Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE DISTAL 10H/158MM/RIGHT

Facility

$2,933.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,642.48
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: MDX Hawaii PPO	$2,845.01
Rate for Payer: University Health Alliance Commercial	$1,642.48

PLATE DISTAL 4H/80MM/LEFT

Facility

$2,200.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,540.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,232.00

PLATE DISTAL 4H/80MM/LEFT

Facility

$2,200.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,232.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,540.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,232.00

PLATE DISTAL 4H/80MM/RIGHT

Facility

$3,220.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,642.20
Max. Negotiated Rate	$3,123.40
Rate for Payer: Cash Price	$1,932.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,254.00
Rate for Payer: Health Management Network Commercial	$2,737.00
Rate for Payer: Kaiser Permanente Commercial	$2,028.60
Rate for Payer: Kaiser Permanente Medicaid	$1,642.20
Rate for Payer: MDX Hawaii PPO	$3,123.40
Rate for Payer: University Health Alliance Commercial	$1,803.20

PLATE DISTAL 4H/80MM/RIGHT

Facility

$3,220.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,803.20
Max. Negotiated Rate	$3,123.40
Rate for Payer: Cash Price	$1,932.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,254.00
Rate for Payer: Health Management Network Commercial	$2,737.00
Rate for Payer: MDX Hawaii PPO	$3,123.40
Rate for Payer: University Health Alliance Commercial	$1,803.20

PLATE DISTAL 8H/132MM/LEFT

Facility

$2,754.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,542.24
Max. Negotiated Rate	$2,671.38
Rate for Payer: Cash Price	$1,652.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,927.80
Rate for Payer: Health Management Network Commercial	$2,340.90
Rate for Payer: MDX Hawaii PPO	$2,671.38
Rate for Payer: University Health Alliance Commercial	$1,542.24

PLATE DISTAL 8H/132MM/LEFT

Facility

$2,754.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,404.54
Max. Negotiated Rate	$2,671.38
Rate for Payer: Cash Price	$1,652.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,927.80
Rate for Payer: Health Management Network Commercial	$2,340.90
Rate for Payer: Kaiser Permanente Commercial	$1,735.02
Rate for Payer: Kaiser Permanente Medicaid	$1,404.54
Rate for Payer: MDX Hawaii PPO	$2,671.38
Rate for Payer: University Health Alliance Commercial	$1,542.24

PLATE DISTAL 8H/132MM/RIGHT

Facility

$2,410.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,349.60
Max. Negotiated Rate	$2,337.70
Rate for Payer: Cash Price	$1,446.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,687.00
Rate for Payer: Health Management Network Commercial	$2,048.50
Rate for Payer: MDX Hawaii PPO	$2,337.70
Rate for Payer: University Health Alliance Commercial	$1,349.60

PLATE DISTAL 8H/132MM/RIGHT

Facility

$2,410.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,229.10
Max. Negotiated Rate	$2,337.70
Rate for Payer: Cash Price	$1,446.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,687.00
Rate for Payer: Health Management Network Commercial	$2,048.50
Rate for Payer: Kaiser Permanente Commercial	$1,518.30
Rate for Payer: Kaiser Permanente Medicaid	$1,229.10
Rate for Payer: MDX Hawaii PPO	$2,337.70
Rate for Payer: University Health Alliance Commercial	$1,349.60

PLATE DISTAL FEMUR 166 6H

Facility

$4,503.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,521.68
Max. Negotiated Rate	$4,367.91
Rate for Payer: Cash Price	$2,701.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,152.10
Rate for Payer: Health Management Network Commercial	$3,827.55
Rate for Payer: MDX Hawaii PPO	$4,367.91
Rate for Payer: University Health Alliance Commercial	$2,521.68

PLATE DISTAL FEMUR 166 6H

Facility

$4,503.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,296.53
Max. Negotiated Rate	$4,367.91
Rate for Payer: Cash Price	$2,701.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,152.10
Rate for Payer: Health Management Network Commercial	$3,827.55
Rate for Payer: Kaiser Permanente Commercial	$2,836.89
Rate for Payer: Kaiser Permanente Medicaid	$2,296.53
Rate for Payer: MDX Hawaii PPO	$4,367.91
Rate for Payer: University Health Alliance Commercial	$2,521.68

PLATE DISTAL FIB AR-8943DR-08

Facility

$2,756.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,543.36
Max. Negotiated Rate	$2,673.32
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,929.20
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: MDX Hawaii PPO	$2,673.32
Rate for Payer: University Health Alliance Commercial	$1,543.36

PLATE DISTAL FIB AR-8943DR-08

Facility

$2,756.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,405.56
Max. Negotiated Rate	$2,673.32
Rate for Payer: Cash Price	$1,653.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,929.20
Rate for Payer: Health Management Network Commercial	$2,342.60
Rate for Payer: Kaiser Permanente Commercial	$1,736.28
Rate for Payer: Kaiser Permanente Medicaid	$1,405.56
Rate for Payer: MDX Hawaii PPO	$2,673.32
Rate for Payer: University Health Alliance Commercial	$1,543.36

PLATE DISTAL LATERA FIB 540648

Facility

$3,690.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,066.40
Max. Negotiated Rate	$3,579.30
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,583.00
Rate for Payer: Health Management Network Commercial	$3,136.50
Rate for Payer: MDX Hawaii PPO	$3,579.30
Rate for Payer: University Health Alliance Commercial	$2,066.40

PLATE DISTAL LATERA FIB 540648

Facility

$3,690.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,881.90
Max. Negotiated Rate	$3,579.30
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,583.00
Rate for Payer: Health Management Network Commercial	$3,136.50
Rate for Payer: Kaiser Permanente Commercial	$2,324.70
Rate for Payer: Kaiser Permanente Medicaid	$1,881.90
Rate for Payer: MDX Hawaii PPO	$3,579.30
Rate for Payer: University Health Alliance Commercial	$2,066.40

PLATE DISTAL LATERAL 40-20908

Facility

$2,172.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,216.32
Max. Negotiated Rate	$2,106.84
Rate for Payer: Cash Price	$1,303.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,520.40
Rate for Payer: Health Management Network Commercial	$1,846.20
Rate for Payer: MDX Hawaii PPO	$2,106.84
Rate for Payer: University Health Alliance Commercial	$1,216.32

PLATE DISTAL LATERAL 40-20908

Facility

$2,172.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,107.72
Max. Negotiated Rate	$2,106.84
Rate for Payer: Cash Price	$1,303.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,520.40
Rate for Payer: Health Management Network Commercial	$1,846.20
Rate for Payer: Kaiser Permanente Commercial	$1,368.36
Rate for Payer: Kaiser Permanente Medicaid	$1,107.72
Rate for Payer: MDX Hawaii PPO	$2,106.84
Rate for Payer: University Health Alliance Commercial	$1,216.32

PLATE DISTAL LATERAL FEMUR

Facility

$4,810.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,453.10
Max. Negotiated Rate	$4,665.70
Rate for Payer: Cash Price	$2,886.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,367.00
Rate for Payer: Health Management Network Commercial	$4,088.50
Rate for Payer: Kaiser Permanente Commercial	$3,030.30
Rate for Payer: Kaiser Permanente Medicaid	$2,453.10
Rate for Payer: MDX Hawaii PPO	$4,665.70
Rate for Payer: University Health Alliance Commercial	$2,693.60

PLATE DISTAL LATERAL FEMUR

Facility

$4,810.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,693.60
Max. Negotiated Rate	$4,665.70
Rate for Payer: Cash Price	$2,886.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,367.00
Rate for Payer: Health Management Network Commercial	$4,088.50
Rate for Payer: MDX Hawaii PPO	$4,665.70
Rate for Payer: University Health Alliance Commercial	$2,693.60

PLATE DISTAL LATERAL FEMUR RT

Facility

$5,015.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,557.65
Max. Negotiated Rate	$4,864.55
Rate for Payer: Cash Price	$3,009.00
Rate for Payer: Cash Price	$2,762.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,222.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,510.50
Rate for Payer: Health Management Network Commercial	$4,262.75
Rate for Payer: Health Management Network Commercial	$3,913.40
Rate for Payer: Kaiser Permanente Commercial	$2,900.52
Rate for Payer: Kaiser Permanente Commercial	$3,159.45
Rate for Payer: Kaiser Permanente Medicaid	$2,557.65
Rate for Payer: Kaiser Permanente Medicaid	$2,348.04
Rate for Payer: MDX Hawaii PPO	$4,465.88
Rate for Payer: MDX Hawaii PPO	$4,864.55
Rate for Payer: University Health Alliance Commercial	$2,578.24
Rate for Payer: University Health Alliance Commercial	$2,808.40

PLATE DISTAL LATERAL FEMUR RT

Facility

$5,015.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,808.40
Max. Negotiated Rate	$4,864.55
Rate for Payer: Cash Price	$3,009.00
Rate for Payer: Cash Price	$2,762.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,222.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,510.50
Rate for Payer: Health Management Network Commercial	$3,913.40
Rate for Payer: Health Management Network Commercial	$4,262.75
Rate for Payer: MDX Hawaii PPO	$4,465.88
Rate for Payer: MDX Hawaii PPO	$4,864.55
Rate for Payer: University Health Alliance Commercial	$2,808.40
Rate for Payer: University Health Alliance Commercial	$2,578.24

PLATE DISTAL LF 8H AR-2657DL

Facility

$2,678.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,365.78
Max. Negotiated Rate	$2,597.66
Rate for Payer: Cash Price	$1,606.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,874.60
Rate for Payer: Health Management Network Commercial	$2,276.30
Rate for Payer: Kaiser Permanente Commercial	$1,687.14
Rate for Payer: Kaiser Permanente Medicaid	$1,365.78
Rate for Payer: MDX Hawaii PPO	$2,597.66
Rate for Payer: University Health Alliance Commercial	$1,499.68

PLATE DISTAL LF 8H AR-2657DL

Facility

$2,678.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,499.68
Max. Negotiated Rate	$2,597.66
Rate for Payer: Cash Price	$1,606.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,874.60
Rate for Payer: Health Management Network Commercial	$2,276.30
Rate for Payer: MDX Hawaii PPO	$2,597.66
Rate for Payer: University Health Alliance Commercial	$1,499.68

PLATE DISTAL LT 6H 626246

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 DISTAL LT 6H 626246

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

Know your out-of-pocket cost for care.

All Charges