Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HUMERAL INSERT 5571-S-3204-E

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,792.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

HUMERAL INSERT 5571-S-3204-E

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,632.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: Kaiser Permanente Commercial	$2,016.00
Rate for Payer: Kaiser Permanente Medicaid	$1,632.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

HUMERAL INSRT 36X4 5571-S-3604

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,632.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: Kaiser Permanente Commercial	$2,016.00
Rate for Payer: Kaiser Permanente Medicaid	$1,632.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

HUMERAL INSRT 36X4 5571-S-3604

Facility

$3,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,792.00
Max. Negotiated Rate	$3,104.00
Rate for Payer: Cash Price	$1,920.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,240.00
Rate for Payer: Health Management Network Commercial	$2,720.00
Rate for Payer: MDX Hawaii PPO	$3,104.00
Rate for Payer: University Health Alliance Commercial	$1,792.00

HUMERAL LF 72MM 02.117.701

Facility

$2,837.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,446.87
Max. Negotiated Rate	$2,751.89
Rate for Payer: Cash Price	$1,702.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,985.90
Rate for Payer: Health Management Network Commercial	$2,411.45
Rate for Payer: Kaiser Permanente Commercial	$1,787.31
Rate for Payer: Kaiser Permanente Medicaid	$1,446.87
Rate for Payer: MDX Hawaii PPO	$2,751.89
Rate for Payer: University Health Alliance Commercial	$1,588.72

HUMERAL LF 72MM 02.117.701

Facility

$2,837.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,588.72
Max. Negotiated Rate	$2,751.89
Rate for Payer: Cash Price	$1,702.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,985.90
Rate for Payer: Health Management Network Commercial	$2,411.45
Rate for Payer: MDX Hawaii PPO	$2,751.89
Rate for Payer: University Health Alliance Commercial	$1,588.72

HUMERAL LF 88MM 02.117.304

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,401.99
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: Kaiser Permanente Commercial	$1,731.87
Rate for Payer: Kaiser Permanente Medicaid	$1,401.99
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

HUMERAL LF 88MM 02.117.304

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,539.44
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

HUMERAL PF STEM #01.04201.092

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,480.00
Max. Negotiated Rate	$7,760.00
Rate for Payer: Cash Price	$4,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,600.00
Rate for Payer: Health Management Network Commercial	$6,800.00
Rate for Payer: MDX Hawaii PPO	$7,760.00
Rate for Payer: University Health Alliance Commercial	$4,480.00

HUMERAL PF STEM #01.04201.092

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,080.00
Max. Negotiated Rate	$7,760.00
Rate for Payer: Cash Price	$4,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,600.00
Rate for Payer: Health Management Network Commercial	$6,800.00
Rate for Payer: Kaiser Permanente Commercial	$5,040.00
Rate for Payer: Kaiser Permanente Medicaid	$4,080.00
Rate for Payer: MDX Hawaii PPO	$7,760.00
Rate for Payer: University Health Alliance Commercial	$4,480.00

HUMERAL PIN 7000-35-130

Facility

$480.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$465.60
Rate for Payer: Cash Price	$288.00
Rate for Payer: Hawaii Western Management Group Commercial	$456.00
Rate for Payer: Health Management Network Commercial	$408.00
Rate for Payer: Kaiser Permanente Commercial	$302.40
Rate for Payer: Kaiser Permanente Medicaid	$244.80
Rate for Payer: MDX Hawaii PPO	$465.60
Rate for Payer: University Health Alliance Commercial	$349.87

HUMERAL PIN 7000-35-130

Facility

$480.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$408.00
Max. Negotiated Rate	$465.60
Rate for Payer: Cash Price	$288.00
Rate for Payer: Health Management Network Commercial	$408.00
Rate for Payer: MDX Hawaii PPO	$465.60

HUMERAL REVERSE INSERT DWP1360

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,550.08
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

HUMERAL REVERSE INSERT DWP1360

Facility

$2,768.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.68
Max. Negotiated Rate	$2,684.96
Rate for Payer: Cash Price	$1,660.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,937.60
Rate for Payer: Health Management Network Commercial	$2,352.80
Rate for Payer: Kaiser Permanente Commercial	$1,743.84
Rate for Payer: Kaiser Permanente Medicaid	$1,411.68
Rate for Payer: MDX Hawaii PPO	$2,684.96
Rate for Payer: University Health Alliance Commercial	$1,550.08

HUMERAL SPOOL SMALL LEFT

Facility

$6,622.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,708.32
Max. Negotiated Rate	$6,423.34
Rate for Payer: Cash Price	$3,973.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,635.40
Rate for Payer: Health Management Network Commercial	$5,628.70
Rate for Payer: MDX Hawaii PPO	$6,423.34
Rate for Payer: University Health Alliance Commercial	$3,708.32

HUMERAL SPOOL SMALL LEFT

Facility

$6,622.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,377.22
Max. Negotiated Rate	$6,423.34
Rate for Payer: Cash Price	$3,973.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,635.40
Rate for Payer: Health Management Network Commercial	$5,628.70
Rate for Payer: Kaiser Permanente Commercial	$4,171.86
Rate for Payer: Kaiser Permanente Medicaid	$3,377.22
Rate for Payer: MDX Hawaii PPO	$6,423.34
Rate for Payer: University Health Alliance Commercial	$3,708.32

HUMERAL STB HEAD 51MM DWG051

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 STB HEAD 51MM DWG051

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 STEM 11MM AR-9100-11S

Facility

$8,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,676.00
Max. Negotiated Rate	$8,099.50
Rate for Payer: Cash Price	$5,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,845.00
Rate for Payer: Health Management Network Commercial	$7,097.50
Rate for Payer: MDX Hawaii PPO	$8,099.50
Rate for Payer: University Health Alliance Commercial	$4,676.00

HUMERAL STEM 11MM AR-9100-11S

Facility

$8,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,258.50
Max. Negotiated Rate	$8,099.50
Rate for Payer: Cash Price	$5,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,845.00
Rate for Payer: Health Management Network Commercial	$7,097.50
Rate for Payer: Kaiser Permanente Commercial	$5,260.50
Rate for Payer: Kaiser Permanente Medicaid	$4,258.50
Rate for Payer: MDX Hawaii PPO	$8,099.50
Rate for Payer: University Health Alliance Commercial	$4,676.00

HUMERAL STEM 12-1 01.04201.123

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,480.00
Max. Negotiated Rate	$7,760.00
Rate for Payer: Cash Price	$4,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,600.00
Rate for Payer: Health Management Network Commercial	$6,800.00
Rate for Payer: MDX Hawaii PPO	$7,760.00
Rate for Payer: University Health Alliance Commercial	$4,480.00

HUMERAL STEM 12-1 01.04201.123

Facility

$8,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,080.00
Max. Negotiated Rate	$7,760.00
Rate for Payer: Cash Price	$4,800.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,600.00
Rate for Payer: Health Management Network Commercial	$6,800.00
Rate for Payer: Kaiser Permanente Commercial	$5,040.00
Rate for Payer: Kaiser Permanente Medicaid	$4,080.00
Rate for Payer: MDX Hawaii PPO	$7,760.00
Rate for Payer: University Health Alliance Commercial	$4,480.00

HUMERAL STEM 13MM AR-9100-13S

Facility

$8,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,258.50
Max. Negotiated Rate	$8,099.50
Rate for Payer: Cash Price	$5,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,845.00
Rate for Payer: Health Management Network Commercial	$7,097.50
Rate for Payer: Kaiser Permanente Commercial	$5,260.50
Rate for Payer: Kaiser Permanente Medicaid	$4,258.50
Rate for Payer: MDX Hawaii PPO	$8,099.50
Rate for Payer: University Health Alliance Commercial	$4,676.00

HUMERAL STEM 13MM AR-9100-13S

Facility

$8,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,676.00
Max. Negotiated Rate	$8,099.50
Rate for Payer: Cash Price	$5,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$5,845.00
Rate for Payer: Health Management Network Commercial	$7,097.50
Rate for Payer: MDX Hawaii PPO	$8,099.50
Rate for Payer: University Health Alliance Commercial	$4,676.00

HUMERAL STEM 8X118MM 5568-0008

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

Know your out-of-pocket cost for care.

All Charges