Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TIB BEARING SZ 7 #5532-G-709

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.76
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: Kaiser Permanente Commercial	$1,685.88
Rate for Payer: Kaiser Permanente Medicaid	$1,364.76
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

TIB BEARING SZ 7 #5532-G-709

Facility

$2,676.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,498.56
Max. Negotiated Rate	$2,595.72
Rate for Payer: Cash Price	$1,605.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,873.20
Rate for Payer: Health Management Network Commercial	$2,274.60
Rate for Payer: MDX Hawaii PPO	$2,595.72
Rate for Payer: University Health Alliance Commercial	$1,498.56

TIBIA CAP 11.5 10MM 2341-0010S

Facility

$1,071.00

Hospital Revenue Code	278
Min. Negotiated Rate	$599.76
Max. Negotiated Rate	$1,038.87
Rate for Payer: Cash Price	$642.60
Rate for Payer: Hawaii Western Management Group Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$910.35
Rate for Payer: MDX Hawaii PPO	$1,038.87
Rate for Payer: University Health Alliance Commercial	$599.76

TIBIA CAP 11.5 10MM 2341-0010S

Facility

$1,071.00

Hospital Revenue Code	278
Min. Negotiated Rate	$546.21
Max. Negotiated Rate	$1,038.87
Rate for Payer: Cash Price	$642.60
Rate for Payer: Hawaii Western Management Group Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$910.35
Rate for Payer: Kaiser Permanente Commercial	$674.73
Rate for Payer: Kaiser Permanente Medicaid	$546.21
Rate for Payer: MDX Hawaii PPO	$1,038.87
Rate for Payer: University Health Alliance Commercial	$599.76

TIBIA CAP 11.5 20MM 2341-0020S

Facility

$1,071.00

Hospital Revenue Code	278
Min. Negotiated Rate	$546.21
Max. Negotiated Rate	$1,038.87
Rate for Payer: Cash Price	$642.60
Rate for Payer: Hawaii Western Management Group Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$910.35
Rate for Payer: Kaiser Permanente Commercial	$674.73
Rate for Payer: Kaiser Permanente Medicaid	$546.21
Rate for Payer: MDX Hawaii PPO	$1,038.87
Rate for Payer: University Health Alliance Commercial	$599.76

TIBIA CAP 11.5 20MM 2341-0020S

Facility

$1,071.00

Hospital Revenue Code	278
Min. Negotiated Rate	$599.76
Max. Negotiated Rate	$1,038.87
Rate for Payer: Cash Price	$642.60
Rate for Payer: Hawaii Western Management Group Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$910.35
Rate for Payer: MDX Hawaii PPO	$1,038.87
Rate for Payer: University Health Alliance Commercial	$599.76

TIBIA END CAP 11.5 2341-0015S

Facility

$1,071.00

Hospital Revenue Code	278
Min. Negotiated Rate	$599.76
Max. Negotiated Rate	$1,038.87
Rate for Payer: Cash Price	$642.60
Rate for Payer: Hawaii Western Management Group Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$910.35
Rate for Payer: MDX Hawaii PPO	$1,038.87
Rate for Payer: University Health Alliance Commercial	$599.76

TIBIA END CAP 11.5 2341-0015S

Facility

$1,071.00

Hospital Revenue Code	278
Min. Negotiated Rate	$546.21
Max. Negotiated Rate	$1,038.87
Rate for Payer: Cash Price	$642.60
Rate for Payer: Hawaii Western Management Group Commercial	$749.70
Rate for Payer: Health Management Network Commercial	$910.35
Rate for Payer: Kaiser Permanente Commercial	$674.73
Rate for Payer: Kaiser Permanente Medicaid	$546.21
Rate for Payer: MDX Hawaii PPO	$1,038.87
Rate for Payer: University Health Alliance Commercial	$599.76

TIBIAL 4X9MM BRNG 5531-G-409-E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,513.68
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

TIBIAL 4X9MM BRNG 5531-G-409-E

Facility

$2,703.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,378.53
Max. Negotiated Rate	$2,621.91
Rate for Payer: Cash Price	$1,621.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,892.10
Rate for Payer: Health Management Network Commercial	$2,297.55
Rate for Payer: Kaiser Permanente Commercial	$1,702.89
Rate for Payer: Kaiser Permanente Medicaid	$1,378.53
Rate for Payer: MDX Hawaii PPO	$2,621.91
Rate for Payer: University Health Alliance Commercial	$1,513.68

TIBIAL ASYMMETRICE 5549-A-241

Facility

$11,136.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,236.16
Max. Negotiated Rate	$10,801.92
Rate for Payer: Cash Price	$6,681.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,795.20
Rate for Payer: Health Management Network Commercial	$9,465.60
Rate for Payer: MDX Hawaii PPO	$10,801.92
Rate for Payer: University Health Alliance Commercial	$6,236.16

TIBIAL ASYMMETRICE 5549-A-241

Facility

$11,136.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,679.36
Max. Negotiated Rate	$10,801.92
Rate for Payer: Cash Price	$6,681.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,795.20
Rate for Payer: Health Management Network Commercial	$9,465.60
Rate for Payer: Kaiser Permanente Commercial	$7,015.68
Rate for Payer: Kaiser Permanente Medicaid	$5,679.36
Rate for Payer: MDX Hawaii PPO	$10,801.92
Rate for Payer: University Health Alliance Commercial	$6,236.16

TIBIAL AUGMENT 5545-A-401

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-401

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,082.73
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,337.49
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-402

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,082.73
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,337.49
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-402

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-601

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,082.73
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,337.49
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-601

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-602

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,188.88
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT 5545-A-602

Facility

$2,123.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,082.73
Max. Negotiated Rate	$2,059.31
Rate for Payer: Cash Price	$1,273.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.10
Rate for Payer: Health Management Network Commercial	$1,804.55
Rate for Payer: Kaiser Permanente Commercial	$1,337.49
Rate for Payer: Kaiser Permanente Medicaid	$1,082.73
Rate for Payer: MDX Hawaii PPO	$2,059.31
Rate for Payer: University Health Alliance Commercial	$1,188.88

TIBIAL AUGMENT #5 5546-A-502

Facility

$2,173.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,108.23
Max. Negotiated Rate	$2,107.81
Rate for Payer: Cash Price	$1,303.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,521.10
Rate for Payer: Health Management Network Commercial	$1,847.05
Rate for Payer: Kaiser Permanente Commercial	$1,368.99
Rate for Payer: Kaiser Permanente Medicaid	$1,108.23
Rate for Payer: MDX Hawaii PPO	$2,107.81
Rate for Payer: University Health Alliance Commercial	$1,216.88

TIBIAL AUGMENT #5 5546-A-502

Facility

$2,173.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,216.88
Max. Negotiated Rate	$2,107.81
Rate for Payer: Cash Price	$1,303.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,521.10
Rate for Payer: Health Management Network Commercial	$1,847.05
Rate for Payer: MDX Hawaii PPO	$2,107.81
Rate for Payer: University Health Alliance Commercial	$1,216.88

TIBIAL AUGMENT HALF BLK SIZE 3

Facility

$2,229.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,136.79
Max. Negotiated Rate	$2,162.13
Rate for Payer: Cash Price	$1,337.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,560.30
Rate for Payer: Health Management Network Commercial	$1,894.65
Rate for Payer: Kaiser Permanente Commercial	$1,404.27
Rate for Payer: Kaiser Permanente Medicaid	$1,136.79
Rate for Payer: MDX Hawaii PPO	$2,162.13
Rate for Payer: University Health Alliance Commercial	$1,248.24

TIBIAL AUGMENT HALF BLK SIZE 3

Facility

$2,229.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,248.24
Max. Negotiated Rate	$2,162.13
Rate for Payer: Cash Price	$1,337.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,560.30
Rate for Payer: Health Management Network Commercial	$1,894.65
Rate for Payer: MDX Hawaii PPO	$2,162.13
Rate for Payer: University Health Alliance Commercial	$1,248.24

TIBIAL BEARING 5MM 1516-40-605

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

Know your out-of-pocket cost for care.

All Charges