Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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	$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 Half Block Sz Cd 5mm Rl 42-5558-032-05 [3643919]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3643919
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 Tib Half Block Sz Cd 5mm Rl 42-5558-032-05 [3643919]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3643919
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 Tib Half Block Sz Cd 5mm Rm 42-5558-034-05 [3643916]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3643916
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 Tib Half Block Sz Cd 5mm Rm 42-5558-034-05 [3643916]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3643916
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 Tib Half Blocksz EF LL 5mm 42-5558-051-05 [3644803]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644803
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 Tib Half Blocksz EF LL 5mm 42-5558-051-05 [3644803]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644803
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 Tib Half Block Sz Gh Lm 5mm 42-5558-073-05 [3644389]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644389
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 Tib Half Block Sz Gh Lm 5mm 42-5558-073-05 [3644389]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644389
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 Tib Half Block Sz GH RL 5mm 42-5558-072-05 [3644573]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644573
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 Tib Half Block Sz GH RL 5mm 42-5558-072-05 [3644573]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644573
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 Tib Half Block Sz GH RM 5mm 42-5558-074-05 [3644570]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644570
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 Tib Half Block Sz GH RM 5mm 42-5558-074-05 [3644570]

Facility

$5,703.00

Service Code	HCPCS C1776
Hospital Charge Code	3644570
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 TM Tib Central Cone Sz Fixed LT 42-5450-005-08 [3642501]

Facility

$16,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3642501
Hospital Revenue Code	278
Min. Negotiated Rate	$9,073.68
Max. Negotiated Rate	$15,716.91
Rate for Payer: Cash Price	$10,531.95
Rate for Payer: Hawaii Western Management Group Commercial	$11,342.10
Rate for Payer: Health Management Network Commercial	$13,772.55
Rate for Payer: MDX Hawaii PPO	$15,716.91
Rate for Payer: University Health Alliance Commercial	$9,073.68

Total Knee PSN REV TM Tib Central Cone Sz Fixed LT 42-5450-005-08 [3642501]

Facility

$16,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3642501
Hospital Revenue Code	278
Min. Negotiated Rate	$8,263.53
Max. Negotiated Rate	$15,716.91
Rate for Payer: Cash Price	$10,531.95
Rate for Payer: Hawaii Western Management Group Commercial	$11,342.10
Rate for Payer: Health Management Network Commercial	$13,772.55
Rate for Payer: Kaiser Permanente Commercial	$10,207.89
Rate for Payer: Kaiser Permanente Medicaid	$8,263.53
Rate for Payer: MDX Hawaii PPO	$15,716.91
Rate for Payer: University Health Alliance Commercial	$9,073.68

Total Knee PSN REV TM Tib Central Cone Sz Lrg 42-5450-005-13 [3644388]

Facility

$16,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3644388
Hospital Revenue Code	278
Min. Negotiated Rate	$8,263.53
Max. Negotiated Rate	$15,716.91
Rate for Payer: Cash Price	$10,531.95
Rate for Payer: Hawaii Western Management Group Commercial	$11,342.10
Rate for Payer: Health Management Network Commercial	$13,772.55
Rate for Payer: Kaiser Permanente Commercial	$10,207.89
Rate for Payer: Kaiser Permanente Medicaid	$8,263.53
Rate for Payer: MDX Hawaii PPO	$15,716.91
Rate for Payer: University Health Alliance Commercial	$9,073.68

Total Knee PSN REV TM Tib Central Cone Sz Lrg 42-5450-005-13 [3644388]

Facility

$16,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3644388
Hospital Revenue Code	278
Min. Negotiated Rate	$9,073.68
Max. Negotiated Rate	$15,716.91
Rate for Payer: Cash Price	$10,531.95
Rate for Payer: Hawaii Western Management Group Commercial	$11,342.10
Rate for Payer: Health Management Network Commercial	$13,772.55
Rate for Payer: MDX Hawaii PPO	$15,716.91
Rate for Payer: University Health Alliance Commercial	$9,073.68

Total Knee Psn Rev Tm Tib Central Cone Sz Sm 42-5450-005-11 [3643920]

Facility

$16,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3643920
Hospital Revenue Code	278
Min. Negotiated Rate	$9,073.68
Max. Negotiated Rate	$15,716.91
Rate for Payer: Cash Price	$10,531.95
Rate for Payer: Hawaii Western Management Group Commercial	$11,342.10
Rate for Payer: Health Management Network Commercial	$13,772.55
Rate for Payer: MDX Hawaii PPO	$15,716.91
Rate for Payer: University Health Alliance Commercial	$9,073.68

Total Knee Psn Rev Tm Tib Central Cone Sz Sm 42-5450-005-11 [3643920]

Facility

$16,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3643920
Hospital Revenue Code	278
Min. Negotiated Rate	$8,263.53
Max. Negotiated Rate	$15,716.91
Rate for Payer: Cash Price	$10,531.95
Rate for Payer: Hawaii Western Management Group Commercial	$11,342.10
Rate for Payer: Health Management Network Commercial	$13,772.55
Rate for Payer: Kaiser Permanente Commercial	$10,207.89
Rate for Payer: Kaiser Permanente Medicaid	$8,263.53
Rate for Payer: MDX Hawaii PPO	$15,716.91
Rate for Payer: University Health Alliance Commercial	$9,073.68

Total Knee PSN Rev TM Tib Central Cone Sz XSM Lt 42-5450-005-10 [3644802]

Facility

$16,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3644802
Hospital Revenue Code	278
Min. Negotiated Rate	$8,263.53
Max. Negotiated Rate	$15,716.91
Rate for Payer: Cash Price	$10,531.95
Rate for Payer: Hawaii Western Management Group Commercial	$11,342.10
Rate for Payer: Health Management Network Commercial	$13,772.55
Rate for Payer: Kaiser Permanente Commercial	$10,207.89
Rate for Payer: Kaiser Permanente Medicaid	$8,263.53
Rate for Payer: MDX Hawaii PPO	$15,716.91
Rate for Payer: University Health Alliance Commercial	$9,073.68

Total Knee PSN Rev TM Tib Central Cone Sz XSM Lt 42-5450-005-10 [3644802]

Facility

$16,203.00

Service Code	HCPCS C1776
Hospital Charge Code	3644802
Hospital Revenue Code	278
Min. Negotiated Rate	$9,073.68
Max. Negotiated Rate	$15,716.91
Rate for Payer: Cash Price	$10,531.95
Rate for Payer: Hawaii Western Management Group Commercial	$11,342.10
Rate for Payer: Health Management Network Commercial	$13,772.55
Rate for Payer: MDX Hawaii PPO	$15,716.91
Rate for Payer: University Health Alliance Commercial	$9,073.68

Total Knee PSN REV TM Tib Peripheral Cone Sz Small LT 42545001511 [3642503]

Facility

$18,578.13

Service Code	HCPCS C1776
Hospital Charge Code	3642503
Hospital Revenue Code	278
Min. Negotiated Rate	$10,403.75
Max. Negotiated Rate	$18,020.79
Rate for Payer: Cash Price	$12,075.78
Rate for Payer: Hawaii Western Management Group Commercial	$13,004.69
Rate for Payer: Health Management Network Commercial	$15,791.41
Rate for Payer: MDX Hawaii PPO	$18,020.79
Rate for Payer: University Health Alliance Commercial	$10,403.75

Total Knee PSN REV TM Tib Peripheral Cone Sz Small LT 42545001511 [3642503]

Facility

$18,578.13

Service Code	HCPCS C1776
Hospital Charge Code	3642503
Hospital Revenue Code	278
Min. Negotiated Rate	$9,474.85
Max. Negotiated Rate	$18,020.79
Rate for Payer: Cash Price	$12,075.78
Rate for Payer: Hawaii Western Management Group Commercial	$13,004.69
Rate for Payer: Health Management Network Commercial	$15,791.41
Rate for Payer: Kaiser Permanente Commercial	$11,704.22
Rate for Payer: Kaiser Permanente Medicaid	$9,474.85
Rate for Payer: MDX Hawaii PPO	$18,020.79
Rate for Payer: University Health Alliance Commercial	$10,403.75

Total Knee PSN STR HYB ST 14 X +30 M 42-5570-001-14 [3640893]

Facility

$3,932.00

Service Code	HCPCS C1776
Hospital Charge Code	3640893
Hospital Revenue Code	278
Min. Negotiated Rate	$2,201.92
Max. Negotiated Rate	$3,814.04
Rate for Payer: MDX Hawaii PPO	$3,814.04
Rate for Payer: Cash Price	$2,555.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,752.40
Rate for Payer: Health Management Network Commercial	$3,342.20
Rate for Payer: University Health Alliance Commercial	$2,201.92

Total Knee PSN STR HYB ST 14 X +30 M 42-5570-001-14 [3640893]

Facility

$3,932.00

Service Code	HCPCS C1776
Hospital Charge Code	3640893
Hospital Revenue Code	278
Min. Negotiated Rate	$2,005.32
Max. Negotiated Rate	$3,814.04
Rate for Payer: Cash Price	$2,555.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,752.40
Rate for Payer: Health Management Network Commercial	$3,342.20
Rate for Payer: Kaiser Permanente Commercial	$2,477.16
Rate for Payer: Kaiser Permanente Medicaid	$2,005.32
Rate for Payer: MDX Hawaii PPO	$3,814.04
Rate for Payer: University Health Alliance Commercial	$2,201.92

Know your out-of-pocket cost for care.

All Charges