Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GLENOID POLY PEG SM AR-9105-01

Facility

$4,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,520.00
Max. Negotiated Rate	$4,365.00
Rate for Payer: Cash Price	$2,700.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,150.00
Rate for Payer: Health Management Network Commercial	$3,825.00
Rate for Payer: MDX Hawaii PPO	$4,365.00
Rate for Payer: University Health Alliance Commercial	$2,520.00

GLENOID POLY PEG SM AR-9105-01

Facility

$4,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,295.00
Max. Negotiated Rate	$4,365.00
Rate for Payer: Cash Price	$2,700.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,150.00
Rate for Payer: Health Management Network Commercial	$3,825.00
Rate for Payer: Kaiser Permanente Commercial	$2,835.00
Rate for Payer: Kaiser Permanente Medicaid	$2,295.00
Rate for Payer: MDX Hawaii PPO	$4,365.00
Rate for Payer: University Health Alliance Commercial	$2,520.00

GLENOID PRESS-FIT SHORT POST

Facility

$1,605.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$898.80
Max. Negotiated Rate	$1,556.85
Rate for Payer: Cash Price	$963.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,123.50
Rate for Payer: Health Management Network Commercial	$1,364.25
Rate for Payer: MDX Hawaii PPO	$1,556.85
Rate for Payer: University Health Alliance Commercial	$898.80

GLENOID PRESS-FIT SHORT POST

Facility

$1,605.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$818.55
Max. Negotiated Rate	$1,556.85
Rate for Payer: Cash Price	$963.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,123.50
Rate for Payer: Health Management Network Commercial	$1,364.25
Rate for Payer: Kaiser Permanente Commercial	$1,011.15
Rate for Payer: Kaiser Permanente Medicaid	$818.55
Rate for Payer: MDX Hawaii PPO	$1,556.85
Rate for Payer: University Health Alliance Commercial	$898.80

GLENOID PT HYBRID PT-113950

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

GLENOID PT HYBRID PT-113950

Facility

$1,050.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,018.50
Rate for Payer: Cash Price	$630.00
Rate for Payer: Hawaii Western Management Group Commercial	$735.00
Rate for Payer: Health Management Network Commercial	$892.50
Rate for Payer: Kaiser Permanente Commercial	$661.50
Rate for Payer: Kaiser Permanente Medicaid	$535.50
Rate for Payer: MDX Hawaii PPO	$1,018.50
Rate for Payer: University Health Alliance Commercial	$588.00

GLENOID REVERSE AUGMENT DWJ505

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 REVERSE AUGMENT DWJ505

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 SIZE 56 5542-P0056

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 SIZE 56 5542-P0056

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 SZ44 TSA-X3 5542-P-004

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 SZ44 TSA-X3 5542-P-004

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

GLENOSPHER 36X2MM 5573-2E-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$2,520.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHER 36X2MM 5573-2E-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHERE 32X6MM 5573-C-3202

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHERE 32X6MM 5573-C-3202

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$2,520.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHERE 36X2MM 5573-C-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,040.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: Kaiser Permanente Commercial	$2,520.00
Rate for Payer: Kaiser Permanente Medicaid	$2,040.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHERE 36X2MM 5573-C-3602

Facility

$4,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,240.00
Max. Negotiated Rate	$3,880.00
Rate for Payer: Cash Price	$2,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,800.00
Rate for Payer: Health Management Network Commercial	$3,400.00
Rate for Payer: MDX Hawaii PPO	$3,880.00
Rate for Payer: University Health Alliance Commercial	$2,240.00

GLENOSPHERE COCR + TI6AI4V

Facility

$9,558.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,874.58
Max. Negotiated Rate	$9,271.26
Rate for Payer: Cash Price	$5,734.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,690.60
Rate for Payer: Health Management Network Commercial	$8,124.30
Rate for Payer: Kaiser Permanente Commercial	$6,021.54
Rate for Payer: Kaiser Permanente Medicaid	$4,874.58
Rate for Payer: MDX Hawaii PPO	$9,271.26
Rate for Payer: University Health Alliance Commercial	$5,352.48

GLENOSPHERE COCR + TI6AI4V

Facility

$9,558.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,352.48
Max. Negotiated Rate	$9,271.26
Rate for Payer: Cash Price	$5,734.80
Rate for Payer: Hawaii Western Management Group Commercial	$6,690.60
Rate for Payer: Health Management Network Commercial	$8,124.30
Rate for Payer: MDX Hawaii PPO	$9,271.26
Rate for Payer: University Health Alliance Commercial	$5,352.48

GLENOSPHERE DWJ1017301

Facility

$6,028.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,375.68
Max. Negotiated Rate	$5,847.16
Rate for Payer: Cash Price	$3,616.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,219.60
Rate for Payer: Health Management Network Commercial	$5,123.80
Rate for Payer: MDX Hawaii PPO	$5,847.16
Rate for Payer: University Health Alliance Commercial	$3,375.68

GLENOSPHERE DWJ1017301

Facility

$6,028.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,074.28
Max. Negotiated Rate	$5,847.16
Rate for Payer: Cash Price	$3,616.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,219.60
Rate for Payer: Health Management Network Commercial	$5,123.80
Rate for Payer: Kaiser Permanente Commercial	$3,797.64
Rate for Payer: Kaiser Permanente Medicaid	$3,074.28
Rate for Payer: MDX Hawaii PPO	$5,847.16
Rate for Payer: University Health Alliance Commercial	$3,375.68

GLENOSPHERE RVS SHDR STD 36M

Facility

$1,845.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,033.20
Max. Negotiated Rate	$1,789.65
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,291.50
Rate for Payer: Health Management Network Commercial	$1,568.25
Rate for Payer: MDX Hawaii PPO	$1,789.65
Rate for Payer: University Health Alliance Commercial	$1,033.20

GLENOSPHERE RVS SHDR STD 36M

Facility

$1,845.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$940.95
Max. Negotiated Rate	$1,789.65
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,291.50
Rate for Payer: Health Management Network Commercial	$1,568.25
Rate for Payer: Kaiser Permanente Commercial	$1,162.35
Rate for Payer: Kaiser Permanente Medicaid	$940.95
Rate for Payer: MDX Hawaii PPO	$1,789.65
Rate for Payer: University Health Alliance Commercial	$1,033.20

GLIDEWIRE .25ANGL M0066802021

Facility

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: MDX Hawaii PPO	$177.51

Know your out-of-pocket cost for care.

All Charges