28
Rate for Payer: MDX Hawaii PPO	$7,714.90
Rate for Payer: University Health Alliance Commercial	$4,453.96

Total Knee PSN REV Straight Spline Stem Ext 18 x 135mm 42-5601-135-18 [3644454]

Facility

$7,953.50

Service Code	HCPCS C1776
Hospital Charge Code	3644454
Hospital Revenue Code	278
Min. Negotiated Rate	$4,056.28
Max. Negotiated Rate	$7,714.90
Rate for Payer: Cash Price	$5,169.78
Rate for Payer: Hawaii Western Management Group Commercial	$5,567.45
Rate for Payer: Health Management Network Commercial	$6,760.48
Rate for Payer: Kaiser Permanente Commercial	$5,010.70
Rate for Payer: Kaiser Permanente Medicaid	$4,056.28
Rate for Payer: MDX Hawaii PPO	$7,714.90
Rate for Payer: University Health Alliance Commercial	$4,453.96

Total Knee PSN REV Straight Spline Stem Ext 18 x 135mm 42-5601-135-18 [3644454]

Facility

$7,953.50

Service Code	HCPCS C1776
Hospital Charge Code	3644454
Hospital Revenue Code	278
Min. Negotiated Rate	$4,453.96
Max. Negotiated Rate	$7,714.90
Rate for Payer: Cash Price	$5,169.78
Rate for Payer: Hawaii Western Management Group Commercial	$5,567.45
Rate for Payer: Health Management Network Commercial	$6,760.48
Rate for Payer: MDX Hawaii PPO	$7,714.90
Rate for Payer: University Health Alliance Commercial	$4,453.96

Total Knee PSN REV Straight Spline Stem Ext 20 x 135mm 42-5601-135-20 [3644391]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644391
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 Straight Spline Stem Ext 20 x 135mm 42-5601-135-20 [3644391]

Facility

$7,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644391
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 Tib Fixed Keel CMT Sz D Lt 42-5420-067-01 [3644433]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3644433
Hospital Revenue Code	278
Min. Negotiated Rate	$4,693.53
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: Kaiser Permanente Commercial	$5,797.89
Rate for Payer: Kaiser Permanente Medicaid	$4,693.53
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Total Knee PSN REV Tib Fixed Keel CMT Sz D Lt 42-5420-067-01 [3644433]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3644433
Hospital Revenue Code	278
Min. Negotiated Rate	$5,153.68
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Total Knee PSN REV Tib Fixed Keel CMT Sz D RT 42-5420-067-02 [3643170]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3643170
Hospital Revenue Code	278
Min. Negotiated Rate	$5,153.68
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Total Knee PSN REV Tib Fixed Keel CMT Sz D RT 42-5420-067-02 [3643170]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3643170
Hospital Revenue Code	278
Min. Negotiated Rate	$4,693.53
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: Kaiser Permanente Commercial	$5,797.89
Rate for Payer: Kaiser Permanente Medicaid	$4,693.53
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Total Knee PSN REV Tib Fixed Keel CMT Sz E LT 42-5420-071-01 [3642499]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3642499
Hospital Revenue Code	278
Min. Negotiated Rate	$4,693.53
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: Kaiser Permanente Commercial	$5,797.89
Rate for Payer: Kaiser Permanente Medicaid	$4,693.53
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Total Knee PSN REV Tib Fixed Keel CMT Sz E LT 42-5420-071-01 [3642499]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3642499
Hospital Revenue Code	278
Min. Negotiated Rate	$5,153.68
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Total Knee PSN REV Tib Fixed Keel CMT Sz F Rt 42-5420-075-02 [3644456]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3644456
Hospital Revenue Code	278
Min. Negotiated Rate	$4,693.53
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: Kaiser Permanente Commercial	$5,797.89
Rate for Payer: Kaiser Permanente Medicaid	$4,693.53
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Total Knee PSN REV Tib Fixed Keel CMT Sz F Rt 42-5420-075-02 [3644456]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3644456
Hospital Revenue Code	278
Min. Negotiated Rate	$5,153.68
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Total Knee PSN REV Tib Fixed Keel CMT Sz G RT 42-5420-079-02 [3644362]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3644362
Hospital Revenue Code	278
Min. Negotiated Rate	$5,153.68
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Total Knee PSN REV Tib Fixed Keel CMT Sz G RT 42-5420-079-02 [3644362]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3644362
Hospital Revenue Code	278
Min. Negotiated Rate	$4,693.53
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: Kaiser Permanente Commercial	$5,797.89
Rate for Payer: Kaiser Permanente Medicaid	$4,693.53
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Total Knee PSN REV Tib Fixed Keel CMT Sz H RT 42-5420-083-02 [3641927]

Facility

$9,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3641927
Hospital Revenue Code	278
Min. Negotiated Rate	$5,153.68
Max. Negotiated Rate	$8,926.91
Rate for Payer: Cash Price	$5,981.95
Rate for Payer: Hawaii Western Management Group Commercial	$6,442.10
Rate for Payer: Health Management Network Commercial	$7,822.55
Rate for Payer: MDX Hawaii PPO	$8,926.91
Rate for Payer: University Health Alliance Commercial	$5,153.68

Know your out-of-pocket cost for care.

All Charges