Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GIA ENDO 60MEDIUM EGIA60AVM

Facility

$705.00

Hospital Revenue Code	272
Min. Negotiated Rate	$599.25
Max. Negotiated Rate	$683.85
Rate for Payer: Cash Price	$423.00
Rate for Payer: Health Management Network Commercial	$599.25
Rate for Payer: MDX Hawaii PPO	$683.85

GI ANCHOR SET 98701

Facility

$455.00

Hospital Revenue Code	278
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$441.35
Rate for Payer: Cash Price	$273.00
Rate for Payer: Hawaii Western Management Group Commercial	$318.50
Rate for Payer: Health Management Network Commercial	$386.75
Rate for Payer: MDX Hawaii PPO	$441.35
Rate for Payer: University Health Alliance Commercial	$254.80

GI ANCHOR SET 98701

Facility

$455.00

Hospital Revenue Code	278
Min. Negotiated Rate	$232.05
Max. Negotiated Rate	$441.35
Rate for Payer: Cash Price	$273.00
Rate for Payer: Hawaii Western Management Group Commercial	$318.50
Rate for Payer: Health Management Network Commercial	$386.75
Rate for Payer: Kaiser Permanente Commercial	$286.65
Rate for Payer: Kaiser Permanente Medicaid	$232.05
Rate for Payer: MDX Hawaii PPO	$441.35
Rate for Payer: University Health Alliance Commercial	$254.80

GIA ULTRA UNIV STPLR EGIAUSTND

Facility

$292.00

Hospital Revenue Code	272
Min. Negotiated Rate	$248.20
Max. Negotiated Rate	$283.24
Rate for Payer: Cash Price	$175.20
Rate for Payer: Health Management Network Commercial	$248.20
Rate for Payer: MDX Hawaii PPO	$283.24

GIA ULTRA UNIV STPLR EGIAUSTND

Facility

$292.00

Hospital Revenue Code	272
Min. Negotiated Rate	$148.92
Max. Negotiated Rate	$283.24
Rate for Payer: Cash Price	$175.20
Rate for Payer: Hawaii Western Management Group Commercial	$277.40
Rate for Payer: Health Management Network Commercial	$248.20
Rate for Payer: Kaiser Permanente Commercial	$183.96
Rate for Payer: Kaiser Permanente Medicaid	$148.92
Rate for Payer: MDX Hawaii PPO	$283.24
Rate for Payer: University Health Alliance Commercial	$212.84

GIDEWIRE TIP 3X1000 1806-0085S

Facility

$785.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$667.25
Max. Negotiated Rate	$761.45
Rate for Payer: Cash Price	$471.00
Rate for Payer: Health Management Network Commercial	$667.25
Rate for Payer: MDX Hawaii PPO	$761.45

GIDEWIRE TIP 3X1000 1806-0085S

Facility

$785.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$400.35
Max. Negotiated Rate	$761.45
Rate for Payer: Cash Price	$471.00
Rate for Payer: Hawaii Western Management Group Commercial	$745.75
Rate for Payer: Health Management Network Commercial	$667.25
Rate for Payer: Kaiser Permanente Commercial	$494.55
Rate for Payer: Kaiser Permanente Medicaid	$400.35
Rate for Payer: MDX Hawaii PPO	$761.45
Rate for Payer: University Health Alliance Commercial	$572.19

GII QUICKANCHOR SZ 2 222983

Facility

$2,487.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,268.37
Max. Negotiated Rate	$2,412.39
Rate for Payer: Cash Price	$1,492.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,740.90
Rate for Payer: Health Management Network Commercial	$2,113.95
Rate for Payer: Kaiser Permanente Commercial	$1,566.81
Rate for Payer: Kaiser Permanente Medicaid	$1,268.37
Rate for Payer: MDX Hawaii PPO	$2,412.39
Rate for Payer: University Health Alliance Commercial	$1,392.72

GII QUICKANCHOR SZ 2 222983

Facility

$2,487.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,392.72
Max. Negotiated Rate	$2,412.39
Rate for Payer: Cash Price	$1,492.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,740.90
Rate for Payer: Health Management Network Commercial	$2,113.95
Rate for Payer: MDX Hawaii PPO	$2,412.39
Rate for Payer: University Health Alliance Commercial	$1,392.72

GLENOID 4MM MED HYBRID 113954

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

GLENOID 4MM MED HYBRID 113954

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

GLENOID 52MM REUN 5542-P-0052

Facility

$4,721.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,643.76
Max. Negotiated Rate	$4,579.37
Rate for Payer: Cash Price	$2,832.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,304.70
Rate for Payer: Health Management Network Commercial	$4,012.85
Rate for Payer: MDX Hawaii PPO	$4,579.37
Rate for Payer: University Health Alliance Commercial	$2,643.76

GLENOID 52MM REUN 5542-P-0052

Facility

$4,721.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,407.71
Max. Negotiated Rate	$4,579.37
Rate for Payer: Cash Price	$2,832.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,304.70
Rate for Payer: Health Management Network Commercial	$4,012.85
Rate for Payer: Kaiser Permanente Commercial	$2,974.23
Rate for Payer: Kaiser Permanente Medicaid	$2,407.71
Rate for Payer: MDX Hawaii PPO	$4,579.37
Rate for Payer: University Health Alliance Commercial	$2,643.76

GLENOID ARTICULAR G203-2010-W

Facility

$4,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,320.50
Max. Negotiated Rate	$4,413.50
Rate for Payer: Cash Price	$2,730.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,185.00
Rate for Payer: Health Management Network Commercial	$3,867.50
Rate for Payer: Kaiser Permanente Commercial	$2,866.50
Rate for Payer: Kaiser Permanente Medicaid	$2,320.50
Rate for Payer: MDX Hawaii PPO	$4,413.50
Rate for Payer: University Health Alliance Commercial	$2,548.00

GLENOID ARTICULAR G203-2010-W

Facility

$4,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,548.00
Max. Negotiated Rate	$4,413.50
Rate for Payer: Cash Price	$2,730.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,185.00
Rate for Payer: Health Management Network Commercial	$3,867.50
Rate for Payer: MDX Hawaii PPO	$4,413.50
Rate for Payer: University Health Alliance Commercial	$2,548.00

GLENOID CORTILOC PEGGED DWE401

Facility

$4,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,591.68
Max. Negotiated Rate	$4,489.16
Rate for Payer: Cash Price	$2,776.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,239.60
Rate for Payer: Health Management Network Commercial	$3,933.80
Rate for Payer: MDX Hawaii PPO	$4,489.16
Rate for Payer: University Health Alliance Commercial	$2,591.68

GLENOID CORTILOC PEGGED DWE401

Facility

$4,628.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.28
Max. Negotiated Rate	$4,489.16
Rate for Payer: Cash Price	$2,776.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,239.60
Rate for Payer: Health Management Network Commercial	$3,933.80
Rate for Payer: Kaiser Permanente Commercial	$2,915.64
Rate for Payer: Kaiser Permanente Medicaid	$2,360.28
Rate for Payer: MDX Hawaii PPO	$4,489.16
Rate for Payer: University Health Alliance Commercial	$2,591.68

GLENOID HEAD AS 01.04223.236

Facility

$3,444.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,928.64
Max. Negotiated Rate	$3,340.68
Rate for Payer: Cash Price	$2,066.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,410.80
Rate for Payer: Health Management Network Commercial	$2,927.40
Rate for Payer: MDX Hawaii PPO	$3,340.68
Rate for Payer: University Health Alliance Commercial	$1,928.64

GLENOID HEAD AS 01.04223.236

Facility

$3,444.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,756.44
Max. Negotiated Rate	$3,340.68
Rate for Payer: Cash Price	$2,066.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,410.80
Rate for Payer: Health Management Network Commercial	$2,927.40
Rate for Payer: Kaiser Permanente Commercial	$2,169.72
Rate for Payer: Kaiser Permanente Medicaid	$1,756.44
Rate for Payer: MDX Hawaii PPO	$3,340.68
Rate for Payer: University Health Alliance Commercial	$1,928.64

GLENOID LATERALIZED BASEPLATE

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

GLENOID LATERALIZED BASEPLATE

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

GLENOID LATERALIZED DWJ022

Facility

$9,566.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,356.96
Max. Negotiated Rate	$9,279.02
Rate for Payer: Cash Price	$5,739.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,696.20
Rate for Payer: Health Management Network Commercial	$8,131.10
Rate for Payer: MDX Hawaii PPO	$9,279.02
Rate for Payer: University Health Alliance Commercial	$5,356.96

GLENOID LATERALIZED DWJ022

Facility

$9,566.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,878.66
Max. Negotiated Rate	$9,279.02
Rate for Payer: Cash Price	$5,739.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,696.20
Rate for Payer: Health Management Network Commercial	$8,131.10
Rate for Payer: Kaiser Permanente Commercial	$6,026.58
Rate for Payer: Kaiser Permanente Medicaid	$4,878.66
Rate for Payer: MDX Hawaii PPO	$9,279.02
Rate for Payer: University Health Alliance Commercial	$5,356.96

GLENOID MED PE PEG AR-9105-02

Facility

$3,150.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,606.50
Max. Negotiated Rate	$3,055.50
Rate for Payer: Cash Price	$1,890.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.00
Rate for Payer: Health Management Network Commercial	$2,677.50
Rate for Payer: Kaiser Permanente Commercial	$1,984.50
Rate for Payer: Kaiser Permanente Medicaid	$1,606.50
Rate for Payer: MDX Hawaii PPO	$3,055.50
Rate for Payer: University Health Alliance Commercial	$1,764.00

GLENOID MED PE PEG AR-9105-02

Facility

$3,150.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,764.00
Max. Negotiated Rate	$3,055.50
Rate for Payer: Cash Price	$1,890.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.00
Rate for Payer: Health Management Network Commercial	$2,677.50
Rate for Payer: MDX Hawaii PPO	$3,055.50
Rate for Payer: University Health Alliance Commercial	$1,764.00

Know your out-of-pocket cost for care.

All Charges