Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HUMERAL STEM 8X118MM 5568-0008

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 STEM 9X118 5569-P-2009

Facility

$9,010.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,595.10
Max. Negotiated Rate	$8,739.70
Rate for Payer: Cash Price	$5,406.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,307.00
Rate for Payer: Health Management Network Commercial	$7,658.50
Rate for Payer: Kaiser Permanente Commercial	$5,676.30
Rate for Payer: Kaiser Permanente Medicaid	$4,595.10
Rate for Payer: MDX Hawaii PPO	$8,739.70
Rate for Payer: University Health Alliance Commercial	$5,045.60

HUMERAL STEM 9X118 5569-P-2009

Facility

$9,010.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,045.60
Max. Negotiated Rate	$8,739.70
Rate for Payer: Cash Price	$5,406.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,307.00
Rate for Payer: Health Management Network Commercial	$7,658.50
Rate for Payer: MDX Hawaii PPO	$8,739.70
Rate for Payer: University Health Alliance Commercial	$5,045.60

HUMERAL STEM AS PRESS-FIT

Facility

$10,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,146.56
Max. Negotiated Rate	$10,646.72
Rate for Payer: Cash Price	$6,585.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,683.20
Rate for Payer: Health Management Network Commercial	$9,329.60
Rate for Payer: MDX Hawaii PPO	$10,646.72
Rate for Payer: University Health Alliance Commercial	$6,146.56

HUMERAL STEM AS PRESS-FIT

Facility

$10,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,597.76
Max. Negotiated Rate	$10,646.72
Rate for Payer: Cash Price	$6,585.60
Rate for Payer: Hawaii Western Management Group Commercial	$7,683.20
Rate for Payer: Health Management Network Commercial	$9,329.60
Rate for Payer: Kaiser Permanente Commercial	$6,914.88
Rate for Payer: Kaiser Permanente Medicaid	$5,597.76
Rate for Payer: MDX Hawaii PPO	$10,646.72
Rate for Payer: University Health Alliance Commercial	$6,146.56

HUMERAL STEM C9#01.04211.092

Facility

$6,608.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,370.08
Max. Negotiated Rate	$6,409.76
Rate for Payer: Cash Price	$3,964.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,625.60
Rate for Payer: Health Management Network Commercial	$5,616.80
Rate for Payer: Kaiser Permanente Commercial	$4,163.04
Rate for Payer: Kaiser Permanente Medicaid	$3,370.08
Rate for Payer: MDX Hawaii PPO	$6,409.76
Rate for Payer: University Health Alliance Commercial	$3,700.48

HUMERAL STEM C9#01.04211.092

Facility

$6,608.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,700.48
Max. Negotiated Rate	$6,409.76
Rate for Payer: Cash Price	$3,964.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,625.60
Rate for Payer: Health Management Network Commercial	$5,616.80
Rate for Payer: MDX Hawaii PPO	$6,409.76
Rate for Payer: University Health Alliance Commercial	$3,700.48

HUMERAL STEM CEMENTED DWF702B

Facility

$10,750.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,020.00
Max. Negotiated Rate	$10,427.50
Rate for Payer: Cash Price	$6,450.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,525.00
Rate for Payer: Health Management Network Commercial	$9,137.50
Rate for Payer: MDX Hawaii PPO	$10,427.50
Rate for Payer: University Health Alliance Commercial	$6,020.00

HUMERAL STEM CEMENTED DWF702B

Facility

$10,750.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,482.50
Max. Negotiated Rate	$10,427.50
Rate for Payer: Cash Price	$6,450.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,525.00
Rate for Payer: Health Management Network Commercial	$9,137.50
Rate for Payer: Kaiser Permanente Commercial	$6,772.50
Rate for Payer: Kaiser Permanente Medicaid	$5,482.50
Rate for Payer: MDX Hawaii PPO	$10,427.50
Rate for Payer: University Health Alliance Commercial	$6,020.00

HUMERAL STEM CEMENTED X10.5-10

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 CEMENTED X10.5-10

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 CEMENTED X5-70

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 CEMENTED X5-70

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 CEMENTED X6-70

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 CEMENTED X6-70

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 CEMENTED X7-90

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 CEMENTED X7-90

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 CEMENTED X9-100

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 CEMENTED X9-100

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 LNG PTC DWF613B

Facility

$11,368.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,797.68
Max. Negotiated Rate	$11,026.96
Rate for Payer: Cash Price	$6,820.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,957.60
Rate for Payer: Health Management Network Commercial	$9,662.80
Rate for Payer: Kaiser Permanente Commercial	$7,161.84
Rate for Payer: Kaiser Permanente Medicaid	$5,797.68
Rate for Payer: MDX Hawaii PPO	$11,026.96
Rate for Payer: University Health Alliance Commercial	$6,366.08

HUMERAL STEM LNG PTC DWF613B

Facility

$11,368.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,366.08
Max. Negotiated Rate	$11,026.96
Rate for Payer: Cash Price	$6,820.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,957.60
Rate for Payer: Health Management Network Commercial	$9,662.80
Rate for Payer: MDX Hawaii PPO	$11,026.96
Rate for Payer: University Health Alliance Commercial	$6,366.08

HUMERAL STEM MICRO 11MM 113611

Facility

$8,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,488.00
Max. Negotiated Rate	$8,536.00
Rate for Payer: Cash Price	$5,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,160.00
Rate for Payer: Health Management Network Commercial	$7,480.00
Rate for Payer: Kaiser Permanente Commercial	$5,544.00
Rate for Payer: Kaiser Permanente Medicaid	$4,488.00
Rate for Payer: MDX Hawaii PPO	$8,536.00
Rate for Payer: University Health Alliance Commercial	$4,928.00

HUMERAL STEM MICRO 11MM 113611

Facility

$8,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,928.00
Max. Negotiated Rate	$8,536.00
Rate for Payer: Cash Price	$5,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$6,160.00
Rate for Payer: Health Management Network Commercial	$7,480.00
Rate for Payer: MDX Hawaii PPO	$8,536.00
Rate for Payer: University Health Alliance Commercial	$4,928.00

HUMERAL STEM MINI 10MM 113630

Facility

$13,880.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$7,772.80
Max. Negotiated Rate	$13,463.60
Rate for Payer: Cash Price	$8,328.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,716.00
Rate for Payer: Health Management Network Commercial	$11,798.00
Rate for Payer: MDX Hawaii PPO	$13,463.60
Rate for Payer: University Health Alliance Commercial	$7,772.80

HUMERAL STEM MINI 10MM 113630

Facility

$13,880.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$7,078.80
Max. Negotiated Rate	$13,463.60
Rate for Payer: Cash Price	$8,328.00
Rate for Payer: Hawaii Western Management Group Commercial	$9,716.00
Rate for Payer: Health Management Network Commercial	$11,798.00
Rate for Payer: Kaiser Permanente Commercial	$8,744.40
Rate for Payer: Kaiser Permanente Medicaid	$7,078.80
Rate for Payer: MDX Hawaii PPO	$13,463.60
Rate for Payer: University Health Alliance Commercial	$7,772.80

Know your out-of-pocket cost for care.

All Charges