Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE 2.7MM 10H 336-2710

Facility

$2,597.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,454.32
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: MDX Hawaii PPO	$2,519.09
Rate for Payer: University Health Alliance Commercial	$1,454.32

PLATE 2.7MM 1ST LEFT 336-2752

Facility

$3,031.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,697.36
Max. Negotiated Rate	$2,940.07
Rate for Payer: Cash Price	$1,818.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,121.70
Rate for Payer: Health Management Network Commercial	$2,576.35
Rate for Payer: MDX Hawaii PPO	$2,940.07
Rate for Payer: University Health Alliance Commercial	$1,697.36

PLATE 2.7MM 1ST LEFT 336-2752

Facility

$3,031.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,545.81
Max. Negotiated Rate	$2,940.07
Rate for Payer: Cash Price	$1,818.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,121.70
Rate for Payer: Health Management Network Commercial	$2,576.35
Rate for Payer: Kaiser Permanente Commercial	$1,909.53
Rate for Payer: Kaiser Permanente Medicaid	$1,545.81
Rate for Payer: MDX Hawaii PPO	$2,940.07
Rate for Payer: University Health Alliance Commercial	$1,697.36

PLATE 2.7MM 1ST PRIM 336-2757

Facility

$3,031.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,545.81
Max. Negotiated Rate	$2,940.07
Rate for Payer: Cash Price	$1,818.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,121.70
Rate for Payer: Health Management Network Commercial	$2,576.35
Rate for Payer: Kaiser Permanente Commercial	$1,909.53
Rate for Payer: Kaiser Permanente Medicaid	$1,545.81
Rate for Payer: MDX Hawaii PPO	$2,940.07
Rate for Payer: University Health Alliance Commercial	$1,697.36

PLATE 2.7MM 1ST PRIM 336-2757

Facility

$3,031.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,697.36
Max. Negotiated Rate	$2,940.07
Rate for Payer: Cash Price	$1,818.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,121.70
Rate for Payer: Health Management Network Commercial	$2,576.35
Rate for Payer: MDX Hawaii PPO	$2,940.07
Rate for Payer: University Health Alliance Commercial	$1,697.36

PLATE 2.7MM 2H/3H SFT 249.685

Facility

$2,525.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,414.00
Max. Negotiated Rate	$2,449.25
Rate for Payer: Cash Price	$1,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.50
Rate for Payer: Health Management Network Commercial	$2,146.25
Rate for Payer: MDX Hawaii PPO	$2,449.25
Rate for Payer: University Health Alliance Commercial	$1,414.00

PLATE 2.7MM 2H/3H SFT 249.685

Facility

$2,525.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,287.75
Max. Negotiated Rate	$2,449.25
Rate for Payer: Cash Price	$1,515.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,767.50
Rate for Payer: Health Management Network Commercial	$2,146.25
Rate for Payer: Kaiser Permanente Commercial	$1,590.75
Rate for Payer: Kaiser Permanente Medicaid	$1,287.75
Rate for Payer: MDX Hawaii PPO	$2,449.25
Rate for Payer: University Health Alliance Commercial	$1,414.00

PLATE 2.7MM 6-HOLE/48MM 245.20

Facility

$1,043.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$584.08
Max. Negotiated Rate	$1,011.71
Rate for Payer: Cash Price	$625.80
Rate for Payer: Hawaii Western Management Group Commercial	$730.10
Rate for Payer: Health Management Network Commercial	$886.55
Rate for Payer: MDX Hawaii PPO	$1,011.71
Rate for Payer: University Health Alliance Commercial	$584.08

PLATE 2.7MM 6-HOLE/48MM 245.20

Facility

$1,043.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$531.93
Max. Negotiated Rate	$1,011.71
Rate for Payer: Cash Price	$625.80
Rate for Payer: Hawaii Western Management Group Commercial	$730.10
Rate for Payer: Health Management Network Commercial	$886.55
Rate for Payer: Kaiser Permanente Commercial	$657.09
Rate for Payer: Kaiser Permanente Medicaid	$531.93
Rate for Payer: MDX Hawaii PPO	$1,011.71
Rate for Payer: University Health Alliance Commercial	$584.08

PLATE 2.7MM CND 7H SFT 249.684

Facility

$2,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

PLATE 2.7MM CND 7H SFT 249.684

Facility

$2,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,147.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

PLATE 2.7MM LEFT SMALL 58MM

Facility

$2,351.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,199.01
Max. Negotiated Rate	$2,280.47
Rate for Payer: Cash Price	$1,410.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,645.70
Rate for Payer: Health Management Network Commercial	$1,998.35
Rate for Payer: Kaiser Permanente Commercial	$1,481.13
Rate for Payer: Kaiser Permanente Medicaid	$1,199.01
Rate for Payer: MDX Hawaii PPO	$2,280.47
Rate for Payer: University Health Alliance Commercial	$1,316.56

PLATE 2.7MM LEFT SMALL 58MM

Facility

$2,351.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,316.56
Max. Negotiated Rate	$2,280.47
Rate for Payer: Cash Price	$1,410.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,645.70
Rate for Payer: Health Management Network Commercial	$1,998.35
Rate for Payer: MDX Hawaii PPO	$2,280.47
Rate for Payer: University Health Alliance Commercial	$1,316.56

PLATE 2.7MM LT 2H 249.689

Facility

$1,606.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$819.06
Max. Negotiated Rate	$1,557.82
Rate for Payer: Cash Price	$963.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,124.20
Rate for Payer: Health Management Network Commercial	$1,365.10
Rate for Payer: Kaiser Permanente Commercial	$1,011.78
Rate for Payer: Kaiser Permanente Medicaid	$819.06
Rate for Payer: MDX Hawaii PPO	$1,557.82
Rate for Payer: University Health Alliance Commercial	$899.36

PLATE 2.7MM LT 2H 249.689

Facility

$1,606.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$899.36
Max. Negotiated Rate	$1,557.82
Rate for Payer: Cash Price	$963.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,124.20
Rate for Payer: Health Management Network Commercial	$1,365.10
Rate for Payer: MDX Hawaii PPO	$1,557.82
Rate for Payer: University Health Alliance Commercial	$899.36

PLATE 2.7MM OBL LT 2H 249.687

Facility

$1,606.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$819.06
Max. Negotiated Rate	$1,557.82
Rate for Payer: Cash Price	$963.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,124.20
Rate for Payer: Health Management Network Commercial	$1,365.10
Rate for Payer: Kaiser Permanente Commercial	$1,011.78
Rate for Payer: Kaiser Permanente Medicaid	$819.06
Rate for Payer: MDX Hawaii PPO	$1,557.82
Rate for Payer: University Health Alliance Commercial	$899.36

PLATE 2.7MM OBL LT 2H 249.687

Facility

$1,606.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$899.36
Max. Negotiated Rate	$1,557.82
Rate for Payer: Cash Price	$963.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,124.20
Rate for Payer: Health Management Network Commercial	$1,365.10
Rate for Payer: MDX Hawaii PPO	$1,557.82
Rate for Payer: University Health Alliance Commercial	$899.36

PLATE 2.7MM OBL RT 2H 249.686

Facility

$1,606.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$819.06
Max. Negotiated Rate	$1,557.82
Rate for Payer: Cash Price	$963.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,124.20
Rate for Payer: Health Management Network Commercial	$1,365.10
Rate for Payer: Kaiser Permanente Commercial	$1,011.78
Rate for Payer: Kaiser Permanente Medicaid	$819.06
Rate for Payer: MDX Hawaii PPO	$1,557.82
Rate for Payer: University Health Alliance Commercial	$899.36

PLATE 2.7MM OBL RT 2H 249.686

Facility

$1,606.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$899.36
Max. Negotiated Rate	$1,557.82
Rate for Payer: Cash Price	$963.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,124.20
Rate for Payer: Health Management Network Commercial	$1,365.10
Rate for Payer: MDX Hawaii PPO	$1,557.82
Rate for Payer: University Health Alliance Commercial	$899.36

PLATE 2.7MM RT 2H 249.688

Facility

$1,606.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$819.06
Max. Negotiated Rate	$1,557.82
Rate for Payer: Cash Price	$963.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,124.20
Rate for Payer: Health Management Network Commercial	$1,365.10
Rate for Payer: Kaiser Permanente Commercial	$1,011.78
Rate for Payer: Kaiser Permanente Medicaid	$819.06
Rate for Payer: MDX Hawaii PPO	$1,557.82
Rate for Payer: University Health Alliance Commercial	$899.36

PLATE 2.7MM RT 2H 249.688

Facility

$1,606.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$899.36
Max. Negotiated Rate	$1,557.82
Rate for Payer: Cash Price	$963.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,124.20
Rate for Payer: Health Management Network Commercial	$1,365.10
Rate for Payer: MDX Hawaii PPO	$1,557.82
Rate for Payer: University Health Alliance Commercial	$899.36

PLATE 2.7 NARR LOK 8H 629728

Facility

$2,614.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,333.14
Max. Negotiated Rate	$2,535.58
Rate for Payer: Cash Price	$1,568.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,829.80
Rate for Payer: Health Management Network Commercial	$2,221.90
Rate for Payer: Kaiser Permanente Commercial	$1,646.82
Rate for Payer: Kaiser Permanente Medicaid	$1,333.14
Rate for Payer: MDX Hawaii PPO	$2,535.58
Rate for Payer: University Health Alliance Commercial	$1,463.84

PLATE 2.7 NARR LOK 8H 629728

Facility

$2,614.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,463.84
Max. Negotiated Rate	$2,535.58
Rate for Payer: Cash Price	$1,568.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,829.80
Rate for Payer: Health Management Network Commercial	$2,221.90
Rate for Payer: MDX Hawaii PPO	$2,535.58
Rate for Payer: University Health Alliance Commercial	$1,463.84

PLATE 2.7 NARR T-PLATE 629782

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 2.7 NARR T-PLATE 629782

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

Know your out-of-pocket cost for care.

All Charges