Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Shoulder 24mm +2 Lat Baseplate Modular AR-9560-24-2 [3642760]

Facility

$14,337.50

Service Code	HCPCS C1776
Hospital Charge Code	3642760
Hospital Revenue Code	278
Min. Negotiated Rate	$7,312.12
Max. Negotiated Rate	$13,907.38
Rate for Payer: Cash Price	$9,319.38
Rate for Payer: Hawaii Western Management Group Commercial	$10,036.25
Rate for Payer: Health Management Network Commercial	$12,186.88
Rate for Payer: Kaiser Permanente Commercial	$9,032.62
Rate for Payer: Kaiser Permanente Medicaid	$7,312.12
Rate for Payer: MDX Hawaii PPO	$13,907.38
Rate for Payer: University Health Alliance Commercial	$8,029.00

Total Shoulder 24mm +2 Lat Baseplate Modular AR-9560-24-2 [3642760]

Facility

$14,337.50

Service Code	HCPCS C1776
Hospital Charge Code	3642760
Hospital Revenue Code	278
Min. Negotiated Rate	$8,029.00
Max. Negotiated Rate	$13,907.38
Rate for Payer: Cash Price	$9,319.38
Rate for Payer: Hawaii Western Management Group Commercial	$10,036.25
Rate for Payer: Health Management Network Commercial	$12,186.88
Rate for Payer: MDX Hawaii PPO	$13,907.38
Rate for Payer: University Health Alliance Commercial	$8,029.00

Total Shoulder 24mm +4 Lat Baseplate Modular AR-9560-24-4 [3644615]

Facility

$14,337.50

Service Code	HCPCS C1776
Hospital Charge Code	3644615
Hospital Revenue Code	278
Min. Negotiated Rate	$8,029.00
Max. Negotiated Rate	$13,907.38
Rate for Payer: Cash Price	$9,319.38
Rate for Payer: Hawaii Western Management Group Commercial	$10,036.25
Rate for Payer: Health Management Network Commercial	$12,186.88
Rate for Payer: MDX Hawaii PPO	$13,907.38
Rate for Payer: University Health Alliance Commercial	$8,029.00

Total Shoulder 24mm +4 Lat Baseplate Modular AR-9560-24-4 [3644615]

Facility

$14,337.50

Service Code	HCPCS C1776
Hospital Charge Code	3644615
Hospital Revenue Code	278
Min. Negotiated Rate	$7,312.12
Max. Negotiated Rate	$13,907.38
Rate for Payer: Cash Price	$9,319.38
Rate for Payer: Hawaii Western Management Group Commercial	$10,036.25
Rate for Payer: Health Management Network Commercial	$12,186.88
Rate for Payer: Kaiser Permanente Commercial	$9,032.62
Rate for Payer: Kaiser Permanente Medicaid	$7,312.12
Rate for Payer: MDX Hawaii PPO	$13,907.38
Rate for Payer: University Health Alliance Commercial	$8,029.00

Total Shoulder 24mm Baseplate 20 Full Aug St AR-9580-2420S [3643949]

Facility

$13,335.00

Service Code	HCPCS C1776
Hospital Charge Code	3643949
Hospital Revenue Code	278
Min. Negotiated Rate	$7,467.60
Max. Negotiated Rate	$12,934.95
Rate for Payer: Cash Price	$8,667.75
Rate for Payer: Hawaii Western Management Group Commercial	$9,334.50
Rate for Payer: Health Management Network Commercial	$11,334.75
Rate for Payer: MDX Hawaii PPO	$12,934.95
Rate for Payer: University Health Alliance Commercial	$7,467.60

Total Shoulder 24mm Baseplate 20 Full Aug St AR-9580-2420S [3643949]

Facility

$13,335.00

Service Code	HCPCS C1776
Hospital Charge Code	3643949
Hospital Revenue Code	278
Min. Negotiated Rate	$6,800.85
Max. Negotiated Rate	$12,934.95
Rate for Payer: Cash Price	$8,667.75
Rate for Payer: Hawaii Western Management Group Commercial	$9,334.50
Rate for Payer: Health Management Network Commercial	$11,334.75
Rate for Payer: Kaiser Permanente Commercial	$8,401.05
Rate for Payer: Kaiser Permanente Medicaid	$6,800.85
Rate for Payer: MDX Hawaii PPO	$12,934.95
Rate for Payer: University Health Alliance Commercial	$7,467.60

Total Shoulder 30mm Central Screw Modular AR-9561-30S [3643403]

Facility

$7,047.00

Service Code	HCPCS C1713
Hospital Charge Code	3643403
Hospital Revenue Code	278
Min. Negotiated Rate	$3,946.32
Max. Negotiated Rate	$6,835.59
Rate for Payer: Cash Price	$4,580.55
Rate for Payer: Hawaii Western Management Group Commercial	$4,932.90
Rate for Payer: Health Management Network Commercial	$5,989.95
Rate for Payer: MDX Hawaii PPO	$6,835.59
Rate for Payer: University Health Alliance Commercial	$3,946.32

Total Shoulder 30mm Central Screw Modular AR-9561-30S [3643403]

Facility

$7,047.00

Service Code	HCPCS C1713
Hospital Charge Code	3643403
Hospital Revenue Code	278
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	$4,932.90
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	$3,946.32

Total Shoulder 33 +4 Lat/24 Glenosphere AR-9564-2433-LAT [3644746]

Facility

$14,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644746
Hospital Revenue Code	278
Min. Negotiated Rate	$8,356.32
Max. Negotiated Rate	$14,474.34
Rate for Payer: Cash Price	$9,699.30
Rate for Payer: Hawaii Western Management Group Commercial	$10,445.40
Rate for Payer: Health Management Network Commercial	$12,683.70
Rate for Payer: MDX Hawaii PPO	$14,474.34
Rate for Payer: University Health Alliance Commercial	$8,356.32

Total Shoulder 33 +4 Lat/24 Glenosphere AR-9564-2433-LAT [3644746]

Facility

$14,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644746
Hospital Revenue Code	278
Min. Negotiated Rate	$7,610.22
Max. Negotiated Rate	$14,474.34
Rate for Payer: Cash Price	$9,699.30
Rate for Payer: Hawaii Western Management Group Commercial	$10,445.40
Rate for Payer: Health Management Network Commercial	$12,683.70
Rate for Payer: Kaiser Permanente Commercial	$9,400.86
Rate for Payer: Kaiser Permanente Medicaid	$7,610.22
Rate for Payer: MDX Hawaii PPO	$14,474.34
Rate for Payer: University Health Alliance Commercial	$8,356.32

Total Shoulder 35mm Central Screw Modular AR-9561-35S [3644616]

Facility

$7,047.00

Hospital Charge Code	3644616
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 35mm Central Screw Modular AR-9561-35S [3644616]

Facility

$7,047.00

Hospital Charge Code	3644616
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

Total Shoulder 36 +2.5 Inf/24 Glenosphere AR-9564-2436-INF [3643407]

Facility

$14,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3643407
Hospital Revenue Code	278
Min. Negotiated Rate	$8,356.32
Max. Negotiated Rate	$14,474.34
Rate for Payer: Cash Price	$9,699.30
Rate for Payer: Hawaii Western Management Group Commercial	$10,445.40
Rate for Payer: Health Management Network Commercial	$12,683.70
Rate for Payer: MDX Hawaii PPO	$14,474.34
Rate for Payer: University Health Alliance Commercial	$8,356.32

Total Shoulder 36 +2.5 Inf/24 Glenosphere AR-9564-2436-INF [3643407]

Facility

$14,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3643407
Hospital Revenue Code	278
Min. Negotiated Rate	$7,610.22
Max. Negotiated Rate	$14,474.34
Rate for Payer: Cash Price	$9,699.30
Rate for Payer: Hawaii Western Management Group Commercial	$10,445.40
Rate for Payer: Health Management Network Commercial	$12,683.70
Rate for Payer: Kaiser Permanente Commercial	$9,400.86
Rate for Payer: Kaiser Permanente Medicaid	$7,610.22
Rate for Payer: MDX Hawaii PPO	$14,474.34
Rate for Payer: University Health Alliance Commercial	$8,356.32

Total Shoulder 36 +4 Lat/24 Glenosphere AR-9564-2436-LAT [3643441]

Facility

$14,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3643441
Hospital Revenue Code	278
Min. Negotiated Rate	$8,356.32
Max. Negotiated Rate	$14,474.34
Rate for Payer: Cash Price	$9,699.30
Rate for Payer: Hawaii Western Management Group Commercial	$10,445.40
Rate for Payer: Health Management Network Commercial	$12,683.70
Rate for Payer: MDX Hawaii PPO	$14,474.34
Rate for Payer: University Health Alliance Commercial	$8,356.32

Total Shoulder 36 +4 Lat/24 Glenosphere AR-9564-2436-LAT [3643441]

Facility

$14,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3643441
Hospital Revenue Code	278
Min. Negotiated Rate	$7,610.22
Max. Negotiated Rate	$14,474.34
Rate for Payer: Cash Price	$9,699.30
Rate for Payer: Hawaii Western Management Group Commercial	$10,445.40
Rate for Payer: Health Management Network Commercial	$12,683.70
Rate for Payer: Kaiser Permanente Commercial	$9,400.86
Rate for Payer: Kaiser Permanente Medicaid	$7,610.22
Rate for Payer: MDX Hawaii PPO	$14,474.34
Rate for Payer: University Health Alliance Commercial	$8,356.32

Total Shoulder 39 +2.5 INF/24 Glenosphere AR-9564-2439-INF [3644618]

Facility

$14,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644618
Hospital Revenue Code	278
Min. Negotiated Rate	$7,610.22
Max. Negotiated Rate	$14,474.34
Rate for Payer: Cash Price	$9,699.30
Rate for Payer: Hawaii Western Management Group Commercial	$10,445.40
Rate for Payer: Health Management Network Commercial	$12,683.70
Rate for Payer: Kaiser Permanente Commercial	$9,400.86
Rate for Payer: Kaiser Permanente Medicaid	$7,610.22
Rate for Payer: MDX Hawaii PPO	$14,474.34
Rate for Payer: University Health Alliance Commercial	$8,356.32

Total Shoulder 39 +2.5 INF/24 Glenosphere AR-9564-2439-INF [3644618]

Facility

$14,922.00

Service Code	HCPCS C1776
Hospital Charge Code	3644618
Hospital Revenue Code	278
Min. Negotiated Rate	$8,356.32
Max. Negotiated Rate	$14,474.34
Rate for Payer: Cash Price	$9,699.30
Rate for Payer: Hawaii Western Management Group Commercial	$10,445.40
Rate for Payer: Health Management Network Commercial	$12,683.70
Rate for Payer: MDX Hawaii PPO	$14,474.34
Rate for Payer: University Health Alliance Commercial	$8,356.32

Total Shoulder 4 Peg Mod Glen Sz 3 SAGL2043 [3644445]

Facility

$4,958.00

Service Code	HCPCS C1776
Hospital Charge Code	3644445
Hospital Revenue Code	278
Min. Negotiated Rate	$2,776.48
Max. Negotiated Rate	$4,809.26
Rate for Payer: Cash Price	$3,222.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,470.60
Rate for Payer: Health Management Network Commercial	$4,214.30
Rate for Payer: MDX Hawaii PPO	$4,809.26
Rate for Payer: University Health Alliance Commercial	$2,776.48

Total Shoulder 4 Peg Mod Glen Sz 3 SAGL2043 [3644445]

Facility

$4,958.00

Service Code	HCPCS C1776
Hospital Charge Code	3644445
Hospital Revenue Code	278
Min. Negotiated Rate	$2,528.58
Max. Negotiated Rate	$4,809.26
Rate for Payer: Cash Price	$3,222.70
Rate for Payer: Hawaii Western Management Group Commercial	$3,470.60
Rate for Payer: Health Management Network Commercial	$4,214.30
Rate for Payer: Kaiser Permanente Commercial	$3,123.54
Rate for Payer: Kaiser Permanente Medicaid	$2,528.58
Rate for Payer: MDX Hawaii PPO	$4,809.26
Rate for Payer: University Health Alliance Commercial	$2,776.48

Total Shoulder Alt Rev Glen Non Cann Tap 6.5mm 804-06-418 [3645396]

Facility

$2,688.44

Hospital Charge Code	3645396
Hospital Revenue Code	272
Min. Negotiated Rate	$1,371.10
Max. Negotiated Rate	$2,607.79
Rate for Payer: Cash Price	$1,747.49
Rate for Payer: Hawaii Western Management Group Commercial	$2,554.02
Rate for Payer: Health Management Network Commercial	$2,285.17
Rate for Payer: Kaiser Permanente Commercial	$1,693.72
Rate for Payer: Kaiser Permanente Medicaid	$1,371.10
Rate for Payer: MDX Hawaii PPO	$2,607.79
Rate for Payer: University Health Alliance Commercial	$1,959.60

Total Shoulder Alt Rev Glen Non Cann Tap 6.5mm 804-06-418 [3645396]

Facility

$2,688.44

Hospital Charge Code	3645396
Hospital Revenue Code	272
Min. Negotiated Rate	$2,285.17
Max. Negotiated Rate	$2,607.79
Rate for Payer: Cash Price	$1,747.49
Rate for Payer: Health Management Network Commercial	$2,285.17
Rate for Payer: MDX Hawaii PPO	$2,607.79

Total Shoulder Comp Primary Hum Stem Micro 11mm 113611 [3642342]

Facility

$17,603.00

Service Code	HCPCS C1776
Hospital Charge Code	3642342
Hospital Revenue Code	278
Min. Negotiated Rate	$8,977.53
Max. Negotiated Rate	$17,074.91
Rate for Payer: Cash Price	$11,441.95
Rate for Payer: Hawaii Western Management Group Commercial	$12,322.10
Rate for Payer: Health Management Network Commercial	$14,962.55
Rate for Payer: Kaiser Permanente Commercial	$11,089.89
Rate for Payer: Kaiser Permanente Medicaid	$8,977.53
Rate for Payer: MDX Hawaii PPO	$17,074.91
Rate for Payer: University Health Alliance Commercial	$9,857.68

Total Shoulder Comp Primary Hum Stem Micro 11mm 113611 [3642342]

Facility

$17,603.00

Service Code	HCPCS C1776
Hospital Charge Code	3642342
Hospital Revenue Code	278
Min. Negotiated Rate	$9,857.68
Max. Negotiated Rate	$17,074.91
Rate for Payer: Cash Price	$11,441.95
Rate for Payer: Hawaii Western Management Group Commercial	$12,322.10
Rate for Payer: Health Management Network Commercial	$14,962.55
Rate for Payer: MDX Hawaii PPO	$17,074.91
Rate for Payer: University Health Alliance Commercial	$9,857.68

Total Shoulder Comp Steinmann Pin 9" 405800 [3641567]

Facility

$903.48

Hospital Charge Code	3641567
Hospital Revenue Code	272
Min. Negotiated Rate	$767.96
Max. Negotiated Rate	$876.38
Rate for Payer: Cash Price	$587.26
Rate for Payer: Health Management Network Commercial	$767.96
Rate for Payer: MDX Hawaii PPO	$876.38

Know your out-of-pocket cost for care.

All Charges