Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Shoulder Humeral Stem Std Shell Short 10mmX48mm 53010048 [3641886]

Facility

$33,250.00

Service Code	HCPCS C1776
Hospital Charge Code	3641886
Hospital Revenue Code	278
Min. Negotiated Rate	$16,957.50
Max. Negotiated Rate	$32,252.50
Rate for Payer: Cash Price	$21,612.50
Rate for Payer: Hawaii Western Management Group Commercial	$23,275.00
Rate for Payer: Health Management Network Commercial	$28,262.50
Rate for Payer: Kaiser Permanente Commercial	$20,947.50
Rate for Payer: Kaiser Permanente Medicaid	$16,957.50
Rate for Payer: MDX Hawaii PPO	$32,252.50
Rate for Payer: University Health Alliance Commercial	$18,620.00

Total Shoulder Humeral Stem Std Shell Short 10mmX48mm 53010048 [3641886]

Facility

$33,250.00

Service Code	HCPCS C1776
Hospital Charge Code	3641886
Hospital Revenue Code	278
Min. Negotiated Rate	$18,620.00
Max. Negotiated Rate	$32,252.50
Rate for Payer: Cash Price	$21,612.50
Rate for Payer: Hawaii Western Management Group Commercial	$23,275.00
Rate for Payer: Health Management Network Commercial	$28,262.50
Rate for Payer: MDX Hawaii PPO	$32,252.50
Rate for Payer: University Health Alliance Commercial	$18,620.00

Total Shoulder Humeral Stem Std Shell Short 12mmX48mm 53012048 [3641887]

Facility

$49,933.00

Service Code	HCPCS C1776
Hospital Charge Code	3641887
Hospital Revenue Code	278
Min. Negotiated Rate	$27,962.48
Max. Negotiated Rate	$48,435.01
Rate for Payer: Cash Price	$32,456.45
Rate for Payer: Hawaii Western Management Group Commercial	$34,953.10
Rate for Payer: Health Management Network Commercial	$42,443.05
Rate for Payer: MDX Hawaii PPO	$48,435.01
Rate for Payer: University Health Alliance Commercial	$27,962.48

Total Shoulder Humeral Stem Std Shell Short 12mmX48mm 53012048 [3641887]

Facility

$49,933.00

Service Code	HCPCS C1776
Hospital Charge Code	3641887
Hospital Revenue Code	278
Min. Negotiated Rate	$25,465.83
Max. Negotiated Rate	$48,435.01
Rate for Payer: Cash Price	$32,456.45
Rate for Payer: Hawaii Western Management Group Commercial	$34,953.10
Rate for Payer: Health Management Network Commercial	$42,443.05
Rate for Payer: Kaiser Permanente Commercial	$31,457.79
Rate for Payer: Kaiser Permanente Medicaid	$25,465.83
Rate for Payer: MDX Hawaii PPO	$48,435.01
Rate for Payer: University Health Alliance Commercial	$27,962.48

Total Shoulder Humeral Stem Std Shell Short 14mmX48mm 53014048 [3641888]

Facility

$49,933.00

Service Code	HCPCS C1776
Hospital Charge Code	3641888
Hospital Revenue Code	278
Min. Negotiated Rate	$25,465.83
Max. Negotiated Rate	$48,435.01
Rate for Payer: Cash Price	$32,456.45
Rate for Payer: Hawaii Western Management Group Commercial	$34,953.10
Rate for Payer: Health Management Network Commercial	$42,443.05
Rate for Payer: Kaiser Permanente Commercial	$31,457.79
Rate for Payer: Kaiser Permanente Medicaid	$25,465.83
Rate for Payer: MDX Hawaii PPO	$48,435.01
Rate for Payer: University Health Alliance Commercial	$27,962.48

Total Shoulder Humeral Stem Std Shell Short 14mmX48mm 53014048 [3641888]

Facility

$49,933.00

Service Code	HCPCS C1776
Hospital Charge Code	3641888
Hospital Revenue Code	278
Min. Negotiated Rate	$27,962.48
Max. Negotiated Rate	$48,435.01
Rate for Payer: Cash Price	$32,456.45
Rate for Payer: Hawaii Western Management Group Commercial	$34,953.10
Rate for Payer: Health Management Network Commercial	$42,443.05
Rate for Payer: MDX Hawaii PPO	$48,435.01
Rate for Payer: University Health Alliance Commercial	$27,962.48

Total Shoulder Humeral Stem Std Shell Short 16mmX48mm 53016048 [3641889]

Facility

$33,250.00

Service Code	HCPCS C1776
Hospital Charge Code	3641889
Hospital Revenue Code	278
Min. Negotiated Rate	$16,957.50
Max. Negotiated Rate	$32,252.50
Rate for Payer: Cash Price	$21,612.50
Rate for Payer: Hawaii Western Management Group Commercial	$23,275.00
Rate for Payer: Health Management Network Commercial	$28,262.50
Rate for Payer: Kaiser Permanente Commercial	$20,947.50
Rate for Payer: Kaiser Permanente Medicaid	$16,957.50
Rate for Payer: MDX Hawaii PPO	$32,252.50
Rate for Payer: University Health Alliance Commercial	$18,620.00

Total Shoulder Humeral Stem Std Shell Short 16mmX48mm 53016048 [3641889]

Facility

$33,250.00

Service Code	HCPCS C1776
Hospital Charge Code	3641889
Hospital Revenue Code	278
Min. Negotiated Rate	$18,620.00
Max. Negotiated Rate	$32,252.50
Rate for Payer: Cash Price	$21,612.50
Rate for Payer: Hawaii Western Management Group Commercial	$23,275.00
Rate for Payer: Health Management Network Commercial	$28,262.50
Rate for Payer: MDX Hawaii PPO	$32,252.50
Rate for Payer: University Health Alliance Commercial	$18,620.00

Total Shoulder Hum Insert M/39 +6 To Fit In 39 Cup AR-9503M-06 [3644614]

Facility

$7,425.00

Service Code	HCPCS C1776
Hospital Charge Code	3644614
Hospital Revenue Code	278
Min. Negotiated Rate	$3,786.75
Max. Negotiated Rate	$7,202.25
Rate for Payer: Cash Price	$4,826.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,197.50
Rate for Payer: Health Management Network Commercial	$6,311.25
Rate for Payer: Kaiser Permanente Commercial	$4,677.75
Rate for Payer: Kaiser Permanente Medicaid	$3,786.75
Rate for Payer: MDX Hawaii PPO	$7,202.25
Rate for Payer: University Health Alliance Commercial	$4,158.00

Total Shoulder Hum Insert M/39 +6 To Fit In 39 Cup AR-9503M-06 [3644614]

Facility

$7,425.00

Service Code	HCPCS C1776
Hospital Charge Code	3644614
Hospital Revenue Code	278
Min. Negotiated Rate	$4,158.00
Max. Negotiated Rate	$7,202.25
Rate for Payer: Cash Price	$4,826.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,197.50
Rate for Payer: Health Management Network Commercial	$6,311.25
Rate for Payer: MDX Hawaii PPO	$7,202.25
Rate for Payer: University Health Alliance Commercial	$4,158.00

Total Shoulder Hum Insert XS 33 +3mm AR-9503XS-03 [3644744]

Facility

$7,425.00

Service Code	HCPCS C1776
Hospital Charge Code	3644744
Hospital Revenue Code	278
Min. Negotiated Rate	$4,158.00
Max. Negotiated Rate	$7,202.25
Rate for Payer: Cash Price	$4,826.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,197.50
Rate for Payer: Health Management Network Commercial	$6,311.25
Rate for Payer: MDX Hawaii PPO	$7,202.25
Rate for Payer: University Health Alliance Commercial	$4,158.00

Total Shoulder Hum Insert XS 33 +3mm AR-9503XS-03 [3644744]

Facility

$7,425.00

Service Code	HCPCS C1776
Hospital Charge Code	3644744
Hospital Revenue Code	278
Min. Negotiated Rate	$3,786.75
Max. Negotiated Rate	$7,202.25
Rate for Payer: Cash Price	$4,826.25
Rate for Payer: Hawaii Western Management Group Commercial	$5,197.50
Rate for Payer: Health Management Network Commercial	$6,311.25
Rate for Payer: Kaiser Permanente Commercial	$4,677.75
Rate for Payer: Kaiser Permanente Medicaid	$3,786.75
Rate for Payer: MDX Hawaii PPO	$7,202.25
Rate for Payer: University Health Alliance Commercial	$4,158.00

Total Shoulder Hum Stem & Neck Kit Sz 1 18mm 520-08-018 [3643850]

Facility

$23,825.00

Service Code	HCPCS C1776
Hospital Charge Code	3643850
Hospital Revenue Code	278
Min. Negotiated Rate	$12,150.75
Max. Negotiated Rate	$23,110.25
Rate for Payer: Cash Price	$15,486.25
Rate for Payer: Hawaii Western Management Group Commercial	$16,677.50
Rate for Payer: Health Management Network Commercial	$20,251.25
Rate for Payer: Kaiser Permanente Commercial	$15,009.75
Rate for Payer: Kaiser Permanente Medicaid	$12,150.75
Rate for Payer: MDX Hawaii PPO	$23,110.25
Rate for Payer: University Health Alliance Commercial	$13,342.00

Total Shoulder Hum Stem & Neck Kit Sz 1 18mm 520-08-018 [3643850]

Facility

$23,825.00

Service Code	HCPCS C1776
Hospital Charge Code	3643850
Hospital Revenue Code	278
Min. Negotiated Rate	$13,342.00
Max. Negotiated Rate	$23,110.25
Rate for Payer: Cash Price	$15,486.25
Rate for Payer: Hawaii Western Management Group Commercial	$16,677.50
Rate for Payer: Health Management Network Commercial	$20,251.25
Rate for Payer: MDX Hawaii PPO	$23,110.25
Rate for Payer: University Health Alliance Commercial	$13,342.00

Total Shoulder Hum Stem Rev Small Shell 12 x 48mm 533-12-048 [3644837]

Facility

$30,514.50

Service Code	HCPCS C1776
Hospital Charge Code	3644837
Hospital Revenue Code	278
Min. Negotiated Rate	$15,562.40
Max. Negotiated Rate	$29,599.06
Rate for Payer: Cash Price	$19,834.42
Rate for Payer: Hawaii Western Management Group Commercial	$21,360.15
Rate for Payer: Health Management Network Commercial	$25,937.33
Rate for Payer: Kaiser Permanente Commercial	$19,224.13
Rate for Payer: Kaiser Permanente Medicaid	$15,562.40
Rate for Payer: MDX Hawaii PPO	$29,599.06
Rate for Payer: University Health Alliance Commercial	$17,088.12

Total Shoulder Hum Stem Rev Small Shell 12 x 48mm 533-12-048 [3644837]

Facility

$30,514.50

Service Code	HCPCS C1776
Hospital Charge Code	3644837
Hospital Revenue Code	278
Min. Negotiated Rate	$17,088.12
Max. Negotiated Rate	$29,599.06
Rate for Payer: Cash Price	$19,834.42
Rate for Payer: Hawaii Western Management Group Commercial	$21,360.15
Rate for Payer: Health Management Network Commercial	$25,937.33
Rate for Payer: MDX Hawaii PPO	$29,599.06
Rate for Payer: University Health Alliance Commercial	$17,088.12

Total Shoulder Hum Stem Small Shell 10x108mm 533-10-108 [3643863]

Facility

$24,760.50

Service Code	HCPCS C1776
Hospital Charge Code	3643863
Hospital Revenue Code	278
Min. Negotiated Rate	$12,627.85
Max. Negotiated Rate	$24,017.69
Rate for Payer: Cash Price	$16,094.32
Rate for Payer: Hawaii Western Management Group Commercial	$17,332.35
Rate for Payer: Health Management Network Commercial	$21,046.42
Rate for Payer: Kaiser Permanente Commercial	$15,599.11
Rate for Payer: Kaiser Permanente Medicaid	$12,627.85
Rate for Payer: MDX Hawaii PPO	$24,017.69
Rate for Payer: University Health Alliance Commercial	$13,865.88

Total Shoulder Hum Stem Small Shell 10x108mm 533-10-108 [3643863]

Facility

$24,760.50

Service Code	HCPCS C1776
Hospital Charge Code	3643863
Hospital Revenue Code	278
Min. Negotiated Rate	$13,865.88
Max. Negotiated Rate	$24,017.69
Rate for Payer: Cash Price	$16,094.32
Rate for Payer: Hawaii Western Management Group Commercial	$17,332.35
Rate for Payer: Health Management Network Commercial	$21,046.42
Rate for Payer: MDX Hawaii PPO	$24,017.69
Rate for Payer: University Health Alliance Commercial	$13,865.88

Total Shoulder Hum Stem Small Shell 8x48mm 533-08-048 [3643928]

Facility

$30,514.50

Service Code	HCPCS C1769
Hospital Charge Code	3643928
Hospital Revenue Code	272
Min. Negotiated Rate	$25,937.33
Max. Negotiated Rate	$29,599.06
Rate for Payer: Cash Price	$19,834.42
Rate for Payer: Health Management Network Commercial	$25,937.33
Rate for Payer: MDX Hawaii PPO	$29,599.06

Total Shoulder Hum Stem Small Shell 8x48mm 533-08-048 [3643928]

Facility

$30,514.50

Service Code	HCPCS C1769
Hospital Charge Code	3643928
Hospital Revenue Code	272
Min. Negotiated Rate	$15,562.40
Max. Negotiated Rate	$29,599.06
Rate for Payer: Cash Price	$19,834.42
Rate for Payer: Hawaii Western Management Group Commercial	$28,988.78
Rate for Payer: Health Management Network Commercial	$25,937.33
Rate for Payer: Kaiser Permanente Commercial	$19,224.13
Rate for Payer: Kaiser Permanente Medicaid	$15,562.40
Rate for Payer: MDX Hawaii PPO	$29,599.06
Rate for Payer: University Health Alliance Commercial	$22,242.02

Total Shoulder Modular Post 20mm AR-9582-20 [3643950]

Facility

$6,042.50

Service Code	HCPCS C1776
Hospital Charge Code	3643950
Hospital Revenue Code	278
Min. Negotiated Rate	$3,081.68
Max. Negotiated Rate	$5,861.23
Rate for Payer: Cash Price	$3,927.62
Rate for Payer: Hawaii Western Management Group Commercial	$4,229.75
Rate for Payer: Health Management Network Commercial	$5,136.12
Rate for Payer: Kaiser Permanente Commercial	$3,806.78
Rate for Payer: Kaiser Permanente Medicaid	$3,081.68
Rate for Payer: MDX Hawaii PPO	$5,861.23
Rate for Payer: University Health Alliance Commercial	$3,383.80

Total Shoulder Modular Post 20mm AR-9582-20 [3643950]

Facility

$6,042.50

Service Code	HCPCS C1776
Hospital Charge Code	3643950
Hospital Revenue Code	278
Min. Negotiated Rate	$3,383.80
Max. Negotiated Rate	$5,861.23
Rate for Payer: Cash Price	$3,927.62
Rate for Payer: Hawaii Western Management Group Commercial	$4,229.75
Rate for Payer: Health Management Network Commercial	$5,136.12
Rate for Payer: MDX Hawaii PPO	$5,861.23
Rate for Payer: University Health Alliance Commercial	$3,383.80

Total Shoulder Neutral Humeral Head 50mm x 18mm 520-50-218 [3642608]

Facility

$8,338.50

Service Code	HCPCS C1776
Hospital Charge Code	3642608
Hospital Revenue Code	278
Min. Negotiated Rate	$4,669.56
Max. Negotiated Rate	$8,088.35
Rate for Payer: Cash Price	$5,420.02
Rate for Payer: Hawaii Western Management Group Commercial	$5,836.95
Rate for Payer: Health Management Network Commercial	$7,087.73
Rate for Payer: MDX Hawaii PPO	$8,088.35
Rate for Payer: University Health Alliance Commercial	$4,669.56

Total Shoulder Neutral Humeral Head 50mm x 18mm 520-50-218 [3642608]

Facility

$8,338.50

Service Code	HCPCS C1776
Hospital Charge Code	3642608
Hospital Revenue Code	278
Min. Negotiated Rate	$4,252.64
Max. Negotiated Rate	$8,088.35
Rate for Payer: Cash Price	$5,420.02
Rate for Payer: Hawaii Western Management Group Commercial	$5,836.95
Rate for Payer: Health Management Network Commercial	$7,087.73
Rate for Payer: Kaiser Permanente Commercial	$5,253.26
Rate for Payer: Kaiser Permanente Medicaid	$4,252.64
Rate for Payer: MDX Hawaii PPO	$8,088.35
Rate for Payer: University Health Alliance Commercial	$4,669.56

Total Shoulder Neutral Humeral Head 50mm x 20mm 52050220 [3642606]

Facility

$9,070.00

Service Code	HCPCS C1776
Hospital Charge Code	3642606
Hospital Revenue Code	278
Min. Negotiated Rate	$5,079.20
Max. Negotiated Rate	$8,797.90
Rate for Payer: Cash Price	$5,895.50
Rate for Payer: Hawaii Western Management Group Commercial	$6,349.00
Rate for Payer: Health Management Network Commercial	$7,709.50
Rate for Payer: MDX Hawaii PPO	$8,797.90
Rate for Payer: University Health Alliance Commercial	$5,079.20

Know your out-of-pocket cost for care.

All Charges