Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE DISTAL MEDIAL LF 627410

Facility

$3,786.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,120.16
Max. Negotiated Rate	$3,672.42
Rate for Payer: Cash Price	$2,271.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,650.20
Rate for Payer: Health Management Network Commercial	$3,218.10
Rate for Payer: MDX Hawaii PPO	$3,672.42
Rate for Payer: University Health Alliance Commercial	$2,120.16

PLATE DISTAL MEDIAL LF 627410

Facility

$3,786.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,930.86
Max. Negotiated Rate	$3,672.42
Rate for Payer: Cash Price	$2,271.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,650.20
Rate for Payer: Health Management Network Commercial	$3,218.10
Rate for Payer: Kaiser Permanente Commercial	$2,385.18
Rate for Payer: Kaiser Permanente Medicaid	$1,930.86
Rate for Payer: MDX Hawaii PPO	$3,672.42
Rate for Payer: University Health Alliance Commercial	$2,120.16

PLATE DISTAL POST 629263

Facility

$2,193.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,127.21
Rate for Payer: Cash Price	$1,315.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,535.10
Rate for Payer: Health Management Network Commercial	$1,864.05
Rate for Payer: MDX Hawaii PPO	$2,127.21
Rate for Payer: University Health Alliance Commercial	$1,228.08

PLATE DISTAL POST 629263

Facility

$2,193.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,118.43
Max. Negotiated Rate	$2,127.21
Rate for Payer: Cash Price	$1,315.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,535.10
Rate for Payer: Health Management Network Commercial	$1,864.05
Rate for Payer: Kaiser Permanente Commercial	$1,381.59
Rate for Payer: Kaiser Permanente Medicaid	$1,118.43
Rate for Payer: MDX Hawaii PPO	$2,127.21
Rate for Payer: University Health Alliance Commercial	$1,228.08

PLATE DISTAL POSTERIOR LF

Facility

$2,193.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,127.21
Rate for Payer: Cash Price	$1,315.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,535.10
Rate for Payer: Health Management Network Commercial	$1,864.05
Rate for Payer: MDX Hawaii PPO	$2,127.21
Rate for Payer: University Health Alliance Commercial	$1,228.08

PLATE DISTAL POSTERIOR LF

Facility

$2,193.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,118.43
Max. Negotiated Rate	$2,127.21
Rate for Payer: Cash Price	$1,315.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,535.10
Rate for Payer: Health Management Network Commercial	$1,864.05
Rate for Payer: Kaiser Permanente Commercial	$1,381.59
Rate for Payer: Kaiser Permanente Medicaid	$1,118.43
Rate for Payer: MDX Hawaii PPO	$2,127.21
Rate for Payer: University Health Alliance Commercial	$1,228.08

PLATE DISTAL THIRD RT 8H

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 THIRD RT 8H

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 TIB RT 627438

Facility

$3,684.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,878.84
Max. Negotiated Rate	$3,573.48
Rate for Payer: Cash Price	$2,210.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,578.80
Rate for Payer: Health Management Network Commercial	$3,131.40
Rate for Payer: Kaiser Permanente Commercial	$2,320.92
Rate for Payer: Kaiser Permanente Medicaid	$1,878.84
Rate for Payer: MDX Hawaii PPO	$3,573.48
Rate for Payer: University Health Alliance Commercial	$2,063.04

PLATE DISTAL TIB RT 627438

Facility

$3,684.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,063.04
Max. Negotiated Rate	$3,573.48
Rate for Payer: Cash Price	$2,210.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,578.80
Rate for Payer: Health Management Network Commercial	$3,131.40
Rate for Payer: MDX Hawaii PPO	$3,573.48
Rate for Payer: University Health Alliance Commercial	$2,063.04

PLATE DIST LAT 89MM 40-20904

Facility

$2,891.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,474.41
Max. Negotiated Rate	$2,804.27
Rate for Payer: Cash Price	$1,734.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,023.70
Rate for Payer: Health Management Network Commercial	$2,457.35
Rate for Payer: Kaiser Permanente Commercial	$1,821.33
Rate for Payer: Kaiser Permanente Medicaid	$1,474.41
Rate for Payer: MDX Hawaii PPO	$2,804.27
Rate for Payer: University Health Alliance Commercial	$1,618.96

PLATE DIST LAT 89MM 40-20904

Facility

$2,891.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,618.96
Max. Negotiated Rate	$2,804.27
Rate for Payer: Cash Price	$1,734.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,023.70
Rate for Payer: Health Management Network Commercial	$2,457.35
Rate for Payer: MDX Hawaii PPO	$2,804.27
Rate for Payer: University Health Alliance Commercial	$1,618.96

PLATE DISTL POST 128 6H 629246

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 DISTL POST 128 6H 629246

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 DORSAL/ULNAR 3H DUP3

Facility

$2,385.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,216.35
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,669.50
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: Kaiser Permanente Commercial	$1,502.55
Rate for Payer: Kaiser Permanente Medicaid	$1,216.35
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: University Health Alliance Commercial	$1,335.60

PLATE DORSAL/ULNAR 3H DUP3

Facility

$2,385.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,335.60
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,669.50
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: University Health Alliance Commercial	$1,335.60

PLATE DORSAL/ULNAR 5H DUP5

Facility

$2,385.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,335.60
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,669.50
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: University Health Alliance Commercial	$1,335.60

PLATE DORSAL/ULNAR 5H DUP5

Facility

$2,385.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,216.35
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,669.50
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: Kaiser Permanente Commercial	$1,502.55
Rate for Payer: Kaiser Permanente Medicaid	$1,216.35
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: University Health Alliance Commercial	$1,335.60

PLATE DORSAL/ULNAR 7H DUP7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLATE DORSAL/ULNAR 7H DUP7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLATE DVR CROSLCK RT 131813050

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,485.63
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,747.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: Kaiser Permanente Commercial	$1,835.19
Rate for Payer: Kaiser Permanente Medicaid	$1,485.63
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

PLATE DVR CROSLCK RT 131813050

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,631.28
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,747.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

PLATE DVR CROSSLCK R 131812040

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,485.63
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,747.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: Kaiser Permanente Commercial	$1,835.19
Rate for Payer: Kaiser Permanente Medicaid	$1,485.63
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

PLATE DVR CROSSLCK R 131812040

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,631.28
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,747.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

PLATE DVR LF 131821040

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,631.28
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,747.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

Know your out-of-pocket cost for care.

All Charges