Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRI CR XS TIB INSRT 5530-G-609

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-611

Facility

$6,964.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,899.84
Max. Negotiated Rate	$6,755.08
Rate for Payer: Cash Price	$4,178.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,874.80
Rate for Payer: Health Management Network Commercial	$5,919.40
Rate for Payer: MDX Hawaii PPO	$6,755.08
Rate for Payer: University Health Alliance Commercial	$3,899.84

TRI CR XS TIB INSRT 5530-G-611

Facility

$6,964.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,551.64
Max. Negotiated Rate	$6,755.08
Rate for Payer: Cash Price	$4,178.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,874.80
Rate for Payer: Health Management Network Commercial	$5,919.40
Rate for Payer: Kaiser Permanente Commercial	$4,387.32
Rate for Payer: Kaiser Permanente Medicaid	$3,551.64
Rate for Payer: MDX Hawaii PPO	$6,755.08
Rate for Payer: University Health Alliance Commercial	$3,899.84

TRI CR XS TIB INSRT 5530-G-616

Facility

$6,616.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,374.16
Max. Negotiated Rate	$6,417.52
Rate for Payer: Cash Price	$3,969.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,631.20
Rate for Payer: Health Management Network Commercial	$5,623.60
Rate for Payer: Kaiser Permanente Commercial	$4,168.08
Rate for Payer: Kaiser Permanente Medicaid	$3,374.16
Rate for Payer: MDX Hawaii PPO	$6,417.52
Rate for Payer: University Health Alliance Commercial	$3,704.96

TRI CR XS TIB INSRT 5530-G-616

Facility

$6,616.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,704.96
Max. Negotiated Rate	$6,417.52
Rate for Payer: Cash Price	$3,969.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,631.20
Rate for Payer: Health Management Network Commercial	$5,623.60
Rate for Payer: MDX Hawaii PPO	$6,417.52
Rate for Payer: University Health Alliance Commercial	$3,704.96

TRI CR XS TIB INSRT 5530-G-709

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-709

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

TRIDEN II TRITANIUM 702-04-62G

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

TRIDEN II TRITANIUM 702-04-62G

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

TRIDENT ACETABULAR 690-00-22D

Facility

$6,105.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,418.80
Max. Negotiated Rate	$5,921.85
Rate for Payer: Cash Price	$3,663.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,273.50
Rate for Payer: Health Management Network Commercial	$5,189.25
Rate for Payer: MDX Hawaii PPO	$5,921.85
Rate for Payer: University Health Alliance Commercial	$3,418.80

TRIDENT ACETABULAR 690-00-22D

Facility

$6,105.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,113.55
Max. Negotiated Rate	$5,921.85
Rate for Payer: Cash Price	$3,663.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,273.50
Rate for Payer: Health Management Network Commercial	$5,189.25
Rate for Payer: Kaiser Permanente Commercial	$3,846.15
Rate for Payer: Kaiser Permanente Medicaid	$3,113.55
Rate for Payer: MDX Hawaii PPO	$5,921.85
Rate for Payer: University Health Alliance Commercial	$3,418.80

TRIDENT CUP 3/36MM 623-00-36I

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,904.96
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Kaiser Permanente Commercial	$3,588.48
Rate for Payer: Kaiser Permanente Medicaid	$2,904.96
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-00-36I

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,189.76
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-00-36J

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,904.96
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Kaiser Permanente Commercial	$3,588.48
Rate for Payer: Kaiser Permanente Medicaid	$2,904.96
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-00-36J

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,189.76
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-10-36E

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

TRIDENT CUP 3/36MM 623-10-36E

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

TRIDENT CUP 3/36MM 623-10-36I

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,904.96
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Kaiser Permanente Commercial	$3,588.48
Rate for Payer: Kaiser Permanente Medicaid	$2,904.96
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-10-36I

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,189.76
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-10-36J

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,189.76
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT CUP 3/36MM 623-10-36J

Facility

$5,696.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,904.96
Max. Negotiated Rate	$5,525.12
Rate for Payer: Cash Price	$3,417.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,987.20
Rate for Payer: Health Management Network Commercial	$4,841.60
Rate for Payer: Kaiser Permanente Commercial	$3,588.48
Rate for Payer: Kaiser Permanente Medicaid	$2,904.96
Rate for Payer: MDX Hawaii PPO	$5,525.12
Rate for Payer: University Health Alliance Commercial	$3,189.76

TRIDENT II 702-04-46C

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

TRIDENT II 702-04-46C

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

TRIDENT II SHELL 702-04-56F

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

TRIDENT II SHELL 702-04-56F

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