Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE 2.4 LCP 6 HOLE 249.676

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 7H 60MM 247.377

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 7H 60MM 247.377

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 2.4MM NARROW LOCK ST 8H

Facility

$2,260.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,152.60
Max. Negotiated Rate	$2,192.20
Rate for Payer: Cash Price	$1,356.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,582.00
Rate for Payer: Health Management Network Commercial	$1,921.00
Rate for Payer: Kaiser Permanente Commercial	$1,423.80
Rate for Payer: Kaiser Permanente Medicaid	$1,152.60
Rate for Payer: MDX Hawaii PPO	$2,192.20
Rate for Payer: University Health Alliance Commercial	$1,265.60

PLATE 2.4MM NARROW LOCK ST 8H

Facility

$2,260.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,265.60
Max. Negotiated Rate	$2,192.20
Rate for Payer: Cash Price	$1,356.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,582.00
Rate for Payer: Health Management Network Commercial	$1,921.00
Rate for Payer: MDX Hawaii PPO	$2,192.20
Rate for Payer: University Health Alliance Commercial	$1,265.60

PLATE 2.4MM NARROW ST 6H

Facility

$2,260.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,265.60
Max. Negotiated Rate	$2,192.20
Rate for Payer: Cash Price	$1,356.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,582.00
Rate for Payer: Health Management Network Commercial	$1,921.00
Rate for Payer: MDX Hawaii PPO	$2,192.20
Rate for Payer: University Health Alliance Commercial	$1,265.60

PLATE 2.4MM NARROW ST 6H

Facility

$2,260.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,152.60
Max. Negotiated Rate	$2,192.20
Rate for Payer: Cash Price	$1,356.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,582.00
Rate for Payer: Health Management Network Commercial	$1,921.00
Rate for Payer: Kaiser Permanente Commercial	$1,423.80
Rate for Payer: Kaiser Permanente Medicaid	$1,152.60
Rate for Payer: MDX Hawaii PPO	$2,192.20
Rate for Payer: University Health Alliance Commercial	$1,265.60

PLATE 2.4 NARR LCK Y 629790

Facility

$2,446.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,247.46
Max. Negotiated Rate	$2,372.62
Rate for Payer: Cash Price	$1,467.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,712.20
Rate for Payer: Health Management Network Commercial	$2,079.10
Rate for Payer: Kaiser Permanente Commercial	$1,540.98
Rate for Payer: Kaiser Permanente Medicaid	$1,247.46
Rate for Payer: MDX Hawaii PPO	$2,372.62
Rate for Payer: University Health Alliance Commercial	$1,369.76

PLATE 2.4 NARR LCK Y 629790

Facility

$2,446.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,369.76
Max. Negotiated Rate	$2,372.62
Rate for Payer: Cash Price	$1,467.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,712.20
Rate for Payer: Health Management Network Commercial	$2,079.10
Rate for Payer: MDX Hawaii PPO	$2,372.62
Rate for Payer: University Health Alliance Commercial	$1,369.76

PLATE 25X2MM 00-4349-025-02

Facility

$7,125.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,633.75
Max. Negotiated Rate	$6,911.25
Rate for Payer: Cash Price	$4,275.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,987.50
Rate for Payer: Health Management Network Commercial	$6,056.25
Rate for Payer: Kaiser Permanente Commercial	$4,488.75
Rate for Payer: Kaiser Permanente Medicaid	$3,633.75
Rate for Payer: MDX Hawaii PPO	$6,911.25
Rate for Payer: University Health Alliance Commercial	$3,990.00

PLATE 25X2MM 00-4349-025-02

Facility

$7,125.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,990.00
Max. Negotiated Rate	$6,911.25
Rate for Payer: Cash Price	$4,275.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,987.50
Rate for Payer: Health Management Network Commercial	$6,056.25
Rate for Payer: MDX Hawaii PPO	$6,911.25
Rate for Payer: University Health Alliance Commercial	$3,990.00

PLATE 2.7/3.5 3H/LT 02.112.107

Facility

$2,271.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.21
Max. Negotiated Rate	$2,202.87
Rate for Payer: Cash Price	$1,362.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,589.70
Rate for Payer: Health Management Network Commercial	$1,930.35
Rate for Payer: Kaiser Permanente Commercial	$1,430.73
Rate for Payer: Kaiser Permanente Medicaid	$1,158.21
Rate for Payer: MDX Hawaii PPO	$2,202.87
Rate for Payer: University Health Alliance Commercial	$1,271.76

PLATE 2.7/3.5 3H/LT 02.112.107

Facility

$2,271.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,271.76
Max. Negotiated Rate	$2,202.87
Rate for Payer: Cash Price	$1,362.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,589.70
Rate for Payer: Health Management Network Commercial	$1,930.35
Rate for Payer: MDX Hawaii PPO	$2,202.87
Rate for Payer: University Health Alliance Commercial	$1,271.76

PLATE 2.7/3.5 LCP 02.107.202

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,449.28
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.202

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,319.88
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: Kaiser Permanente Commercial	$1,630.44
Rate for Payer: Kaiser Permanente Medicaid	$1,319.88
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.204

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,319.88
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: Kaiser Permanente Commercial	$1,630.44
Rate for Payer: Kaiser Permanente Medicaid	$1,319.88
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.204

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,449.28
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.206

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,319.88
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: Kaiser Permanente Commercial	$1,630.44
Rate for Payer: Kaiser Permanente Medicaid	$1,319.88
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.206

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,449.28
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.302

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,449.28
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.302

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,319.88
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: Kaiser Permanente Commercial	$1,630.44
Rate for Payer: Kaiser Permanente Medicaid	$1,319.88
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.304

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,449.28
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.304

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,319.88
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: Kaiser Permanente Commercial	$1,630.44
Rate for Payer: Kaiser Permanente Medicaid	$1,319.88
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.306

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,319.88
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: Kaiser Permanente Commercial	$1,630.44
Rate for Payer: Kaiser Permanente Medicaid	$1,319.88
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

PLATE 2.7/3.5 LCP 02.107.306

Facility

$2,588.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,449.28
Max. Negotiated Rate	$2,510.36
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: University Health Alliance Commercial	$1,449.28

Know your out-of-pocket cost for care.

All Charges