Kona Community Hospital

All Charges

Charge

Type

Setting

Price

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	$4,336.53
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 Sz 32mm 509-01-432 [3641766]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3641766
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 509-01-432 [3641766]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3641766
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 Standard 50900032 [3641270]

Facility

$8,503.00

Service Code	HCPCS C1776
Hospital Charge Code	3641270
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 Socket Insert Sz 32mm Standard 50900032 [3641270]

Facility

$8,503.00

Service Code	HCPCS C1776
Hospital Charge Code	3641270
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 Sz 36mm +4mm 50900436 [3642171]

Facility

$8,503.00

Service Code	HCPCS C1776
Hospital Charge Code	3642171
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 Socket Insert Sz 36mm +4mm 50900436 [3642171]

Facility

$8,503.00

Service Code	HCPCS C1776
Hospital Charge Code	3642171
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 Sz 36mm 509-01-036 [3642161]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3642161
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 36mm 509-01-036 [3642161]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3642161
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 36mm 509-01-436 [3641662]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3641662
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 36mm 509-01-436 [3641662]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3641662
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 Hum Small Socket Insrt Sz 32mm Ntrl 509-02-032 [3643261]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3643261
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 Hum Small Socket Insrt Sz 32mm Ntrl 509-02-032 [3643261]

Facility

$6,126.50

Service Code	HCPCS C1776
Hospital Charge Code	3643261
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 Hum Sm Socket Insert Sz32mm Semi Constrained +4 509-03-432 [3643216]

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	3643216
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

Total Shoulder RSP Hum Sm Socket Insert Sz32mm Semi Constrained +4 509-03-432 [3643216]

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Charge Code	3643216
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,250.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

Total Shoulder RSP Monoblock Hemi Adapter w/Screw 51099000 [3642330]

Facility

$7,607.00

Service Code	HCPCS C1776
Hospital Charge Code	3642330
Hospital Revenue Code	278
Min. Negotiated Rate	$3,879.57
Max. Negotiated Rate	$7,378.79
Rate for Payer: Cash Price	$4,944.55
Rate for Payer: Hawaii Western Management Group Commercial	$5,324.90
Rate for Payer: Health Management Network Commercial	$6,465.95
Rate for Payer: Kaiser Permanente Commercial	$4,792.41
Rate for Payer: Kaiser Permanente Medicaid	$3,879.57
Rate for Payer: MDX Hawaii PPO	$7,378.79
Rate for Payer: University Health Alliance Commercial	$4,259.92

Total Shoulder RSP Monoblock Hemi Adapter w/Screw 51099000 [3642330]

Facility

$7,607.00

Service Code	HCPCS C1776
Hospital Charge Code	3642330
Hospital Revenue Code	278
Min. Negotiated Rate	$4,259.92
Max. Negotiated Rate	$7,378.79
Rate for Payer: Cash Price	$4,944.55
Rate for Payer: Hawaii Western Management Group Commercial	$5,324.90
Rate for Payer: Health Management Network Commercial	$6,465.95
Rate for Payer: MDX Hawaii PPO	$7,378.79
Rate for Payer: University Health Alliance Commercial	$4,259.92

Total Shoulder Rsp Retaining Screw, Replacement 508-000-01 [3643397]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643397
Hospital Revenue Code	278
Min. Negotiated Rate	$670.88
Max. Negotiated Rate	$1,162.06
Rate for Payer: Cash Price	$778.70
Rate for Payer: Hawaii Western Management Group Commercial	$838.60
Rate for Payer: Health Management Network Commercial	$1,018.30
Rate for Payer: MDX Hawaii PPO	$1,162.06
Rate for Payer: University Health Alliance Commercial	$670.88

Total Shoulder Rsp Retaining Screw, Replacement 508-000-01 [3643397]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643397
Hospital Revenue Code	278
Min. Negotiated Rate	$610.98
Max. Negotiated Rate	$1,162.06
Rate for Payer: Cash Price	$778.70
Rate for Payer: Hawaii Western Management Group Commercial	$838.60
Rate for Payer: Health Management Network Commercial	$1,018.30
Rate for Payer: Kaiser Permanente Commercial	$754.74
Rate for Payer: Kaiser Permanente Medicaid	$610.98
Rate for Payer: MDX Hawaii PPO	$1,162.06
Rate for Payer: University Health Alliance Commercial	$670.88

Total Shoulder Screw Peripheral Lock 5.5mmx16mm AR-9563-16 [3643438]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643438
Hospital Revenue Code	278
Min. Negotiated Rate	$670.88
Max. Negotiated Rate	$1,162.06
Rate for Payer: Cash Price	$778.70
Rate for Payer: Hawaii Western Management Group Commercial	$838.60
Rate for Payer: Health Management Network Commercial	$1,018.30
Rate for Payer: MDX Hawaii PPO	$1,162.06
Rate for Payer: University Health Alliance Commercial	$670.88

Total Shoulder Screw Peripheral Lock 5.5mmx16mm AR-9563-16 [3643438]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643438
Hospital Revenue Code	278
Min. Negotiated Rate	$610.98
Max. Negotiated Rate	$1,162.06
Rate for Payer: Cash Price	$778.70
Rate for Payer: Hawaii Western Management Group Commercial	$838.60
Rate for Payer: Health Management Network Commercial	$1,018.30
Rate for Payer: Kaiser Permanente Commercial	$754.74
Rate for Payer: Kaiser Permanente Medicaid	$610.98
Rate for Payer: MDX Hawaii PPO	$1,162.06
Rate for Payer: University Health Alliance Commercial	$670.88

Total Shoulder Screw Peripheral Lock 5.5mmx20mm AR-9563-20 [3643405]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643405
Hospital Revenue Code	278
Min. Negotiated Rate	$670.88
Max. Negotiated Rate	$1,162.06
Rate for Payer: Cash Price	$778.70
Rate for Payer: Hawaii Western Management Group Commercial	$838.60
Rate for Payer: Health Management Network Commercial	$1,018.30
Rate for Payer: MDX Hawaii PPO	$1,162.06
Rate for Payer: University Health Alliance Commercial	$670.88

Total Shoulder Screw Peripheral Lock 5.5mmx20mm AR-9563-20 [3643405]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643405
Hospital Revenue Code	278
Min. Negotiated Rate	$610.98
Max. Negotiated Rate	$1,162.06
Rate for Payer: Cash Price	$778.70
Rate for Payer: Hawaii Western Management Group Commercial	$838.60
Rate for Payer: Health Management Network Commercial	$1,018.30
Rate for Payer: Kaiser Permanente Commercial	$754.74
Rate for Payer: Kaiser Permanente Medicaid	$610.98
Rate for Payer: MDX Hawaii PPO	$1,162.06
Rate for Payer: University Health Alliance Commercial	$670.88

Total Shoulder Screw Peripheral Lock 5.5mmX24mm AR956324 [3642763]

Facility

$525.00

Service Code	HCPCS C1713
Hospital Charge Code	3642763
Hospital Revenue Code	278
Min. Negotiated Rate	$294.00
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Hawaii Western Management Group Commercial	$367.50
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: University Health Alliance Commercial	$294.00

Total Shoulder Screw Peripheral Lock 5.5mmX24mm AR956324 [3642763]

Facility

$525.00

Service Code	HCPCS C1713
Hospital Charge Code	3642763
Hospital Revenue Code	278
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$341.25
Rate for Payer: Hawaii Western Management Group Commercial	$367.50
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$330.75
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: University Health Alliance Commercial	$294.00

Know your out-of-pocket cost for care.

All Charges