Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE 4.5/6H/170MM RT 222.656

Facility

$5,042.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,823.52
Max. Negotiated Rate	$4,890.74
Rate for Payer: Cash Price	$3,025.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,529.40
Rate for Payer: Health Management Network Commercial	$4,285.70
Rate for Payer: MDX Hawaii PPO	$4,890.74
Rate for Payer: University Health Alliance Commercial	$2,823.52

PLATE 4.5MM 6H/211MM 242.106

Facility

$4,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,328.66
Max. Negotiated Rate	$4,429.02
Rate for Payer: Cash Price	$2,739.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,196.20
Rate for Payer: Health Management Network Commercial	$3,881.10
Rate for Payer: Kaiser Permanente Commercial	$2,876.58
Rate for Payer: Kaiser Permanente Medicaid	$2,328.66
Rate for Payer: MDX Hawaii PPO	$4,429.02
Rate for Payer: University Health Alliance Commercial	$2,556.96

PLATE 4.5MM 6H/211MM 242.106

Facility

$4,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,556.96
Max. Negotiated Rate	$4,429.02
Rate for Payer: Cash Price	$2,739.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,196.20
Rate for Payer: Health Management Network Commercial	$3,881.10
Rate for Payer: MDX Hawaii PPO	$4,429.02
Rate for Payer: University Health Alliance Commercial	$2,556.96

PLATE 4.5MM 6H/211MM 242.806

Facility

$4,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,328.66
Max. Negotiated Rate	$4,429.02
Rate for Payer: Cash Price	$2,739.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,196.20
Rate for Payer: Health Management Network Commercial	$3,881.10
Rate for Payer: Kaiser Permanente Commercial	$2,876.58
Rate for Payer: Kaiser Permanente Medicaid	$2,328.66
Rate for Payer: MDX Hawaii PPO	$4,429.02
Rate for Payer: University Health Alliance Commercial	$2,556.96

PLATE 4.5MM 6H/211MM 242.806

Facility

$4,566.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,556.96
Max. Negotiated Rate	$4,429.02
Rate for Payer: Cash Price	$2,739.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,196.20
Rate for Payer: Health Management Network Commercial	$3,881.10
Rate for Payer: MDX Hawaii PPO	$4,429.02
Rate for Payer: University Health Alliance Commercial	$2,556.96

PLATE 4.5MM 8H/247MM 242.108

Facility

$3,536.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,803.36
Max. Negotiated Rate	$3,429.92
Rate for Payer: Cash Price	$2,121.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,475.20
Rate for Payer: Health Management Network Commercial	$3,005.60
Rate for Payer: Kaiser Permanente Commercial	$2,227.68
Rate for Payer: Kaiser Permanente Medicaid	$1,803.36
Rate for Payer: MDX Hawaii PPO	$3,429.92
Rate for Payer: University Health Alliance Commercial	$1,980.16

PLATE 4.5MM 8H/247MM 242.108

Facility

$3,536.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,980.16
Max. Negotiated Rate	$3,429.92
Rate for Payer: Cash Price	$2,121.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,475.20
Rate for Payer: Health Management Network Commercial	$3,005.60
Rate for Payer: MDX Hawaii PPO	$3,429.92
Rate for Payer: University Health Alliance Commercial	$1,980.16

PLATE 4.5MM 8H/247MM 242.808

Facility

$4,788.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,681.28
Max. Negotiated Rate	$4,644.36
Rate for Payer: Cash Price	$2,872.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,351.60
Rate for Payer: Health Management Network Commercial	$4,069.80
Rate for Payer: MDX Hawaii PPO	$4,644.36
Rate for Payer: University Health Alliance Commercial	$2,681.28

PLATE 4.5MM 8H/247MM 242.808

Facility

$4,788.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,441.88
Max. Negotiated Rate	$4,644.36
Rate for Payer: Cash Price	$2,872.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,351.60
Rate for Payer: Health Management Network Commercial	$4,069.80
Rate for Payer: Kaiser Permanente Commercial	$3,016.44
Rate for Payer: Kaiser Permanente Medicaid	$2,441.88
Rate for Payer: MDX Hawaii PPO	$4,644.36
Rate for Payer: University Health Alliance Commercial	$2,681.28

PLATE 4.5MM LCP 6H 02.124.407

Facility

$4,056.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,068.56
Max. Negotiated Rate	$3,934.32
Rate for Payer: Cash Price	$2,433.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,839.20
Rate for Payer: Health Management Network Commercial	$3,447.60
Rate for Payer: Kaiser Permanente Commercial	$2,555.28
Rate for Payer: Kaiser Permanente Medicaid	$2,068.56
Rate for Payer: MDX Hawaii PPO	$3,934.32
Rate for Payer: University Health Alliance Commercial	$2,271.36

PLATE 4.5MM LCP 6H 02.124.407

Facility

$4,056.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,271.36
Max. Negotiated Rate	$3,934.32
Rate for Payer: Cash Price	$2,433.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,839.20
Rate for Payer: Health Management Network Commercial	$3,447.60
Rate for Payer: MDX Hawaii PPO	$3,934.32
Rate for Payer: University Health Alliance Commercial	$2,271.36

PLATE 4.5X195 8H LF 02.124.409

Facility

$4,136.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,109.36
Max. Negotiated Rate	$4,011.92
Rate for Payer: Cash Price	$2,481.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,895.20
Rate for Payer: Health Management Network Commercial	$3,515.60
Rate for Payer: Kaiser Permanente Commercial	$2,605.68
Rate for Payer: Kaiser Permanente Medicaid	$2,109.36
Rate for Payer: MDX Hawaii PPO	$4,011.92
Rate for Payer: University Health Alliance Commercial	$2,316.16

PLATE 4.5X195 8H LF 02.124.409

Facility

$4,136.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,316.16
Max. Negotiated Rate	$4,011.92
Rate for Payer: Cash Price	$2,481.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,895.20
Rate for Payer: Health Management Network Commercial	$3,515.60
Rate for Payer: MDX Hawaii PPO	$4,011.92
Rate for Payer: University Health Alliance Commercial	$2,316.16

PLATE 45X195 RT 8H 02.124.408

Facility

$4,136.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,316.16
Max. Negotiated Rate	$4,011.92
Rate for Payer: Cash Price	$2,481.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,895.20
Rate for Payer: Health Management Network Commercial	$3,515.60
Rate for Payer: MDX Hawaii PPO	$4,011.92
Rate for Payer: University Health Alliance Commercial	$2,316.16

PLATE 45X195 RT 8H 02.124.408

Facility

$4,136.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,109.36
Max. Negotiated Rate	$4,011.92
Rate for Payer: Cash Price	$2,481.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,895.20
Rate for Payer: Health Management Network Commercial	$3,515.60
Rate for Payer: Kaiser Permanente Commercial	$2,605.68
Rate for Payer: Kaiser Permanente Medicaid	$2,109.36
Rate for Payer: MDX Hawaii PPO	$4,011.92
Rate for Payer: University Health Alliance Commercial	$2,316.16

PLATE 4 HOLE 236.504

Facility

$2,163.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.13
Max. Negotiated Rate	$2,098.11
Rate for Payer: Cash Price	$1,297.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,514.10
Rate for Payer: Health Management Network Commercial	$1,838.55
Rate for Payer: Kaiser Permanente Commercial	$1,362.69
Rate for Payer: Kaiser Permanente Medicaid	$1,103.13
Rate for Payer: MDX Hawaii PPO	$2,098.11
Rate for Payer: University Health Alliance Commercial	$1,211.28

PLATE 4 HOLE 236.504

Facility

$2,163.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,211.28
Max. Negotiated Rate	$2,098.11
Rate for Payer: Cash Price	$1,297.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,514.10
Rate for Payer: Health Management Network Commercial	$1,838.55
Rate for Payer: MDX Hawaii PPO	$2,098.11
Rate for Payer: University Health Alliance Commercial	$1,211.28

PLATE 4 HOLE 629364

Facility

$3,151.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,764.56
Max. Negotiated Rate	$3,056.47
Rate for Payer: Cash Price	$1,890.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.70
Rate for Payer: Health Management Network Commercial	$2,678.35
Rate for Payer: MDX Hawaii PPO	$3,056.47
Rate for Payer: University Health Alliance Commercial	$1,764.56

PLATE 4 HOLE 629364

Facility

$3,151.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,607.01
Max. Negotiated Rate	$3,056.47
Rate for Payer: Cash Price	$1,890.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,205.70
Rate for Payer: Health Management Network Commercial	$2,678.35
Rate for Payer: Kaiser Permanente Commercial	$1,985.13
Rate for Payer: Kaiser Permanente Medicaid	$1,607.01
Rate for Payer: MDX Hawaii PPO	$3,056.47
Rate for Payer: University Health Alliance Commercial	$1,764.56

PLATE 4 HOLES 92MM

Facility

$2,058.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,049.58
Max. Negotiated Rate	$1,996.26
Rate for Payer: Cash Price	$1,234.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,440.60
Rate for Payer: Health Management Network Commercial	$1,749.30
Rate for Payer: Kaiser Permanente Commercial	$1,296.54
Rate for Payer: Kaiser Permanente Medicaid	$1,049.58
Rate for Payer: MDX Hawaii PPO	$1,996.26
Rate for Payer: University Health Alliance Commercial	$1,152.48

PLATE 4 HOLES 92MM

Facility

$2,058.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,152.48
Max. Negotiated Rate	$1,996.26
Rate for Payer: Cash Price	$1,234.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,440.60
Rate for Payer: Health Management Network Commercial	$1,749.30
Rate for Payer: MDX Hawaii PPO	$1,996.26
Rate for Payer: University Health Alliance Commercial	$1,152.48

PLATE 4 HOLES 96MM

Facility

$2,058.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,152.48
Max. Negotiated Rate	$1,996.26
Rate for Payer: Cash Price	$1,234.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,440.60
Rate for Payer: Health Management Network Commercial	$1,749.30
Rate for Payer: MDX Hawaii PPO	$1,996.26
Rate for Payer: University Health Alliance Commercial	$1,152.48

PLATE 4 HOLES 96MM

Facility

$2,058.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,049.58
Max. Negotiated Rate	$1,996.26
Rate for Payer: Cash Price	$1,234.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,440.60
Rate for Payer: Health Management Network Commercial	$1,749.30
Rate for Payer: Kaiser Permanente Commercial	$1,296.54
Rate for Payer: Kaiser Permanente Medicaid	$1,049.58
Rate for Payer: MDX Hawaii PPO	$1,996.26
Rate for Payer: University Health Alliance Commercial	$1,152.48

PLATE 4H/RT/111MM 02.117.604

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 4H/RT/111MM 02.117.604

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

Know your out-of-pocket cost for care.

All Charges