Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRI CR FEM CEMENT #5510-F-501

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

TRI CR FEM CEMENT #5510-F-501

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

TRI CR FEM CEMENT #5510-F-701

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

TRI CR FEM CEMENT #5510-F-701

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

TRI CR FEM CEMENT #5510-F-801

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

TRI CR FEM CEMENT #5510-F-801

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

TRI CR FEM CEMENT #5510-F-802

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

TRI CR FEM CEMENT #5510-F-802

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

TRI CR FEM CEMENT #5515-F-401

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

TRI CR FEM CEMENT #5515-F-401

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

TRI CR FEM CEMENT #5515-F-601

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

TRI CR FEM CEMENT #5515-F-601

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

TRI CR XS TIB INSRT 5530-G-311

Facility

$6,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,448.62
Max. Negotiated Rate	$6,559.14
Rate for Payer: Cash Price	$4,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,733.40
Rate for Payer: Health Management Network Commercial	$5,747.70
Rate for Payer: Kaiser Permanente Commercial	$4,260.06
Rate for Payer: Kaiser Permanente Medicaid	$3,448.62
Rate for Payer: MDX Hawaii PPO	$6,559.14
Rate for Payer: University Health Alliance Commercial	$3,786.72

TRI CR XS TIB INSRT 5530-G-311

Facility

$6,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,786.72
Max. Negotiated Rate	$6,559.14
Rate for Payer: Cash Price	$4,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,733.40
Rate for Payer: Health Management Network Commercial	$5,747.70
Rate for Payer: MDX Hawaii PPO	$6,559.14
Rate for Payer: University Health Alliance Commercial	$3,786.72

TRI CR XS TIB INSRT 5530-G-313

Facility

$6,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,448.62
Max. Negotiated Rate	$6,559.14
Rate for Payer: Cash Price	$4,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,733.40
Rate for Payer: Health Management Network Commercial	$5,747.70
Rate for Payer: Kaiser Permanente Commercial	$4,260.06
Rate for Payer: Kaiser Permanente Medicaid	$3,448.62
Rate for Payer: MDX Hawaii PPO	$6,559.14
Rate for Payer: University Health Alliance Commercial	$3,786.72

TRI CR XS TIB INSRT 5530-G-313

Facility

$6,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,786.72
Max. Negotiated Rate	$6,559.14
Rate for Payer: Cash Price	$4,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,733.40
Rate for Payer: Health Management Network Commercial	$5,747.70
Rate for Payer: MDX Hawaii PPO	$6,559.14
Rate for Payer: University Health Alliance Commercial	$3,786.72

TRI CR XS TIB INSRT 5530-G-409

Facility

$7,316.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,096.96
Max. Negotiated Rate	$7,096.52
Rate for Payer: Cash Price	$4,389.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,121.20
Rate for Payer: Health Management Network Commercial	$6,218.60
Rate for Payer: MDX Hawaii PPO	$7,096.52
Rate for Payer: University Health Alliance Commercial	$4,096.96

TRI CR XS TIB INSRT 5530-G-409

Facility

$7,316.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,731.16
Max. Negotiated Rate	$7,096.52
Rate for Payer: Cash Price	$4,389.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,121.20
Rate for Payer: Health Management Network Commercial	$6,218.60
Rate for Payer: Kaiser Permanente Commercial	$4,609.08
Rate for Payer: Kaiser Permanente Medicaid	$3,731.16
Rate for Payer: MDX Hawaii PPO	$7,096.52
Rate for Payer: University Health Alliance Commercial	$4,096.96

TRI CR XS TIB INSRT 5530-G-411

Facility

$6,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,448.62
Max. Negotiated Rate	$6,559.14
Rate for Payer: Cash Price	$4,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,733.40
Rate for Payer: Health Management Network Commercial	$5,747.70
Rate for Payer: Kaiser Permanente Commercial	$4,260.06
Rate for Payer: Kaiser Permanente Medicaid	$3,448.62
Rate for Payer: MDX Hawaii PPO	$6,559.14
Rate for Payer: University Health Alliance Commercial	$3,786.72

TRI CR XS TIB INSRT 5530-G-411

Facility

$6,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,786.72
Max. Negotiated Rate	$6,559.14
Rate for Payer: Cash Price	$4,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,733.40
Rate for Payer: Health Management Network Commercial	$5,747.70
Rate for Payer: MDX Hawaii PPO	$6,559.14
Rate for Payer: University Health Alliance Commercial	$3,786.72

TRI CR XS TIB INSRT 5530-G-509

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

TRI CR XS TIB INSRT 5530-G-509

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

TRI CR XS TIB INSRT 5530-G-511

Facility

$6,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,786.72
Max. Negotiated Rate	$6,559.14
Rate for Payer: Cash Price	$4,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,733.40
Rate for Payer: Health Management Network Commercial	$5,747.70
Rate for Payer: MDX Hawaii PPO	$6,559.14
Rate for Payer: University Health Alliance Commercial	$3,786.72

TRI CR XS TIB INSRT 5530-G-511

Facility

$6,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,448.62
Max. Negotiated Rate	$6,559.14
Rate for Payer: Cash Price	$4,057.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,733.40
Rate for Payer: Health Management Network Commercial	$5,747.70
Rate for Payer: Kaiser Permanente Commercial	$4,260.06
Rate for Payer: Kaiser Permanente Medicaid	$3,448.62
Rate for Payer: MDX Hawaii PPO	$6,559.14
Rate for Payer: University Health Alliance Commercial	$3,786.72

TRI CR XS TIB INSRT 5530-G-609

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

Know your out-of-pocket cost for care.

All Charges