Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Shoulder Rsp Bone Screw Non-Lock 3.5mm x 22mm Long 506-02-122 [3645398]

Facility

$595.00

Service Code	HCPCS C1713
Hospital Charge Code	3645398
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 Non-Lock 3.5mm x 22mm Long 506-02-122 [3645398]

Facility

$595.00

Service Code	HCPCS C1713
Hospital Charge Code	3645398
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 Non-Lock 3.5mm x 28mm Long 506-02-128 [3645399]

Facility

$595.00

Service Code	HCPCS C1713
Hospital Charge Code	3645399
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 Non-Lock 3.5mm x 28mm Long 506-02-128 [3645399]

Facility

$595.00

Service Code	HCPCS C1713
Hospital Charge Code	3645399
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 Non-Lock 3.5x18mm Long 506-02-118 [3643864]

Facility

$1,006.25

Service Code	HCPCS C1713
Hospital Charge Code	3643864
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 3.5x18mm Long 506-02-118 [3643864]

Facility

$1,006.25

Service Code	HCPCS C1713
Hospital Charge Code	3643864
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 Glenoid Baseplate 30mm 508-32-104 [3641207]

Facility

$7,628.00

Service Code	HCPCS C1713
Hospital Charge Code	3641207
Hospital Revenue Code	278
Min. Negotiated Rate	$4,271.68
Max. Negotiated Rate	$7,399.16
Rate for Payer: Cash Price	$4,958.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,339.60
Rate for Payer: Health Management Network Commercial	$6,483.80
Rate for Payer: MDX Hawaii PPO	$7,399.16
Rate for Payer: University Health Alliance Commercial	$4,271.68

Total Shoulder RSP Glenoid Baseplate 30mm 508-32-104 [3641207]

Facility

$7,628.00

Service Code	HCPCS C1713
Hospital Charge Code	3641207
Hospital Revenue Code	278
Min. Negotiated Rate	$3,890.28
Max. Negotiated Rate	$7,399.16
Rate for Payer: Cash Price	$4,958.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,339.60
Rate for Payer: Health Management Network Commercial	$6,483.80
Rate for Payer: Kaiser Permanente Commercial	$4,805.64
Rate for Payer: Kaiser Permanente Medicaid	$3,890.28
Rate for Payer: MDX Hawaii PPO	$7,399.16
Rate for Payer: University Health Alliance Commercial	$4,271.68

Total Shoulder RSP Glenoid Baseplate 30mm 50832204 [3641113]

Facility

$12,003.00

Service Code	HCPCS C1713
Hospital Charge Code	3641113
Hospital Revenue Code	278
Min. Negotiated Rate	$6,721.68
Max. Negotiated Rate	$11,642.91
Rate for Payer: Cash Price	$7,801.95
Rate for Payer: Hawaii Western Management Group Commercial	$8,402.10
Rate for Payer: Health Management Network Commercial	$10,202.55
Rate for Payer: MDX Hawaii PPO	$11,642.91
Rate for Payer: University Health Alliance Commercial	$6,721.68

Total Shoulder RSP Glenoid Baseplate 30mm 50832204 [3641113]

Facility

$12,003.00

Service Code	HCPCS C1713
Hospital Charge Code	3641113
Hospital Revenue Code	278
Min. Negotiated Rate	$6,121.53
Max. Negotiated Rate	$11,642.91
Rate for Payer: Cash Price	$7,801.95
Rate for Payer: Hawaii Western Management Group Commercial	$8,402.10
Rate for Payer: Health Management Network Commercial	$10,202.55
Rate for Payer: Kaiser Permanente Commercial	$7,561.89
Rate for Payer: Kaiser Permanente Medicaid	$6,121.53
Rate for Payer: MDX Hawaii PPO	$11,642.91
Rate for Payer: University Health Alliance Commercial	$6,721.68

Total Shoulder RSP Glenoid Head w/Retain Screw -4mm Size 36mm 508-36-103 [3642336]

Facility

$6,798.50

Service Code	HCPCS C1776
Hospital Charge Code	3642336
Hospital Revenue Code	278
Min. Negotiated Rate	$3,807.16
Max. Negotiated Rate	$6,594.55
Rate for Payer: Cash Price	$4,419.03
Rate for Payer: Hawaii Western Management Group Commercial	$4,758.95
Rate for Payer: Health Management Network Commercial	$5,778.73
Rate for Payer: MDX Hawaii PPO	$6,594.55
Rate for Payer: University Health Alliance Commercial	$3,807.16

Total Shoulder RSP Glenoid Head w/Retain Screw -4mm Size 36mm 508-36-103 [3642336]

Facility

$6,798.50

Service Code	HCPCS C1776
Hospital Charge Code	3642336
Hospital Revenue Code	278
Min. Negotiated Rate	$3,467.24
Max. Negotiated Rate	$6,594.55
Rate for Payer: Cash Price	$4,419.03
Rate for Payer: Hawaii Western Management Group Commercial	$4,758.95
Rate for Payer: Health Management Network Commercial	$5,778.73
Rate for Payer: Kaiser Permanente Commercial	$4,283.06
Rate for Payer: Kaiser Permanente Medicaid	$3,467.24
Rate for Payer: MDX Hawaii PPO	$6,594.55
Rate for Payer: University Health Alliance Commercial	$3,807.16

Total Shoulder RSP Glenoid Head w/Retain Screw -4mm Sz 32mm 50832103 [3642283]

Facility

$9,553.00

Service Code	HCPCS C1776
Hospital Charge Code	3642283
Hospital Revenue Code	278
Min. Negotiated Rate	$4,872.03
Max. Negotiated Rate	$9,266.41
Rate for Payer: Cash Price	$6,209.45
Rate for Payer: Hawaii Western Management Group Commercial	$6,687.10
Rate for Payer: Health Management Network Commercial	$8,120.05
Rate for Payer: Kaiser Permanente Commercial	$6,018.39
Rate for Payer: Kaiser Permanente Medicaid	$4,872.03
Rate for Payer: MDX Hawaii PPO	$9,266.41
Rate for Payer: University Health Alliance Commercial	$5,349.68

Total Shoulder RSP Glenoid Head w/Retain Screw -4mm Sz 32mm 50832103 [3642283]

Facility

$9,553.00

Service Code	HCPCS C1776
Hospital Charge Code	3642283
Hospital Revenue Code	278
Min. Negotiated Rate	$5,349.68
Max. Negotiated Rate	$9,266.41
Rate for Payer: Cash Price	$6,209.45
Rate for Payer: Hawaii Western Management Group Commercial	$6,687.10
Rate for Payer: Health Management Network Commercial	$8,120.05
Rate for Payer: MDX Hawaii PPO	$9,266.41
Rate for Payer: University Health Alliance Commercial	$5,349.68

Total Shoulder RSP Glenoid Head w/Retain Screw Neutral 32mm 50832101 [3641110]

Facility

$9,553.00

Service Code	HCPCS C1776
Hospital Charge Code	3641110
Hospital Revenue Code	278
Min. Negotiated Rate	$4,872.03
Max. Negotiated Rate	$9,266.41
Rate for Payer: Cash Price	$6,209.45
Rate for Payer: Hawaii Western Management Group Commercial	$6,687.10
Rate for Payer: Health Management Network Commercial	$8,120.05
Rate for Payer: Kaiser Permanente Commercial	$6,018.39
Rate for Payer: Kaiser Permanente Medicaid	$4,872.03
Rate for Payer: MDX Hawaii PPO	$9,266.41
Rate for Payer: University Health Alliance Commercial	$5,349.68

Total Shoulder RSP Glenoid Head w/Retain Screw Neutral 32mm 50832101 [3641110]

Facility

$9,553.00

Service Code	HCPCS C1776
Hospital Charge Code	3641110
Hospital Revenue Code	278
Min. Negotiated Rate	$5,349.68
Max. Negotiated Rate	$9,266.41
Rate for Payer: Cash Price	$6,209.45
Rate for Payer: Hawaii Western Management Group Commercial	$6,687.10
Rate for Payer: Health Management Network Commercial	$8,120.05
Rate for Payer: MDX Hawaii PPO	$9,266.41
Rate for Payer: University Health Alliance Commercial	$5,349.68

Total Shoulder RSP Glenoid Head w/Retain Screw Neutral 36mm 50836101 [3641265]

Facility

$9,553.00

Service Code	HCPCS C1776
Hospital Charge Code	3641265
Hospital Revenue Code	278
Min. Negotiated Rate	$4,872.03
Max. Negotiated Rate	$9,266.41
Rate for Payer: Cash Price	$6,209.45
Rate for Payer: Hawaii Western Management Group Commercial	$6,687.10
Rate for Payer: Health Management Network Commercial	$8,120.05
Rate for Payer: Kaiser Permanente Commercial	$6,018.39
Rate for Payer: Kaiser Permanente Medicaid	$4,872.03
Rate for Payer: MDX Hawaii PPO	$9,266.41
Rate for Payer: University Health Alliance Commercial	$5,349.68

Total Shoulder RSP Glenoid Head w/Retain Screw Neutral 36mm 50836101 [3641265]

Facility

$9,553.00

Service Code	HCPCS C1776
Hospital Charge Code	3641265
Hospital Revenue Code	278
Min. Negotiated Rate	$5,349.68
Max. Negotiated Rate	$9,266.41
Rate for Payer: Cash Price	$6,209.45
Rate for Payer: Hawaii Western Management Group Commercial	$6,687.10
Rate for Payer: Health Management Network Commercial	$8,120.05
Rate for Payer: MDX Hawaii PPO	$9,266.41
Rate for Payer: University Health Alliance Commercial	$5,349.68

Total Shoulder RSP Humeral Small Socket Insert Sz 32mm Semi Constrained 50903032 [3643023]

Facility

$8,503.00

Service Code	HCPCS C1776
Hospital Charge Code	3643023
Hospital Revenue Code	278
Min. Negotiated Rate	$4,761.68
Max. Negotiated Rate	$8,247.91
Rate for Payer: Cash Price	$5,526.95
Rate for Payer: Hawaii Western Management Group Commercial	$5,952.10
Rate for Payer: Health Management Network Commercial	$7,227.55
Rate for Payer: MDX Hawaii PPO	$8,247.91
Rate for Payer: University Health Alliance Commercial	$4,761.68

Total Shoulder RSP Humeral Small Socket Insert Sz 32mm Semi Constrained 50903032 [3643023]

Facility

$8,503.00

Service Code	HCPCS C1776
Hospital Charge Code	3643023
Hospital Revenue Code	278
Min. Negotiated Rate	$4,336.53
Max. Negotiated Rate	$8,247.91
Rate for Payer: Cash Price	$5,526.95
Rate for Payer: Hawaii Western Management Group Commercial	$5,952.10
Rate for Payer: Health Management Network Commercial	$7,227.55
Rate for Payer: Kaiser Permanente Commercial	$5,356.89
Rate for Payer: Kaiser Permanente Medicaid	$4,336.53
Rate for Payer: MDX Hawaii PPO	$8,247.91
Rate for Payer: University Health Alliance Commercial	$4,761.68

Total Shoulder RSP Humeral Socket Insert 36mm 50900036 [3641267]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3641267
Hospital Revenue Code	278
Min. Negotiated Rate	$3,124.51
Max. Negotiated Rate	$5,942.70
Rate for Payer: Cash Price	$3,982.22
Rate for Payer: Hawaii Western Management Group Commercial	$4,288.55
Rate for Payer: Health Management Network Commercial	$5,207.52
Rate for Payer: Kaiser Permanente Commercial	$3,859.70
Rate for Payer: Kaiser Permanente Medicaid	$3,124.51
Rate for Payer: MDX Hawaii PPO	$5,942.70
Rate for Payer: University Health Alliance Commercial	$3,430.84

Total Shoulder RSP Humeral Socket Insert 36mm 50900036 [3641267]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3641267
Hospital Revenue Code	278
Min. Negotiated Rate	$3,430.84
Max. Negotiated Rate	$5,942.70
Rate for Payer: Cash Price	$3,982.22
Rate for Payer: Hawaii Western Management Group Commercial	$4,288.55
Rate for Payer: Health Management Network Commercial	$5,207.52
Rate for Payer: MDX Hawaii PPO	$5,942.70
Rate for Payer: University Health Alliance Commercial	$3,430.84

Total Shoulder RSP Humeral Socket Insert Sz 32mm +4mm 509-00-432 [3641209]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3641209
Hospital Revenue Code	278
Min. Negotiated Rate	$3,124.51
Max. Negotiated Rate	$5,942.70
Rate for Payer: Cash Price	$3,982.22
Rate for Payer: Hawaii Western Management Group Commercial	$4,288.55
Rate for Payer: Health Management Network Commercial	$5,207.52
Rate for Payer: Kaiser Permanente Commercial	$3,859.70
Rate for Payer: Kaiser Permanente Medicaid	$3,124.51
Rate for Payer: MDX Hawaii PPO	$5,942.70
Rate for Payer: University Health Alliance Commercial	$3,430.84

Total Shoulder RSP Humeral Socket Insert Sz 32mm +4mm 509-00-432 [3641209]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3641209
Hospital Revenue Code	278
Min. Negotiated Rate	$3,430.84
Max. Negotiated Rate	$5,942.70
Rate for Payer: Cash Price	$3,982.22
Rate for Payer: Hawaii Western Management Group Commercial	$4,288.55
Rate for Payer: Health Management Network Commercial	$5,207.52
Rate for Payer: MDX Hawaii PPO	$5,942.70
Rate for Payer: University Health Alliance Commercial	$3,430.84

Total Shoulder RSP Humeral Socket Insert Sz 32mm 50901032 [3641112]

Facility

$8,503.00

Service Code	HCPCS C1776
Hospital Charge Code	3641112
Hospital Revenue Code	278
Min. Negotiated Rate	$4,761.68
Max. Negotiated Rate	$8,247.91
Rate for Payer: Cash Price	$5,526.95
Rate for Payer: Hawaii Western Management Group Commercial	$5,952.10
Rate for Payer: Health Management Network Commercial	$7,227.55
Rate for Payer: MDX Hawaii PPO	$8,247.91
Rate for Payer: University Health Alliance Commercial	$4,761.68

Know your out-of-pocket cost for care.

All Charges