Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

HUMERAL STEM STD PTC

Facility

$8,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,906.72
Max. Negotiated Rate	$8,499.14
Rate for Payer: Cash Price	$5,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,133.40
Rate for Payer: Health Management Network Commercial	$7,447.70
Rate for Payer: MDX Hawaii PPO	$8,499.14
Rate for Payer: University Health Alliance Commercial	$4,906.72

HUMERAL STEM STD PTC

Facility

$8,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,468.62
Max. Negotiated Rate	$8,499.14
Rate for Payer: Cash Price	$5,257.20
Rate for Payer: Hawaii Western Management Group Commercial	$6,133.40
Rate for Payer: Health Management Network Commercial	$7,447.70
Rate for Payer: Kaiser Permanente Commercial	$5,520.06
Rate for Payer: Kaiser Permanente Medicaid	$4,468.62
Rate for Payer: MDX Hawaii PPO	$8,499.14
Rate for Payer: University Health Alliance Commercial	$4,906.72

HUMERAL STEM STND PTC DWF604A

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 STND PTC DWF604A

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 SZ 2+ DWX2PS

Facility

$10,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,488.62
Max. Negotiated Rate	$10,439.14
Rate for Payer: Cash Price	$6,457.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,533.40
Rate for Payer: Health Management Network Commercial	$9,147.70
Rate for Payer: Kaiser Permanente Commercial	$6,780.06
Rate for Payer: Kaiser Permanente Medicaid	$5,488.62
Rate for Payer: MDX Hawaii PPO	$10,439.14
Rate for Payer: University Health Alliance Commercial	$6,026.72

HUMERAL STEM SZ 2+ DWX2PS

Facility

$10,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,026.72
Max. Negotiated Rate	$10,439.14
Rate for Payer: Cash Price	$6,457.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,533.40
Rate for Payer: Health Management Network Commercial	$9,147.70
Rate for Payer: MDX Hawaii PPO	$10,439.14
Rate for Payer: University Health Alliance Commercial	$6,026.72

HUMERAL STEM UC12 01.04201.122

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 UC12 01.04201.122

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 UNCEMENTED X14-1

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 UNCEMENTED X14-1

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 SYS +0MM DWP1390

Facility

$5,812.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,964.12
Max. Negotiated Rate	$5,637.64
Rate for Payer: Cash Price	$3,487.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,068.40
Rate for Payer: Health Management Network Commercial	$4,940.20
Rate for Payer: Kaiser Permanente Commercial	$3,661.56
Rate for Payer: Kaiser Permanente Medicaid	$2,964.12
Rate for Payer: MDX Hawaii PPO	$5,637.64
Rate for Payer: University Health Alliance Commercial	$3,254.72

HUMERAL SYS +0MM DWP1390

Facility

$5,812.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,254.72
Max. Negotiated Rate	$5,637.64
Rate for Payer: Cash Price	$3,487.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,068.40
Rate for Payer: Health Management Network Commercial	$4,940.20
Rate for Payer: MDX Hawaii PPO	$5,637.64
Rate for Payer: University Health Alliance Commercial	$3,254.72

HUMERAL SYS 3.0X100 MWM100

Facility

$600.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Hawaii Western Management Group Commercial	$570.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: University Health Alliance Commercial	$437.34

HUMERAL SYS 3.0X100 MWM100

Facility

$600.00

Service Code	HCPCS C1776
Hospital Revenue Code	272
Min. Negotiated Rate	$510.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: MDX Hawaii PPO	$582.00

HUMERAL SYS STD SH DWX2SS

Facility

$10,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$5,488.62
Max. Negotiated Rate	$10,439.14
Rate for Payer: Cash Price	$6,457.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,533.40
Rate for Payer: Health Management Network Commercial	$9,147.70
Rate for Payer: Kaiser Permanente Commercial	$6,780.06
Rate for Payer: Kaiser Permanente Medicaid	$5,488.62
Rate for Payer: MDX Hawaii PPO	$10,439.14
Rate for Payer: University Health Alliance Commercial	$6,026.72

HUMERAL SYS STD SH DWX2SS

Facility

$10,762.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,026.72
Max. Negotiated Rate	$10,439.14
Rate for Payer: Cash Price	$6,457.20
Rate for Payer: Hawaii Western Management Group Commercial	$7,533.40
Rate for Payer: Health Management Network Commercial	$9,147.70
Rate for Payer: MDX Hawaii PPO	$10,439.14
Rate for Payer: University Health Alliance Commercial	$6,026.72

HUMERAL TRAY 40MM 110031402

Facility

$2,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,785.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$1,300.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: University Health Alliance Commercial	$1,428.00

HUMERAL TRAY 40MM 110031402

Facility

$2,550.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,428.00
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,785.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: University Health Alliance Commercial	$1,428.00

HUM INSERT 32X8MM 5571-S-3208

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

HUM INSERT 32X8MM 5571-S-3208

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

HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION [125430]

Facility

$4,277.00

Service Code	HCPCS J7168
Hospital Revenue Code	636
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$4,148.69
Rate for Payer: AlohaCare Medicaid	$2.05
Rate for Payer: AlohaCare Medicare	$2.05
Rate for Payer: Cash Price	$2,566.20
Rate for Payer: Cash Price	$2,566.20
Rate for Payer: Devoted Health Medicare	$2.25
Rate for Payer: Hawaii Medical Service Association Commercial	$2.56
Rate for Payer: Hawaii Medical Service Association Medicare	$2.05
Rate for Payer: Hawaii Western Management Group Commercial	$4,063.15
Rate for Payer: Health Management Network Commercial	$3,635.45
Rate for Payer: Humana Medicare	$2.05
Rate for Payer: Kaiser Permanente Commercial	$2,694.51
Rate for Payer: Kaiser Permanente Medicaid	$2,181.27
Rate for Payer: Kaiser Permanente Medicare	$2.05
Rate for Payer: MDX Hawaii PPO	$4,148.69
Rate for Payer: Ohana Health Plan Medicaid	$2.25
Rate for Payer: Ohana Health Plan Medicare	$2.05
Rate for Payer: UnitedHealthcare Medicaid	$2,566.20
Rate for Payer: UnitedHealthcare Medicare	$2.05
Rate for Payer: University Health Alliance Commercial	$3,117.51

HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION [125430]

Facility

$4,277.00

Service Code	HCPCS J7168
Hospital Revenue Code	636
Min. Negotiated Rate	$3,635.45
Max. Negotiated Rate	$4,148.69
Rate for Payer: Cash Price	$2,566.20
Rate for Payer: Health Management Network Commercial	$3,635.45
Rate for Payer: MDX Hawaii PPO	$4,148.69

HUM STEM 12X128MM 5569-P-2012

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

HUM STEM 12X128MM 5569-P-2012

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

HYALURONATE SODIUM, STABILIZED 60 MG/3 ML INTRA-ARTICULAR SYRINGE [150807]

Facility

$2,007.00

Service Code	HCPCS J7318
Hospital Revenue Code	250
Min. Negotiated Rate	$1,705.95
Max. Negotiated Rate	$1,946.79
Rate for Payer: Cash Price	$1,204.20
Rate for Payer: Health Management Network Commercial	$1,705.95
Rate for Payer: MDX Hawaii PPO	$1,946.79

Know your out-of-pocket cost for care.

All Charges