Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

LCP 3.5 MED PROX TIBIA 239.954

Facility

$3,291.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,678.41
Max. Negotiated Rate	$3,192.27
Rate for Payer: Cash Price	$1,974.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,303.70
Rate for Payer: Health Management Network Commercial	$2,797.35
Rate for Payer: Kaiser Permanente Commercial	$2,073.33
Rate for Payer: Kaiser Permanente Medicaid	$1,678.41
Rate for Payer: MDX Hawaii PPO	$3,192.27
Rate for Payer: University Health Alliance Commercial	$1,842.96

LCP 3.5 MED PROX TIBIA 239.954

Facility

$3,291.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,842.96
Max. Negotiated Rate	$3,192.27
Rate for Payer: Cash Price	$1,974.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,303.70
Rate for Payer: Health Management Network Commercial	$2,797.35
Rate for Payer: MDX Hawaii PPO	$3,192.27
Rate for Payer: University Health Alliance Commercial	$1,842.96

LCP 3.5MM 3 HOLE 02.113.103

Facility

$1,926.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$982.26
Max. Negotiated Rate	$1,868.22
Rate for Payer: Cash Price	$1,155.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,348.20
Rate for Payer: Health Management Network Commercial	$1,637.10
Rate for Payer: Kaiser Permanente Commercial	$1,213.38
Rate for Payer: Kaiser Permanente Medicaid	$982.26
Rate for Payer: MDX Hawaii PPO	$1,868.22
Rate for Payer: University Health Alliance Commercial	$1,078.56

LCP 3.5MM 3 HOLE 02.113.103

Facility

$1,926.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,078.56
Max. Negotiated Rate	$1,868.22
Rate for Payer: Cash Price	$1,155.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,348.20
Rate for Payer: Health Management Network Commercial	$1,637.10
Rate for Payer: MDX Hawaii PPO	$1,868.22
Rate for Payer: University Health Alliance Commercial	$1,078.56

LCP 4.5X336MM LF 02.124.417

Facility

$4,808.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,452.08
Max. Negotiated Rate	$4,663.76
Rate for Payer: Cash Price	$2,884.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.60
Rate for Payer: Health Management Network Commercial	$4,086.80
Rate for Payer: Kaiser Permanente Commercial	$3,029.04
Rate for Payer: Kaiser Permanente Medicaid	$2,452.08
Rate for Payer: MDX Hawaii PPO	$4,663.76
Rate for Payer: University Health Alliance Commercial	$2,692.48

LCP 4.5X336MM LF 02.124.417

Facility

$4,808.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,692.48
Max. Negotiated Rate	$4,663.76
Rate for Payer: Cash Price	$2,884.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.60
Rate for Payer: Health Management Network Commercial	$4,086.80
Rate for Payer: MDX Hawaii PPO	$4,663.76
Rate for Payer: University Health Alliance Commercial	$2,692.48

LCP HUMERUS 2.7X3.5 02.117.704

Facility

$2,837.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,446.87
Max. Negotiated Rate	$2,751.89
Rate for Payer: Cash Price	$1,702.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,985.90
Rate for Payer: Health Management Network Commercial	$2,411.45
Rate for Payer: Kaiser Permanente Commercial	$1,787.31
Rate for Payer: Kaiser Permanente Medicaid	$1,446.87
Rate for Payer: MDX Hawaii PPO	$2,751.89
Rate for Payer: University Health Alliance Commercial	$1,588.72

LCP HUMERUS 2.7X3.5 02.117.704

Facility

$2,837.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,588.72
Max. Negotiated Rate	$2,751.89
Rate for Payer: Cash Price	$1,702.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,985.90
Rate for Payer: Health Management Network Commercial	$2,411.45
Rate for Payer: MDX Hawaii PPO	$2,751.89
Rate for Payer: University Health Alliance Commercial	$1,588.72

LCP PLATE 2.0, 5 HOLE/38MM

Facility

$1,180.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$601.80
Max. Negotiated Rate	$1,144.60
Rate for Payer: Cash Price	$708.00
Rate for Payer: Hawaii Western Management Group Commercial	$826.00
Rate for Payer: Health Management Network Commercial	$1,003.00
Rate for Payer: Kaiser Permanente Commercial	$743.40
Rate for Payer: Kaiser Permanente Medicaid	$601.80
Rate for Payer: MDX Hawaii PPO	$1,144.60
Rate for Payer: University Health Alliance Commercial	$660.80

LCP PLATE 2.0, 5 HOLE/38MM

Facility

$1,180.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$660.80
Max. Negotiated Rate	$1,144.60
Rate for Payer: Cash Price	$708.00
Rate for Payer: Hawaii Western Management Group Commercial	$826.00
Rate for Payer: Health Management Network Commercial	$1,003.00
Rate for Payer: MDX Hawaii PPO	$1,144.60
Rate for Payer: University Health Alliance Commercial	$660.80

LCP PLATE 3H 4.5X62MM 224.531

Facility

$1,530.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,484.10
Rate for Payer: Cash Price	$918.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: University Health Alliance Commercial	$856.80

LCP PLATE 3H 4.5X62MM 224.531

Facility

$1,530.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$780.30
Max. Negotiated Rate	$1,484.10
Rate for Payer: Cash Price	$918.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: Kaiser Permanente Commercial	$963.90
Rate for Payer: Kaiser Permanente Medicaid	$780.30
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: University Health Alliance Commercial	$856.80

LCP PLATE 9H RT 02.110.009S

Facility

$1,039.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$529.89
Max. Negotiated Rate	$1,007.83
Rate for Payer: Cash Price	$623.40
Rate for Payer: Hawaii Western Management Group Commercial	$727.30
Rate for Payer: Health Management Network Commercial	$883.15
Rate for Payer: Kaiser Permanente Commercial	$654.57
Rate for Payer: Kaiser Permanente Medicaid	$529.89
Rate for Payer: MDX Hawaii PPO	$1,007.83
Rate for Payer: University Health Alliance Commercial	$581.84

LCP PLATE 9H RT 02.110.009S

Facility

$1,039.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$581.84
Max. Negotiated Rate	$1,007.83
Rate for Payer: Cash Price	$623.40
Rate for Payer: Hawaii Western Management Group Commercial	$727.30
Rate for Payer: Health Management Network Commercial	$883.15
Rate for Payer: MDX Hawaii PPO	$1,007.83
Rate for Payer: University Health Alliance Commercial	$581.84

LCP PROX HUM PL 241.921

Facility

$3,834.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,955.34
Max. Negotiated Rate	$3,718.98
Rate for Payer: Cash Price	$2,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,683.80
Rate for Payer: Health Management Network Commercial	$3,258.90
Rate for Payer: Kaiser Permanente Commercial	$2,415.42
Rate for Payer: Kaiser Permanente Medicaid	$1,955.34
Rate for Payer: MDX Hawaii PPO	$3,718.98
Rate for Payer: University Health Alliance Commercial	$2,147.04

LCP PROX HUM PL 241.921

Facility

$3,834.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,147.04
Max. Negotiated Rate	$3,718.98
Rate for Payer: Cash Price	$2,300.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,683.80
Rate for Payer: Health Management Network Commercial	$3,258.90
Rate for Payer: MDX Hawaii PPO	$3,718.98
Rate for Payer: University Health Alliance Commercial	$2,147.04

LEAD BASIC EVALUATION 306001

Facility

$240.00

Service Code	HCPCS C1897
Hospital Revenue Code	278
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$168.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$134.40

LEAD BASIC EVALUATION 306001

Facility

$240.00

Service Code	HCPCS C1897
Hospital Revenue Code	278
Min. Negotiated Rate	$134.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$168.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$134.40

LEAD CAP 109185

Facility

$200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: MDX Hawaii PPO	$194.00

LEAD CAP 109185

Facility

$200.00

Hospital Revenue Code	272
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$194.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Hawaii Western Management Group Commercial	$190.00
Rate for Payer: Health Management Network Commercial	$170.00
Rate for Payer: Kaiser Permanente Commercial	$126.00
Rate for Payer: Kaiser Permanente Medicaid	$102.00
Rate for Payer: MDX Hawaii PPO	$194.00
Rate for Payer: University Health Alliance Commercial	$145.78

LEAD KIT INTRODUCER 3550-18

Facility

$980.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$833.00
Max. Negotiated Rate	$950.60
Rate for Payer: Cash Price	$588.00
Rate for Payer: Health Management Network Commercial	$833.00
Rate for Payer: MDX Hawaii PPO	$950.60

LEAD KIT INTRODUCER 3550-18

Facility

$980.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$499.80
Max. Negotiated Rate	$950.60
Rate for Payer: Cash Price	$588.00
Rate for Payer: Hawaii Western Management Group Commercial	$931.00
Rate for Payer: Health Management Network Commercial	$833.00
Rate for Payer: Kaiser Permanente Commercial	$617.40
Rate for Payer: Kaiser Permanente Medicaid	$499.80
Rate for Payer: MDX Hawaii PPO	$950.60
Rate for Payer: University Health Alliance Commercial	$714.32

LEAD KIT QUADRIPOLAR 3889-28

Facility

$7,110.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$3,981.60
Max. Negotiated Rate	$6,896.70
Rate for Payer: Cash Price	$4,266.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,977.00
Rate for Payer: Health Management Network Commercial	$6,043.50
Rate for Payer: MDX Hawaii PPO	$6,896.70
Rate for Payer: University Health Alliance Commercial	$3,981.60

LEAD KIT QUADRIPOLAR 3889-28

Facility

$7,110.00

Service Code	HCPCS C1778
Hospital Revenue Code	278
Min. Negotiated Rate	$3,626.10
Max. Negotiated Rate	$6,896.70
Rate for Payer: Cash Price	$4,266.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,977.00
Rate for Payer: Health Management Network Commercial	$6,043.50
Rate for Payer: Kaiser Permanente Commercial	$4,479.30
Rate for Payer: Kaiser Permanente Medicaid	$3,626.10
Rate for Payer: MDX Hawaii PPO	$6,896.70
Rate for Payer: University Health Alliance Commercial	$3,981.60

LEAD PLEXA PROMRI 413997

Facility

$8,000.00

Service Code	HCPCS C1777
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