Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TIBIAL BEARING 5MM 1516-40-605

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,530.00
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: Kaiser Permanente Commercial	$1,890.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

TIBIAL BEARING INS 5531-G-609

Facility

$7,716.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,320.96
Max. Negotiated Rate	$7,484.52
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,401.20
Rate for Payer: Health Management Network Commercial	$6,558.60
Rate for Payer: MDX Hawaii PPO	$7,484.52
Rate for Payer: University Health Alliance Commercial	$4,320.96

TIBIAL BEARING INS 5531-G-609

Facility

$7,716.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,935.16
Max. Negotiated Rate	$7,484.52
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,401.20
Rate for Payer: Health Management Network Commercial	$6,558.60
Rate for Payer: Kaiser Permanente Commercial	$4,861.08
Rate for Payer: Kaiser Permanente Medicaid	$3,935.16
Rate for Payer: MDX Hawaii PPO	$7,484.52
Rate for Payer: University Health Alliance Commercial	$4,320.96

TIBIAL BEARING SZ5 1506-70-005

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,904.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

TIBIAL BEARING SZ5 1506-70-005

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

TIBIAL BEARING SZ6 1506-70-006

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,904.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

TIBIAL BEARING SZ6 1506-70-006

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

TIBIAL BEARING X3 5532-G-511-E

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

TIBIAL BEARING X3 5532-G-511-E

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

TIBIAL BEARING XS 4MM L 160791

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

TIBIAL BEARING XS 4MM L 160791

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

TIBIAL BEARNG 10MM 1516-20-610

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,530.00
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: Kaiser Permanente Commercial	$1,890.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

TIBIAL BEARNG 10MM 1516-20-610

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

TIBIAL BEARNG SZ4 5531-G-411-E

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

TIBIAL BEARNG SZ4 5531-G-411-E

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

TIBIAL BEARNG SZ5 5531-G-509-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 BEARNG SZ5 5531-G-509-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 BEARNG SZ5 5532-G-513-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 BEARNG SZ5 5532-G-513-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 CEMENTED TRAY 154718

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

TIBIAL CEMENTED TRAY 154718

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,683.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

TIBIAL COMP 70MM MED RKTBMD

Facility

$9,160.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,129.60
Max. Negotiated Rate	$8,885.20
Rate for Payer: Cash Price	$5,496.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,412.00
Rate for Payer: Health Management Network Commercial	$7,786.00
Rate for Payer: MDX Hawaii PPO	$8,885.20
Rate for Payer: University Health Alliance Commercial	$5,129.60

TIBIAL COMP 70MM MED RKTBMD

Facility

$9,160.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,671.60
Max. Negotiated Rate	$8,885.20
Rate for Payer: Cash Price	$5,496.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,412.00
Rate for Payer: Health Management Network Commercial	$7,786.00
Rate for Payer: Kaiser Permanente Commercial	$5,770.80
Rate for Payer: Kaiser Permanente Medicaid	$4,671.60
Rate for Payer: MDX Hawaii PPO	$8,885.20
Rate for Payer: University Health Alliance Commercial	$5,129.60

TIBIAL COMPONENT #5 5534-A-516

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,637.61
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: Kaiser Permanente Commercial	$2,022.93
Rate for Payer: Kaiser Permanente Medicaid	$1,637.61
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

TIBIAL COMPONENT #5 5534-A-516

Facility

$3,211.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,798.16
Max. Negotiated Rate	$3,114.67
Rate for Payer: Cash Price	$1,926.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,247.70
Rate for Payer: Health Management Network Commercial	$2,729.35
Rate for Payer: MDX Hawaii PPO	$3,114.67
Rate for Payer: University Health Alliance Commercial	$1,798.16

Know your out-of-pocket cost for care.

All Charges