Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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	$4,625.70
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: Kaiser Permanente Commercial	$5,714.10
Rate for Payer: Kaiser Permanente Medicaid	$4,625.70
Rate for Payer: MDX Hawaii PPO	$8,797.90
Rate for Payer: University Health Alliance Commercial	$5,079.20

Total Shoulder Neutral Humeral Head 54mm x 18mm 52054218 [3642460]

Facility

$9,070.00

Service Code	HCPCS C1776
Hospital Charge Code	3642460
Hospital Revenue Code	278
Min. Negotiated Rate	$4,625.70
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: Kaiser Permanente Commercial	$5,714.10
Rate for Payer: Kaiser Permanente Medicaid	$4,625.70
Rate for Payer: MDX Hawaii PPO	$8,797.90
Rate for Payer: University Health Alliance Commercial	$5,079.20

Total Shoulder Neutral Humeral Head 54mm x 18mm 52054218 [3642460]

Facility

$9,070.00

Service Code	HCPCS C1776
Hospital Charge Code	3642460
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

Total Shoulder Neutral Humeral Head 54x20mm 520-54-220 [3643363]

Facility

$8,510.00

Service Code	HCPCS C1776
Hospital Charge Code	3643363
Hospital Revenue Code	278
Min. Negotiated Rate	$4,340.10
Max. Negotiated Rate	$8,254.70
Rate for Payer: Cash Price	$5,531.50
Rate for Payer: Hawaii Western Management Group Commercial	$5,957.00
Rate for Payer: Health Management Network Commercial	$7,233.50
Rate for Payer: Kaiser Permanente Commercial	$5,361.30
Rate for Payer: Kaiser Permanente Medicaid	$4,340.10
Rate for Payer: MDX Hawaii PPO	$8,254.70
Rate for Payer: University Health Alliance Commercial	$4,765.60

Total Shoulder Neutral Humeral Head 54x20mm 520-54-220 [3643363]

Facility

$8,510.00

Service Code	HCPCS C1776
Hospital Charge Code	3643363
Hospital Revenue Code	278
Min. Negotiated Rate	$4,765.60
Max. Negotiated Rate	$8,254.70
Rate for Payer: Cash Price	$5,531.50
Rate for Payer: Hawaii Western Management Group Commercial	$5,957.00
Rate for Payer: Health Management Network Commercial	$7,233.50
Rate for Payer: MDX Hawaii PPO	$8,254.70
Rate for Payer: University Health Alliance Commercial	$4,765.60

Total Shoulder Pegged Glenoid Poly E-Plus 50mm 521-07-250 [3641340]

Facility

$16,892.50

Service Code	HCPCS C1776
Hospital Charge Code	3641340
Hospital Revenue Code	278
Min. Negotiated Rate	$8,615.17
Max. Negotiated Rate	$16,385.72
Rate for Payer: Cash Price	$10,980.12
Rate for Payer: Hawaii Western Management Group Commercial	$11,824.75
Rate for Payer: Health Management Network Commercial	$14,358.62
Rate for Payer: Kaiser Permanente Commercial	$10,642.27
Rate for Payer: Kaiser Permanente Medicaid	$8,615.17
Rate for Payer: MDX Hawaii PPO	$16,385.72
Rate for Payer: University Health Alliance Commercial	$9,459.80

Total Shoulder Pegged Glenoid Poly E-Plus 50mm 521-07-250 [3641340]

Facility

$16,892.50

Service Code	HCPCS C1776
Hospital Charge Code	3641340
Hospital Revenue Code	278
Min. Negotiated Rate	$9,459.80
Max. Negotiated Rate	$16,385.72
Rate for Payer: Cash Price	$10,980.12
Rate for Payer: Hawaii Western Management Group Commercial	$11,824.75
Rate for Payer: Health Management Network Commercial	$14,358.62
Rate for Payer: MDX Hawaii PPO	$16,385.72
Rate for Payer: University Health Alliance Commercial	$9,459.80

Total Shoulder Pin Set Modular Glenoid Sys AR9607S [3642765]

Facility

$2,240.00

Service Code	HCPCS C1713
Hospital Charge Code	3642765
Hospital Revenue Code	278
Min. Negotiated Rate	$1,142.40
Max. Negotiated Rate	$2,172.80
Rate for Payer: Cash Price	$1,456.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,568.00
Rate for Payer: Health Management Network Commercial	$1,904.00
Rate for Payer: Kaiser Permanente Commercial	$1,411.20
Rate for Payer: Kaiser Permanente Medicaid	$1,142.40
Rate for Payer: MDX Hawaii PPO	$2,172.80
Rate for Payer: University Health Alliance Commercial	$1,254.40

Total Shoulder Pin Set Modular Glenoid Sys AR9607S [3642765]

Facility

$2,240.00

Service Code	HCPCS C1713
Hospital Charge Code	3642765
Hospital Revenue Code	278
Min. Negotiated Rate	$1,254.40
Max. Negotiated Rate	$2,172.80
Rate for Payer: Cash Price	$1,456.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,568.00
Rate for Payer: Health Management Network Commercial	$1,904.00
Rate for Payer: MDX Hawaii PPO	$2,172.80
Rate for Payer: University Health Alliance Commercial	$1,254.40

Total Shoulder RSP Bone Screw Locking 5.0mm 14mm 506-03-114 [3641109]

Facility

$595.00

Service Code	HCPCS C1713
Hospital Charge Code	3641109
Hospital Revenue Code	278
Min. Negotiated Rate	$303.45
Max. Negotiated Rate	$577.15
Rate for Payer: Cash Price	$386.75
Rate for Payer: Hawaii Western Management Group Commercial	$416.50
Rate for Payer: Health Management Network Commercial	$505.75
Rate for Payer: Kaiser Permanente Commercial	$374.85
Rate for Payer: Kaiser Permanente Medicaid	$303.45
Rate for Payer: MDX Hawaii PPO	$577.15
Rate for Payer: University Health Alliance Commercial	$333.20

Total Shoulder RSP Bone Screw Locking 5.0mm 14mm 506-03-114 [3641109]

Facility

$595.00

Service Code	HCPCS C1713
Hospital Charge Code	3641109
Hospital Revenue Code	278
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$577.15
Rate for Payer: Cash Price	$386.75
Rate for Payer: Hawaii Western Management Group Commercial	$416.50
Rate for Payer: Health Management Network Commercial	$505.75
Rate for Payer: MDX Hawaii PPO	$577.15
Rate for Payer: University Health Alliance Commercial	$333.20

Total Shoulder RSP Bone Screw Locking 5.0mm 18mm 50603118 [3641264]

Facility

$1,471.25

Service Code	HCPCS C1713
Hospital Charge Code	3641264
Hospital Revenue Code	278
Min. Negotiated Rate	$823.90
Max. Negotiated Rate	$1,427.11
Rate for Payer: Cash Price	$956.31
Rate for Payer: Hawaii Western Management Group Commercial	$1,029.88
Rate for Payer: Health Management Network Commercial	$1,250.56
Rate for Payer: MDX Hawaii PPO	$1,427.11
Rate for Payer: University Health Alliance Commercial	$823.90

Total Shoulder RSP Bone Screw Locking 5.0mm 18mm 50603118 [3641264]

Facility

$1,471.25

Service Code	HCPCS C1713
Hospital Charge Code	3641264
Hospital Revenue Code	278
Min. Negotiated Rate	$750.34
Max. Negotiated Rate	$1,427.11
Rate for Payer: Kaiser Permanente Commercial	$926.89
Rate for Payer: Cash Price	$956.31
Rate for Payer: Hawaii Western Management Group Commercial	$1,029.88
Rate for Payer: Health Management Network Commercial	$1,250.56
Rate for Payer: Kaiser Permanente Medicaid	$750.34
Rate for Payer: MDX Hawaii PPO	$1,427.11
Rate for Payer: University Health Alliance Commercial	$823.90

Total Shoulder RSP Bone Screw Locking 5.0mm 22mm 50603122 [3641109C]

Facility

$1,031.25

Service Code	HCPCS C1713
Hospital Charge Code	3641109C
Hospital Revenue Code	278
Min. Negotiated Rate	$577.50
Max. Negotiated Rate	$1,000.31
Rate for Payer: Cash Price	$670.31
Rate for Payer: Hawaii Western Management Group Commercial	$721.88
Rate for Payer: Health Management Network Commercial	$876.56
Rate for Payer: MDX Hawaii PPO	$1,000.31
Rate for Payer: University Health Alliance Commercial	$577.50

Total Shoulder RSP Bone Screw Locking 5.0mm 22mm 50603122 [3641109C]

Facility

$1,031.25

Service Code	HCPCS C1713
Hospital Charge Code	3641109C
Hospital Revenue Code	278
Min. Negotiated Rate	$525.94
Max. Negotiated Rate	$1,000.31
Rate for Payer: Cash Price	$670.31
Rate for Payer: Hawaii Western Management Group Commercial	$721.88
Rate for Payer: Health Management Network Commercial	$876.56
Rate for Payer: Kaiser Permanente Commercial	$649.69
Rate for Payer: Kaiser Permanente Medicaid	$525.94
Rate for Payer: MDX Hawaii PPO	$1,000.31
Rate for Payer: University Health Alliance Commercial	$577.50

Total Shoulder RSP Bone Screw Locking 5.0mm 26mm 506-03-126 [3641109B]

Facility

$595.00

Service Code	HCPCS C1713
Hospital Charge Code	3641109B
Hospital Revenue Code	278
Min. Negotiated Rate	$303.45
Max. Negotiated Rate	$577.15
Rate for Payer: Cash Price	$386.75
Rate for Payer: Hawaii Western Management Group Commercial	$416.50
Rate for Payer: Health Management Network Commercial	$505.75
Rate for Payer: Kaiser Permanente Commercial	$374.85
Rate for Payer: Kaiser Permanente Medicaid	$303.45
Rate for Payer: MDX Hawaii PPO	$577.15
Rate for Payer: University Health Alliance Commercial	$333.20

Total Shoulder RSP Bone Screw Locking 5.0mm 26mm 506-03-126 [3641109B]

Facility

$595.00

Service Code	HCPCS C1713
Hospital Charge Code	3641109B
Hospital Revenue Code	278
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$577.15
Rate for Payer: Cash Price	$386.75
Rate for Payer: Hawaii Western Management Group Commercial	$416.50
Rate for Payer: Health Management Network Commercial	$505.75
Rate for Payer: MDX Hawaii PPO	$577.15
Rate for Payer: University Health Alliance Commercial	$333.20

Total Shoulder RSP Bone Screw Locking 5.0mm 30mm 50603130 [3641109A]

Facility

$1,031.25

Service Code	HCPCS C1713
Hospital Charge Code	3641109A
Hospital Revenue Code	278
Min. Negotiated Rate	$577.50
Max. Negotiated Rate	$1,000.31
Rate for Payer: Cash Price	$670.31
Rate for Payer: Hawaii Western Management Group Commercial	$721.88
Rate for Payer: Health Management Network Commercial	$876.56
Rate for Payer: MDX Hawaii PPO	$1,000.31
Rate for Payer: University Health Alliance Commercial	$577.50

Total Shoulder RSP Bone Screw Locking 5.0mm 30mm 50603130 [3641109A]

Facility

$1,031.25

Service Code	HCPCS C1713
Hospital Charge Code	3641109A
Hospital Revenue Code	278
Min. Negotiated Rate	$525.94
Max. Negotiated Rate	$1,000.31
Rate for Payer: Cash Price	$670.31
Rate for Payer: Hawaii Western Management Group Commercial	$721.88
Rate for Payer: Health Management Network Commercial	$876.56
Rate for Payer: Kaiser Permanente Commercial	$649.69
Rate for Payer: Kaiser Permanente Medicaid	$525.94
Rate for Payer: MDX Hawaii PPO	$1,000.31
Rate for Payer: University Health Alliance Commercial	$577.50

Total Shoulder RSP Bone Screw Locking 5.0mm 34mm 50603134 [3641282]

Facility

$1,471.25

Service Code	HCPCS C1713
Hospital Charge Code	3641282
Hospital Revenue Code	278
Min. Negotiated Rate	$823.90
Max. Negotiated Rate	$1,427.11
Rate for Payer: Cash Price	$956.31
Rate for Payer: Hawaii Western Management Group Commercial	$1,029.88
Rate for Payer: Health Management Network Commercial	$1,250.56
Rate for Payer: MDX Hawaii PPO	$1,427.11
Rate for Payer: University Health Alliance Commercial	$823.90

Total Shoulder RSP Bone Screw Locking 5.0mm 34mm 50603134 [3641282]

Facility

$1,471.25

Service Code	HCPCS C1713
Hospital Charge Code	3641282
Hospital Revenue Code	278
Min. Negotiated Rate	$750.34
Max. Negotiated Rate	$1,427.11
Rate for Payer: Cash Price	$956.31
Rate for Payer: Hawaii Western Management Group Commercial	$1,029.88
Rate for Payer: Health Management Network Commercial	$1,250.56
Rate for Payer: Kaiser Permanente Commercial	$926.89
Rate for Payer: Kaiser Permanente Medicaid	$750.34
Rate for Payer: MDX Hawaii PPO	$1,427.11
Rate for Payer: University Health Alliance Commercial	$823.90

Total Shoulder RSP Bone Screw Non-Lock 3.5mm 30mm Long 50602130 [3642044]

Facility

$1,006.25

Service Code	HCPCS C1713
Hospital Charge Code	3642044
Hospital Revenue Code	278
Min. Negotiated Rate	$513.19
Max. Negotiated Rate	$976.06
Rate for Payer: Cash Price	$654.06
Rate for Payer: Hawaii Western Management Group Commercial	$704.38
Rate for Payer: Health Management Network Commercial	$855.31
Rate for Payer: Kaiser Permanente Commercial	$633.94
Rate for Payer: Kaiser Permanente Medicaid	$513.19
Rate for Payer: MDX Hawaii PPO	$976.06
Rate for Payer: University Health Alliance Commercial	$563.50

Total Shoulder RSP Bone Screw Non-Lock 3.5mm 30mm Long 50602130 [3642044]

Facility

$1,006.25

Service Code	HCPCS C1713
Hospital Charge Code	3642044
Hospital Revenue Code	278
Min. Negotiated Rate	$563.50
Max. Negotiated Rate	$976.06
Rate for Payer: Cash Price	$654.06
Rate for Payer: Hawaii Western Management Group Commercial	$704.38
Rate for Payer: Health Management Network Commercial	$855.31
Rate for Payer: MDX Hawaii PPO	$976.06
Rate for Payer: University Health Alliance Commercial	$563.50

Total Shoulder RSP Bone Screw Non-Lock 3.5mm 38mm Long 50602138 [3642043]

Facility

$1,006.25

Service Code	HCPCS C1713
Hospital Charge Code	3642043
Hospital Revenue Code	278
Min. Negotiated Rate	$563.50
Max. Negotiated Rate	$976.06
Rate for Payer: Cash Price	$654.06
Rate for Payer: Hawaii Western Management Group Commercial	$704.38
Rate for Payer: Health Management Network Commercial	$855.31
Rate for Payer: MDX Hawaii PPO	$976.06
Rate for Payer: University Health Alliance Commercial	$563.50

Total Shoulder RSP Bone Screw Non-Lock 3.5mm 38mm Long 50602138 [3642043]

Facility

$1,006.25

Service Code	HCPCS C1713
Hospital Charge Code	3642043
Hospital Revenue Code	278
Min. Negotiated Rate	$513.19
Max. Negotiated Rate	$976.06
Rate for Payer: Cash Price	$654.06
Rate for Payer: Hawaii Western Management Group Commercial	$704.38
Rate for Payer: Health Management Network Commercial	$855.31
Rate for Payer: Kaiser Permanente Commercial	$633.94
Rate for Payer: Kaiser Permanente Medicaid	$513.19
Rate for Payer: MDX Hawaii PPO	$976.06
Rate for Payer: University Health Alliance Commercial	$563.50

Know your out-of-pocket cost for care.

All Charges