Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

KNEE SZH 9MM 42-5182-008-09

Facility

$2,520.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,285.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Commercial	$1,587.60
Rate for Payer: Kaiser Permanente Medicaid	$1,285.20
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: University Health Alliance Commercial	$1,411.20

KNEE TIB SZ:3 00-5842-003-01

Facility

$2,861.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,602.16
Max. Negotiated Rate	$2,775.17
Rate for Payer: Cash Price	$1,716.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,002.70
Rate for Payer: Health Management Network Commercial	$2,431.85
Rate for Payer: MDX Hawaii PPO	$2,775.17
Rate for Payer: University Health Alliance Commercial	$1,602.16

KNEE TIB SZ:3 00-5842-003-01

Facility

$2,861.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,459.11
Max. Negotiated Rate	$2,775.17
Rate for Payer: Cash Price	$1,716.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,002.70
Rate for Payer: Health Management Network Commercial	$2,431.85
Rate for Payer: Kaiser Permanente Commercial	$1,802.43
Rate for Payer: Kaiser Permanente Medicaid	$1,459.11
Rate for Payer: MDX Hawaii PPO	$2,775.17
Rate for Payer: University Health Alliance Commercial	$1,602.16

KNEE TIB SZ:5 00-5842-005-01

Facility

$4,220.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,152.20
Max. Negotiated Rate	$4,093.40
Rate for Payer: Cash Price	$2,532.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,954.00
Rate for Payer: Health Management Network Commercial	$3,587.00
Rate for Payer: Kaiser Permanente Commercial	$2,658.60
Rate for Payer: Kaiser Permanente Medicaid	$2,152.20
Rate for Payer: MDX Hawaii PPO	$4,093.40
Rate for Payer: University Health Alliance Commercial	$2,363.20

KNEE TIB SZ:5 00-5842-005-01

Facility

$4,220.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,363.20
Max. Negotiated Rate	$4,093.40
Rate for Payer: Cash Price	$2,532.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,954.00
Rate for Payer: Health Management Network Commercial	$3,587.00
Rate for Payer: MDX Hawaii PPO	$4,093.40
Rate for Payer: University Health Alliance Commercial	$2,363.20

KNE FEM SZ:D/LT 00-5956-014-01

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:D/LT 00-5956-014-01

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:E 00-5842-015-01

Facility

$6,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,557.76
Max. Negotiated Rate	$6,766.72
Rate for Payer: Cash Price	$4,185.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,883.20
Rate for Payer: Health Management Network Commercial	$5,929.60
Rate for Payer: Kaiser Permanente Commercial	$4,394.88
Rate for Payer: Kaiser Permanente Medicaid	$3,557.76
Rate for Payer: MDX Hawaii PPO	$6,766.72
Rate for Payer: University Health Alliance Commercial	$3,906.56

KNE FEM SZ:E 00-5842-015-01

Facility

$6,976.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,906.56
Max. Negotiated Rate	$6,766.72
Rate for Payer: Cash Price	$4,185.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,883.20
Rate for Payer: Health Management Network Commercial	$5,929.60
Rate for Payer: MDX Hawaii PPO	$6,766.72
Rate for Payer: University Health Alliance Commercial	$3,906.56

KNE FEM SZ:E/LT 00-5750-015-01

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:E/LT 00-5750-015-01

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:E/LT 00-5956-015-01

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:E/LT 00-5956-015-01

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:E/LT 00-5964-015-51

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:E/LT 00-5964-015-51

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:E/RT 00-5750-015-02

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:E/RT 00-5750-015-02

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:F/LT 00-5956-016-01

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:F/LT 00-5956-016-01

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:F/RT 00-5750-016-02

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:F/RT 00-5750-016-02

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:G/LT 00-5956-017-01

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:G/LT 00-5956-017-01

Facility

$5,000.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

KNE FEM SZ:G/LT 00-5956-017-02

Facility

$7,308.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,092.48
Max. Negotiated Rate	$7,088.76
Rate for Payer: Cash Price	$4,384.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,115.60
Rate for Payer: Health Management Network Commercial	$6,211.80
Rate for Payer: MDX Hawaii PPO	$7,088.76
Rate for Payer: University Health Alliance Commercial	$4,092.48

KNE FEM SZ:G/LT 00-5956-017-02

Facility

$7,308.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,727.08
Max. Negotiated Rate	$7,088.76
Rate for Payer: Cash Price	$4,384.80
Rate for Payer: Hawaii Western Management Group Commercial	$5,115.60
Rate for Payer: Health Management Network Commercial	$6,211.80
Rate for Payer: Kaiser Permanente Commercial	$4,604.04
Rate for Payer: Kaiser Permanente Medicaid	$3,727.08
Rate for Payer: MDX Hawaii PPO	$7,088.76
Rate for Payer: University Health Alliance Commercial	$4,092.48

Know your out-of-pocket cost for care.

All Charges