Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HUMERAL CUP 40 STD 110031427

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,456.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

HUMERAL CUP 40 STD 110031427

Facility

$2,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,326.00
Max. Negotiated Rate	$2,522.00
Rate for Payer: Cash Price	$1,560.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,820.00
Rate for Payer: Health Management Network Commercial	$2,210.00
Rate for Payer: Kaiser Permanente Commercial	$1,638.00
Rate for Payer: Kaiser Permanente Medicaid	$1,326.00
Rate for Payer: MDX Hawaii PPO	$2,522.00
Rate for Payer: University Health Alliance Commercial	$1,456.00

HUMERAL CUP AS 01.04223.100

Facility

$2,302.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,174.02
Max. Negotiated Rate	$2,232.94
Rate for Payer: Cash Price	$1,381.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,611.40
Rate for Payer: Health Management Network Commercial	$1,956.70
Rate for Payer: Kaiser Permanente Commercial	$1,450.26
Rate for Payer: Kaiser Permanente Medicaid	$1,174.02
Rate for Payer: MDX Hawaii PPO	$2,232.94
Rate for Payer: University Health Alliance Commercial	$1,289.12

HUMERAL CUP AS 01.04223.100

Facility

$2,302.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,289.12
Max. Negotiated Rate	$2,232.94
Rate for Payer: Cash Price	$1,381.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,611.40
Rate for Payer: Health Management Network Commercial	$1,956.70
Rate for Payer: MDX Hawaii PPO	$2,232.94
Rate for Payer: University Health Alliance Commercial	$1,289.12

HUMERAL CUP AS 01.04223.106

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

HUMERAL CUP AS 01.04223.106

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

HUMERAL FRACT STEM 5568-0006

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,738.72
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

HUMERAL FRACT STEM 5568-0006

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,315.62
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: Kaiser Permanente Commercial	$5,331.06
Rate for Payer: Kaiser Permanente Medicaid	$4,315.62
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

HUMERAL FRACTUR STEM 5568-0013

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,315.62
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: Kaiser Permanente Commercial	$5,331.06
Rate for Payer: Kaiser Permanente Medicaid	$4,315.62
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

HUMERAL FRACTUR STEM 5568-0013

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,738.72
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

HUMERAL HD X42-15 01.04212.425

Facility

$4,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,346.00
Max. Negotiated Rate	$4,462.00
Rate for Payer: Cash Price	$2,760.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,220.00
Rate for Payer: Health Management Network Commercial	$3,910.00
Rate for Payer: Kaiser Permanente Commercial	$2,898.00
Rate for Payer: Kaiser Permanente Medicaid	$2,346.00
Rate for Payer: MDX Hawaii PPO	$4,462.00
Rate for Payer: University Health Alliance Commercial	$2,576.00

HUMERAL HD X42-15 01.04212.425

Facility

$4,600.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,576.00
Max. Negotiated Rate	$4,462.00
Rate for Payer: Cash Price	$2,760.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,220.00
Rate for Payer: Health Management Network Commercial	$3,910.00
Rate for Payer: MDX Hawaii PPO	$4,462.00
Rate for Payer: University Health Alliance Commercial	$2,576.00

HUMERAL HEAD 19X56 5552-S-5619

Facility

$4,067.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,074.17
Max. Negotiated Rate	$3,944.99
Rate for Payer: Cash Price	$2,440.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.90
Rate for Payer: Health Management Network Commercial	$3,456.95
Rate for Payer: Kaiser Permanente Commercial	$2,562.21
Rate for Payer: Kaiser Permanente Medicaid	$2,074.17
Rate for Payer: MDX Hawaii PPO	$3,944.99
Rate for Payer: University Health Alliance Commercial	$2,277.52

HUMERAL HEAD 19X56 5552-S-5619

Facility

$4,067.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,277.52
Max. Negotiated Rate	$3,944.99
Rate for Payer: Cash Price	$2,440.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.90
Rate for Payer: Health Management Network Commercial	$3,456.95
Rate for Payer: MDX Hawaii PPO	$3,944.99
Rate for Payer: University Health Alliance Commercial	$2,277.52

HUMERAL HEAD 40MM 110030776

Facility

$2,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,316.00
Max. Negotiated Rate	$2,279.50
Rate for Payer: Cash Price	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,645.00
Rate for Payer: Health Management Network Commercial	$1,997.50
Rate for Payer: MDX Hawaii PPO	$2,279.50
Rate for Payer: University Health Alliance Commercial	$1,316.00

HUMERAL HEAD 40MM 110030776

Facility

$2,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,198.50
Max. Negotiated Rate	$2,279.50
Rate for Payer: Cash Price	$1,410.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,645.00
Rate for Payer: Health Management Network Commercial	$1,997.50
Rate for Payer: Kaiser Permanente Commercial	$1,480.50
Rate for Payer: Kaiser Permanente Medicaid	$1,198.50
Rate for Payer: MDX Hawaii PPO	$2,279.50
Rate for Payer: University Health Alliance Commercial	$1,316.00

HUMERAL HEAD 44X19 5552-S-4419

Facility

$4,067.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,277.52
Max. Negotiated Rate	$3,944.99
Rate for Payer: Cash Price	$2,440.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.90
Rate for Payer: Health Management Network Commercial	$3,456.95
Rate for Payer: MDX Hawaii PPO	$3,944.99
Rate for Payer: University Health Alliance Commercial	$2,277.52

HUMERAL HEAD 44X19 5552-S-4419

Facility

$4,067.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,074.17
Max. Negotiated Rate	$3,944.99
Rate for Payer: Cash Price	$2,440.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.90
Rate for Payer: Health Management Network Commercial	$3,456.95
Rate for Payer: Kaiser Permanente Commercial	$2,562.21
Rate for Payer: Kaiser Permanente Medicaid	$2,074.17
Rate for Payer: MDX Hawaii PPO	$3,944.99
Rate for Payer: University Health Alliance Commercial	$2,277.52

HUMERAL HEAD 50/19 AR-9150-19P

Facility

$3,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,785.00
Max. Negotiated Rate	$3,395.00
Rate for Payer: Cash Price	$2,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,450.00
Rate for Payer: Health Management Network Commercial	$2,975.00
Rate for Payer: Kaiser Permanente Commercial	$2,205.00
Rate for Payer: Kaiser Permanente Medicaid	$1,785.00
Rate for Payer: MDX Hawaii PPO	$3,395.00
Rate for Payer: University Health Alliance Commercial	$1,960.00

HUMERAL HEAD 50/19 AR-9150-19P

Facility

$3,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,960.00
Max. Negotiated Rate	$3,395.00
Rate for Payer: Cash Price	$2,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,450.00
Rate for Payer: Health Management Network Commercial	$2,975.00
Rate for Payer: MDX Hawaii PPO	$3,395.00
Rate for Payer: University Health Alliance Commercial	$1,960.00

HUMERAL HEAD 52/20 AR-9152-20P

Facility

$3,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,785.00
Max. Negotiated Rate	$3,395.00
Rate for Payer: Cash Price	$2,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,450.00
Rate for Payer: Health Management Network Commercial	$2,975.00
Rate for Payer: Kaiser Permanente Commercial	$2,205.00
Rate for Payer: Kaiser Permanente Medicaid	$1,785.00
Rate for Payer: MDX Hawaii PPO	$3,395.00
Rate for Payer: University Health Alliance Commercial	$1,960.00

HUMERAL HEAD 52/20 AR-9152-20P

Facility

$3,500.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,960.00
Max. Negotiated Rate	$3,395.00
Rate for Payer: Cash Price	$2,100.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,450.00
Rate for Payer: Health Management Network Commercial	$2,975.00
Rate for Payer: MDX Hawaii PPO	$3,395.00
Rate for Payer: University Health Alliance Commercial	$1,960.00

HUMERAL HEAD 7122872

Facility

$11,146.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,684.46
Max. Negotiated Rate	$10,811.62
Rate for Payer: Cash Price	$6,687.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,802.20
Rate for Payer: Health Management Network Commercial	$9,474.10
Rate for Payer: Kaiser Permanente Commercial	$7,021.98
Rate for Payer: Kaiser Permanente Medicaid	$5,684.46
Rate for Payer: MDX Hawaii PPO	$10,811.62
Rate for Payer: University Health Alliance Commercial	$6,241.76

HUMERAL HEAD 7122872

Facility

$11,146.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,241.76
Max. Negotiated Rate	$10,811.62
Rate for Payer: Cash Price	$6,687.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,802.20
Rate for Payer: Health Management Network Commercial	$9,474.10
Rate for Payer: MDX Hawaii PPO	$10,811.62
Rate for Payer: University Health Alliance Commercial	$6,241.76

HUMERAL HEAD AS #01.04212.500

Facility

$4,794.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,684.64
Max. Negotiated Rate	$4,650.18
Rate for Payer: Cash Price	$2,876.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,355.80
Rate for Payer: Health Management Network Commercial	$4,074.90
Rate for Payer: MDX Hawaii PPO	$4,650.18
Rate for Payer: University Health Alliance Commercial	$2,684.64

Know your out-of-pocket cost for care.

All Charges