Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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

PLATE 3.5MM 10HOL/118MM 245.00

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 3.5MM 10HOL/118MM 245.00

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 3.5MM 10HOL/121MM 248.10

Facility

$701.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$357.51
Max. Negotiated Rate	$679.97
Rate for Payer: Cash Price	$420.60
Rate for Payer: Hawaii Western Management Group Commercial	$490.70
Rate for Payer: Health Management Network Commercial	$595.85
Rate for Payer: Kaiser Permanente Commercial	$441.63
Rate for Payer: Kaiser Permanente Medicaid	$357.51
Rate for Payer: MDX Hawaii PPO	$679.97
Rate for Payer: University Health Alliance Commercial	$392.56

PLATE 3.5MM 10HOL/121MM 248.10

Facility

$701.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$392.56
Max. Negotiated Rate	$679.97
Rate for Payer: Cash Price	$420.60
Rate for Payer: Hawaii Western Management Group Commercial	$490.70
Rate for Payer: Health Management Network Commercial	$595.85
Rate for Payer: MDX Hawaii PPO	$679.97
Rate for Payer: University Health Alliance Commercial	$392.56

PLATE 3.5MM 12HL/220MM 239.916

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 12HL/220MM 239.916

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 12HL/220MM 239.917

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 12HL/220MM 239.917

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 5-HOLE/58MM 245.15

Facility

$931.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$521.36
Max. Negotiated Rate	$903.07
Rate for Payer: Cash Price	$558.60
Rate for Payer: Hawaii Western Management Group Commercial	$651.70
Rate for Payer: Health Management Network Commercial	$791.35
Rate for Payer: MDX Hawaii PPO	$903.07
Rate for Payer: University Health Alliance Commercial	$521.36

PLATE 3.5MM 5-HOLE/58MM 245.15

Facility

$931.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$474.81
Max. Negotiated Rate	$903.07
Rate for Payer: Cash Price	$558.60
Rate for Payer: Hawaii Western Management Group Commercial	$651.70
Rate for Payer: Health Management Network Commercial	$791.35
Rate for Payer: Kaiser Permanente Commercial	$586.53
Rate for Payer: Kaiser Permanente Medicaid	$474.81
Rate for Payer: MDX Hawaii PPO	$903.07
Rate for Payer: University Health Alliance Commercial	$521.36

PLATE 3.5MM 6HOL/142MM 239.905

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 6HOL/142MM 239.905

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 6-HOLE/70MM 245.16

Facility

$1,075.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$548.25
Max. Negotiated Rate	$1,042.75
Rate for Payer: Cash Price	$645.00
Rate for Payer: Hawaii Western Management Group Commercial	$752.50
Rate for Payer: Health Management Network Commercial	$913.75
Rate for Payer: Kaiser Permanente Commercial	$677.25
Rate for Payer: Kaiser Permanente Medicaid	$548.25
Rate for Payer: MDX Hawaii PPO	$1,042.75
Rate for Payer: University Health Alliance Commercial	$602.00

PLATE 3.5MM 6-HOLE/70MM 245.16

Facility

$1,075.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$602.00
Max. Negotiated Rate	$1,042.75
Rate for Payer: Cash Price	$645.00
Rate for Payer: Hawaii Western Management Group Commercial	$752.50
Rate for Payer: Health Management Network Commercial	$913.75
Rate for Payer: MDX Hawaii PPO	$1,042.75
Rate for Payer: University Health Alliance Commercial	$602.00

PLATE 3.5MM 7-HOLE/82MM 245.17

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 3.5MM 7-HOLE/82MM 245.17

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 3.5MM 7HOLE/85MM 248.07

Facility

$626.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$319.26
Max. Negotiated Rate	$607.22
Rate for Payer: Cash Price	$375.60
Rate for Payer: Hawaii Western Management Group Commercial	$438.20
Rate for Payer: Health Management Network Commercial	$532.10
Rate for Payer: Kaiser Permanente Commercial	$394.38
Rate for Payer: Kaiser Permanente Medicaid	$319.26
Rate for Payer: MDX Hawaii PPO	$607.22
Rate for Payer: University Health Alliance Commercial	$350.56

PLATE 3.5MM 7HOLE/85MM 248.07

Facility

$626.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$350.56
Max. Negotiated Rate	$607.22
Rate for Payer: Cash Price	$375.60
Rate for Payer: Hawaii Western Management Group Commercial	$438.20
Rate for Payer: Health Management Network Commercial	$532.10
Rate for Payer: MDX Hawaii PPO	$607.22
Rate for Payer: University Health Alliance Commercial	$350.56

PLATE 3.5MM 8-HOLE/94MM 245.18

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 3.5MM 8-HOLE/94MM 245.18

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 3.5MM 8HOLE/97MM 248.08

Facility

$626.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$319.26
Max. Negotiated Rate	$607.22
Rate for Payer: Cash Price	$375.60
Rate for Payer: Hawaii Western Management Group Commercial	$438.20
Rate for Payer: Health Management Network Commercial	$532.10
Rate for Payer: Kaiser Permanente Commercial	$394.38
Rate for Payer: Kaiser Permanente Medicaid	$319.26
Rate for Payer: MDX Hawaii PPO	$607.22
Rate for Payer: University Health Alliance Commercial	$350.56

PLATE 3.5MM 8HOLE/97MM 248.08

Facility

$626.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$350.56
Max. Negotiated Rate	$607.22
Rate for Payer: Cash Price	$375.60
Rate for Payer: Hawaii Western Management Group Commercial	$438.20
Rate for Payer: Health Management Network Commercial	$532.10
Rate for Payer: MDX Hawaii PPO	$607.22
Rate for Payer: University Health Alliance Commercial	$350.56

PLATE 3.5MM 9HOLE/106MM 245.19

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 3.5MM 9HOLE/106MM 245.19

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

Know your out-of-pocket cost for care.

All Charges