Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HUMERAL HEAD AS #01.04212.500

Facility

$4,794.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,444.94
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: Kaiser Permanente Commercial	$3,020.22
Rate for Payer: Kaiser Permanente Medicaid	$2,444.94
Rate for Payer: MDX Hawaii PPO	$4,650.18
Rate for Payer: University Health Alliance Commercial	$2,684.64

HUMERAL HEAD COCR 7122880

Facility

$6,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,076.32
Max. Negotiated Rate	$5,851.04
Rate for Payer: Cash Price	$3,619.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,222.40
Rate for Payer: Health Management Network Commercial	$5,127.20
Rate for Payer: Kaiser Permanente Commercial	$3,800.16
Rate for Payer: Kaiser Permanente Medicaid	$3,076.32
Rate for Payer: MDX Hawaii PPO	$5,851.04
Rate for Payer: University Health Alliance Commercial	$3,377.92

HUMERAL HEAD COCR 7122880

Facility

$6,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,377.92
Max. Negotiated Rate	$5,851.04
Rate for Payer: Cash Price	$3,619.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,222.40
Rate for Payer: Health Management Network Commercial	$5,127.20
Rate for Payer: MDX Hawaii PPO	$5,851.04
Rate for Payer: University Health Alliance Commercial	$3,377.92

HUMERAL HEAD COCR DWG048

Facility

$8,306.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,651.36
Max. Negotiated Rate	$8,056.82
Rate for Payer: Cash Price	$4,983.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,814.20
Rate for Payer: Health Management Network Commercial	$7,060.10
Rate for Payer: MDX Hawaii PPO	$8,056.82
Rate for Payer: University Health Alliance Commercial	$4,651.36

HUMERAL HEAD COCR DWG048

Facility

$8,306.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,236.06
Max. Negotiated Rate	$8,056.82
Rate for Payer: Cash Price	$4,983.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,814.20
Rate for Payer: Health Management Network Commercial	$7,060.10
Rate for Payer: Kaiser Permanente Commercial	$5,232.78
Rate for Payer: Kaiser Permanente Medicaid	$4,236.06
Rate for Payer: MDX Hawaii PPO	$8,056.82
Rate for Payer: University Health Alliance Commercial	$4,651.36

HUMERAL HEAD COCR DWN4314

Facility

$6,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,076.32
Max. Negotiated Rate	$5,851.04
Rate for Payer: Cash Price	$3,619.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,222.40
Rate for Payer: Health Management Network Commercial	$5,127.20
Rate for Payer: Kaiser Permanente Commercial	$3,800.16
Rate for Payer: Kaiser Permanente Medicaid	$3,076.32
Rate for Payer: MDX Hawaii PPO	$5,851.04
Rate for Payer: University Health Alliance Commercial	$3,377.92

HUMERAL HEAD COCR DWN4314

Facility

$6,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,377.92
Max. Negotiated Rate	$5,851.04
Rate for Payer: Cash Price	$3,619.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,222.40
Rate for Payer: Health Management Network Commercial	$5,127.20
Rate for Payer: MDX Hawaii PPO	$5,851.04
Rate for Payer: University Health Alliance Commercial	$3,377.92

HUMERAL HEAD COCR DWN4615

Facility

$6,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,377.92
Max. Negotiated Rate	$5,851.04
Rate for Payer: Cash Price	$3,619.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,222.40
Rate for Payer: Health Management Network Commercial	$5,127.20
Rate for Payer: MDX Hawaii PPO	$5,851.04
Rate for Payer: University Health Alliance Commercial	$3,377.92

HUMERAL HEAD COCR DWN4615

Facility

$6,032.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,076.32
Max. Negotiated Rate	$5,851.04
Rate for Payer: Cash Price	$3,619.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,222.40
Rate for Payer: Health Management Network Commercial	$5,127.20
Rate for Payer: Kaiser Permanente Commercial	$3,800.16
Rate for Payer: Kaiser Permanente Medicaid	$3,076.32
Rate for Payer: MDX Hawaii PPO	$5,851.04
Rate for Payer: University Health Alliance Commercial	$3,377.92

HUMERAL HEAD COUPLER DWT100

Facility

$1,593.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$812.43
Max. Negotiated Rate	$1,545.21
Rate for Payer: Cash Price	$955.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,115.10
Rate for Payer: Health Management Network Commercial	$1,354.05
Rate for Payer: Kaiser Permanente Commercial	$1,003.59
Rate for Payer: Kaiser Permanente Medicaid	$812.43
Rate for Payer: MDX Hawaii PPO	$1,545.21
Rate for Payer: University Health Alliance Commercial	$892.08

HUMERAL HEAD COUPLER DWT100

Facility

$1,593.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$892.08
Max. Negotiated Rate	$1,545.21
Rate for Payer: Cash Price	$955.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,115.10
Rate for Payer: Health Management Network Commercial	$1,354.05
Rate for Payer: MDX Hawaii PPO	$1,545.21
Rate for Payer: University Health Alliance Commercial	$892.08

HUMERAL HEAD REMV AS 16X46

Facility

$3,356.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,711.56
Max. Negotiated Rate	$3,255.32
Rate for Payer: Cash Price	$2,013.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,349.20
Rate for Payer: Health Management Network Commercial	$2,852.60
Rate for Payer: Kaiser Permanente Commercial	$2,114.28
Rate for Payer: Kaiser Permanente Medicaid	$1,711.56
Rate for Payer: MDX Hawaii PPO	$3,255.32
Rate for Payer: University Health Alliance Commercial	$1,879.36

HUMERAL HEAD REMV AS 16X46

Facility

$3,356.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,879.36
Max. Negotiated Rate	$3,255.32
Rate for Payer: Cash Price	$2,013.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,349.20
Rate for Payer: Health Management Network Commercial	$2,852.60
Rate for Payer: MDX Hawaii PPO	$3,255.32
Rate for Payer: University Health Alliance Commercial	$1,879.36

HUMERALHEAD SINGLE 5552-S-5622

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

HUMERALHEAD SINGLE 5552-S-5622

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 SNGL 5552-S-5220

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 SNGL 5552-S-5220

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 STB - COCR DWG044

Facility

$8,834.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,505.34
Max. Negotiated Rate	$8,568.98
Rate for Payer: Cash Price	$5,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,183.80
Rate for Payer: Health Management Network Commercial	$7,508.90
Rate for Payer: Kaiser Permanente Commercial	$5,565.42
Rate for Payer: Kaiser Permanente Medicaid	$4,505.34
Rate for Payer: MDX Hawaii PPO	$8,568.98
Rate for Payer: University Health Alliance Commercial	$4,947.04

HUMERAL HEAD STB - COCR DWG044

Facility

$8,834.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,947.04
Max. Negotiated Rate	$8,568.98
Rate for Payer: Cash Price	$5,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,183.80
Rate for Payer: Health Management Network Commercial	$7,508.90
Rate for Payer: MDX Hawaii PPO	$8,568.98
Rate for Payer: University Health Alliance Commercial	$4,947.04

HUMERAL HEAD STB COCR DWG047

Facility

$9,036.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,060.16
Max. Negotiated Rate	$8,764.92
Rate for Payer: Cash Price	$5,421.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,325.20
Rate for Payer: Health Management Network Commercial	$7,680.60
Rate for Payer: MDX Hawaii PPO	$8,764.92
Rate for Payer: University Health Alliance Commercial	$5,060.16

HUMERAL HEAD STB COCR DWG047

Facility

$9,036.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,608.36
Max. Negotiated Rate	$8,764.92
Rate for Payer: Cash Price	$5,421.60
Rate for Payer: Hawaii Western Management Group Commercial	$6,325.20
Rate for Payer: Health Management Network Commercial	$7,680.60
Rate for Payer: Kaiser Permanente Commercial	$5,692.68
Rate for Payer: Kaiser Permanente Medicaid	$4,608.36
Rate for Payer: MDX Hawaii PPO	$8,764.92
Rate for Payer: University Health Alliance Commercial	$5,060.16

HUMERAL HEAD STB - COCR DWG151

Facility

$8,834.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,505.34
Max. Negotiated Rate	$8,568.98
Rate for Payer: Cash Price	$5,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,183.80
Rate for Payer: Health Management Network Commercial	$7,508.90
Rate for Payer: Kaiser Permanente Commercial	$5,565.42
Rate for Payer: Kaiser Permanente Medicaid	$4,505.34
Rate for Payer: MDX Hawaii PPO	$8,568.98
Rate for Payer: University Health Alliance Commercial	$4,947.04

HUMERAL HEAD STB - COCR DWG151

Facility

$8,834.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,947.04
Max. Negotiated Rate	$8,568.98
Rate for Payer: Cash Price	$5,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$6,183.80
Rate for Payer: Health Management Network Commercial	$7,508.90
Rate for Payer: MDX Hawaii PPO	$8,568.98
Rate for Payer: University Health Alliance Commercial	$4,947.04

HUMERAL HEAD STB DWG152

Facility

$9,540.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,342.40
Max. Negotiated Rate	$9,253.80
Rate for Payer: Cash Price	$5,724.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,678.00
Rate for Payer: Health Management Network Commercial	$8,109.00
Rate for Payer: MDX Hawaii PPO	$9,253.80
Rate for Payer: University Health Alliance Commercial	$5,342.40

HUMERAL HEAD STB DWG152

Facility

$9,540.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,865.40
Max. Negotiated Rate	$9,253.80
Rate for Payer: Cash Price	$5,724.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,678.00
Rate for Payer: Health Management Network Commercial	$8,109.00
Rate for Payer: Kaiser Permanente Commercial	$6,010.20
Rate for Payer: Kaiser Permanente Medicaid	$4,865.40
Rate for Payer: MDX Hawaii PPO	$9,253.80
Rate for Payer: University Health Alliance Commercial	$5,342.40

Know your out-of-pocket cost for care.

All Charges