Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE ANKLE HOOK RT 6H HOOKR-6

Facility

$2,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.00
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: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

PLATE ANKLE HOOK RT 8H HOOKR-8

Facility

$2,550.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,428.00
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,785.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: University Health Alliance Commercial	$1,428.00

PLATE ANKLE HOOK RT 8H HOOKR-8

Facility

$2,550.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,785.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$1,300.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: University Health Alliance Commercial	$1,428.00

PLATE ANKLE TI LARGE 28.14.107

Facility

$4,700.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,632.00
Max. Negotiated Rate	$4,559.00
Rate for Payer: Cash Price	$2,820.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,290.00
Rate for Payer: Health Management Network Commercial	$3,995.00
Rate for Payer: MDX Hawaii PPO	$4,559.00
Rate for Payer: University Health Alliance Commercial	$2,632.00

PLATE ANKLE TI LARGE 28.14.107

Facility

$4,700.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,397.00
Max. Negotiated Rate	$4,559.00
Rate for Payer: Cash Price	$2,820.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,290.00
Rate for Payer: Health Management Network Commercial	$3,995.00
Rate for Payer: Kaiser Permanente Commercial	$2,961.00
Rate for Payer: Kaiser Permanente Medicaid	$2,397.00
Rate for Payer: MDX Hawaii PPO	$4,559.00
Rate for Payer: University Health Alliance Commercial	$2,632.00

PLATE BASE IJS-ELB-BPA

Facility

$11,378.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$6,371.68
Max. Negotiated Rate	$11,036.66
Rate for Payer: Cash Price	$6,826.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,964.60
Rate for Payer: Health Management Network Commercial	$9,671.30
Rate for Payer: MDX Hawaii PPO	$11,036.66
Rate for Payer: University Health Alliance Commercial	$6,371.68

PLATE BASE IJS-ELB-BPA

Facility

$11,378.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$5,802.78
Max. Negotiated Rate	$11,036.66
Rate for Payer: Cash Price	$6,826.80
Rate for Payer: Hawaii Western Management Group Commercial	$7,964.60
Rate for Payer: Health Management Network Commercial	$9,671.30
Rate for Payer: Kaiser Permanente Commercial	$7,168.14
Rate for Payer: Kaiser Permanente Medicaid	$5,802.78
Rate for Payer: MDX Hawaii PPO	$11,036.66
Rate for Payer: University Health Alliance Commercial	$6,371.68

PLATE BNE LCK OLECRANON 629366

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 BNE LCK OLECRANON 629366

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 BNE LCK OLECRANON 629626

Facility

$2,509.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,405.04
Max. Negotiated Rate	$2,433.73
Rate for Payer: Cash Price	$1,505.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,756.30
Rate for Payer: Health Management Network Commercial	$2,132.65
Rate for Payer: MDX Hawaii PPO	$2,433.73
Rate for Payer: University Health Alliance Commercial	$1,405.04

PLATE BNE LCK OLECRANON 629626

Facility

$2,509.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,279.59
Max. Negotiated Rate	$2,433.73
Rate for Payer: Cash Price	$1,505.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,756.30
Rate for Payer: Health Management Network Commercial	$2,132.65
Rate for Payer: Kaiser Permanente Commercial	$1,580.67
Rate for Payer: Kaiser Permanente Medicaid	$1,279.59
Rate for Payer: MDX Hawaii PPO	$2,433.73
Rate for Payer: University Health Alliance Commercial	$1,405.04

PLATE BONE 16H 336M 02.124.416

Facility

$4,808.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,452.08
Max. Negotiated Rate	$4,663.76
Rate for Payer: Cash Price	$2,884.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.60
Rate for Payer: Health Management Network Commercial	$4,086.80
Rate for Payer: Kaiser Permanente Commercial	$3,029.04
Rate for Payer: Kaiser Permanente Medicaid	$2,452.08
Rate for Payer: MDX Hawaii PPO	$4,663.76
Rate for Payer: University Health Alliance Commercial	$2,692.48

PLATE BONE 16H 336M 02.124.416

Facility

$4,808.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,692.48
Max. Negotiated Rate	$4,663.76
Rate for Payer: Cash Price	$2,884.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,365.60
Rate for Payer: Health Management Network Commercial	$4,086.80
Rate for Payer: MDX Hawaii PPO	$4,663.76
Rate for Payer: University Health Alliance Commercial	$2,692.48

PLATE BONE 2X10 HOLE 629783

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 BONE 2X10 HOLE 629783

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

PLATE BONE 5 X 10 HOLE T-PLATE

Facility

$2,437.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,242.87
Max. Negotiated Rate	$2,363.89
Rate for Payer: Cash Price	$1,462.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,705.90
Rate for Payer: Health Management Network Commercial	$2,071.45
Rate for Payer: Kaiser Permanente Commercial	$1,535.31
Rate for Payer: Kaiser Permanente Medicaid	$1,242.87
Rate for Payer: MDX Hawaii PPO	$2,363.89
Rate for Payer: University Health Alliance Commercial	$1,364.72

PLATE BONE 5 X 10 HOLE T-PLATE

Facility

$2,437.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.72
Max. Negotiated Rate	$2,363.89
Rate for Payer: Cash Price	$1,462.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,705.90
Rate for Payer: Health Management Network Commercial	$2,071.45
Rate for Payer: MDX Hawaii PPO	$2,363.89
Rate for Payer: University Health Alliance Commercial	$1,364.72

PLATE BONE FEM LF 02.124.411

Facility

$4,329.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,207.79
Max. Negotiated Rate	$4,199.13
Rate for Payer: Cash Price	$2,597.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,030.30
Rate for Payer: Health Management Network Commercial	$3,679.65
Rate for Payer: Kaiser Permanente Commercial	$2,727.27
Rate for Payer: Kaiser Permanente Medicaid	$2,207.79
Rate for Payer: MDX Hawaii PPO	$4,199.13
Rate for Payer: University Health Alliance Commercial	$2,424.24

PLATE BONE FEM LF 02.124.411

Facility

$4,329.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,424.24
Max. Negotiated Rate	$4,199.13
Rate for Payer: Cash Price	$2,597.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,030.30
Rate for Payer: Health Management Network Commercial	$3,679.65
Rate for Payer: MDX Hawaii PPO	$4,199.13
Rate for Payer: University Health Alliance Commercial	$2,424.24

PLATE BONE LCK 02.112.108

Facility

$2,306.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,176.06
Max. Negotiated Rate	$2,236.82
Rate for Payer: Cash Price	$1,383.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,614.20
Rate for Payer: Health Management Network Commercial	$1,960.10
Rate for Payer: Kaiser Permanente Commercial	$1,452.78
Rate for Payer: Kaiser Permanente Medicaid	$1,176.06
Rate for Payer: MDX Hawaii PPO	$2,236.82
Rate for Payer: University Health Alliance Commercial	$1,291.36

PLATE BONE LCK 02.112.108

Facility

$2,306.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,291.36
Max. Negotiated Rate	$2,236.82
Rate for Payer: Cash Price	$1,383.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,614.20
Rate for Payer: Health Management Network Commercial	$1,960.10
Rate for Payer: MDX Hawaii PPO	$2,236.82
Rate for Payer: University Health Alliance Commercial	$1,291.36

PLATE BONE LCK 7H 02.117.004

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 BONE LCK 7H 02.117.004

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 BONE LCK COMP CRV 629559

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 BONE LCK COMP CRV 629559

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

Know your out-of-pocket cost for care.

All Charges