Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Knee PSN TIB STM 5 Deg SzC RT 42532006402 [3641072]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3641072
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 TIB STM 5 Deg SzD LT 42-5320-067-01 [3640892]

Facility

$4,665.50

Service Code	HCPCS C1776
Hospital Charge Code	3640892
Hospital Revenue Code	278
Min. Negotiated Rate	$2,379.41
Max. Negotiated Rate	$4,525.53
Rate for Payer: Cash Price	$3,032.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,265.85
Rate for Payer: Health Management Network Commercial	$3,965.68
Rate for Payer: Kaiser Permanente Commercial	$2,939.26
Rate for Payer: Kaiser Permanente Medicaid	$2,379.41
Rate for Payer: MDX Hawaii PPO	$4,525.53
Rate for Payer: University Health Alliance Commercial	$2,612.68

Total Knee PSN TIB STM 5 Deg SzD LT 42-5320-067-01 [3640892]

Facility

$4,665.50

Service Code	HCPCS C1776
Hospital Charge Code	3640892
Hospital Revenue Code	278
Min. Negotiated Rate	$2,612.68
Max. Negotiated Rate	$4,525.53
Rate for Payer: Cash Price	$3,032.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,265.85
Rate for Payer: Health Management Network Commercial	$3,965.68
Rate for Payer: MDX Hawaii PPO	$4,525.53
Rate for Payer: University Health Alliance Commercial	$2,612.68

Total Knee PSN TIB STM 5 Deg SzD RT 42-5320-067-02 [3641521]

Facility

$4,665.50

Service Code	HCPCS C1776
Hospital Charge Code	3641521
Hospital Revenue Code	278
Min. Negotiated Rate	$2,379.41
Max. Negotiated Rate	$4,525.53
Rate for Payer: Cash Price	$3,032.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,265.85
Rate for Payer: Health Management Network Commercial	$3,965.68
Rate for Payer: Kaiser Permanente Commercial	$2,939.26
Rate for Payer: Kaiser Permanente Medicaid	$2,379.41
Rate for Payer: MDX Hawaii PPO	$4,525.53
Rate for Payer: University Health Alliance Commercial	$2,612.68

Total Knee PSN TIB STM 5 Deg SzD RT 42-5320-067-02 [3641521]

Facility

$4,665.50

Service Code	HCPCS C1776
Hospital Charge Code	3641521
Hospital Revenue Code	278
Min. Negotiated Rate	$2,612.68
Max. Negotiated Rate	$4,525.53
Rate for Payer: Cash Price	$3,032.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,265.85
Rate for Payer: Health Management Network Commercial	$3,965.68
Rate for Payer: MDX Hawaii PPO	$4,525.53
Rate for Payer: University Health Alliance Commercial	$2,612.68

Total Knee PSN TIB STM 5 Deg SzE LT 42532007101 [3640859]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3640859
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 TIB STM 5 Deg SzE LT 42532007101 [3640859]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3640859
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 TIB STM 5 Deg SzE RT 42-5320-071-02 [3640834]

Facility

$4,665.50

Service Code	HCPCS C1776
Hospital Charge Code	3640834
Hospital Revenue Code	278
Min. Negotiated Rate	$2,612.68
Max. Negotiated Rate	$4,525.53
Rate for Payer: Cash Price	$3,032.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,265.85
Rate for Payer: Health Management Network Commercial	$3,965.68
Rate for Payer: MDX Hawaii PPO	$4,525.53
Rate for Payer: University Health Alliance Commercial	$2,612.68

Total Knee PSN TIB STM 5 Deg SzE RT 42-5320-071-02 [3640834]

Facility

$4,665.50

Service Code	HCPCS C1776
Hospital Charge Code	3640834
Hospital Revenue Code	278
Min. Negotiated Rate	$2,379.41
Max. Negotiated Rate	$4,525.53
Rate for Payer: Cash Price	$3,032.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,265.85
Rate for Payer: Health Management Network Commercial	$3,965.68
Rate for Payer: Kaiser Permanente Commercial	$2,939.26
Rate for Payer: Kaiser Permanente Medicaid	$2,379.41
Rate for Payer: MDX Hawaii PPO	$4,525.53
Rate for Payer: University Health Alliance Commercial	$2,612.68

Total Knee PSN TIB STM 5 Deg SzF LT 42532007501 [3640801]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3640801
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 TIB STM 5 Deg SzF LT 42532007501 [3640801]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3640801
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 TIB STM 5 Deg SzF RT 42532007502 [3640880]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3640880
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 TIB STM 5 Deg SzF RT 42532007502 [3640880]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3640880
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 TIB STM 5 Deg SzG LT 42532007901 [3640827]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3640827
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 TIB STM 5 Deg SzG LT 42532007901 [3640827]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3640827
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 TIB STM 5 Deg SzG RT 42532007902 [3640805]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3640805
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 TIB STM 5 Deg SzG RT 42532007902 [3640805]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3640805
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 TIB STM 5 Deg SzH LT 42-5320-083-01 [3641733]

Facility

$4,665.50

Service Code	HCPCS C1776
Hospital Charge Code	3641733
Hospital Revenue Code	278
Min. Negotiated Rate	$2,612.68
Max. Negotiated Rate	$4,525.53
Rate for Payer: Cash Price	$3,032.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,265.85
Rate for Payer: Health Management Network Commercial	$3,965.68
Rate for Payer: MDX Hawaii PPO	$4,525.53
Rate for Payer: University Health Alliance Commercial	$2,612.68

Total Knee PSN TIB STM 5 Deg SzH LT 42-5320-083-01 [3641733]

Facility

$4,665.50

Service Code	HCPCS C1776
Hospital Charge Code	3641733
Hospital Revenue Code	278
Min. Negotiated Rate	$2,379.41
Max. Negotiated Rate	$4,525.53
Rate for Payer: Cash Price	$3,032.58
Rate for Payer: Hawaii Western Management Group Commercial	$3,265.85
Rate for Payer: Health Management Network Commercial	$3,965.68
Rate for Payer: Kaiser Permanente Commercial	$2,939.26
Rate for Payer: Kaiser Permanente Medicaid	$2,379.41
Rate for Payer: MDX Hawaii PPO	$4,525.53
Rate for Payer: University Health Alliance Commercial	$2,612.68

Total Knee PSN TIB STM 5 Deg SzH RT 42532008302 [3641118]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3641118
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 TIB STM 5 Deg SzH RT 42532008302 [3641118]

Facility

$3,325.00

Service Code	HCPCS C1776
Hospital Charge Code	3641118
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 Shoudler Alt Rev Hum Stem Std Shell 14mm x 175mm 530-14-175 [3645397]

Facility

$30,721.00

Service Code	HCPCS C1776
Hospital Charge Code	3645397
Hospital Revenue Code	278
Min. Negotiated Rate	$17,203.76
Max. Negotiated Rate	$29,799.37
Rate for Payer: Cash Price	$19,968.65
Rate for Payer: Hawaii Western Management Group Commercial	$21,504.70
Rate for Payer: Health Management Network Commercial	$26,112.85
Rate for Payer: MDX Hawaii PPO	$29,799.37
Rate for Payer: University Health Alliance Commercial	$17,203.76

Total Shoudler Alt Rev Hum Stem Std Shell 14mm x 175mm 530-14-175 [3645397]

Facility

$30,721.00

Service Code	HCPCS C1776
Hospital Charge Code	3645397
Hospital Revenue Code	278
Min. Negotiated Rate	$15,667.71
Max. Negotiated Rate	$29,799.37
Rate for Payer: Cash Price	$19,968.65
Rate for Payer: Hawaii Western Management Group Commercial	$21,504.70
Rate for Payer: Health Management Network Commercial	$26,112.85
Rate for Payer: Kaiser Permanente Commercial	$19,354.23
Rate for Payer: Kaiser Permanente Medicaid	$15,667.71
Rate for Payer: MDX Hawaii PPO	$29,799.37
Rate for Payer: University Health Alliance Commercial	$17,203.76

Total Shoulder 20mm Central Screw Modular AR-9561-20S [3644745]

Facility

$7,047.00

Hospital Charge Code	3644745
Hospital Revenue Code	272
Min. Negotiated Rate	$5,989.95
Max. Negotiated Rate	$6,835.59
Rate for Payer: Cash Price	$4,580.55
Rate for Payer: Health Management Network Commercial	$5,989.95
Rate for Payer: MDX Hawaii PPO	$6,835.59

Total Shoulder 20mm Central Screw Modular AR-9561-20S [3644745]

Facility

$7,047.00

Hospital Charge Code	3644745
Hospital Revenue Code	272
Min. Negotiated Rate	$3,593.97
Max. Negotiated Rate	$6,835.59
Rate for Payer: Cash Price	$4,580.55
Rate for Payer: Hawaii Western Management Group Commercial	$6,694.65
Rate for Payer: Health Management Network Commercial	$5,989.95
Rate for Payer: Kaiser Permanente Commercial	$4,439.61
Rate for Payer: Kaiser Permanente Medicaid	$3,593.97
Rate for Payer: MDX Hawaii PPO	$6,835.59
Rate for Payer: University Health Alliance Commercial	$5,136.56

Know your out-of-pocket cost for care.

All Charges