Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HIP LINER 40X56 00-8751-012-40

Facility

$3,270.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,667.70
Max. Negotiated Rate	$3,171.90
Rate for Payer: Cash Price	$1,962.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,289.00
Rate for Payer: Health Management Network Commercial	$2,779.50
Rate for Payer: Kaiser Permanente Commercial	$2,060.10
Rate for Payer: Kaiser Permanente Medicaid	$1,667.70
Rate for Payer: MDX Hawaii PPO	$3,171.90
Rate for Payer: University Health Alliance Commercial	$1,831.20

HIP LINER 40X56 00-8751-012-40

Facility

$3,270.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,831.20
Max. Negotiated Rate	$3,171.90
Rate for Payer: Cash Price	$1,962.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,289.00
Rate for Payer: Health Management Network Commercial	$2,779.50
Rate for Payer: MDX Hawaii PPO	$3,171.90
Rate for Payer: University Health Alliance Commercial	$1,831.20

HIP LINER 40X60 00-8751-014-40

Facility

$2,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,428.00
Max. Negotiated Rate	$2,716.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,960.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: Kaiser Permanente Commercial	$1,764.00
Rate for Payer: Kaiser Permanente Medicaid	$1,428.00
Rate for Payer: MDX Hawaii PPO	$2,716.00
Rate for Payer: University Health Alliance Commercial	$1,568.00

HIP LINER 40X60 00-8751-014-40

Facility

$2,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,568.00
Max. Negotiated Rate	$2,716.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,960.00
Rate for Payer: Health Management Network Commercial	$2,380.00
Rate for Payer: MDX Hawaii PPO	$2,716.00
Rate for Payer: University Health Alliance Commercial	$1,568.00

HIP PAC DISPOSABLE

Facility

$2,246.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$1,909.10
Max. Negotiated Rate	$2,178.62
Rate for Payer: Cash Price	$1,347.60
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: MDX Hawaii PPO	$2,178.62

HIP PAC DISPOSABLE

Facility

$2,246.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$1,145.46
Max. Negotiated Rate	$2,178.62
Rate for Payer: Cash Price	$1,347.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,133.70
Rate for Payer: Health Management Network Commercial	$1,909.10
Rate for Payer: Kaiser Permanente Commercial	$1,414.98
Rate for Payer: Kaiser Permanente Medicaid	$1,145.46
Rate for Payer: MDX Hawaii PPO	$2,178.62
Rate for Payer: University Health Alliance Commercial	$1,637.11

HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC

Facility

$51,783.64

Service Code	MSDRG 521
Min. Negotiated Rate	$32,646.39
Max. Negotiated Rate	$51,783.64
Rate for Payer: AlohaCare Medicare	$32,646.39
Rate for Payer: Devoted Health Medicare	$35,911.03
Rate for Payer: Hawaii Medical Service Association Commercial	$51,783.64
Rate for Payer: Hawaii Medical Service Association Medicare	$32,646.39
Rate for Payer: Humana Medicare	$32,646.39
Rate for Payer: Kaiser Permanente Commercial	$49,510.95
Rate for Payer: Kaiser Permanente Medicare	$32,646.39
Rate for Payer: Ohana Health Plan Medicare	$32,646.39
Rate for Payer: UnitedHealthcare Medicare	$32,646.39

HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC

Facility

$37,757.90

Service Code	MSDRG 522
Min. Negotiated Rate	$24,087.27
Max. Negotiated Rate	$37,757.90
Rate for Payer: AlohaCare Medicare	$24,087.27
Rate for Payer: Devoted Health Medicare	$26,496.00
Rate for Payer: Hawaii Medical Service Association Commercial	$37,757.90
Rate for Payer: Hawaii Medical Service Association Medicare	$24,087.27
Rate for Payer: Humana Medicare	$24,087.27
Rate for Payer: Kaiser Permanente Commercial	$36,530.32
Rate for Payer: Kaiser Permanente Medicare	$24,087.27
Rate for Payer: Ohana Health Plan Medicare	$24,087.27
Rate for Payer: UnitedHealthcare Medicare	$24,087.27

HIP STEM #10 35X160 6051-1035S

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,236.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

HIP STEM #10 35X160 6051-1035S

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,947.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Kaiser Permanente Commercial	$3,641.40
Rate for Payer: Kaiser Permanente Medicaid	$2,947.80
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

HIP STEM 11 STD 00-7711-11-10

Facility

$5,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,912.00
Max. Negotiated Rate	$5,044.00
Rate for Payer: Cash Price	$3,120.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,640.00
Rate for Payer: Health Management Network Commercial	$4,420.00
Rate for Payer: MDX Hawaii PPO	$5,044.00
Rate for Payer: University Health Alliance Commercial	$2,912.00

HIP STEM 11 STD 00-7711-11-10

Facility

$5,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,652.00
Max. Negotiated Rate	$5,044.00
Rate for Payer: Cash Price	$3,120.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,640.00
Rate for Payer: Health Management Network Commercial	$4,420.00
Rate for Payer: Kaiser Permanente Commercial	$3,276.00
Rate for Payer: Kaiser Permanente Medicaid	$2,652.00
Rate for Payer: MDX Hawaii PPO	$5,044.00
Rate for Payer: University Health Alliance Commercial	$2,912.00

HIP STEM 11X120 00-7833-011-00

Facility

$4,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,193.00
Max. Negotiated Rate	$4,171.00
Rate for Payer: Cash Price	$2,580.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,010.00
Rate for Payer: Health Management Network Commercial	$3,655.00
Rate for Payer: Kaiser Permanente Commercial	$2,709.00
Rate for Payer: Kaiser Permanente Medicaid	$2,193.00
Rate for Payer: MDX Hawaii PPO	$4,171.00
Rate for Payer: University Health Alliance Commercial	$2,408.00

HIP STEM 11X120 00-7833-011-00

Facility

$4,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,408.00
Max. Negotiated Rate	$4,171.00
Rate for Payer: Cash Price	$2,580.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,010.00
Rate for Payer: Health Management Network Commercial	$3,655.00
Rate for Payer: MDX Hawaii PPO	$4,171.00
Rate for Payer: University Health Alliance Commercial	$2,408.00

HIP STEM #12 40X170 6051-1240S

Facility

$5,839.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,269.84
Max. Negotiated Rate	$5,663.83
Rate for Payer: Cash Price	$3,503.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,087.30
Rate for Payer: Health Management Network Commercial	$4,963.15
Rate for Payer: MDX Hawaii PPO	$5,663.83
Rate for Payer: University Health Alliance Commercial	$3,269.84

HIP STEM #12 40X170 6051-1240S

Facility

$5,839.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,977.89
Max. Negotiated Rate	$5,663.83
Rate for Payer: Cash Price	$3,503.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,087.30
Rate for Payer: Health Management Network Commercial	$4,963.15
Rate for Payer: Kaiser Permanente Commercial	$3,678.57
Rate for Payer: Kaiser Permanente Medicaid	$2,977.89
Rate for Payer: MDX Hawaii PPO	$5,663.83
Rate for Payer: University Health Alliance Commercial	$3,269.84

HIP STEM 12.5 00-7711-012-00

Facility

$10,154.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,178.54
Max. Negotiated Rate	$9,849.38
Rate for Payer: Cash Price	$6,092.40
Rate for Payer: Hawaii Western Management Group Commercial	$7,107.80
Rate for Payer: Health Management Network Commercial	$8,630.90
Rate for Payer: Kaiser Permanente Commercial	$6,397.02
Rate for Payer: Kaiser Permanente Medicaid	$5,178.54
Rate for Payer: MDX Hawaii PPO	$9,849.38
Rate for Payer: University Health Alliance Commercial	$5,686.24

HIP STEM 12.5 00-7711-012-00

Facility

$10,154.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,686.24
Max. Negotiated Rate	$9,849.38
Rate for Payer: Cash Price	$6,092.40
Rate for Payer: Hawaii Western Management Group Commercial	$7,107.80
Rate for Payer: Health Management Network Commercial	$8,630.90
Rate for Payer: MDX Hawaii PPO	$9,849.38
Rate for Payer: University Health Alliance Commercial	$5,686.24

HIP STEM 12.5 00-7711-012-10

Facility

$5,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,652.00
Max. Negotiated Rate	$5,044.00
Rate for Payer: Cash Price	$3,120.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,640.00
Rate for Payer: Health Management Network Commercial	$4,420.00
Rate for Payer: Kaiser Permanente Commercial	$3,276.00
Rate for Payer: Kaiser Permanente Medicaid	$2,652.00
Rate for Payer: MDX Hawaii PPO	$5,044.00
Rate for Payer: University Health Alliance Commercial	$2,912.00

HIP STEM 12.5 00-7711-012-10

Facility

$5,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,912.00
Max. Negotiated Rate	$5,044.00
Rate for Payer: Cash Price	$3,120.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,640.00
Rate for Payer: Health Management Network Commercial	$4,420.00
Rate for Payer: MDX Hawaii PPO	$5,044.00
Rate for Payer: University Health Alliance Commercial	$2,912.00

HIP STEM 127DEGREE 6721-0127

Facility

$5,839.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,269.84
Max. Negotiated Rate	$5,663.83
Rate for Payer: Cash Price	$3,503.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,087.30
Rate for Payer: Health Management Network Commercial	$4,963.15
Rate for Payer: MDX Hawaii PPO	$5,663.83
Rate for Payer: University Health Alliance Commercial	$3,269.84

HIP STEM 127DEGREE 6721-0127

Facility

$5,839.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,977.89
Max. Negotiated Rate	$5,663.83
Rate for Payer: Cash Price	$3,503.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,087.30
Rate for Payer: Health Management Network Commercial	$4,963.15
Rate for Payer: Kaiser Permanente Commercial	$3,678.57
Rate for Payer: Kaiser Permanente Medicaid	$2,977.89
Rate for Payer: MDX Hawaii PPO	$5,663.83
Rate for Payer: University Health Alliance Commercial	$3,269.84

HIP STEM 13.5 00-7711-013-00

Facility

$5,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,912.00
Max. Negotiated Rate	$5,044.00
Rate for Payer: Cash Price	$3,120.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,640.00
Rate for Payer: Health Management Network Commercial	$4,420.00
Rate for Payer: MDX Hawaii PPO	$5,044.00
Rate for Payer: University Health Alliance Commercial	$2,912.00

HIP STEM 13.5 00-7711-013-00

Facility

$5,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,652.00
Max. Negotiated Rate	$5,044.00
Rate for Payer: Cash Price	$3,120.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,640.00
Rate for Payer: Health Management Network Commercial	$4,420.00
Rate for Payer: Kaiser Permanente Commercial	$3,276.00
Rate for Payer: Kaiser Permanente Medicaid	$2,652.00
Rate for Payer: MDX Hawaii PPO	$5,044.00
Rate for Payer: University Health Alliance Commercial	$2,912.00

HIP STEM 14/225MM 01-00102-214

Facility

$13,867.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$7,072.17
Max. Negotiated Rate	$13,450.99
Rate for Payer: Cash Price	$8,320.20
Rate for Payer: Hawaii Western Management Group Commercial	$9,706.90
Rate for Payer: Health Management Network Commercial	$11,786.95
Rate for Payer: Kaiser Permanente Commercial	$8,736.21
Rate for Payer: Kaiser Permanente Medicaid	$7,072.17
Rate for Payer: MDX Hawaii PPO	$13,450.99
Rate for Payer: University Health Alliance Commercial	$7,765.52

Know your out-of-pocket cost for care.

All Charges