Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE 2.7 VA-LCK RT 02.211.400

Facility

$2,280.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,276.80
Max. Negotiated Rate	$2,211.60
Rate for Payer: Cash Price	$1,368.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,596.00
Rate for Payer: Health Management Network Commercial	$1,938.00
Rate for Payer: MDX Hawaii PPO	$2,211.60
Rate for Payer: University Health Alliance Commercial	$1,276.80

PLATE 2.7 VA-LCK RT 02.211.400

Facility

$2,280.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,162.80
Max. Negotiated Rate	$2,211.60
Rate for Payer: Cash Price	$1,368.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,596.00
Rate for Payer: Health Management Network Commercial	$1,938.00
Rate for Payer: Kaiser Permanente Commercial	$1,436.40
Rate for Payer: Kaiser Permanente Medicaid	$1,162.80
Rate for Payer: MDX Hawaii PPO	$2,211.60
Rate for Payer: University Health Alliance Commercial	$1,276.80

PLATE 2.7X2MM STEP 336-2722

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 2.7X2MM STEP 336-2722

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 2H/LT/85MM 02.117.702

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 2H/LT/85MM 02.117.702

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 2H SYNDESMOS AR-8959-01S

Facility

$2,834.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,445.34
Max. Negotiated Rate	$2,748.98
Rate for Payer: Cash Price	$1,700.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,983.80
Rate for Payer: Health Management Network Commercial	$2,408.90
Rate for Payer: Kaiser Permanente Commercial	$1,785.42
Rate for Payer: Kaiser Permanente Medicaid	$1,445.34
Rate for Payer: MDX Hawaii PPO	$2,748.98
Rate for Payer: University Health Alliance Commercial	$1,587.04

PLATE 2H SYNDESMOS AR-8959-01S

Facility

$2,834.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,587.04
Max. Negotiated Rate	$2,748.98
Rate for Payer: Cash Price	$1,700.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,983.80
Rate for Payer: Health Management Network Commercial	$2,408.90
Rate for Payer: MDX Hawaii PPO	$2,748.98
Rate for Payer: University Health Alliance Commercial	$1,587.04

PLATE 2X2 HOLES

Facility

$668.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$340.68
Max. Negotiated Rate	$647.96
Rate for Payer: Cash Price	$400.80
Rate for Payer: Hawaii Western Management Group Commercial	$467.60
Rate for Payer: Health Management Network Commercial	$567.80
Rate for Payer: Kaiser Permanente Commercial	$420.84
Rate for Payer: Kaiser Permanente Medicaid	$340.68
Rate for Payer: MDX Hawaii PPO	$647.96
Rate for Payer: University Health Alliance Commercial	$374.08

PLATE 2X2 HOLES

Facility

$668.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$374.08
Max. Negotiated Rate	$647.96
Rate for Payer: Cash Price	$400.80
Rate for Payer: Hawaii Western Management Group Commercial	$467.60
Rate for Payer: Health Management Network Commercial	$567.80
Rate for Payer: MDX Hawaii PPO	$647.96
Rate for Payer: University Health Alliance Commercial	$374.08

PLATE 3.2MM CLAV HOOK 241.073S

Facility

$2,937.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,497.87
Max. Negotiated Rate	$2,848.89
Rate for Payer: Cash Price	$1,762.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,055.90
Rate for Payer: Health Management Network Commercial	$2,496.45
Rate for Payer: Kaiser Permanente Commercial	$1,850.31
Rate for Payer: Kaiser Permanente Medicaid	$1,497.87
Rate for Payer: MDX Hawaii PPO	$2,848.89
Rate for Payer: University Health Alliance Commercial	$1,644.72

PLATE 3.2MM CLAV HOOK 241.073S

Facility

$2,937.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,644.72
Max. Negotiated Rate	$2,848.89
Rate for Payer: Cash Price	$1,762.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,055.90
Rate for Payer: Health Management Network Commercial	$2,496.45
Rate for Payer: MDX Hawaii PPO	$2,848.89
Rate for Payer: University Health Alliance Commercial	$1,644.72

PLATE 3.5 4-HOLE/51MM 223.54

Facility

$1,246.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$635.46
Max. Negotiated Rate	$1,208.62
Rate for Payer: Cash Price	$747.60
Rate for Payer: Hawaii Western Management Group Commercial	$872.20
Rate for Payer: Health Management Network Commercial	$1,059.10
Rate for Payer: Kaiser Permanente Commercial	$784.98
Rate for Payer: Kaiser Permanente Medicaid	$635.46
Rate for Payer: MDX Hawaii PPO	$1,208.62
Rate for Payer: University Health Alliance Commercial	$697.76

PLATE 3.5 4-HOLE/51MM 223.54

Facility

$1,246.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$697.76
Max. Negotiated Rate	$1,208.62
Rate for Payer: Cash Price	$747.60
Rate for Payer: Hawaii Western Management Group Commercial	$872.20
Rate for Payer: Health Management Network Commercial	$1,059.10
Rate for Payer: MDX Hawaii PPO	$1,208.62
Rate for Payer: University Health Alliance Commercial	$697.76

PLATE 3.5 5-HOLE/64MM 223.55

Facility

$1,285.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$655.35
Max. Negotiated Rate	$1,246.45
Rate for Payer: Cash Price	$771.00
Rate for Payer: Hawaii Western Management Group Commercial	$899.50
Rate for Payer: Health Management Network Commercial	$1,092.25
Rate for Payer: Kaiser Permanente Commercial	$809.55
Rate for Payer: Kaiser Permanente Medicaid	$655.35
Rate for Payer: MDX Hawaii PPO	$1,246.45
Rate for Payer: University Health Alliance Commercial	$719.60

PLATE 3.5 5-HOLE/64MM 223.55

Facility

$1,285.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$719.60
Max. Negotiated Rate	$1,246.45
Rate for Payer: Cash Price	$771.00
Rate for Payer: Hawaii Western Management Group Commercial	$899.50
Rate for Payer: Health Management Network Commercial	$1,092.25
Rate for Payer: MDX Hawaii PPO	$1,246.45
Rate for Payer: University Health Alliance Commercial	$719.60

PLATE 3.5 7-HOLE/90MM 223.57

Facility

$1,422.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$796.32
Max. Negotiated Rate	$1,379.34
Rate for Payer: Cash Price	$853.20
Rate for Payer: Hawaii Western Management Group Commercial	$995.40
Rate for Payer: Health Management Network Commercial	$1,208.70
Rate for Payer: MDX Hawaii PPO	$1,379.34
Rate for Payer: University Health Alliance Commercial	$796.32

PLATE 3.5 7-HOLE/90MM 223.57

Facility

$1,422.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$725.22
Max. Negotiated Rate	$1,379.34
Rate for Payer: Cash Price	$853.20
Rate for Payer: Hawaii Western Management Group Commercial	$995.40
Rate for Payer: Health Management Network Commercial	$1,208.70
Rate for Payer: Kaiser Permanente Commercial	$895.86
Rate for Payer: Kaiser Permanente Medicaid	$725.22
Rate for Payer: MDX Hawaii PPO	$1,379.34
Rate for Payer: University Health Alliance Commercial	$796.32

PLATE 3.5 LCP 2H 02.120.702S

Facility

$2,414.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,231.14
Max. Negotiated Rate	$2,341.58
Rate for Payer: Cash Price	$1,448.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,689.80
Rate for Payer: Health Management Network Commercial	$2,051.90
Rate for Payer: Kaiser Permanente Commercial	$1,520.82
Rate for Payer: Kaiser Permanente Medicaid	$1,231.14
Rate for Payer: MDX Hawaii PPO	$2,341.58
Rate for Payer: University Health Alliance Commercial	$1,351.84

PLATE 3.5 LCP 2H 02.120.702S

Facility

$2,414.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.84
Max. Negotiated Rate	$2,341.58
Rate for Payer: Cash Price	$1,448.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,689.80
Rate for Payer: Health Management Network Commercial	$2,051.90
Rate for Payer: MDX Hawaii PPO	$2,341.58
Rate for Payer: University Health Alliance Commercial	$1,351.84

PLATE 3.5 LF 4 HOLE 02.110.107

Facility

$3,709.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,077.04
Max. Negotiated Rate	$3,597.73
Rate for Payer: Cash Price	$2,225.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,596.30
Rate for Payer: Health Management Network Commercial	$3,152.65
Rate for Payer: MDX Hawaii PPO	$3,597.73
Rate for Payer: University Health Alliance Commercial	$2,077.04

PLATE 3.5 LF 4 HOLE 02.110.107

Facility

$3,709.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,891.59
Max. Negotiated Rate	$3,597.73
Rate for Payer: Cash Price	$2,225.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,596.30
Rate for Payer: Health Management Network Commercial	$3,152.65
Rate for Payer: Kaiser Permanente Commercial	$2,336.67
Rate for Payer: Kaiser Permanente Medicaid	$1,891.59
Rate for Payer: MDX Hawaii PPO	$3,597.73
Rate for Payer: University Health Alliance Commercial	$2,077.04

PLATE 3.5MM 10HL/194MM 239.913

Facility

$3,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,716.96
Max. Negotiated Rate	$2,974.02
Rate for Payer: Cash Price	$1,839.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,146.20
Rate for Payer: Health Management Network Commercial	$2,606.10
Rate for Payer: MDX Hawaii PPO	$2,974.02
Rate for Payer: University Health Alliance Commercial	$1,716.96

PLATE 3.5MM 10HL/194MM 239.913

Facility

$3,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,563.66
Max. Negotiated Rate	$2,974.02
Rate for Payer: Cash Price	$1,839.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,146.20
Rate for Payer: Health Management Network Commercial	$2,606.10
Rate for Payer: Kaiser Permanente Commercial	$1,931.58
Rate for Payer: Kaiser Permanente Medicaid	$1,563.66
Rate for Payer: MDX Hawaii PPO	$2,974.02
Rate for Payer: University Health Alliance Commercial	$1,716.96

PLATE 3.5MM 10HL/195MM 239.912

Facility

$3,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,716.96
Max. Negotiated Rate	$2,974.02
Rate for Payer: Cash Price	$1,839.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,146.20
Rate for Payer: Health Management Network Commercial	$2,606.10
Rate for Payer: MDX Hawaii PPO	$2,974.02
Rate for Payer: University Health Alliance Commercial	$1,716.96

Know your out-of-pocket cost for care.

All Charges