Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE 626675

Facility

$1,234.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$691.04
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$740.40
Rate for Payer: Hawaii Western Management Group Commercial	$863.80
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: University Health Alliance Commercial	$691.04

PLATE 626675

Facility

$1,234.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$629.34
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$740.40
Rate for Payer: Hawaii Western Management Group Commercial	$863.80
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Kaiser Permanente Commercial	$777.42
Rate for Payer: Kaiser Permanente Medicaid	$629.34
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: University Health Alliance Commercial	$691.04

PLATE 626993

Facility

$3,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,538.16
Max. Negotiated Rate	$2,925.52
Rate for Payer: Cash Price	$1,809.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,111.20
Rate for Payer: Health Management Network Commercial	$2,563.60
Rate for Payer: Kaiser Permanente Commercial	$1,900.08
Rate for Payer: Kaiser Permanente Medicaid	$1,538.16
Rate for Payer: MDX Hawaii PPO	$2,925.52
Rate for Payer: University Health Alliance Commercial	$1,688.96

PLATE 626993

Facility

$3,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,688.96
Max. Negotiated Rate	$2,925.52
Rate for Payer: Cash Price	$1,809.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,111.20
Rate for Payer: Health Management Network Commercial	$2,563.60
Rate for Payer: MDX Hawaii PPO	$2,925.52
Rate for Payer: University Health Alliance Commercial	$1,688.96

PLATE 6 HOLE 627306

Facility

$5,101.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,601.51
Max. Negotiated Rate	$4,947.97
Rate for Payer: Cash Price	$3,060.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,570.70
Rate for Payer: Health Management Network Commercial	$4,335.85
Rate for Payer: Kaiser Permanente Commercial	$3,213.63
Rate for Payer: Kaiser Permanente Medicaid	$2,601.51
Rate for Payer: MDX Hawaii PPO	$4,947.97
Rate for Payer: University Health Alliance Commercial	$2,856.56

PLATE 6 HOLE 627306

Facility

$5,101.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,856.56
Max. Negotiated Rate	$4,947.97
Rate for Payer: Cash Price	$3,060.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,570.70
Rate for Payer: Health Management Network Commercial	$4,335.85
Rate for Payer: MDX Hawaii PPO	$4,947.97
Rate for Payer: University Health Alliance Commercial	$2,856.56

PLATE 6 HOLES 629506

Facility

$1,514.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$772.14
Max. Negotiated Rate	$1,468.58
Rate for Payer: Cash Price	$908.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,059.80
Rate for Payer: Health Management Network Commercial	$1,286.90
Rate for Payer: Kaiser Permanente Commercial	$953.82
Rate for Payer: Kaiser Permanente Medicaid	$772.14
Rate for Payer: MDX Hawaii PPO	$1,468.58
Rate for Payer: University Health Alliance Commercial	$847.84

PLATE 6 HOLES 629506

Facility

$1,514.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$847.84
Max. Negotiated Rate	$1,468.58
Rate for Payer: Cash Price	$908.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,059.80
Rate for Payer: Health Management Network Commercial	$1,286.90
Rate for Payer: MDX Hawaii PPO	$1,468.58
Rate for Payer: University Health Alliance Commercial	$847.84

PLATE 77MM 3 HOLES

Facility

$2,156.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,207.36
Max. Negotiated Rate	$2,091.32
Rate for Payer: Cash Price	$1,293.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,509.20
Rate for Payer: Health Management Network Commercial	$1,832.60
Rate for Payer: MDX Hawaii PPO	$2,091.32
Rate for Payer: University Health Alliance Commercial	$1,207.36

PLATE 77MM 3 HOLES

Facility

$2,156.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,099.56
Max. Negotiated Rate	$2,091.32
Rate for Payer: Cash Price	$1,293.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,509.20
Rate for Payer: Health Management Network Commercial	$1,832.60
Rate for Payer: Kaiser Permanente Commercial	$1,358.28
Rate for Payer: Kaiser Permanente Medicaid	$1,099.56
Rate for Payer: MDX Hawaii PPO	$2,091.32
Rate for Payer: University Health Alliance Commercial	$1,207.36

PLATE 8H 1MM CRV 04.503.709

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 8H 1MM CRV 04.503.709

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 8 HOLE 629508

Facility

$2,225.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,134.75
Max. Negotiated Rate	$2,158.25
Rate for Payer: Cash Price	$1,335.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,557.50
Rate for Payer: Health Management Network Commercial	$1,891.25
Rate for Payer: Kaiser Permanente Commercial	$1,401.75
Rate for Payer: Kaiser Permanente Medicaid	$1,134.75
Rate for Payer: MDX Hawaii PPO	$2,158.25
Rate for Payer: University Health Alliance Commercial	$1,246.00

PLATE 8 HOLE 629508

Facility

$2,225.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,246.00
Max. Negotiated Rate	$2,158.25
Rate for Payer: Cash Price	$1,335.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,557.50
Rate for Payer: Health Management Network Commercial	$1,891.25
Rate for Payer: MDX Hawaii PPO	$2,158.25
Rate for Payer: University Health Alliance Commercial	$1,246.00

PLATE 9H CRVD 5MMX188MM

Facility

$6,054.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,390.24
Max. Negotiated Rate	$5,872.38
Rate for Payer: Cash Price	$3,632.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,237.80
Rate for Payer: Health Management Network Commercial	$5,145.90
Rate for Payer: MDX Hawaii PPO	$5,872.38
Rate for Payer: University Health Alliance Commercial	$3,390.24

PLATE 9H CRVD 5MMX188MM

Facility

$6,054.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,087.54
Max. Negotiated Rate	$5,872.38
Rate for Payer: Cash Price	$3,632.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,237.80
Rate for Payer: Health Management Network Commercial	$5,145.90
Rate for Payer: Kaiser Permanente Commercial	$3,814.02
Rate for Payer: Kaiser Permanente Medicaid	$3,087.54
Rate for Payer: MDX Hawaii PPO	$5,872.38
Rate for Payer: University Health Alliance Commercial	$3,390.24

PLATE 9H MED LEFT P53-009-L001

Facility

$3,293.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,679.43
Max. Negotiated Rate	$3,194.21
Rate for Payer: Cash Price	$1,975.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,305.10
Rate for Payer: Health Management Network Commercial	$2,799.05
Rate for Payer: Kaiser Permanente Commercial	$2,074.59
Rate for Payer: Kaiser Permanente Medicaid	$1,679.43
Rate for Payer: MDX Hawaii PPO	$3,194.21
Rate for Payer: University Health Alliance Commercial	$1,844.08

PLATE 9H MED LEFT P53-009-L001

Facility

$3,293.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,844.08
Max. Negotiated Rate	$3,194.21
Rate for Payer: Cash Price	$1,975.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,305.10
Rate for Payer: Health Management Network Commercial	$2,799.05
Rate for Payer: MDX Hawaii PPO	$3,194.21
Rate for Payer: University Health Alliance Commercial	$1,844.08

PLATE ANKLE FIX TI STANDARD LT

Facility

$3,800.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,128.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

PLATE ANKLE FIX TI STANDARD LT

Facility

$3,800.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,938.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Kaiser Permanente Commercial	$2,394.00
Rate for Payer: Kaiser Permanente Medicaid	$1,938.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

PLATE ANKLE HOOK LT 4H HOOKL-4

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 ANKLE HOOK LT 4H HOOKL-4

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 ANKLE HOOK RT 4H HOOKR-4

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 ANKLE HOOK RT 4H HOOKR-4

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 ANKLE HOOK RT 6H HOOKR-6

Facility

$2,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
Max. Negotiated Rate	$2,328.00
Rate for Payer: Cash Price	$1,440.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,680.00
Rate for Payer: Health Management Network Commercial	$2,040.00
Rate for Payer: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

Know your out-of-pocket cost for care.

All Charges