Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

FEMORAL CEMENT SZ6 1504-10-206

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

FEMORAL CEMENT SZ7 1504-00-107

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,904.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

FEMORAL CEMENT SZ7 1504-00-107

Facility

$3,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,734.00
Max. Negotiated Rate	$3,298.00
Rate for Payer: Cash Price	$2,040.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,380.00
Rate for Payer: Health Management Network Commercial	$2,890.00
Rate for Payer: Kaiser Permanente Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Medicaid	$1,734.00
Rate for Payer: MDX Hawaii PPO	$3,298.00
Rate for Payer: University Health Alliance Commercial	$1,904.00

FEMORAL COMPO HINGE 5612-F-501

Facility

$19,073.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$9,727.23
Max. Negotiated Rate	$18,500.81
Rate for Payer: Cash Price	$11,443.80
Rate for Payer: Hawaii Western Management Group Commercial	$13,351.10
Rate for Payer: Health Management Network Commercial	$16,212.05
Rate for Payer: Kaiser Permanente Commercial	$12,015.99
Rate for Payer: Kaiser Permanente Medicaid	$9,727.23
Rate for Payer: MDX Hawaii PPO	$18,500.81
Rate for Payer: University Health Alliance Commercial	$10,680.88

FEMORAL COMPO HINGE 5612-F-501

Facility

$19,073.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$10,680.88
Max. Negotiated Rate	$18,500.81
Rate for Payer: Cash Price	$11,443.80
Rate for Payer: Hawaii Western Management Group Commercial	$13,351.10
Rate for Payer: Health Management Network Commercial	$16,212.05
Rate for Payer: MDX Hawaii PPO	$18,500.81
Rate for Payer: University Health Alliance Commercial	$10,680.88

FEMORAL CR SZ 6 LF 1504-00-106

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

FEMORAL CR SZ 6 LF 1504-00-106

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

FEMORAL DISTAL LF 5540-A-501

Facility

$2,322.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.32
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,393.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,625.40
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: University Health Alliance Commercial	$1,300.32

FEMORAL DISTAL LF 5540-A-501

Facility

$2,322.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,184.22
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,393.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,625.40
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Kaiser Permanente Commercial	$1,462.86
Rate for Payer: Kaiser Permanente Medicaid	$1,184.22
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: University Health Alliance Commercial	$1,300.32

FEMORAL DISTAL LF 5542-A-501

Facility

$2,559.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,305.09
Max. Negotiated Rate	$2,482.23
Rate for Payer: Cash Price	$1,535.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,791.30
Rate for Payer: Health Management Network Commercial	$2,175.15
Rate for Payer: Kaiser Permanente Commercial	$1,612.17
Rate for Payer: Kaiser Permanente Medicaid	$1,305.09
Rate for Payer: MDX Hawaii PPO	$2,482.23
Rate for Payer: University Health Alliance Commercial	$1,433.04

FEMORAL DISTAL LF 5542-A-501

Facility

$2,559.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,433.04
Max. Negotiated Rate	$2,482.23
Rate for Payer: Cash Price	$1,535.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,791.30
Rate for Payer: Health Management Network Commercial	$2,175.15
Rate for Payer: MDX Hawaii PPO	$2,482.23
Rate for Payer: University Health Alliance Commercial	$1,433.04

FEMORAL DISTAL RT 5 5540-A-502

Facility

$2,322.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,184.22
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,393.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,625.40
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Kaiser Permanente Commercial	$1,462.86
Rate for Payer: Kaiser Permanente Medicaid	$1,184.22
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: University Health Alliance Commercial	$1,300.32

FEMORAL DISTAL RT 5 5540-A-502

Facility

$2,322.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.32
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,393.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,625.40
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: University Health Alliance Commercial	$1,300.32

FEMORAL DIST AUG RT 5540-A-402

Facility

$2,322.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.32
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,393.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,625.40
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: University Health Alliance Commercial	$1,300.32

FEMORAL DIST AUG RT 5540-A-402

Facility

$2,322.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,184.22
Max. Negotiated Rate	$2,252.34
Rate for Payer: Cash Price	$1,393.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,625.40
Rate for Payer: Health Management Network Commercial	$1,973.70
Rate for Payer: Kaiser Permanente Commercial	$1,462.86
Rate for Payer: Kaiser Permanente Medicaid	$1,184.22
Rate for Payer: MDX Hawaii PPO	$2,252.34
Rate for Payer: University Health Alliance Commercial	$1,300.32

FEMORAL DIST AUG RT 5542-A-402

Facility

$2,559.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,305.09
Max. Negotiated Rate	$2,482.23
Rate for Payer: Cash Price	$1,535.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,791.30
Rate for Payer: Health Management Network Commercial	$2,175.15
Rate for Payer: Kaiser Permanente Commercial	$1,612.17
Rate for Payer: Kaiser Permanente Medicaid	$1,305.09
Rate for Payer: MDX Hawaii PPO	$2,482.23
Rate for Payer: University Health Alliance Commercial	$1,433.04

FEMORAL DIST AUG RT 5542-A-402

Facility

$2,559.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,433.04
Max. Negotiated Rate	$2,482.23
Rate for Payer: Cash Price	$1,535.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,791.30
Rate for Payer: Health Management Network Commercial	$2,175.15
Rate for Payer: MDX Hawaii PPO	$2,482.23
Rate for Payer: University Health Alliance Commercial	$1,433.04

FEMORAL HEAD 12/14, 46MM

Facility

$2,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,428.00
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,785.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: University Health Alliance Commercial	$1,428.00

FEMORAL HEAD 12/14, 46MM

Facility

$2,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,785.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$1,300.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: University Health Alliance Commercial	$1,428.00

FEMORAL HEAD 12/14 COCR

Facility

$1,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,008.00
Max. Negotiated Rate	$1,746.00
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,260.00
Rate for Payer: Health Management Network Commercial	$1,530.00
Rate for Payer: MDX Hawaii PPO	$1,746.00
Rate for Payer: University Health Alliance Commercial	$1,008.00

FEMORAL HEAD 12/14 COCR

Facility

$1,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$918.00
Max. Negotiated Rate	$1,746.00
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,260.00
Rate for Payer: Health Management Network Commercial	$1,530.00
Rate for Payer: Kaiser Permanente Commercial	$1,134.00
Rate for Payer: Kaiser Permanente Medicaid	$918.00
Rate for Payer: MDX Hawaii PPO	$1,746.00
Rate for Payer: University Health Alliance Commercial	$1,008.00

FEMORAL HEAD 12/14 COCR 22MM

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

FEMORAL HEAD 12/14 COCR 22MM

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

FEMORAL HEAD 26MM 6260-9-026

Facility

$1,971.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,005.21
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.70
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: Kaiser Permanente Commercial	$1,241.73
Rate for Payer: Kaiser Permanente Medicaid	$1,005.21
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: University Health Alliance Commercial	$1,103.76

FEMORAL HEAD 26MM 6260-9-026

Facility

$1,971.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.76
Max. Negotiated Rate	$1,911.87
Rate for Payer: Cash Price	$1,182.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,379.70
Rate for Payer: Health Management Network Commercial	$1,675.35
Rate for Payer: MDX Hawaii PPO	$1,911.87
Rate for Payer: University Health Alliance Commercial	$1,103.76

Know your out-of-pocket cost for care.

All Charges