Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

STEM AS CEMENTED HUMERAL 7X100

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 CEMENTED HUMERAL 9X110

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 9X110

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 CEMENT 12X50MM 5560-S-112

Facility

$2,271.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.21
Max. Negotiated Rate	$2,202.87
Rate for Payer: Cash Price	$1,362.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,589.70
Rate for Payer: Health Management Network Commercial	$1,930.35
Rate for Payer: Kaiser Permanente Commercial	$1,430.73
Rate for Payer: Kaiser Permanente Medicaid	$1,158.21
Rate for Payer: MDX Hawaii PPO	$2,202.87
Rate for Payer: University Health Alliance Commercial	$1,271.76

STEM CEMENT 12X50MM 5560-S-112

Facility

$2,271.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,271.76
Max. Negotiated Rate	$2,202.87
Rate for Payer: Cash Price	$1,362.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,589.70
Rate for Payer: Health Management Network Commercial	$1,930.35
Rate for Payer: MDX Hawaii PPO	$2,202.87
Rate for Payer: University Health Alliance Commercial	$1,271.76

STEM CEMENTED HIP 6057-0335D

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 CEMENTED HIP 6057-0335D

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 CEMENTED HIP 6058-0335D

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 CEMENTED HIP 6058-0335D

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 CEMENTED TRIAT 5560-S-115

Facility

$2,163.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,211.28
Max. Negotiated Rate	$2,098.11
Rate for Payer: Cash Price	$1,297.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,514.10
Rate for Payer: Health Management Network Commercial	$1,838.55
Rate for Payer: MDX Hawaii PPO	$2,098.11
Rate for Payer: University Health Alliance Commercial	$1,211.28

STEM CEMENTED TRIAT 5560-S-115

Facility

$2,163.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.13
Max. Negotiated Rate	$2,098.11
Rate for Payer: Cash Price	$1,297.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,514.10
Rate for Payer: Health Management Network Commercial	$1,838.55
Rate for Payer: Kaiser Permanente Commercial	$1,362.69
Rate for Payer: Kaiser Permanente Medicaid	$1,103.13
Rate for Payer: MDX Hawaii PPO	$2,098.11
Rate for Payer: University Health Alliance Commercial	$1,211.28

STEM CEMENT HIP 6057-0740D

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 CEMENT HIP 6057-0740D

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 DISTAL P.COAT ARS980902

Facility

$11,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,608.00
Max. Negotiated Rate	$11,446.00
Rate for Payer: Cash Price	$7,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,260.00
Rate for Payer: Health Management Network Commercial	$10,030.00
Rate for Payer: MDX Hawaii PPO	$11,446.00
Rate for Payer: University Health Alliance Commercial	$6,608.00

STEM DISTAL P.COAT ARS980902

Facility

$11,800.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,018.00
Max. Negotiated Rate	$11,446.00
Rate for Payer: Cash Price	$7,080.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,260.00
Rate for Payer: Health Management Network Commercial	$10,030.00
Rate for Payer: Kaiser Permanente Commercial	$7,434.00
Rate for Payer: Kaiser Permanente Medicaid	$6,018.00
Rate for Payer: MDX Hawaii PPO	$11,446.00
Rate for Payer: University Health Alliance Commercial	$6,608.00

STEM EVOLVE PROLIN 7.5 496S075

Facility

$4,530.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,310.30
Max. Negotiated Rate	$4,394.10
Rate for Payer: Cash Price	$2,718.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,171.00
Rate for Payer: Health Management Network Commercial	$3,850.50
Rate for Payer: Kaiser Permanente Commercial	$2,853.90
Rate for Payer: Kaiser Permanente Medicaid	$2,310.30
Rate for Payer: MDX Hawaii PPO	$4,394.10
Rate for Payer: University Health Alliance Commercial	$2,536.80

STEM EVOLVE PROLIN 7.5 496S075

Facility

$4,530.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,536.80
Max. Negotiated Rate	$4,394.10
Rate for Payer: Cash Price	$2,718.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,171.00
Rate for Payer: Health Management Network Commercial	$3,850.50
Rate for Payer: MDX Hawaii PPO	$4,394.10
Rate for Payer: University Health Alliance Commercial	$2,536.80

STEM EXTEND TRIATHL 5571-S-025

Facility

$2,966.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,660.96
Max. Negotiated Rate	$2,877.02
Rate for Payer: Cash Price	$1,779.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,076.20
Rate for Payer: Health Management Network Commercial	$2,521.10
Rate for Payer: MDX Hawaii PPO	$2,877.02
Rate for Payer: University Health Alliance Commercial	$1,660.96

STEM EXTEND TRIATHL 5571-S-025

Facility

$2,966.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,512.66
Max. Negotiated Rate	$2,877.02
Rate for Payer: Cash Price	$1,779.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,076.20
Rate for Payer: Health Management Network Commercial	$2,521.10
Rate for Payer: Kaiser Permanente Commercial	$1,868.58
Rate for Payer: Kaiser Permanente Medicaid	$1,512.66
Rate for Payer: MDX Hawaii PPO	$2,877.02
Rate for Payer: University Health Alliance Commercial	$1,660.96

STEM FEMORAL HIP 6276-7-120

Facility

$6,737.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,435.87
Max. Negotiated Rate	$6,534.89
Rate for Payer: Cash Price	$4,042.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,715.90
Rate for Payer: Health Management Network Commercial	$5,726.45
Rate for Payer: Kaiser Permanente Commercial	$4,244.31
Rate for Payer: Kaiser Permanente Medicaid	$3,435.87
Rate for Payer: MDX Hawaii PPO	$6,534.89
Rate for Payer: University Health Alliance Commercial	$3,772.72

STEM FEMORAL HIP 6276-7-120

Facility

$6,737.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$3,772.72
Max. Negotiated Rate	$6,534.89
Rate for Payer: Cash Price	$4,042.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,715.90
Rate for Payer: Health Management Network Commercial	$5,726.45
Rate for Payer: MDX Hawaii PPO	$6,534.89
Rate for Payer: University Health Alliance Commercial	$3,772.72

STEM FINGER JOINT 470-0010

Facility

$2,522.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,286.22
Max. Negotiated Rate	$2,446.34
Rate for Payer: Cash Price	$1,513.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,765.40
Rate for Payer: Health Management Network Commercial	$2,143.70
Rate for Payer: Kaiser Permanente Commercial	$1,588.86
Rate for Payer: Kaiser Permanente Medicaid	$1,286.22
Rate for Payer: MDX Hawaii PPO	$2,446.34
Rate for Payer: University Health Alliance Commercial	$1,412.32

STEM FINGER JOINT 470-0010

Facility

$2,522.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,412.32
Max. Negotiated Rate	$2,446.34
Rate for Payer: Cash Price	$1,513.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,765.40
Rate for Payer: Health Management Network Commercial	$2,143.70
Rate for Payer: MDX Hawaii PPO	$2,446.34
Rate for Payer: University Health Alliance Commercial	$1,412.32

STEM-FIXED HUM 42X21X43 113034

Facility

$2,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,540.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,232.00

STEM-FIXED HUM 42X21X43 113034

Facility

$2,200.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,232.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,540.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,232.00

Know your out-of-pocket cost for care.

All Charges