Kona Community Hospital

All Charges

Charge

Type

Setting

Price

Total Shoulder Screw Peripheral Lock 5.5mm x 32mm AR-9563-32 [3644617]

Facility

$1,198.00

Hospital Charge Code	3644617
Hospital Revenue Code	272
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	$1,138.10
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	$873.22

Total Shoulder Screw Peripheral Lock 5.5mm x 32mm AR-9563-32 [3644617]

Facility

$1,198.00

Hospital Charge Code	3644617
Hospital Revenue Code	272
Min. Negotiated Rate	$1,018.30
Max. Negotiated Rate	$1,162.06
Rate for Payer: Cash Price	$778.70
Rate for Payer: Health Management Network Commercial	$1,018.30
Rate for Payer: MDX Hawaii PPO	$1,162.06

Total Shoulder Screw Peripheral Lock 5.5mmx40mm AR-9563-40 [3643440]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643440
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 5.5mmx40mm AR-9563-40 [3643440]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643440
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 5.5mmx48mm AR-9563-48 [3643948]

Facility

$875.00

Service Code	HCPCS C1713
Hospital Charge Code	3643948
Hospital Revenue Code	278
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$568.75
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

Total Shoulder Screw Peripheral Lock 5.5mmx48mm AR-9563-48 [3643948]

Facility

$875.00

Service Code	HCPCS C1713
Hospital Charge Code	3643948
Hospital Revenue Code	278
Min. Negotiated Rate	$446.25
Max. Negotiated Rate	$848.75
Rate for Payer: Cash Price	$568.75
Rate for Payer: Hawaii Western Management Group Commercial	$612.50
Rate for Payer: Health Management Network Commercial	$743.75
Rate for Payer: Kaiser Permanente Commercial	$551.25
Rate for Payer: Kaiser Permanente Medicaid	$446.25
Rate for Payer: MDX Hawaii PPO	$848.75
Rate for Payer: University Health Alliance Commercial	$490.00

Total Shoulder Screw Peripheral Lock 5.5x28mm AR-9563-28 [3643406]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643406
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 5.5x28mm AR-9563-28 [3643406]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643406
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 Non-Lock 4.5mmx20mm AR-9562-20NL [3643404]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643404
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 Non-Lock 4.5mmx20mm AR-9562-20NL [3643404]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643404
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 Non Lock 4.5mmx28mm AR-9562-28NL [3643436]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643436
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 Non Lock 4.5mmx28mm AR-9562-28NL [3643436]

Facility

$1,198.00

Service Code	HCPCS C1713
Hospital Charge Code	3643436
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 TM Modular Post SAGP0002 [3644446]

Facility

$1,830.00

Service Code	HCPCS C1776
Hospital Charge Code	3644446
Hospital Revenue Code	278
Min. Negotiated Rate	$1,024.80
Max. Negotiated Rate	$1,775.10
Rate for Payer: Cash Price	$1,189.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,281.00
Rate for Payer: Health Management Network Commercial	$1,555.50
Rate for Payer: MDX Hawaii PPO	$1,775.10
Rate for Payer: University Health Alliance Commercial	$1,024.80

Total Shoulder TM Modular Post SAGP0002 [3644446]

Facility

$1,830.00

Service Code	HCPCS C1776
Hospital Charge Code	3644446
Hospital Revenue Code	278
Min. Negotiated Rate	$933.30
Max. Negotiated Rate	$1,775.10
Rate for Payer: Cash Price	$1,189.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,281.00
Rate for Payer: Health Management Network Commercial	$1,555.50
Rate for Payer: Kaiser Permanente Commercial	$1,152.90
Rate for Payer: Kaiser Permanente Medicaid	$933.30
Rate for Payer: MDX Hawaii PPO	$1,775.10
Rate for Payer: University Health Alliance Commercial	$1,024.80

Total Shoulder Univers Apex Hum Stem 6mm [3643652]

Facility

$17,397.50

Service Code	HCPCS C1776
Hospital Charge Code	3643652
Hospital Revenue Code	278
Min. Negotiated Rate	$9,742.60
Max. Negotiated Rate	$16,875.58
Rate for Payer: Cash Price	$11,308.38
Rate for Payer: Hawaii Western Management Group Commercial	$12,178.25
Rate for Payer: Health Management Network Commercial	$14,787.88
Rate for Payer: MDX Hawaii PPO	$16,875.58
Rate for Payer: University Health Alliance Commercial	$9,742.60

Total Shoulder Univers Apex Hum Stem 6mm [3643652]

Facility

$17,397.50

Service Code	HCPCS C1776
Hospital Charge Code	3643652
Hospital Revenue Code	278
Min. Negotiated Rate	$8,872.73
Max. Negotiated Rate	$16,875.58
Rate for Payer: Cash Price	$11,308.38
Rate for Payer: Hawaii Western Management Group Commercial	$12,178.25
Rate for Payer: Health Management Network Commercial	$14,787.88
Rate for Payer: Kaiser Permanente Commercial	$10,960.42
Rate for Payer: Kaiser Permanente Medicaid	$8,872.73
Rate for Payer: MDX Hawaii PPO	$16,875.58
Rate for Payer: University Health Alliance Commercial	$9,742.60

Total Shoulder Univers/Eclipse Pin Set AR9207S [3642721]

Facility

$2,542.38

Service Code	HCPCS C1713
Hospital Charge Code	3642721
Hospital Revenue Code	278
Min. Negotiated Rate	$1,423.73
Max. Negotiated Rate	$2,466.11
Rate for Payer: Cash Price	$1,652.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,779.67
Rate for Payer: Health Management Network Commercial	$2,161.02
Rate for Payer: MDX Hawaii PPO	$2,466.11
Rate for Payer: University Health Alliance Commercial	$1,423.73

Total Shoulder Univers/Eclipse Pin Set AR9207S [3642721]

Facility

$2,542.38

Service Code	HCPCS C1713
Hospital Charge Code	3642721
Hospital Revenue Code	278
Min. Negotiated Rate	$1,296.61
Max. Negotiated Rate	$2,466.11
Rate for Payer: Cash Price	$1,652.55
Rate for Payer: Hawaii Western Management Group Commercial	$1,779.67
Rate for Payer: Health Management Network Commercial	$2,161.02
Rate for Payer: Kaiser Permanente Commercial	$1,601.70
Rate for Payer: Kaiser Permanente Medicaid	$1,296.61
Rate for Payer: MDX Hawaii PPO	$2,466.11
Rate for Payer: University Health Alliance Commercial	$1,423.73

Total Shoulder Univers Revers Humeral Stem Size 9 AR950109P [3642757]

Facility

$6,212.50

Service Code	HCPCS C1776
Hospital Charge Code	3642757
Hospital Revenue Code	278
Min. Negotiated Rate	$3,479.00
Max. Negotiated Rate	$6,026.12
Rate for Payer: Cash Price	$4,038.12
Rate for Payer: Hawaii Western Management Group Commercial	$4,348.75
Rate for Payer: Health Management Network Commercial	$5,280.62
Rate for Payer: MDX Hawaii PPO	$6,026.12
Rate for Payer: University Health Alliance Commercial	$3,479.00

Total Shoulder Univers Revers Humeral Stem Size 9 AR950109P [3642757]

Facility

$6,212.50

Service Code	HCPCS C1776
Hospital Charge Code	3642757
Hospital Revenue Code	278
Min. Negotiated Rate	$3,168.38
Max. Negotiated Rate	$6,026.12
Rate for Payer: Cash Price	$4,038.12
Rate for Payer: Hawaii Western Management Group Commercial	$4,348.75
Rate for Payer: Health Management Network Commercial	$5,280.62
Rate for Payer: Kaiser Permanente Commercial	$3,913.88
Rate for Payer: Kaiser Permanente Medicaid	$3,168.38
Rate for Payer: MDX Hawaii PPO	$6,026.12
Rate for Payer: University Health Alliance Commercial	$3,479.00

Total Shoulder Univers Revers Hum Stem Sz 5 AR-9501-05P [3644742]

Facility

$16,000.00

Service Code	HCPCS C1776
Hospital Charge Code	3644742
Hospital Revenue Code	278
Min. Negotiated Rate	$8,160.00
Max. Negotiated Rate	$15,520.00
Rate for Payer: Cash Price	$10,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,200.00
Rate for Payer: Health Management Network Commercial	$13,600.00
Rate for Payer: Kaiser Permanente Commercial	$10,080.00
Rate for Payer: Kaiser Permanente Medicaid	$8,160.00
Rate for Payer: MDX Hawaii PPO	$15,520.00
Rate for Payer: University Health Alliance Commercial	$8,960.00

Total Shoulder Univers Revers Hum Stem Sz 5 AR-9501-05P [3644742]

Facility

$16,000.00

Service Code	HCPCS C1776
Hospital Charge Code	3644742
Hospital Revenue Code	278
Min. Negotiated Rate	$8,960.00
Max. Negotiated Rate	$15,520.00
Rate for Payer: Cash Price	$10,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$11,200.00
Rate for Payer: Health Management Network Commercial	$13,600.00
Rate for Payer: MDX Hawaii PPO	$15,520.00
Rate for Payer: University Health Alliance Commercial	$8,960.00

Total Shoulder Univers Revers Suture Cup 33 Ntrl AR-9502F-33CPC [3644743]

Facility

$11,915.50

Service Code	HCPCS C1776
Hospital Charge Code	3644743
Hospital Revenue Code	278
Min. Negotiated Rate	$6,076.90
Max. Negotiated Rate	$11,558.03
Rate for Payer: Cash Price	$7,745.08
Rate for Payer: Hawaii Western Management Group Commercial	$8,340.85
Rate for Payer: Health Management Network Commercial	$10,128.17
Rate for Payer: Kaiser Permanente Commercial	$7,506.77
Rate for Payer: Kaiser Permanente Medicaid	$6,076.90
Rate for Payer: MDX Hawaii PPO	$11,558.03
Rate for Payer: University Health Alliance Commercial	$6,672.68

Total Shoulder Univers Revers Suture Cup 33 Ntrl AR-9502F-33CPC [3644743]

Facility

$11,915.50

Service Code	HCPCS C1776
Hospital Charge Code	3644743
Hospital Revenue Code	278
Min. Negotiated Rate	$6,672.68
Max. Negotiated Rate	$11,558.03
Rate for Payer: Cash Price	$7,745.08
Rate for Payer: Hawaii Western Management Group Commercial	$8,340.85
Rate for Payer: Health Management Network Commercial	$10,128.17
Rate for Payer: MDX Hawaii PPO	$11,558.03
Rate for Payer: University Health Alliance Commercial	$6,672.68

Total Shoulder Univers Revers Suture Cup 36 Neutral AR-9502F-36CPC [3642758]

Facility

$11,915.50

Service Code	HCPCS C1776
Hospital Charge Code	3642758
Hospital Revenue Code	278
Min. Negotiated Rate	$6,672.68
Max. Negotiated Rate	$11,558.03
Rate for Payer: Cash Price	$7,745.08
Rate for Payer: Hawaii Western Management Group Commercial	$8,340.85
Rate for Payer: Health Management Network Commercial	$10,128.17
Rate for Payer: MDX Hawaii PPO	$11,558.03
Rate for Payer: University Health Alliance Commercial	$6,672.68

Know your out-of-pocket cost for care.

All Charges