Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE 1/3 TUBULAR 83 7H 626677

Facility

$1,608.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$820.08
Max. Negotiated Rate	$1,559.76
Rate for Payer: Cash Price	$964.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,125.60
Rate for Payer: Health Management Network Commercial	$1,366.80
Rate for Payer: Kaiser Permanente Commercial	$1,013.04
Rate for Payer: Kaiser Permanente Medicaid	$820.08
Rate for Payer: MDX Hawaii PPO	$1,559.76
Rate for Payer: University Health Alliance Commercial	$900.48

PLATE 1/3 TUB W COLLAR 241.35

Facility

$805.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$410.55
Max. Negotiated Rate	$780.85
Rate for Payer: Cash Price	$483.00
Rate for Payer: Hawaii Western Management Group Commercial	$563.50
Rate for Payer: Health Management Network Commercial	$684.25
Rate for Payer: Kaiser Permanente Commercial	$507.15
Rate for Payer: Kaiser Permanente Medicaid	$410.55
Rate for Payer: MDX Hawaii PPO	$780.85
Rate for Payer: University Health Alliance Commercial	$450.80

PLATE 1/3 TUB W COLLAR 241.35

Facility

$805.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$450.80
Max. Negotiated Rate	$780.85
Rate for Payer: Cash Price	$483.00
Rate for Payer: Hawaii Western Management Group Commercial	$563.50
Rate for Payer: Health Management Network Commercial	$684.25
Rate for Payer: MDX Hawaii PPO	$780.85
Rate for Payer: University Health Alliance Commercial	$450.80

PLATE 1/3 TUB W COLLAR 241.37

Facility

$435.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$221.85
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$261.00
Rate for Payer: Hawaii Western Management Group Commercial	$304.50
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: Kaiser Permanente Commercial	$274.05
Rate for Payer: Kaiser Permanente Medicaid	$221.85
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: University Health Alliance Commercial	$243.60

PLATE 1/3 TUB W COLLAR 241.37

Facility

$435.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$261.00
Rate for Payer: Hawaii Western Management Group Commercial	$304.50
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: University Health Alliance Commercial	$243.60

PLATE 1.5 LCK T-SHP 131220152

Facility

$2,120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,081.20
Max. Negotiated Rate	$2,056.40
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,484.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: Kaiser Permanente Commercial	$1,335.60
Rate for Payer: Kaiser Permanente Medicaid	$1,081.20
Rate for Payer: MDX Hawaii PPO	$2,056.40
Rate for Payer: University Health Alliance Commercial	$1,187.20

PLATE 1.5 LCK T-SHP 131220152

Facility

$2,120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,187.20
Max. Negotiated Rate	$2,056.40
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,484.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: MDX Hawaii PPO	$2,056.40
Rate for Payer: University Health Alliance Commercial	$1,187.20

PLATE 16 HOLE 627616

Facility

$6,753.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,781.68
Max. Negotiated Rate	$6,550.41
Rate for Payer: Cash Price	$4,051.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,727.10
Rate for Payer: Health Management Network Commercial	$5,740.05
Rate for Payer: MDX Hawaii PPO	$6,550.41
Rate for Payer: University Health Alliance Commercial	$3,781.68

PLATE 16 HOLE 627616

Facility

$6,753.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,444.03
Max. Negotiated Rate	$6,550.41
Rate for Payer: Cash Price	$4,051.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,727.10
Rate for Payer: Health Management Network Commercial	$5,740.05
Rate for Payer: Kaiser Permanente Commercial	$4,254.39
Rate for Payer: Kaiser Permanente Medicaid	$3,444.03
Rate for Payer: MDX Hawaii PPO	$6,550.41
Rate for Payer: University Health Alliance Commercial	$3,781.68

PLATE 1.7MM S LCKIN Z, NARR 9H

Facility

$1,900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,064.00
Max. Negotiated Rate	$1,843.00
Rate for Payer: Cash Price	$1,140.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,330.00
Rate for Payer: Health Management Network Commercial	$1,615.00
Rate for Payer: MDX Hawaii PPO	$1,843.00
Rate for Payer: University Health Alliance Commercial	$1,064.00

PLATE 1.7MM S LCKIN Z, NARR 9H

Facility

$1,900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$969.00
Max. Negotiated Rate	$1,843.00
Rate for Payer: Cash Price	$1,140.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,330.00
Rate for Payer: Health Management Network Commercial	$1,615.00
Rate for Payer: Kaiser Permanente Commercial	$1,197.00
Rate for Payer: Kaiser Permanente Medicaid	$969.00
Rate for Payer: MDX Hawaii PPO	$1,843.00
Rate for Payer: University Health Alliance Commercial	$1,064.00

PLATE 1.7 STR 16H 57-08216

Facility

$1,548.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$866.88
Max. Negotiated Rate	$1,501.56
Rate for Payer: Cash Price	$928.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,083.60
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: MDX Hawaii PPO	$1,501.56
Rate for Payer: University Health Alliance Commercial	$866.88

PLATE 1.7 STR 16H 57-08216

Facility

$1,548.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$789.48
Max. Negotiated Rate	$1,501.56
Rate for Payer: Cash Price	$928.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,083.60
Rate for Payer: Health Management Network Commercial	$1,315.80
Rate for Payer: Kaiser Permanente Commercial	$975.24
Rate for Payer: Kaiser Permanente Medicaid	$789.48
Rate for Payer: MDX Hawaii PPO	$1,501.56
Rate for Payer: University Health Alliance Commercial	$866.88

PLATE 2.0 LCP 10H/73 247.360

Facility

$1,033.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$578.48
Max. Negotiated Rate	$1,002.01
Rate for Payer: Cash Price	$619.80
Rate for Payer: Hawaii Western Management Group Commercial	$723.10
Rate for Payer: Health Management Network Commercial	$878.05
Rate for Payer: MDX Hawaii PPO	$1,002.01
Rate for Payer: University Health Alliance Commercial	$578.48

PLATE 2.0 LCP 10H/73 247.360

Facility

$1,033.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$526.83
Max. Negotiated Rate	$1,002.01
Rate for Payer: Cash Price	$619.80
Rate for Payer: Hawaii Western Management Group Commercial	$723.10
Rate for Payer: Health Management Network Commercial	$878.05
Rate for Payer: Kaiser Permanente Commercial	$650.79
Rate for Payer: Kaiser Permanente Medicaid	$526.83
Rate for Payer: MDX Hawaii PPO	$1,002.01
Rate for Payer: University Health Alliance Commercial	$578.48

PLATE 2.0 LCP 3H/7H 247.615

Facility

$1,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$798.66
Max. Negotiated Rate	$1,519.02
Rate for Payer: Cash Price	$939.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,096.20
Rate for Payer: Health Management Network Commercial	$1,331.10
Rate for Payer: Kaiser Permanente Commercial	$986.58
Rate for Payer: Kaiser Permanente Medicaid	$798.66
Rate for Payer: MDX Hawaii PPO	$1,519.02
Rate for Payer: University Health Alliance Commercial	$876.96

PLATE 2.0 LCP 3H/7H 247.615

Facility

$1,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$876.96
Max. Negotiated Rate	$1,519.02
Rate for Payer: Cash Price	$939.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,096.20
Rate for Payer: Health Management Network Commercial	$1,331.10
Rate for Payer: MDX Hawaii PPO	$1,519.02
Rate for Payer: University Health Alliance Commercial	$876.96

PLATE 2.0 LCP 4H/31 247.344

Facility

$1,051.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$588.56
Max. Negotiated Rate	$1,019.47
Rate for Payer: Cash Price	$630.60
Rate for Payer: Hawaii Western Management Group Commercial	$735.70
Rate for Payer: Health Management Network Commercial	$893.35
Rate for Payer: MDX Hawaii PPO	$1,019.47
Rate for Payer: University Health Alliance Commercial	$588.56

PLATE 2.0 LCP 4H/31 247.344

Facility

$1,051.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$536.01
Max. Negotiated Rate	$1,019.47
Rate for Payer: Cash Price	$630.60
Rate for Payer: Hawaii Western Management Group Commercial	$735.70
Rate for Payer: Health Management Network Commercial	$893.35
Rate for Payer: Kaiser Permanente Commercial	$662.13
Rate for Payer: Kaiser Permanente Medicaid	$536.01
Rate for Payer: MDX Hawaii PPO	$1,019.47
Rate for Payer: University Health Alliance Commercial	$588.56

PLATE 2.0 LCP 6H/45 247.346

Facility

$1,126.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$630.56
Max. Negotiated Rate	$1,092.22
Rate for Payer: Cash Price	$675.60
Rate for Payer: Hawaii Western Management Group Commercial	$788.20
Rate for Payer: Health Management Network Commercial	$957.10
Rate for Payer: MDX Hawaii PPO	$1,092.22
Rate for Payer: University Health Alliance Commercial	$630.56

PLATE 2.0 LCP 6H/45 247.346

Facility

$1,126.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$574.26
Max. Negotiated Rate	$1,092.22
Rate for Payer: Cash Price	$675.60
Rate for Payer: Hawaii Western Management Group Commercial	$788.20
Rate for Payer: Health Management Network Commercial	$957.10
Rate for Payer: Kaiser Permanente Commercial	$709.38
Rate for Payer: Kaiser Permanente Medicaid	$574.26
Rate for Payer: MDX Hawaii PPO	$1,092.22
Rate for Payer: University Health Alliance Commercial	$630.56

PLATE 2.0 LCP 7H/52 247.347

Facility

$1,033.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$578.48
Max. Negotiated Rate	$1,002.01
Rate for Payer: Cash Price	$619.80
Rate for Payer: Hawaii Western Management Group Commercial	$723.10
Rate for Payer: Health Management Network Commercial	$878.05
Rate for Payer: MDX Hawaii PPO	$1,002.01
Rate for Payer: University Health Alliance Commercial	$578.48

PLATE 2.0 LCP 7H/52 247.347

Facility

$1,033.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$526.83
Max. Negotiated Rate	$1,002.01
Rate for Payer: Cash Price	$619.80
Rate for Payer: Hawaii Western Management Group Commercial	$723.10
Rate for Payer: Health Management Network Commercial	$878.05
Rate for Payer: Kaiser Permanente Commercial	$650.79
Rate for Payer: Kaiser Permanente Medicaid	$526.83
Rate for Payer: MDX Hawaii PPO	$1,002.01
Rate for Payer: University Health Alliance Commercial	$578.48

PLATE 2.0 LCP 8H/59 247.348

Facility

$1,033.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$526.83
Max. Negotiated Rate	$1,002.01
Rate for Payer: Cash Price	$619.80
Rate for Payer: Hawaii Western Management Group Commercial	$723.10
Rate for Payer: Health Management Network Commercial	$878.05
Rate for Payer: Kaiser Permanente Commercial	$650.79
Rate for Payer: Kaiser Permanente Medicaid	$526.83
Rate for Payer: MDX Hawaii PPO	$1,002.01
Rate for Payer: University Health Alliance Commercial	$578.48

PLATE 2.0 LCP 8H/59 247.348

Facility

$1,033.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$578.48
Max. Negotiated Rate	$1,002.01
Rate for Payer: Cash Price	$619.80
Rate for Payer: Hawaii Western Management Group Commercial	$723.10
Rate for Payer: Health Management Network Commercial	$878.05
Rate for Payer: MDX Hawaii PPO	$1,002.01
Rate for Payer: University Health Alliance Commercial	$578.48

Know your out-of-pocket cost for care.

All Charges