Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE 2.0 STRAIGHT MCS-6

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$931.28
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

PLATE 2.0 STRAIGHT MCS-6

Facility

$1,663.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$848.13
Max. Negotiated Rate	$1,613.11
Rate for Payer: Cash Price	$997.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,164.10
Rate for Payer: Health Management Network Commercial	$1,413.55
Rate for Payer: Kaiser Permanente Commercial	$1,047.69
Rate for Payer: Kaiser Permanente Medicaid	$848.13
Rate for Payer: MDX Hawaii PPO	$1,613.11
Rate for Payer: University Health Alliance Commercial	$931.28

PLATE 2.3 L COMP 6H 57-13408

Facility

$1,272.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$712.32
Max. Negotiated Rate	$1,233.84
Rate for Payer: Cash Price	$763.20
Rate for Payer: Hawaii Western Management Group Commercial	$890.40
Rate for Payer: Health Management Network Commercial	$1,081.20
Rate for Payer: MDX Hawaii PPO	$1,233.84
Rate for Payer: University Health Alliance Commercial	$712.32

PLATE 2.3 L COMP 6H 57-13408

Facility

$1,272.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$648.72
Max. Negotiated Rate	$1,233.84
Rate for Payer: Cash Price	$763.20
Rate for Payer: Hawaii Western Management Group Commercial	$890.40
Rate for Payer: Health Management Network Commercial	$1,081.20
Rate for Payer: Kaiser Permanente Commercial	$801.36
Rate for Payer: Kaiser Permanente Medicaid	$648.72
Rate for Payer: MDX Hawaii PPO	$1,233.84
Rate for Payer: University Health Alliance Commercial	$712.32

PLATE 2.3 M LCK 13H 57-15379

Facility

$2,476.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.76
Max. Negotiated Rate	$2,401.72
Rate for Payer: Cash Price	$1,485.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,733.20
Rate for Payer: Health Management Network Commercial	$2,104.60
Rate for Payer: Kaiser Permanente Commercial	$1,559.88
Rate for Payer: Kaiser Permanente Medicaid	$1,262.76
Rate for Payer: MDX Hawaii PPO	$2,401.72
Rate for Payer: University Health Alliance Commercial	$1,386.56

PLATE 2.3 M LCK 13H 57-15379

Facility

$2,476.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,386.56
Max. Negotiated Rate	$2,401.72
Rate for Payer: Cash Price	$1,485.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,733.20
Rate for Payer: Health Management Network Commercial	$2,104.60
Rate for Payer: MDX Hawaii PPO	$2,401.72
Rate for Payer: University Health Alliance Commercial	$1,386.56

PLATE 2.3MM 16H STR 57-10116

Facility

$1,677.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$855.27
Max. Negotiated Rate	$1,626.69
Rate for Payer: Cash Price	$1,006.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,173.90
Rate for Payer: Health Management Network Commercial	$1,425.45
Rate for Payer: Kaiser Permanente Commercial	$1,056.51
Rate for Payer: Kaiser Permanente Medicaid	$855.27
Rate for Payer: MDX Hawaii PPO	$1,626.69
Rate for Payer: University Health Alliance Commercial	$939.12

PLATE 2.3MM 16H STR 57-10116

Facility

$1,677.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$939.12
Max. Negotiated Rate	$1,626.69
Rate for Payer: Cash Price	$1,006.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,173.90
Rate for Payer: Health Management Network Commercial	$1,425.45
Rate for Payer: MDX Hawaii PPO	$1,626.69
Rate for Payer: University Health Alliance Commercial	$939.12

PLATE 2.3MM STR 4HOLE 57-10101

Facility

$1,277.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$715.12
Max. Negotiated Rate	$1,238.69
Rate for Payer: Cash Price	$766.20
Rate for Payer: Hawaii Western Management Group Commercial	$893.90
Rate for Payer: Health Management Network Commercial	$1,085.45
Rate for Payer: MDX Hawaii PPO	$1,238.69
Rate for Payer: University Health Alliance Commercial	$715.12

PLATE 2.3MM STR 4HOLE 57-10101

Facility

$1,277.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$651.27
Max. Negotiated Rate	$1,238.69
Rate for Payer: Cash Price	$766.20
Rate for Payer: Hawaii Western Management Group Commercial	$893.90
Rate for Payer: Health Management Network Commercial	$1,085.45
Rate for Payer: Kaiser Permanente Commercial	$804.51
Rate for Payer: Kaiser Permanente Medicaid	$651.27
Rate for Payer: MDX Hawaii PPO	$1,238.69
Rate for Payer: University Health Alliance Commercial	$715.12

PLATE 2.3 STANDARD LF 57-10121

Facility

$1,562.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$796.62
Max. Negotiated Rate	$1,515.14
Rate for Payer: Cash Price	$937.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,093.40
Rate for Payer: Health Management Network Commercial	$1,327.70
Rate for Payer: Kaiser Permanente Commercial	$984.06
Rate for Payer: Kaiser Permanente Medicaid	$796.62
Rate for Payer: MDX Hawaii PPO	$1,515.14
Rate for Payer: University Health Alliance Commercial	$874.72

PLATE 2.3 STANDARD LF 57-10121

Facility

$1,562.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$874.72
Max. Negotiated Rate	$1,515.14
Rate for Payer: Cash Price	$937.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,093.40
Rate for Payer: Health Management Network Commercial	$1,327.70
Rate for Payer: MDX Hawaii PPO	$1,515.14
Rate for Payer: University Health Alliance Commercial	$874.72

PLATE 2.3X1.5MM 5HOLE 57-15324

Facility

$2,335.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,190.85
Max. Negotiated Rate	$2,264.95
Rate for Payer: Cash Price	$1,401.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.50
Rate for Payer: Health Management Network Commercial	$1,984.75
Rate for Payer: Kaiser Permanente Commercial	$1,471.05
Rate for Payer: Kaiser Permanente Medicaid	$1,190.85
Rate for Payer: MDX Hawaii PPO	$2,264.95
Rate for Payer: University Health Alliance Commercial	$1,307.60

PLATE 2.3X1.5MM 5HOLE 57-15324

Facility

$2,335.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,307.60
Max. Negotiated Rate	$2,264.95
Rate for Payer: Cash Price	$1,401.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.50
Rate for Payer: Health Management Network Commercial	$1,984.75
Rate for Payer: MDX Hawaii PPO	$2,264.95
Rate for Payer: University Health Alliance Commercial	$1,307.60

PLATE 2.4 CONDYLAR 249.679

Facility

$2,064.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,052.64
Max. Negotiated Rate	$2,002.08
Rate for Payer: Cash Price	$1,238.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.80
Rate for Payer: Health Management Network Commercial	$1,754.40
Rate for Payer: Kaiser Permanente Commercial	$1,300.32
Rate for Payer: Kaiser Permanente Medicaid	$1,052.64
Rate for Payer: MDX Hawaii PPO	$2,002.08
Rate for Payer: University Health Alliance Commercial	$1,155.84

PLATE 2.4 CONDYLAR 249.679

Facility

$2,064.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,155.84
Max. Negotiated Rate	$2,002.08
Rate for Payer: Cash Price	$1,238.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.80
Rate for Payer: Health Management Network Commercial	$1,754.40
Rate for Payer: MDX Hawaii PPO	$2,002.08
Rate for Payer: University Health Alliance Commercial	$1,155.84

PLATE 2.4 LCP 10H 84MM 247.364

Facility

$1,604.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$898.24
Max. Negotiated Rate	$1,555.88
Rate for Payer: Cash Price	$962.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,122.80
Rate for Payer: Health Management Network Commercial	$1,363.40
Rate for Payer: MDX Hawaii PPO	$1,555.88
Rate for Payer: University Health Alliance Commercial	$898.24

PLATE 2.4 LCP 10H 84MM 247.364

Facility

$1,604.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$818.04
Max. Negotiated Rate	$1,555.88
Rate for Payer: Cash Price	$962.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,122.80
Rate for Payer: Health Management Network Commercial	$1,363.40
Rate for Payer: Kaiser Permanente Commercial	$1,010.52
Rate for Payer: Kaiser Permanente Medicaid	$818.04
Rate for Payer: MDX Hawaii PPO	$1,555.88
Rate for Payer: University Health Alliance Commercial	$898.24

PLATE 2.4 LCP 12H 88MM 247.366

Facility

$1,602.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$817.02
Max. Negotiated Rate	$1,553.94
Rate for Payer: Cash Price	$961.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,121.40
Rate for Payer: Health Management Network Commercial	$1,361.70
Rate for Payer: Kaiser Permanente Commercial	$1,009.26
Rate for Payer: Kaiser Permanente Medicaid	$817.02
Rate for Payer: MDX Hawaii PPO	$1,553.94
Rate for Payer: University Health Alliance Commercial	$897.12

PLATE 2.4 LCP 12H 88MM 247.366

Facility

$1,602.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$897.12
Max. Negotiated Rate	$1,553.94
Rate for Payer: Cash Price	$961.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,121.40
Rate for Payer: Health Management Network Commercial	$1,361.70
Rate for Payer: MDX Hawaii PPO	$1,553.94
Rate for Payer: University Health Alliance Commercial	$897.12

PLATE 2.4 LCP 4 HOLE 249.674

Facility

$1,604.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$898.24
Max. Negotiated Rate	$1,555.88
Rate for Payer: Cash Price	$962.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,122.80
Rate for Payer: Health Management Network Commercial	$1,363.40
Rate for Payer: MDX Hawaii PPO	$1,555.88
Rate for Payer: University Health Alliance Commercial	$898.24

PLATE 2.4 LCP 4 HOLE 249.674

Facility

$1,604.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$818.04
Max. Negotiated Rate	$1,555.88
Rate for Payer: Cash Price	$962.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,122.80
Rate for Payer: Health Management Network Commercial	$1,363.40
Rate for Payer: Kaiser Permanente Commercial	$1,010.52
Rate for Payer: Kaiser Permanente Medicaid	$818.04
Rate for Payer: MDX Hawaii PPO	$1,555.88
Rate for Payer: University Health Alliance Commercial	$898.24

PLATE 2.4 LCP 5H 40MM 247.375

Facility

$1,604.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$818.04
Max. Negotiated Rate	$1,555.88
Rate for Payer: Cash Price	$962.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,122.80
Rate for Payer: Health Management Network Commercial	$1,363.40
Rate for Payer: Kaiser Permanente Commercial	$1,010.52
Rate for Payer: Kaiser Permanente Medicaid	$818.04
Rate for Payer: MDX Hawaii PPO	$1,555.88
Rate for Payer: University Health Alliance Commercial	$898.24

PLATE 2.4 LCP 5H 40MM 247.375

Facility

$1,604.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$898.24
Max. Negotiated Rate	$1,555.88
Rate for Payer: Cash Price	$962.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,122.80
Rate for Payer: Health Management Network Commercial	$1,363.40
Rate for Payer: MDX Hawaii PPO	$1,555.88
Rate for Payer: University Health Alliance Commercial	$898.24

PLATE 2.4 LCP 6 HOLE 249.676

Facility

$1,604.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$818.04
Max. Negotiated Rate	$1,555.88
Rate for Payer: Cash Price	$962.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,122.80
Rate for Payer: Health Management Network Commercial	$1,363.40
Rate for Payer: Kaiser Permanente Commercial	$1,010.52
Rate for Payer: Kaiser Permanente Medicaid	$818.04
Rate for Payer: MDX Hawaii PPO	$1,555.88
Rate for Payer: University Health Alliance Commercial	$898.24

Know your out-of-pocket cost for care.

All Charges