Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

STEINMANN 4.8MM 00-0187-007-69

Facility

$120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Hawaii Western Management Group Commercial	$84.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: University Health Alliance Commercial	$67.20

STEINMANN 4.8MM 00-0187-007-69

Facility

$120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Hawaii Western Management Group Commercial	$84.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: University Health Alliance Commercial	$67.20

STEINMANN 4.8X229MM 262-01-04

Facility

$160.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Hawaii Western Management Group Commercial	$112.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: University Health Alliance Commercial	$89.60

STEINMANN 4.8X229MM 262-01-04

Facility

$160.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$155.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Hawaii Western Management Group Commercial	$112.00
Rate for Payer: Health Management Network Commercial	$136.00
Rate for Payer: Kaiser Permanente Commercial	$100.80
Rate for Payer: Kaiser Permanente Medicaid	$81.60
Rate for Payer: MDX Hawaii PPO	$155.20
Rate for Payer: University Health Alliance Commercial	$89.60

STEINMAN PIN 2.4MM 187-02-59

Facility

$120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Hawaii Western Management Group Commercial	$84.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: University Health Alliance Commercial	$67.20

STEINMAN PIN 2.4MM 187-02-59

Facility

$120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Hawaii Western Management Group Commercial	$84.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: University Health Alliance Commercial	$67.20

STEINMAN PIN 2.8MM 187-03-59

Facility

$120.00

Service Code	HCPCS C1769
Hospital Revenue Code	278
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Hawaii Western Management Group Commercial	$84.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: Kaiser Permanente Commercial	$75.60
Rate for Payer: Kaiser Permanente Medicaid	$61.20
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: University Health Alliance Commercial	$67.20

STEINMAN PIN 2.8MM 187-03-59

Facility

$120.00

Service Code	HCPCS C1769
Hospital Revenue Code	278
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$116.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Hawaii Western Management Group Commercial	$84.00
Rate for Payer: Health Management Network Commercial	$102.00
Rate for Payer: MDX Hawaii PPO	$116.40
Rate for Payer: University Health Alliance Commercial	$67.20

STEINMAN PIN 3.2MM 187-04-59

Facility

$140.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Hawaii Western Management Group Commercial	$98.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: Kaiser Permanente Commercial	$88.20
Rate for Payer: Kaiser Permanente Medicaid	$71.40
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: University Health Alliance Commercial	$78.40

STEINMAN PIN 3.2MM 187-04-59

Facility

$140.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$135.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Hawaii Western Management Group Commercial	$98.00
Rate for Payer: Health Management Network Commercial	$119.00
Rate for Payer: MDX Hawaii PPO	$135.80
Rate for Payer: University Health Alliance Commercial	$78.40

STEINMAN PIN 3.6MM 187-05-59

Facility

$110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$77.00
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: University Health Alliance Commercial	$61.60

STEINMAN PIN 3.6MM 187-05-59

Facility

$110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$56.10
Max. Negotiated Rate	$106.70
Rate for Payer: Cash Price	$66.00
Rate for Payer: Hawaii Western Management Group Commercial	$77.00
Rate for Payer: Health Management Network Commercial	$93.50
Rate for Payer: Kaiser Permanente Commercial	$69.30
Rate for Payer: Kaiser Permanente Medicaid	$56.10
Rate for Payer: MDX Hawaii PPO	$106.70
Rate for Payer: University Health Alliance Commercial	$61.60

STEINMAN PIN 4.0MM 187-06-59

Facility

$227.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$115.77
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$136.20
Rate for Payer: Hawaii Western Management Group Commercial	$158.90
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: Kaiser Permanente Commercial	$143.01
Rate for Payer: Kaiser Permanente Medicaid	$115.77
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: University Health Alliance Commercial	$127.12

STEINMAN PIN 4.0MM 187-06-59

Facility

$227.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$127.12
Max. Negotiated Rate	$220.19
Rate for Payer: Cash Price	$136.20
Rate for Payer: Hawaii Western Management Group Commercial	$158.90
Rate for Payer: Health Management Network Commercial	$192.95
Rate for Payer: MDX Hawaii PPO	$220.19
Rate for Payer: University Health Alliance Commercial	$127.12

STEM 11X40MM 127° 6052-1140S

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,236.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

STEM 11X40MM 127° 6052-1140S

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,947.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Kaiser Permanente Commercial	$3,641.40
Rate for Payer: Kaiser Permanente Medicaid	$2,947.80
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

STEM ACCOLADE HIP 6057-0230D

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,733.76
Max. Negotiated Rate	$3,003.12
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: University Health Alliance Commercial	$1,733.76

STEM ACCOLADE HIP 6057-0230D

Facility

$3,096.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,578.96
Max. Negotiated Rate	$3,003.12
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,167.20
Rate for Payer: Health Management Network Commercial	$2,631.60
Rate for Payer: Kaiser Permanente Commercial	$1,950.48
Rate for Payer: Kaiser Permanente Medicaid	$1,578.96
Rate for Payer: MDX Hawaii PPO	$3,003.12
Rate for Payer: University Health Alliance Commercial	$1,733.76

STEM ACCOLADE SZ2 6721-0230

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,947.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: Kaiser Permanente Commercial	$3,641.40
Rate for Payer: Kaiser Permanente Medicaid	$2,947.80
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

STEM ACCOLADE SZ2 6721-0230

Facility

$5,780.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,236.80
Max. Negotiated Rate	$5,606.60
Rate for Payer: Cash Price	$3,468.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,046.00
Rate for Payer: Health Management Network Commercial	$4,913.00
Rate for Payer: MDX Hawaii PPO	$5,606.60
Rate for Payer: University Health Alliance Commercial	$3,236.80

STEM AS CEMENTD HUMERAL 12X110

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

STEM AS CEMENTD HUMERAL 12X110

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

STEM AS CEMENTD HUMERAL 14X110

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

STEM AS CEMENTD HUMERAL 14X110

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

STEM AS CEMENTED HUMERAL 7X100

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

Know your out-of-pocket cost for care.

All Charges