Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

OXFORD BEARING MD 4MM #159576

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD BEARING MD 4MM #159576

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD BEARING MED LEFT 7MM

Facility

$2,649.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,483.44
Max. Negotiated Rate	$2,569.53
Rate for Payer: Cash Price	$1,589.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,854.30
Rate for Payer: Health Management Network Commercial	$2,251.65
Rate for Payer: MDX Hawaii PPO	$2,569.53
Rate for Payer: University Health Alliance Commercial	$1,483.44

OXFORD BEARING MED LEFT 7MM

Facility

$2,649.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.99
Max. Negotiated Rate	$2,569.53
Rate for Payer: Cash Price	$1,589.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,854.30
Rate for Payer: Health Management Network Commercial	$2,251.65
Rate for Payer: Kaiser Permanente Commercial	$1,668.87
Rate for Payer: Kaiser Permanente Medicaid	$1,350.99
Rate for Payer: MDX Hawaii PPO	$2,569.53
Rate for Payer: University Health Alliance Commercial	$1,483.44

OXFORD BEARING PMA SZ5 159549

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD BEARING PMA SZ5 159549

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD FEM LG TWIN-PEG 161470

Facility

$3,340.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,703.40
Max. Negotiated Rate	$3,239.80
Rate for Payer: Cash Price	$2,004.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,338.00
Rate for Payer: Health Management Network Commercial	$2,839.00
Rate for Payer: Kaiser Permanente Commercial	$2,104.20
Rate for Payer: Kaiser Permanente Medicaid	$1,703.40
Rate for Payer: MDX Hawaii PPO	$3,239.80
Rate for Payer: University Health Alliance Commercial	$1,870.40

OXFORD FEM LG TWIN-PEG 161470

Facility

$3,340.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,870.40
Max. Negotiated Rate	$3,239.80
Rate for Payer: Cash Price	$2,004.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,338.00
Rate for Payer: Health Management Network Commercial	$2,839.00
Rate for Payer: MDX Hawaii PPO	$3,239.80
Rate for Payer: University Health Alliance Commercial	$1,870.40

OXFORD FEM MED TWIN-PEG 161469

Facility

$3,340.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,870.40
Max. Negotiated Rate	$3,239.80
Rate for Payer: Cash Price	$2,004.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,338.00
Rate for Payer: Health Management Network Commercial	$2,839.00
Rate for Payer: MDX Hawaii PPO	$3,239.80
Rate for Payer: University Health Alliance Commercial	$1,870.40

OXFORD FEM MED TWIN-PEG 161469

Facility

$3,340.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,703.40
Max. Negotiated Rate	$3,239.80
Rate for Payer: Cash Price	$2,004.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,338.00
Rate for Payer: Health Management Network Commercial	$2,839.00
Rate for Payer: Kaiser Permanente Commercial	$2,104.20
Rate for Payer: Kaiser Permanente Medicaid	$1,703.40
Rate for Payer: MDX Hawaii PPO	$3,239.80
Rate for Payer: University Health Alliance Commercial	$1,870.40

OXFORD FEMORAL LG TWIN PEG

Facility

$3,840.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,958.40
Max. Negotiated Rate	$3,724.80
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,688.00
Rate for Payer: Health Management Network Commercial	$3,264.00
Rate for Payer: Kaiser Permanente Commercial	$2,419.20
Rate for Payer: Kaiser Permanente Medicaid	$1,958.40
Rate for Payer: MDX Hawaii PPO	$3,724.80
Rate for Payer: University Health Alliance Commercial	$2,150.40

OXFORD FEMORAL LG TWIN PEG

Facility

$3,840.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,150.40
Max. Negotiated Rate	$3,724.80
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,688.00
Rate for Payer: Health Management Network Commercial	$3,264.00
Rate for Payer: MDX Hawaii PPO	$3,724.80
Rate for Payer: University Health Alliance Commercial	$2,150.40

OXFORD FEM SM TWIN-PEG 161468

Facility

$3,340.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,703.40
Max. Negotiated Rate	$3,239.80
Rate for Payer: Cash Price	$2,004.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,338.00
Rate for Payer: Health Management Network Commercial	$2,839.00
Rate for Payer: Kaiser Permanente Commercial	$2,104.20
Rate for Payer: Kaiser Permanente Medicaid	$1,703.40
Rate for Payer: MDX Hawaii PPO	$3,239.80
Rate for Payer: University Health Alliance Commercial	$1,870.40

OXFORD FEM SM TWIN-PEG 161468

Facility

$3,340.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,870.40
Max. Negotiated Rate	$3,239.80
Rate for Payer: Cash Price	$2,004.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,338.00
Rate for Payer: Health Management Network Commercial	$2,839.00
Rate for Payer: MDX Hawaii PPO	$3,239.80
Rate for Payer: University Health Alliance Commercial	$1,870.40

OXFORD PART KNEE SYS 159555

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD PART KNEE SYS 159555

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD PKS ARCM MEDIAL #159547

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD PKS ARCM MEDIAL #159547

Facility

$2,400.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

OXFORD PKS SZ-E LEFT #154726

Facility

$3,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,876.00
Max. Negotiated Rate	$3,249.50
Rate for Payer: Cash Price	$2,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,345.00
Rate for Payer: Health Management Network Commercial	$2,847.50
Rate for Payer: MDX Hawaii PPO	$3,249.50
Rate for Payer: University Health Alliance Commercial	$1,876.00

OXFORD PKS SZ-E LEFT #154726

Facility

$3,350.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,708.50
Max. Negotiated Rate	$3,249.50
Rate for Payer: Cash Price	$2,010.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,345.00
Rate for Payer: Health Management Network Commercial	$2,847.50
Rate for Payer: Kaiser Permanente Commercial	$2,110.50
Rate for Payer: Kaiser Permanente Medicaid	$1,708.50
Rate for Payer: MDX Hawaii PPO	$3,249.50
Rate for Payer: University Health Alliance Commercial	$1,876.00

OXFORD SAWBLADE STABLE 506298

Facility

$1,800.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,530.00
Max. Negotiated Rate	$1,746.00
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Health Management Network Commercial	$1,530.00
Rate for Payer: MDX Hawaii PPO	$1,746.00

OXFORD SAWBLADE STABLE 506298

Facility

$1,800.00

Hospital Revenue Code	272
Min. Negotiated Rate	$918.00
Max. Negotiated Rate	$1,746.00
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,710.00
Rate for Payer: Health Management Network Commercial	$1,530.00
Rate for Payer: Kaiser Permanente Commercial	$1,134.00
Rate for Payer: Kaiser Permanente Medicaid	$918.00
Rate for Payer: MDX Hawaii PPO	$1,746.00
Rate for Payer: University Health Alliance Commercial	$1,312.02

OXFORD UNI TIB LM

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

OXFORD UNI TIB LM

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,683.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

OXFORD UNI TIB SZ:D RM 154725

Facility

$3,300.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

Know your out-of-pocket cost for care.

All Charges