Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

TRITANIUM CUP 52MM 502-03-52D

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

TRITANIUM CUP 54MM 502-03-54E

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

TRITANIUM CUP 54MM 502-03-54E

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

TRITANIUM CUP 56MM 502-03-56E

Facility

$4,734.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,651.04
Max. Negotiated Rate	$4,591.98
Rate for Payer: Cash Price	$2,840.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,313.80
Rate for Payer: Health Management Network Commercial	$4,023.90
Rate for Payer: MDX Hawaii PPO	$4,591.98
Rate for Payer: University Health Alliance Commercial	$2,651.04

TRITANIUM CUP 56MM 502-03-56E

Facility

$4,734.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,414.34
Max. Negotiated Rate	$4,591.98
Rate for Payer: Cash Price	$2,840.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,313.80
Rate for Payer: Health Management Network Commercial	$4,023.90
Rate for Payer: Kaiser Permanente Commercial	$2,982.42
Rate for Payer: Kaiser Permanente Medicaid	$2,414.34
Rate for Payer: MDX Hawaii PPO	$4,591.98
Rate for Payer: University Health Alliance Commercial	$2,651.04

TRITANIUM CUP 58MM 502-03-58F

Facility

$4,734.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,651.04
Max. Negotiated Rate	$4,591.98
Rate for Payer: Cash Price	$2,840.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,313.80
Rate for Payer: Health Management Network Commercial	$4,023.90
Rate for Payer: MDX Hawaii PPO	$4,591.98
Rate for Payer: University Health Alliance Commercial	$2,651.04

TRITANIUM CUP 58MM 502-03-58F

Facility

$4,734.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,414.34
Max. Negotiated Rate	$4,591.98
Rate for Payer: Cash Price	$2,840.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,313.80
Rate for Payer: Health Management Network Commercial	$4,023.90
Rate for Payer: Kaiser Permanente Commercial	$2,982.42
Rate for Payer: Kaiser Permanente Medicaid	$2,414.34
Rate for Payer: MDX Hawaii PPO	$4,591.98
Rate for Payer: University Health Alliance Commercial	$2,651.04

TRI TIB BASE CEMENT 5520-B-500

Facility

$5,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

TRI TIB BASE CEMENT 5520-B-500

Facility

$5,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,958.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$3,654.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

TRI TIB BASE CEMENT 5520-B-600

Facility

$5,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,958.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$3,654.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

TRI TIB BASE CEMENT 5520-B-600

Facility

$5,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

TRI TIB BASE CEMENT 5520-B-700

Facility

$5,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,958.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: Kaiser Permanente Commercial	$3,654.00
Rate for Payer: Kaiser Permanente Medicaid	$2,958.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

TRI TIB BASE CEMENT 5520-B-700

Facility

$5,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.00
Max. Negotiated Rate	$5,626.00
Rate for Payer: Cash Price	$3,480.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,060.00
Rate for Payer: Health Management Network Commercial	$4,930.00
Rate for Payer: MDX Hawaii PPO	$5,626.00
Rate for Payer: University Health Alliance Commercial	$3,248.00

TROCAR 11.5 THORACPORT

Facility

$529.00

Hospital Revenue Code	272
Min. Negotiated Rate	$269.79
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Hawaii Western Management Group Commercial	$502.55
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: Kaiser Permanente Commercial	$333.27
Rate for Payer: Kaiser Permanente Medicaid	$269.79
Rate for Payer: MDX Hawaii PPO	$513.13
Rate for Payer: University Health Alliance Commercial	$385.59

TROCAR 11.5 THORACPORT

Facility

$529.00

Hospital Revenue Code	272
Min. Negotiated Rate	$449.65
Max. Negotiated Rate	$513.13
Rate for Payer: Cash Price	$317.40
Rate for Payer: Health Management Network Commercial	$449.65
Rate for Payer: MDX Hawaii PPO	$513.13

TROCAR 11MM VERSAONE

Facility

$165.00

Hospital Revenue Code	272
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$99.00
Rate for Payer: Hawaii Western Management Group Commercial	$156.75
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Kaiser Permanente Commercial	$103.95
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: University Health Alliance Commercial	$120.27

TROCAR 11MM VERSAONE

Facility

$165.00

Hospital Revenue Code	272
Min. Negotiated Rate	$140.25
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$99.00
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: MDX Hawaii PPO	$160.05

TROCAR 12MM BLUNTPORT

Facility

$165.00

Hospital Revenue Code	272
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$99.00
Rate for Payer: Hawaii Western Management Group Commercial	$156.75
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Kaiser Permanente Commercial	$103.95
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: University Health Alliance Commercial	$120.27

TROCAR 12MM BLUNTPORT

Facility

$165.00

Hospital Revenue Code	272
Min. Negotiated Rate	$140.25
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$99.00
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: MDX Hawaii PPO	$160.05

TROCAR 12MM VERSAONE

Facility

$165.00

Hospital Revenue Code	272
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$99.00
Rate for Payer: Hawaii Western Management Group Commercial	$156.75
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Kaiser Permanente Commercial	$103.95
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: University Health Alliance Commercial	$120.27

TROCAR 12MM VERSAONE

Facility

$165.00

Hospital Revenue Code	272
Min. Negotiated Rate	$140.25
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$99.00
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: MDX Hawaii PPO	$160.05

TROCAR 12MM W/CANNULA

Facility

$150.00

Hospital Revenue Code	272
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Hawaii Western Management Group Commercial	$142.50
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: Kaiser Permanente Commercial	$94.50
Rate for Payer: Kaiser Permanente Medicaid	$76.50
Rate for Payer: MDX Hawaii PPO	$145.50
Rate for Payer: University Health Alliance Commercial	$109.33

TROCAR 12MM W/CANNULA

Facility

$150.00

Hospital Revenue Code	272
Min. Negotiated Rate	$127.50
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$90.00
Rate for Payer: Health Management Network Commercial	$127.50
Rate for Payer: MDX Hawaii PPO	$145.50

TROCAR 24F CHEST TUBE THORACIC

Facility

$96.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: MDX Hawaii PPO	$93.12

TROCAR 24F CHEST TUBE THORACIC

Facility

$96.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$48.96
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$57.60
Rate for Payer: Hawaii Western Management Group Commercial	$91.20
Rate for Payer: Health Management Network Commercial	$81.60
Rate for Payer: Kaiser Permanente Commercial	$60.48
Rate for Payer: Kaiser Permanente Medicaid	$48.96
Rate for Payer: MDX Hawaii PPO	$93.12
Rate for Payer: University Health Alliance Commercial	$69.97

Know your out-of-pocket cost for care.

All Charges