Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRIATHLON FEM SZ#4 5515-F-402

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 SZ#4 5515-F-402

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 INSERT 5531-G-513-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

TRIATHLON INSERT 5531-G-513-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

TRIATHLON INSERT 5531-G-609-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

TRIATHLON INSERT 5531-G-609-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

TRIATHLON INSERT 5531-G-809-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

TRIATHLON INSERT 5531-G-809-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

TRIATHLON PATELLA 5551-G-320

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 PATELLA 5551-G-320

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 TIBIA #5532-G-313

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

TRIATHLON TIBIA #5532-G-313

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

TRIATHLON TIBIAL 5531-G-711-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

TRIATHLON TIBIAL 5531-G-711-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

TRIATHLON TIBIAL 5545-A-202

Facility

$2,145.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,093.95
Max. Negotiated Rate	$2,080.65
Rate for Payer: Cash Price	$1,287.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,501.50
Rate for Payer: Health Management Network Commercial	$1,823.25
Rate for Payer: Kaiser Permanente Commercial	$1,351.35
Rate for Payer: Kaiser Permanente Medicaid	$1,093.95
Rate for Payer: MDX Hawaii PPO	$2,080.65
Rate for Payer: University Health Alliance Commercial	$1,201.20

TRIATHLON TIBIAL 5545-A-202

Facility

$2,145.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,201.20
Max. Negotiated Rate	$2,080.65
Rate for Payer: Cash Price	$1,287.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,501.50
Rate for Payer: Health Management Network Commercial	$1,823.25
Rate for Payer: MDX Hawaii PPO	$2,080.65
Rate for Payer: University Health Alliance Commercial	$1,201.20

TRIATHLON TIBIAL LF 5545-A-201

Facility

$2,145.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,201.20
Max. Negotiated Rate	$2,080.65
Rate for Payer: Cash Price	$1,287.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,501.50
Rate for Payer: Health Management Network Commercial	$1,823.25
Rate for Payer: MDX Hawaii PPO	$2,080.65
Rate for Payer: University Health Alliance Commercial	$1,201.20

TRIATHLON TIBIAL LF 5545-A-201

Facility

$2,145.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,093.95
Max. Negotiated Rate	$2,080.65
Rate for Payer: Cash Price	$1,287.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,501.50
Rate for Payer: Health Management Network Commercial	$1,823.25
Rate for Payer: Kaiser Permanente Commercial	$1,351.35
Rate for Payer: Kaiser Permanente Medicaid	$1,093.95
Rate for Payer: MDX Hawaii PPO	$2,080.65
Rate for Payer: University Health Alliance Commercial	$1,201.20

TRIATHLON TIB SZ2 5521-B-200

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

TRIATHLON TIB SZ2 5521-B-200

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

TRIATHLON TIB SZ2 5532-G-211

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

TRIATHLON TIB SZ2 5532-G-211

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

TRIATHLON TK SZ4 5521-B-400

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

TRIATHLON TK SZ4 5521-B-400

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

TRIATHLON TRITANIUM 5536-B-700

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

Know your out-of-pocket cost for care.

All Charges