In an age of cost-consciousness in health care, it is essential that we seek to understand the ramifications of the choices where costs and expected clinical performance differ. When the cost differences are evolving and performance differences are not yet clearly defined, it is even more important for physicians and patients to ponder the consequences of these shared decisions. The case of bearing choice in total hip arthroplasty is the quintessential case where the ceramic-on-polyethylene choice generally costs more, but is expected to perform better by having fewer failed hip replacements that require some 10-20 years for meaningful differences to emerge. This study demonstrated that clinical problems in ceramic-on-ceramic and metal-on-metal surfaces, once thought to be the future of hip arthroplasty, have market consequences. Significantly reduced use and decreased cost premium of these surfaces compared to the cheapest alternative, metal-on-polyethylene, was observed over the study period. Further, in a constant press to increase the bearing life in patients, the use of ceramic-on-polyethylene surfaces grew exponentially across the 2007-2012 study period even before sufficiently rigorous evidence of performance that is just now starting to emerge. This study has revealed that costs of these bearing choices vary widely across time and contextual variables. Analysis showing that more expensive, presumed longer lasting devices were used more frequently in younger, less sick patients that have more potential life years remaining to overcome the added cost indicated that cost-effectiveness principles are often considered. Cost-effectiveness of choosing the more expensive ceramic-on-polyethylene bearing surface was demonstrated to be highly dependent on patient age, implant cost difference, and level of improved performance of the ceramic-on-polyethylene implant. This study’s use of the Premier Research Database’s individual-level costs for both implants and the surgical procedure for almost 2 million patients and multiple literature sources for bearing surface performance brings new information and analysis to the question of spending more to get better results in total hip arthroplasty.