Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRIGEN L-P SCREW 5.0X35

Facility

$1,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$609.96
Max. Negotiated Rate	$1,160.12
Rate for Payer: Cash Price	$717.60
Rate for Payer: Hawaii Western Management Group Commercial	$837.20
Rate for Payer: Health Management Network Commercial	$1,016.60
Rate for Payer: Kaiser Permanente Commercial	$753.48
Rate for Payer: Kaiser Permanente Medicaid	$609.96
Rate for Payer: MDX Hawaii PPO	$1,160.12
Rate for Payer: University Health Alliance Commercial	$669.76

TRI HA ACETAB 40MM 542-11-40A

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 40MM 542-11-40A

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 42MM 542-11-42B

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 42MM 542-11-42B

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 44MM 542-11-44C

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 44MM 542-11-44C

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 46MM #542-11-46D

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 HA ACETAB 46MM #542-11-46D

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 HA ACETAB 48MM #542-11-48D

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,420.48
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 48MM #542-11-48D

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,115.08
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Kaiser Permanente Commercial	$3,848.04
Rate for Payer: Kaiser Permanente Medicaid	$3,115.08
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 50MM #542-11-50E

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,115.08
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Kaiser Permanente Commercial	$3,848.04
Rate for Payer: Kaiser Permanente Medicaid	$3,115.08
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 50MM #542-11-50E

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,420.48
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 52MM #542-11-52E

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 HA ACETAB 52MM #542-11-52E

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 HA ACETAB 54MM #542-11-54F

Facility

$5,988.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,053.88
Max. Negotiated Rate	$5,808.36
Rate for Payer: Cash Price	$3,592.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,191.60
Rate for Payer: Health Management Network Commercial	$5,089.80
Rate for Payer: Kaiser Permanente Commercial	$3,772.44
Rate for Payer: Kaiser Permanente Medicaid	$3,053.88
Rate for Payer: MDX Hawaii PPO	$5,808.36
Rate for Payer: University Health Alliance Commercial	$3,353.28

TRI HA ACETAB 54MM #542-11-54F

Facility

$5,988.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,353.28
Max. Negotiated Rate	$5,808.36
Rate for Payer: Cash Price	$3,592.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,191.60
Rate for Payer: Health Management Network Commercial	$5,089.80
Rate for Payer: MDX Hawaii PPO	$5,808.36
Rate for Payer: University Health Alliance Commercial	$3,353.28

TRI HA ACETAB 56MM #542-11-56F

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,420.48
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 56MM #542-11-56F

Facility

$6,108.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,115.08
Max. Negotiated Rate	$5,924.76
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,275.60
Rate for Payer: Health Management Network Commercial	$5,191.80
Rate for Payer: Kaiser Permanente Commercial	$3,848.04
Rate for Payer: Kaiser Permanente Medicaid	$3,115.08
Rate for Payer: MDX Hawaii PPO	$5,924.76
Rate for Payer: University Health Alliance Commercial	$3,420.48

TRI HA ACETAB 58MM 542-11-58G

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 58MM 542-11-58G

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 60MM 542-11-60G

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 60MM 542-11-60G

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 62MM 542-11-62H

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,255.84
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

TRI HA ACETAB 62MM 542-11-62H

Facility

$5,814.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,965.14
Max. Negotiated Rate	$5,639.58
Rate for Payer: Cash Price	$3,488.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,069.80
Rate for Payer: Health Management Network Commercial	$4,941.90
Rate for Payer: Kaiser Permanente Commercial	$3,662.82
Rate for Payer: Kaiser Permanente Medicaid	$2,965.14
Rate for Payer: MDX Hawaii PPO	$5,639.58
Rate for Payer: University Health Alliance Commercial	$3,255.84

Know your out-of-pocket cost for care.

All Charges