Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

FEMORAL HEAD UNI 6519-1-036

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

FEMORAL INSERT SZ7 1516-20-708

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,680.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

FEMORAL INSERT SZ7 1516-20-708

Facility

$3,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,530.00
Max. Negotiated Rate	$2,910.00
Rate for Payer: Cash Price	$1,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,100.00
Rate for Payer: Health Management Network Commercial	$2,550.00
Rate for Payer: Kaiser Permanente Commercial	$1,890.00
Rate for Payer: Kaiser Permanente Medicaid	$1,530.00
Rate for Payer: MDX Hawaii PPO	$2,910.00
Rate for Payer: University Health Alliance Commercial	$1,680.00

FEMORAL KNEE RT XSMALL 161467

Facility

$4,380.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,233.80
Max. Negotiated Rate	$4,248.60
Rate for Payer: Cash Price	$2,628.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,066.00
Rate for Payer: Health Management Network Commercial	$3,723.00
Rate for Payer: Kaiser Permanente Commercial	$2,759.40
Rate for Payer: Kaiser Permanente Medicaid	$2,233.80
Rate for Payer: MDX Hawaii PPO	$4,248.60
Rate for Payer: University Health Alliance Commercial	$2,452.80

FEMORAL KNEE RT XSMALL 161467

Facility

$4,380.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,452.80
Max. Negotiated Rate	$4,248.60
Rate for Payer: Cash Price	$2,628.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,066.00
Rate for Payer: Health Management Network Commercial	$3,723.00
Rate for Payer: MDX Hawaii PPO	$4,248.60
Rate for Payer: University Health Alliance Commercial	$2,452.80

FEMORAL POST AUGMEN 5544-A-400

Facility

$2,438.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,365.28
Max. Negotiated Rate	$2,364.86
Rate for Payer: Cash Price	$1,462.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,706.60
Rate for Payer: Health Management Network Commercial	$2,072.30
Rate for Payer: MDX Hawaii PPO	$2,364.86
Rate for Payer: University Health Alliance Commercial	$1,365.28

FEMORAL POST AUGMEN 5544-A-400

Facility

$2,438.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.38
Max. Negotiated Rate	$2,364.86
Rate for Payer: Cash Price	$1,462.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,706.60
Rate for Payer: Health Management Network Commercial	$2,072.30
Rate for Payer: Kaiser Permanente Commercial	$1,535.94
Rate for Payer: Kaiser Permanente Medicaid	$1,243.38
Rate for Payer: MDX Hawaii PPO	$2,364.86
Rate for Payer: University Health Alliance Commercial	$1,365.28

FEMORAL POSTERIOR 5544-A-500

Facility

$2,438.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.38
Max. Negotiated Rate	$2,364.86
Rate for Payer: Cash Price	$1,462.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,706.60
Rate for Payer: Health Management Network Commercial	$2,072.30
Rate for Payer: Kaiser Permanente Commercial	$1,535.94
Rate for Payer: Kaiser Permanente Medicaid	$1,243.38
Rate for Payer: MDX Hawaii PPO	$2,364.86
Rate for Payer: University Health Alliance Commercial	$1,365.28

FEMORAL POSTERIOR 5544-A-500

Facility

$2,438.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,365.28
Max. Negotiated Rate	$2,364.86
Rate for Payer: Cash Price	$1,462.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,706.60
Rate for Payer: Health Management Network Commercial	$2,072.30
Rate for Payer: MDX Hawaii PPO	$2,364.86
Rate for Payer: University Health Alliance Commercial	$1,365.28

FEMORAL POSTERIOR 5 5543-A-500

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 POSTERIOR 5 5543-A-500

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 PRECOAT CR-FLEX GSF

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 PRECOAT CR-FLEX GSF

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 SLEEVE 6MM 650-1064

Facility

$563.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$315.28
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: University Health Alliance Commercial	$315.28

FEMORAL SLEEVE 6MM 650-1064

Facility

$563.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$287.13
Max. Negotiated Rate	$546.11
Rate for Payer: Cash Price	$337.80
Rate for Payer: Hawaii Western Management Group Commercial	$394.10
Rate for Payer: Health Management Network Commercial	$478.55
Rate for Payer: Kaiser Permanente Commercial	$354.69
Rate for Payer: Kaiser Permanente Medicaid	$287.13
Rate for Payer: MDX Hawaii PPO	$546.11
Rate for Payer: University Health Alliance Commercial	$315.28

FEMORAL STABILIZER 5512-F-501

Facility

$12,283.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,878.48
Max. Negotiated Rate	$11,914.51
Rate for Payer: Cash Price	$7,369.80
Rate for Payer: Hawaii Western Management Group Commercial	$8,598.10
Rate for Payer: Health Management Network Commercial	$10,440.55
Rate for Payer: MDX Hawaii PPO	$11,914.51
Rate for Payer: University Health Alliance Commercial	$6,878.48

FEMORAL STABILIZER 5512-F-501

Facility

$12,283.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,264.33
Max. Negotiated Rate	$11,914.51
Rate for Payer: Cash Price	$7,369.80
Rate for Payer: Hawaii Western Management Group Commercial	$8,598.10
Rate for Payer: Health Management Network Commercial	$10,440.55
Rate for Payer: Kaiser Permanente Commercial	$7,738.29
Rate for Payer: Kaiser Permanente Medicaid	$6,264.33
Rate for Payer: MDX Hawaii PPO	$11,914.51
Rate for Payer: University Health Alliance Commercial	$6,878.48

FEMORAL STEM #00-7833-012-00

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 STEM #00-7833-012-00

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 SZ3 LEFT PS 5515-F-301

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

FEMORAL SZ3 LEFT PS 5515-F-301

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

FEMORAL SZ#3 RETAIN 5517-F-302

Facility

$15,986.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,952.16
Max. Negotiated Rate	$15,506.42
Rate for Payer: Cash Price	$9,591.60
Rate for Payer: Hawaii Western Management Group Commercial	$11,190.20
Rate for Payer: Health Management Network Commercial	$13,588.10
Rate for Payer: MDX Hawaii PPO	$15,506.42
Rate for Payer: University Health Alliance Commercial	$8,952.16

FEMORAL SZ#3 RETAIN 5517-F-302

Facility

$15,986.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,152.86
Max. Negotiated Rate	$15,506.42
Rate for Payer: Cash Price	$9,591.60
Rate for Payer: Hawaii Western Management Group Commercial	$11,190.20
Rate for Payer: Health Management Network Commercial	$13,588.10
Rate for Payer: Kaiser Permanente Commercial	$10,071.18
Rate for Payer: Kaiser Permanente Medicaid	$8,152.86
Rate for Payer: MDX Hawaii PPO	$15,506.42
Rate for Payer: University Health Alliance Commercial	$8,952.16

FEMORAL SZ#4 RETAIN 5517-F-402

Facility

$15,986.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,952.16
Max. Negotiated Rate	$15,506.42
Rate for Payer: Cash Price	$9,591.60
Rate for Payer: Hawaii Western Management Group Commercial	$11,190.20
Rate for Payer: Health Management Network Commercial	$13,588.10
Rate for Payer: MDX Hawaii PPO	$15,506.42
Rate for Payer: University Health Alliance Commercial	$8,952.16

FEMORAL SZ#4 RETAIN 5517-F-402

Facility

$15,986.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$8,152.86
Max. Negotiated Rate	$15,506.42
Rate for Payer: Cash Price	$9,591.60
Rate for Payer: Hawaii Western Management Group Commercial	$11,190.20
Rate for Payer: Health Management Network Commercial	$13,588.10
Rate for Payer: Kaiser Permanente Commercial	$10,071.18
Rate for Payer: Kaiser Permanente Medicaid	$8,152.86
Rate for Payer: MDX Hawaii PPO	$15,506.42
Rate for Payer: University Health Alliance Commercial	$8,952.16

Know your out-of-pocket cost for care.

All Charges