Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE DHS 130D 2H 46MM 281.502

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,239.30
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$1,530.90
Rate for Payer: Kaiser Permanente Medicaid	$1,239.30
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 130D 2H 46MM 281.502

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.80
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 135D 2H/46MM 281.102

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,239.30
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$1,530.90
Rate for Payer: Kaiser Permanente Medicaid	$1,239.30
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 135D 2H/46MM 281.102

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.80
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 135D 2H 46MM 281.520

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.80
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 135D 2H 46MM 281.520

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,239.30
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$1,530.90
Rate for Payer: Kaiser Permanente Medicaid	$1,239.30
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 135D 4H 78MM 281.140

Facility

$2,064.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,155.84
Max. Negotiated Rate	$2,002.08
Rate for Payer: Cash Price	$1,238.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.80
Rate for Payer: Health Management Network Commercial	$1,754.40
Rate for Payer: MDX Hawaii PPO	$2,002.08
Rate for Payer: University Health Alliance Commercial	$1,155.84

PLATE DHS 135D 4H 78MM 281.140

Facility

$2,064.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,052.64
Max. Negotiated Rate	$2,002.08
Rate for Payer: Cash Price	$1,238.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,444.80
Rate for Payer: Health Management Network Commercial	$1,754.40
Rate for Payer: Kaiser Permanente Commercial	$1,300.32
Rate for Payer: Kaiser Permanente Medicaid	$1,052.64
Rate for Payer: MDX Hawaii PPO	$2,002.08
Rate for Payer: University Health Alliance Commercial	$1,155.84

PLATE DHS 135D/4H/78MM 281.540

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.80
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 135D/4H/78MM 281.540

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,239.30
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$1,530.90
Rate for Payer: Kaiser Permanente Medicaid	$1,239.30
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 135D/5H/94MM 281.150

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,239.30
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$1,530.90
Rate for Payer: Kaiser Permanente Medicaid	$1,239.30
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 135D/5H/94MM 281.150

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.80
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 140D/4H/78MM 281.240

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.80
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 140D/4H/78MM 281.240

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,239.30
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$1,530.90
Rate for Payer: Kaiser Permanente Medicaid	$1,239.30
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 140D/5H/94MM 281.250

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,239.30
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$1,530.90
Rate for Payer: Kaiser Permanente Medicaid	$1,239.30
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 140D/5H/94MM 281.250

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.80
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 145D 4H 78MM 281.340

Facility

$2,001.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.51
Max. Negotiated Rate	$1,940.97
Rate for Payer: Cash Price	$1,200.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.70
Rate for Payer: Health Management Network Commercial	$1,700.85
Rate for Payer: Kaiser Permanente Commercial	$1,260.63
Rate for Payer: Kaiser Permanente Medicaid	$1,020.51
Rate for Payer: MDX Hawaii PPO	$1,940.97
Rate for Payer: University Health Alliance Commercial	$1,120.56

PLATE DHS 145D 4H 78MM 281.340

Facility

$2,001.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.56
Max. Negotiated Rate	$1,940.97
Rate for Payer: Cash Price	$1,200.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.70
Rate for Payer: Health Management Network Commercial	$1,700.85
Rate for Payer: MDX Hawaii PPO	$1,940.97
Rate for Payer: University Health Alliance Commercial	$1,120.56

PLATE DHS 150D 4H 78MM 281.440

Facility

$2,001.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.56
Max. Negotiated Rate	$1,940.97
Rate for Payer: Cash Price	$1,200.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.70
Rate for Payer: Health Management Network Commercial	$1,700.85
Rate for Payer: MDX Hawaii PPO	$1,940.97
Rate for Payer: University Health Alliance Commercial	$1,120.56

PLATE DHS 150D 4H 78MM 281.440

Facility

$2,001.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.51
Max. Negotiated Rate	$1,940.97
Rate for Payer: Cash Price	$1,200.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.70
Rate for Payer: Health Management Network Commercial	$1,700.85
Rate for Payer: Kaiser Permanente Commercial	$1,260.63
Rate for Payer: Kaiser Permanente Medicaid	$1,020.51
Rate for Payer: MDX Hawaii PPO	$1,940.97
Rate for Payer: University Health Alliance Commercial	$1,120.56

PLATE DHS 150D/4H/78MM 281.840

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,239.30
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: Kaiser Permanente Commercial	$1,530.90
Rate for Payer: Kaiser Permanente Medicaid	$1,239.30
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DHS 150D/4H/78MM 281.840

Facility

$2,430.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.80
Max. Negotiated Rate	$2,357.10
Rate for Payer: Cash Price	$1,458.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,701.00
Rate for Payer: Health Management Network Commercial	$2,065.50
Rate for Payer: MDX Hawaii PPO	$2,357.10
Rate for Payer: University Health Alliance Commercial	$1,360.80

PLATE DISTAL 10H/158MM/LEFT

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,691.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLATE DISTAL 10H/158MM/LEFT

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,540.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: Kaiser Permanente Commercial	$1,902.60
Rate for Payer: Kaiser Permanente Medicaid	$1,540.20
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLATE DISTAL 10H/158MM/RIGHT

Facility

$2,933.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,495.83
Max. Negotiated Rate	$2,845.01
Rate for Payer: Cash Price	$1,759.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,053.10
Rate for Payer: Health Management Network Commercial	$2,493.05
Rate for Payer: Kaiser Permanente Commercial	$1,847.79
Rate for Payer: Kaiser Permanente Medicaid	$1,495.83
Rate for Payer: MDX Hawaii PPO	$2,845.01
Rate for Payer: University Health Alliance Commercial	$1,642.48

Know your out-of-pocket cost for care.

All Charges