Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE FIBULA 6H LEFT 336-5106

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 6H LEFT 336-5106

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 FIBULA ANTMC LCKING L 4H

Facility

$2,320.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,299.20
Max. Negotiated Rate	$2,250.40
Rate for Payer: Cash Price	$1,392.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,624.00
Rate for Payer: Health Management Network Commercial	$1,972.00
Rate for Payer: MDX Hawaii PPO	$2,250.40
Rate for Payer: University Health Alliance Commercial	$1,299.20

PLATE FIBULA ANTMC LCKING L 4H

Facility

$2,320.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,183.20
Max. Negotiated Rate	$2,250.40
Rate for Payer: Cash Price	$1,392.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,624.00
Rate for Payer: Health Management Network Commercial	$1,972.00
Rate for Payer: Kaiser Permanente Commercial	$1,461.60
Rate for Payer: Kaiser Permanente Medicaid	$1,183.20
Rate for Payer: MDX Hawaii PPO	$2,250.40
Rate for Payer: University Health Alliance Commercial	$1,299.20

PLATE FIBULA L 4H AR-8943DL-04

Facility

$1,845.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,033.20
Max. Negotiated Rate	$1,789.65
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,291.50
Rate for Payer: Health Management Network Commercial	$1,568.25
Rate for Payer: MDX Hawaii PPO	$1,789.65
Rate for Payer: University Health Alliance Commercial	$1,033.20

PLATE FIBULA L 4H AR-8943DL-04

Facility

$1,845.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$940.95
Max. Negotiated Rate	$1,789.65
Rate for Payer: Cash Price	$1,107.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,291.50
Rate for Payer: Health Management Network Commercial	$1,568.25
Rate for Payer: Kaiser Permanente Commercial	$1,162.35
Rate for Payer: Kaiser Permanente Medicaid	$940.95
Rate for Payer: MDX Hawaii PPO	$1,789.65
Rate for Payer: University Health Alliance Commercial	$1,033.20

PLATE FIBULA L 5H AR-8943DL-05

Facility

$2,284.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,279.04
Max. Negotiated Rate	$2,215.48
Rate for Payer: Cash Price	$1,370.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,598.80
Rate for Payer: Health Management Network Commercial	$1,941.40
Rate for Payer: MDX Hawaii PPO	$2,215.48
Rate for Payer: University Health Alliance Commercial	$1,279.04

PLATE FIBULA L 5H AR-8943DL-05

Facility

$2,284.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,164.84
Max. Negotiated Rate	$2,215.48
Rate for Payer: Cash Price	$1,370.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,598.80
Rate for Payer: Health Management Network Commercial	$1,941.40
Rate for Payer: Kaiser Permanente Commercial	$1,438.92
Rate for Payer: Kaiser Permanente Medicaid	$1,164.84
Rate for Payer: MDX Hawaii PPO	$2,215.48
Rate for Payer: University Health Alliance Commercial	$1,279.04

PLATE FIBULA L 6H AR-8943DL-06

Facility

$2,400.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,224.00
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: Kaiser Permanente Commercial	$1,512.00
Rate for Payer: Kaiser Permanente Medicaid	$1,224.00
Rate for Payer: MDX Hawaii PPO	$2,328.00
Rate for Payer: University Health Alliance Commercial	$1,344.00

PLATE FIBULA L 6H AR-8943DL-06

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 FIBULA L 8H AR-8943DL-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 FIBULA L 8H AR-8943DL-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 FIBULAR 5H 40-20905

Facility

$2,156.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,099.56
Max. Negotiated Rate	$2,091.32
Rate for Payer: Cash Price	$1,293.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,509.20
Rate for Payer: Health Management Network Commercial	$1,832.60
Rate for Payer: Kaiser Permanente Commercial	$1,358.28
Rate for Payer: Kaiser Permanente Medicaid	$1,099.56
Rate for Payer: MDX Hawaii PPO	$2,091.32
Rate for Payer: University Health Alliance Commercial	$1,207.36

PLATE FIBULAR 5H 40-20905

Facility

$2,156.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,207.36
Max. Negotiated Rate	$2,091.32
Rate for Payer: Cash Price	$1,293.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,509.20
Rate for Payer: Health Management Network Commercial	$1,832.60
Rate for Payer: MDX Hawaii PPO	$2,091.32
Rate for Payer: University Health Alliance Commercial	$1,207.36

PLATE FIBULAR AR-8943DR-04

Facility

$1,937.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,084.72
Max. Negotiated Rate	$1,878.89
Rate for Payer: Cash Price	$1,162.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,355.90
Rate for Payer: Health Management Network Commercial	$1,646.45
Rate for Payer: MDX Hawaii PPO	$1,878.89
Rate for Payer: University Health Alliance Commercial	$1,084.72

PLATE FIBULAR AR-8943DR-04

Facility

$1,937.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$987.87
Max. Negotiated Rate	$1,878.89
Rate for Payer: Cash Price	$1,162.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,355.90
Rate for Payer: Health Management Network Commercial	$1,646.45
Rate for Payer: Kaiser Permanente Commercial	$1,220.31
Rate for Payer: Kaiser Permanente Medicaid	$987.87
Rate for Payer: MDX Hawaii PPO	$1,878.89
Rate for Payer: University Health Alliance Commercial	$1,084.72

PLATE FIBULA RT 6HOLE 336-5206

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 RT 6HOLE 336-5206

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 FOOT 220MM 99-56-22100

Facility

$5,700.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,907.00
Max. Negotiated Rate	$5,529.00
Rate for Payer: Cash Price	$3,420.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,990.00
Rate for Payer: Health Management Network Commercial	$4,845.00
Rate for Payer: Kaiser Permanente Commercial	$3,591.00
Rate for Payer: Kaiser Permanente Medicaid	$2,907.00
Rate for Payer: MDX Hawaii PPO	$5,529.00
Rate for Payer: University Health Alliance Commercial	$3,192.00

PLATE FOOT 220MM 99-56-22100

Facility

$5,700.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,192.00
Max. Negotiated Rate	$5,529.00
Rate for Payer: Cash Price	$3,420.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,990.00
Rate for Payer: Health Management Network Commercial	$4,845.00
Rate for Payer: MDX Hawaii PPO	$5,529.00
Rate for Payer: University Health Alliance Commercial	$3,192.00

PLATE FOOT DBL 160MM 56-13635

Facility

$2,565.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,436.40
Max. Negotiated Rate	$2,488.05
Rate for Payer: Cash Price	$1,539.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,795.50
Rate for Payer: Health Management Network Commercial	$2,180.25
Rate for Payer: MDX Hawaii PPO	$2,488.05
Rate for Payer: University Health Alliance Commercial	$1,436.40

PLATE FOOT DBL 160MM 56-13635

Facility

$2,565.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,308.15
Max. Negotiated Rate	$2,488.05
Rate for Payer: Cash Price	$1,539.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,795.50
Rate for Payer: Health Management Network Commercial	$2,180.25
Rate for Payer: Kaiser Permanente Commercial	$1,615.95
Rate for Payer: Kaiser Permanente Medicaid	$1,308.15
Rate for Payer: MDX Hawaii PPO	$2,488.05
Rate for Payer: University Health Alliance Commercial	$1,436.40

PLATE FOOT TL 100MM 56-13580

Facility

$1,339.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$749.84
Max. Negotiated Rate	$1,298.83
Rate for Payer: Cash Price	$803.40
Rate for Payer: Hawaii Western Management Group Commercial	$937.30
Rate for Payer: Health Management Network Commercial	$1,138.15
Rate for Payer: MDX Hawaii PPO	$1,298.83
Rate for Payer: University Health Alliance Commercial	$749.84

PLATE FOOT TL 100MM 56-13580

Facility

$1,339.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$682.89
Max. Negotiated Rate	$1,298.83
Rate for Payer: Cash Price	$803.40
Rate for Payer: Hawaii Western Management Group Commercial	$937.30
Rate for Payer: Health Management Network Commercial	$1,138.15
Rate for Payer: Kaiser Permanente Commercial	$843.57
Rate for Payer: Kaiser Permanente Medicaid	$682.89
Rate for Payer: MDX Hawaii PPO	$1,298.83
Rate for Payer: University Health Alliance Commercial	$749.84

PLATE FOOT TL 120MM 56-13590

Facility

$1,496.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$837.76
Max. Negotiated Rate	$1,451.12
Rate for Payer: Cash Price	$897.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,047.20
Rate for Payer: Health Management Network Commercial	$1,271.60
Rate for Payer: MDX Hawaii PPO	$1,451.12
Rate for Payer: University Health Alliance Commercial	$837.76

Know your out-of-pocket cost for care.

All Charges