Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE 2.7/3.5 LCP 02.117.601

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

PLATE 2.7/3.5 LCP 02.117.601

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

PLATE 2.7/3.5MM LCP 02.107.102

Facility

$2,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,173.00
Max. Negotiated Rate	$2,231.00
Rate for Payer: Cash Price	$1,380.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.00
Rate for Payer: Health Management Network Commercial	$1,955.00
Rate for Payer: Kaiser Permanente Commercial	$1,449.00
Rate for Payer: Kaiser Permanente Medicaid	$1,173.00
Rate for Payer: MDX Hawaii PPO	$2,231.00
Rate for Payer: University Health Alliance Commercial	$1,288.00

PLATE 2.7/3.5MM LCP 02.107.102

Facility

$2,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.00
Max. Negotiated Rate	$2,231.00
Rate for Payer: Cash Price	$1,380.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,610.00
Rate for Payer: Health Management Network Commercial	$1,955.00
Rate for Payer: MDX Hawaii PPO	$2,231.00
Rate for Payer: University Health Alliance Commercial	$1,288.00

PLATE 2.7 BROAD LCK 1H 629750

Facility

$2,787.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,421.37
Max. Negotiated Rate	$2,703.39
Rate for Payer: Cash Price	$1,672.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,950.90
Rate for Payer: Health Management Network Commercial	$2,368.95
Rate for Payer: Kaiser Permanente Commercial	$1,755.81
Rate for Payer: Kaiser Permanente Medicaid	$1,421.37
Rate for Payer: MDX Hawaii PPO	$2,703.39
Rate for Payer: University Health Alliance Commercial	$1,560.72

PLATE 2.7 BROAD LCK 1H 629750

Facility

$2,787.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,560.72
Max. Negotiated Rate	$2,703.39
Rate for Payer: Cash Price	$1,672.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,950.90
Rate for Payer: Health Management Network Commercial	$2,368.95
Rate for Payer: MDX Hawaii PPO	$2,703.39
Rate for Payer: University Health Alliance Commercial	$1,560.72

PLATE 2.7 CALC LCK 02.211.402

Facility

$2,296.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,285.76
Max. Negotiated Rate	$2,227.12
Rate for Payer: Cash Price	$1,377.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,607.20
Rate for Payer: Health Management Network Commercial	$1,951.60
Rate for Payer: MDX Hawaii PPO	$2,227.12
Rate for Payer: University Health Alliance Commercial	$1,285.76

PLATE 2.7 CALC LCK 02.211.402

Facility

$2,296.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,170.96
Max. Negotiated Rate	$2,227.12
Rate for Payer: Cash Price	$1,377.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,607.20
Rate for Payer: Health Management Network Commercial	$1,951.60
Rate for Payer: Kaiser Permanente Commercial	$1,446.48
Rate for Payer: Kaiser Permanente Medicaid	$1,170.96
Rate for Payer: MDX Hawaii PPO	$2,227.12
Rate for Payer: University Health Alliance Commercial	$1,285.76

PLATE 2.7 LCP 10H 94MM 247.374

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$948.08
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7 LCP 10H 94MM 247.374

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$863.43
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: Kaiser Permanente Commercial	$1,066.59
Rate for Payer: Kaiser Permanente Medicaid	$863.43
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7 LCP 12H 97MM 247.370

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 2.7 LCP 12H 97MM 247.370

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 2.7 LCP 4 H 40MM 249.680

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$948.08
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7 LCP 4 H 40MM 249.680

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$863.43
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: Kaiser Permanente Commercial	$1,066.59
Rate for Payer: Kaiser Permanente Medicaid	$863.43
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7 LCP 5 H 49MM 249.681

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$863.43
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: Kaiser Permanente Commercial	$1,066.59
Rate for Payer: Kaiser Permanente Medicaid	$863.43
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7 LCP 5 H 49MM 249.681

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$948.08
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7 LCP 7H 67MM 249.683

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$863.43
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: Kaiser Permanente Commercial	$1,066.59
Rate for Payer: Kaiser Permanente Medicaid	$863.43
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7 LCP 7H 67MM 249.683

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$948.08
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7 LCP 8H 76MM 247.372

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$948.08
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7 LCP 8H 76MM 247.372

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$863.43
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: Kaiser Permanente Commercial	$1,066.59
Rate for Payer: Kaiser Permanente Medicaid	$863.43
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7M LCP 6H 58MM 249.682

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$863.43
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: Kaiser Permanente Commercial	$1,066.59
Rate for Payer: Kaiser Permanente Medicaid	$863.43
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7M LCP 6H 58MM 249.682

Facility

$1,693.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$948.08
Max. Negotiated Rate	$1,642.21
Rate for Payer: Cash Price	$1,015.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.10
Rate for Payer: Health Management Network Commercial	$1,439.05
Rate for Payer: MDX Hawaii PPO	$1,642.21
Rate for Payer: University Health Alliance Commercial	$948.08

PLATE 2.7MM 0MM STEP 336-2720

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.17
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: Kaiser Permanente Commercial	$1,680.21
Rate for Payer: Kaiser Permanente Medicaid	$1,360.17
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE 2.7MM 0MM STEP 336-2720

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,493.52
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE 2.7MM 10H 336-2710

Facility

$2,597.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,324.47
Max. Negotiated Rate	$2,519.09
Rate for Payer: Cash Price	$1,558.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,817.90
Rate for Payer: Health Management Network Commercial	$2,207.45
Rate for Payer: Kaiser Permanente Commercial	$1,636.11
Rate for Payer: Kaiser Permanente Medicaid	$1,324.47
Rate for Payer: MDX Hawaii PPO	$2,519.09
Rate for Payer: University Health Alliance Commercial	$1,454.32

Know your out-of-pocket cost for care.

All Charges