Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE DVR LF 131821040

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 NARROW LF 131821050

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 NARROW LF 131821050

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 SHORT RT DVRANSR

Facility

$2,235.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,251.60
Max. Negotiated Rate	$2,167.95
Rate for Payer: Cash Price	$1,341.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,564.50
Rate for Payer: Health Management Network Commercial	$1,899.75
Rate for Payer: MDX Hawaii PPO	$2,167.95
Rate for Payer: University Health Alliance Commercial	$1,251.60

PLATE DVR SHORT RT DVRANSR

Facility

$2,235.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,139.85
Max. Negotiated Rate	$2,167.95
Rate for Payer: Cash Price	$1,341.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,564.50
Rate for Payer: Health Management Network Commercial	$1,899.75
Rate for Payer: Kaiser Permanente Commercial	$1,408.05
Rate for Payer: Kaiser Permanente Medicaid	$1,139.85
Rate for Payer: MDX Hawaii PPO	$2,167.95
Rate for Payer: University Health Alliance Commercial	$1,251.60

PLATE DVR XLCK LF 131822090

Facility

$5,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,889.60
Max. Negotiated Rate	$5,005.20
Rate for Payer: Cash Price	$3,096.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,612.00
Rate for Payer: Health Management Network Commercial	$4,386.00
Rate for Payer: MDX Hawaii PPO	$5,005.20
Rate for Payer: University Health Alliance Commercial	$2,889.60

PLATE DVR XLCK LF 131822090

Facility

$5,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,631.60
Max. Negotiated Rate	$5,005.20
Rate for Payer: Cash Price	$3,096.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,612.00
Rate for Payer: Health Management Network Commercial	$4,386.00
Rate for Payer: Kaiser Permanente Commercial	$3,250.80
Rate for Payer: Kaiser Permanente Medicaid	$2,631.60
Rate for Payer: MDX Hawaii PPO	$5,005.20
Rate for Payer: University Health Alliance Commercial	$2,889.60

PLATE DVR XLCK NARR 131811040

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 XLCK NARR 131811040

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 XLCK RT 131812050

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 XLCK RT 131812050

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 FEMORAL 627618

Facility

$7,026.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,583.26
Max. Negotiated Rate	$6,815.22
Rate for Payer: Cash Price	$4,215.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,918.20
Rate for Payer: Health Management Network Commercial	$5,972.10
Rate for Payer: Kaiser Permanente Commercial	$4,426.38
Rate for Payer: Kaiser Permanente Medicaid	$3,583.26
Rate for Payer: MDX Hawaii PPO	$6,815.22
Rate for Payer: University Health Alliance Commercial	$3,934.56

PLATE FEMORAL 627618

Facility

$7,026.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,934.56
Max. Negotiated Rate	$6,815.22
Rate for Payer: Cash Price	$4,215.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,918.20
Rate for Payer: Health Management Network Commercial	$5,972.10
Rate for Payer: MDX Hawaii PPO	$6,815.22
Rate for Payer: University Health Alliance Commercial	$3,934.56

PLATE FEMORAL LF DISTAL 627604

Facility

$5,925.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,021.75
Max. Negotiated Rate	$5,747.25
Rate for Payer: Cash Price	$3,555.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,147.50
Rate for Payer: Health Management Network Commercial	$5,036.25
Rate for Payer: Kaiser Permanente Commercial	$3,732.75
Rate for Payer: Kaiser Permanente Medicaid	$3,021.75
Rate for Payer: MDX Hawaii PPO	$5,747.25
Rate for Payer: University Health Alliance Commercial	$3,318.00

PLATE FEMORAL LF DISTAL 627604

Facility

$5,925.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,318.00
Max. Negotiated Rate	$5,747.25
Rate for Payer: Cash Price	$3,555.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,147.50
Rate for Payer: Health Management Network Commercial	$5,036.25
Rate for Payer: MDX Hawaii PPO	$5,747.25
Rate for Payer: University Health Alliance Commercial	$3,318.00

PLATE FEMORAL R DIS LAT 627640

Facility

$4,707.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,400.57
Max. Negotiated Rate	$4,565.79
Rate for Payer: Cash Price	$2,824.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,294.90
Rate for Payer: Health Management Network Commercial	$4,000.95
Rate for Payer: Kaiser Permanente Commercial	$2,965.41
Rate for Payer: Kaiser Permanente Medicaid	$2,400.57
Rate for Payer: MDX Hawaii PPO	$4,565.79
Rate for Payer: University Health Alliance Commercial	$2,635.92

PLATE FEMORAL R DIS LAT 627640

Facility

$4,707.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,635.92
Max. Negotiated Rate	$4,565.79
Rate for Payer: Cash Price	$2,824.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,294.90
Rate for Payer: Health Management Network Commercial	$4,000.95
Rate for Payer: MDX Hawaii PPO	$4,565.79
Rate for Payer: University Health Alliance Commercial	$2,635.92

PLATE FEMORAL RT DISTAL 627634

Facility

$5,925.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,318.00
Max. Negotiated Rate	$5,747.25
Rate for Payer: Cash Price	$3,555.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,147.50
Rate for Payer: Health Management Network Commercial	$5,036.25
Rate for Payer: MDX Hawaii PPO	$5,747.25
Rate for Payer: University Health Alliance Commercial	$3,318.00

PLATE FEMORAL RT DISTAL 627634

Facility

$5,925.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,021.75
Max. Negotiated Rate	$5,747.25
Rate for Payer: Cash Price	$3,555.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,147.50
Rate for Payer: Health Management Network Commercial	$5,036.25
Rate for Payer: Kaiser Permanente Commercial	$3,732.75
Rate for Payer: Kaiser Permanente Medicaid	$3,021.75
Rate for Payer: MDX Hawaii PPO	$5,747.25
Rate for Payer: University Health Alliance Commercial	$3,318.00

PLATE FEMUR 379MM 18H 627648S

Facility

$7,026.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,934.56
Max. Negotiated Rate	$6,815.22
Rate for Payer: Cash Price	$4,215.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,918.20
Rate for Payer: Health Management Network Commercial	$5,972.10
Rate for Payer: MDX Hawaii PPO	$6,815.22
Rate for Payer: University Health Alliance Commercial	$3,934.56

PLATE FEMUR 379MM 18H 627648S

Facility

$7,026.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,583.26
Max. Negotiated Rate	$6,815.22
Rate for Payer: Cash Price	$4,215.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,918.20
Rate for Payer: Health Management Network Commercial	$5,972.10
Rate for Payer: Kaiser Permanente Commercial	$4,426.38
Rate for Payer: Kaiser Permanente Medicaid	$3,583.26
Rate for Payer: MDX Hawaii PPO	$6,815.22
Rate for Payer: University Health Alliance Commercial	$3,934.56

PLATE FIB 3H RT 85MM 336-5203

Facility

$2,884.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,615.04
Max. Negotiated Rate	$2,797.48
Rate for Payer: Cash Price	$1,730.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,018.80
Rate for Payer: Health Management Network Commercial	$2,451.40
Rate for Payer: MDX Hawaii PPO	$2,797.48
Rate for Payer: University Health Alliance Commercial	$1,615.04

PLATE FIB 3H RT 85MM 336-5203

Facility

$2,884.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,470.84
Max. Negotiated Rate	$2,797.48
Rate for Payer: Cash Price	$1,730.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,018.80
Rate for Payer: Health Management Network Commercial	$2,451.40
Rate for Payer: Kaiser Permanente Commercial	$1,816.92
Rate for Payer: Kaiser Permanente Medicaid	$1,470.84
Rate for Payer: MDX Hawaii PPO	$2,797.48
Rate for Payer: University Health Alliance Commercial	$1,615.04

PLATE FIBULA 40-20906

Facility

$2,237.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,140.87
Max. Negotiated Rate	$2,169.89
Rate for Payer: Cash Price	$1,342.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,565.90
Rate for Payer: Health Management Network Commercial	$1,901.45
Rate for Payer: Kaiser Permanente Commercial	$1,409.31
Rate for Payer: Kaiser Permanente Medicaid	$1,140.87
Rate for Payer: MDX Hawaii PPO	$2,169.89
Rate for Payer: University Health Alliance Commercial	$1,252.72

PLATE FIBULA 40-20906

Facility

$2,237.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,252.72
Max. Negotiated Rate	$2,169.89
Rate for Payer: Cash Price	$1,342.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,565.90
Rate for Payer: Health Management Network Commercial	$1,901.45
Rate for Payer: MDX Hawaii PPO	$2,169.89
Rate for Payer: University Health Alliance Commercial	$1,252.72

Know your out-of-pocket cost for care.

All Charges