Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

STEM HUMERAL 9MM 5568-0009

Facility

$8,462.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$4,315.62
Max. Negotiated Rate	$8,208.14
Rate for Payer: Cash Price	$5,077.20
Rate for Payer: Hawaii Western Management Group Commercial	$5,923.40
Rate for Payer: Health Management Network Commercial	$7,192.70
Rate for Payer: Kaiser Permanente Commercial	$5,331.06
Rate for Payer: Kaiser Permanente Medicaid	$4,315.62
Rate for Payer: MDX Hawaii PPO	$8,208.14
Rate for Payer: University Health Alliance Commercial	$4,738.72

STEM HUMERAL 9MM AR-9100-09S

Facility

$11,930.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,680.80
Max. Negotiated Rate	$11,572.10
Rate for Payer: Cash Price	$7,158.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,351.00
Rate for Payer: Health Management Network Commercial	$10,140.50
Rate for Payer: MDX Hawaii PPO	$11,572.10
Rate for Payer: University Health Alliance Commercial	$6,680.80

STEM HUMERAL 9MM AR-9100-09S

Facility

$11,930.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,084.30
Max. Negotiated Rate	$11,572.10
Rate for Payer: Cash Price	$7,158.00
Rate for Payer: Hawaii Western Management Group Commercial	$8,351.00
Rate for Payer: Health Management Network Commercial	$10,140.50
Rate for Payer: Kaiser Permanente Commercial	$7,515.90
Rate for Payer: Kaiser Permanente Medicaid	$6,084.30
Rate for Payer: MDX Hawaii PPO	$11,572.10
Rate for Payer: University Health Alliance Commercial	$6,680.80

STEM HUMERAL CEMENTED X12-100

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 HUMERAL CEMENTED X12-100

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 HUMERAL CEMENTED X14-100

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 HUMERAL CEMENTED X14-100

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 HUMERAL CEMENTED X16-120

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 HUMERAL CEMENTED X16-120

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 HUMERAL CEMENTED X18-120

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 HUMERAL CEMENTED X18-120

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 HUMERAL MODULAR 14X133MM

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

STEM HUMERAL MODULAR 14X133MM

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

STEM HUMERAL SMALL LEFT 72MM

Facility

$13,242.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$6,753.42
Max. Negotiated Rate	$12,844.74
Rate for Payer: Cash Price	$7,945.20
Rate for Payer: Hawaii Western Management Group Commercial	$9,269.40
Rate for Payer: Health Management Network Commercial	$11,255.70
Rate for Payer: Kaiser Permanente Commercial	$8,342.46
Rate for Payer: Kaiser Permanente Medicaid	$6,753.42
Rate for Payer: MDX Hawaii PPO	$12,844.74
Rate for Payer: University Health Alliance Commercial	$7,415.52

STEM HUMERAL SMALL LEFT 72MM

Facility

$13,242.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$7,415.52
Max. Negotiated Rate	$12,844.74
Rate for Payer: Cash Price	$7,945.20
Rate for Payer: Hawaii Western Management Group Commercial	$9,269.40
Rate for Payer: Health Management Network Commercial	$11,255.70
Rate for Payer: MDX Hawaii PPO	$12,844.74
Rate for Payer: University Health Alliance Commercial	$7,415.52

STEM HUMERAL SZ7 AR-9501-07P

Facility

$4,970.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,783.20
Max. Negotiated Rate	$4,820.90
Rate for Payer: Cash Price	$2,982.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,479.00
Rate for Payer: Health Management Network Commercial	$4,224.50
Rate for Payer: MDX Hawaii PPO	$4,820.90
Rate for Payer: University Health Alliance Commercial	$2,783.20

STEM HUMERAL SZ7 AR-9501-07P

Facility

$4,970.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,534.70
Max. Negotiated Rate	$4,820.90
Rate for Payer: Cash Price	$2,982.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,479.00
Rate for Payer: Health Management Network Commercial	$4,224.50
Rate for Payer: Kaiser Permanente Commercial	$3,131.10
Rate for Payer: Kaiser Permanente Medicaid	$2,534.70
Rate for Payer: MDX Hawaii PPO	$4,820.90
Rate for Payer: University Health Alliance Commercial	$2,783.20

STEM HUMERL 11X123 5569-P-2011

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

STEM HUMERL 11X123 5569-P-2011

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

STEM PROLINE EVOLVE 496S055

Facility

$4,532.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,537.92
Max. Negotiated Rate	$4,396.04
Rate for Payer: Cash Price	$2,719.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,172.40
Rate for Payer: Health Management Network Commercial	$3,852.20
Rate for Payer: MDX Hawaii PPO	$4,396.04
Rate for Payer: University Health Alliance Commercial	$2,537.92

STEM PROLINE EVOLVE 496S055

Facility

$4,532.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,311.32
Max. Negotiated Rate	$4,396.04
Rate for Payer: Cash Price	$2,719.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,172.40
Rate for Payer: Health Management Network Commercial	$3,852.20
Rate for Payer: Kaiser Permanente Commercial	$2,855.16
Rate for Payer: Kaiser Permanente Medicaid	$2,311.32
Rate for Payer: MDX Hawaii PPO	$4,396.04
Rate for Payer: University Health Alliance Commercial	$2,537.92

STEM PTC HUMERAL DWF603B

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

STEM PTC HUMERAL DWF603B

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

STEM PTC HUMERAL DWF605B

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

STEM PTC HUMERAL DWF605B

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

Know your out-of-pocket cost for care.

All Charges