OBJECTIVES: Primary Total Hip Arthroplasty(THA) provides quality of life to patients and is cost-effective.   Improvements to implant life have focused on the bearing surface with ceramic-on-polyethylene(CoP) bearing use growing rapidly due to evidence of longer implant life.  We sought to determine if the increased CoP cost over the metal-on-polyethylene(MoP)  provides enough benefit through lower revision rate to justify its utilization.  METHODS: A Markov decision model was designed to determine the reduction in CoP 20-year revision rate required to make this implant cost-effective compared to MoP.  Premier’s 2012 Research Database provided hospitalization costs for primary and revision surgeries.  The Orthopedic Research Network(ORN) provided aggregated implant purchase price information.  The HealthEast Joint Registry was the source of the MoP revision rate used for comparison.  At each 10-year age increment/bearing cost condition, the CoP revision rate was varied until the lifetime costs were equal for the 2 different bearings.  RESULTS: The sample included 20,398 patients aged 45-89+ from 475 US hospitals with identified bearing surfaces.  CoP vs. MoP surface cost differences were $325+/-$177(p=0.014) and $1,003+/-$710(p=0.003), respectively, based on unadjusted and adjusted analysis of Premier data.  ORN reports indicated a $600 difference in 2012.  Revision costs were $23,628+/-$385 on 8,566 patients.  HealthEast’s data indicates a 20-year MoP revision rate of 14.5/100THAs.  An inflection in the revision rate-cost-age curve at 70yo prompted further consideration.  Markov analysis indicated the cost-effective CoP revision rate to be 12.5 revisions/100THAs at $325 cost difference and 9.0/100THAs at $1,003 cost difference, in a 70yo patient, indicating that CoP can be cost-effective. CONCLUSIONS: Shifting from MoP to CoP can be justified depending on the patient age, cost of the device, and actual CoP revision rate.  All else equal, shifting all THAs in patients below age 70 to CoP and over 70 to MoP can be cost justified, even in the highest cost difference case.