Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRIATHLN PE FEMUR #5515-F-502

Facility

$4,282.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,397.92
Max. Negotiated Rate	$4,153.54
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: University Health Alliance Commercial	$2,397.92

TRIATHLN TIBIA PLT 5521-B-500

Facility

$3,311.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,688.61
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Kaiser Permanente Commercial	$2,085.93
Rate for Payer: Kaiser Permanente Medicaid	$1,688.61
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

TRIATHLN TIBIA PLT 5521-B-500

Facility

$3,311.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,854.16
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

TRIATHLN TIBIA PLT 5521-B-600

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,688.61
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: Kaiser Permanente Commercial	$2,085.93
Rate for Payer: Kaiser Permanente Medicaid	$1,688.61
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

TRIATHLN TIBIA PLT 5521-B-600

Facility

$3,311.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,854.16
Max. Negotiated Rate	$3,211.67
Rate for Payer: Cash Price	$1,986.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,317.70
Rate for Payer: Health Management Network Commercial	$2,814.35
Rate for Payer: MDX Hawaii PPO	$3,211.67
Rate for Payer: University Health Alliance Commercial	$1,854.16

TRIATHLON 10X32MM 5551-G-320-E

Facility

$2,341.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,310.96
Max. Negotiated Rate	$2,270.77
Rate for Payer: Cash Price	$1,404.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,638.70
Rate for Payer: Health Management Network Commercial	$1,989.85
Rate for Payer: MDX Hawaii PPO	$2,270.77
Rate for Payer: University Health Alliance Commercial	$1,310.96

TRIATHLON 10X32MM 5551-G-320-E

Facility

$2,341.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,193.91
Max. Negotiated Rate	$2,270.77
Rate for Payer: Cash Price	$1,404.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,638.70
Rate for Payer: Health Management Network Commercial	$1,989.85
Rate for Payer: Kaiser Permanente Commercial	$1,474.83
Rate for Payer: Kaiser Permanente Medicaid	$1,193.91
Rate for Payer: MDX Hawaii PPO	$2,270.77
Rate for Payer: University Health Alliance Commercial	$1,310.96

TRIATHLON 38X11MM 5551-G-381-E

Facility

$2,317.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,297.52
Max. Negotiated Rate	$2,247.49
Rate for Payer: Cash Price	$1,390.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,621.90
Rate for Payer: Health Management Network Commercial	$1,969.45
Rate for Payer: MDX Hawaii PPO	$2,247.49
Rate for Payer: University Health Alliance Commercial	$1,297.52

TRIATHLON 38X11MM 5551-G-381-E

Facility

$2,317.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.67
Max. Negotiated Rate	$2,247.49
Rate for Payer: Cash Price	$1,390.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,621.90
Rate for Payer: Health Management Network Commercial	$1,969.45
Rate for Payer: Kaiser Permanente Commercial	$1,459.71
Rate for Payer: Kaiser Permanente Medicaid	$1,181.67
Rate for Payer: MDX Hawaii PPO	$2,247.49
Rate for Payer: University Health Alliance Commercial	$1,297.52

TRIATHLON ALL POLY 5534-A-511

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,654.44
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: Kaiser Permanente Commercial	$2,043.72
Rate for Payer: Kaiser Permanente Medicaid	$1,654.44
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

TRIATHLON ALL POLY 5534-A-511

Facility

$3,244.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,816.64
Max. Negotiated Rate	$3,146.68
Rate for Payer: Cash Price	$1,946.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,270.80
Rate for Payer: Health Management Network Commercial	$2,757.40
Rate for Payer: MDX Hawaii PPO	$3,146.68
Rate for Payer: University Health Alliance Commercial	$1,816.64

TRIATHLON ALLPOLY 5534-A-713

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

TRIATHLON ALLPOLY 5534-A-713

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

TRIATHLON CR FEM 5517-F-701

Facility

$5,887.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,296.72
Max. Negotiated Rate	$5,710.39
Rate for Payer: Cash Price	$3,532.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,120.90
Rate for Payer: Health Management Network Commercial	$5,003.95
Rate for Payer: MDX Hawaii PPO	$5,710.39
Rate for Payer: University Health Alliance Commercial	$3,296.72

TRIATHLON CR FEM 5517-F-701

Facility

$5,887.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,002.37
Max. Negotiated Rate	$5,710.39
Rate for Payer: Cash Price	$3,532.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,120.90
Rate for Payer: Health Management Network Commercial	$5,003.95
Rate for Payer: Kaiser Permanente Commercial	$3,708.81
Rate for Payer: Kaiser Permanente Medicaid	$3,002.37
Rate for Payer: MDX Hawaii PPO	$5,710.39
Rate for Payer: University Health Alliance Commercial	$3,296.72

TRIATHLON CR FEMUR

Facility

$4,325.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,205.75
Max. Negotiated Rate	$4,195.25
Rate for Payer: Cash Price	$2,595.00
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.50
Rate for Payer: Health Management Network Commercial	$3,676.25
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: Kaiser Permanente Commercial	$2,697.66
Rate for Payer: Kaiser Permanente Commercial	$2,724.75
Rate for Payer: Kaiser Permanente Medicaid	$2,183.82
Rate for Payer: Kaiser Permanente Medicaid	$2,205.75
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: MDX Hawaii PPO	$4,195.25
Rate for Payer: University Health Alliance Commercial	$2,422.00
Rate for Payer: University Health Alliance Commercial	$2,397.92

TRIATHLON CR FEMUR

Facility

$4,282.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,397.92
Max. Negotiated Rate	$4,153.54
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Cash Price	$2,595.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.50
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: Health Management Network Commercial	$3,676.25
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: MDX Hawaii PPO	$4,195.25
Rate for Payer: University Health Alliance Commercial	$2,422.00
Rate for Payer: University Health Alliance Commercial	$2,397.92

TRIATHLONCR FEMUR

Facility

$4,282.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,397.92
Max. Negotiated Rate	$4,153.54
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: University Health Alliance Commercial	$2,397.92

TRIATHLONCR FEMUR

Facility

$4,282.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,183.82
Max. Negotiated Rate	$4,153.54
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: Kaiser Permanente Commercial	$2,697.66
Rate for Payer: Kaiser Permanente Medicaid	$2,183.82
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: University Health Alliance Commercial	$2,397.92

TRIATHLON CR FEMUR COMP

Facility

$4,282.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,397.92
Max. Negotiated Rate	$4,153.54
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: University Health Alliance Commercial	$2,397.92

TRIATHLON CR FEMUR COMP

Facility

$4,282.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,183.82
Max. Negotiated Rate	$4,153.54
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: Kaiser Permanente Commercial	$2,697.66
Rate for Payer: Kaiser Permanente Medicaid	$2,183.82
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: University Health Alliance Commercial	$2,397.92

TRIATHLON CRUCIATE 5510-F-201

Facility

$4,282.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,183.82
Max. Negotiated Rate	$4,153.54
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: Kaiser Permanente Commercial	$2,697.66
Rate for Payer: Kaiser Permanente Medicaid	$2,183.82
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: University Health Alliance Commercial	$2,397.92

TRIATHLON CRUCIATE 5510-F-201

Facility

$4,282.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,397.92
Max. Negotiated Rate	$4,153.54
Rate for Payer: Cash Price	$2,569.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,997.40
Rate for Payer: Health Management Network Commercial	$3,639.70
Rate for Payer: MDX Hawaii PPO	$4,153.54
Rate for Payer: University Health Alliance Commercial	$2,397.92

TRIATHLON FEM SZ2 5515-F-201

Facility

$4,325.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,205.75
Max. Negotiated Rate	$4,195.25
Rate for Payer: Cash Price	$2,595.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.50
Rate for Payer: Health Management Network Commercial	$3,676.25
Rate for Payer: Kaiser Permanente Commercial	$2,724.75
Rate for Payer: Kaiser Permanente Medicaid	$2,205.75
Rate for Payer: MDX Hawaii PPO	$4,195.25
Rate for Payer: University Health Alliance Commercial	$2,422.00

TRIATHLON FEM SZ2 5515-F-201

Facility

$4,325.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,422.00
Max. Negotiated Rate	$4,195.25
Rate for Payer: Cash Price	$2,595.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,027.50
Rate for Payer: Health Management Network Commercial	$3,676.25
Rate for Payer: MDX Hawaii PPO	$4,195.25
Rate for Payer: University Health Alliance Commercial	$2,422.00

Know your out-of-pocket cost for care.

All Charges