Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE FOOT TL 120MM 56-13590

Facility

$1,496.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$762.96
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: Kaiser Permanente Commercial	$942.48
Rate for Payer: Kaiser Permanente Medicaid	$762.96
Rate for Payer: MDX Hawaii PPO	$1,451.12
Rate for Payer: University Health Alliance Commercial	$837.76

PLATE FOOT TL 130MM 56-13600

Facility

$1,496.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$762.96
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: Kaiser Permanente Commercial	$942.48
Rate for Payer: Kaiser Permanente Medicaid	$762.96
Rate for Payer: MDX Hawaii PPO	$1,451.12
Rate for Payer: University Health Alliance Commercial	$837.76

PLATE FOOT TL 130MM 56-13600

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

PLATE FOOT TL 140MM 56-13610

Facility

$1,575.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PLATE FOOT TL 140MM 56-13610

Facility

$1,575.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$803.25
Max. Negotiated Rate	$1,527.75
Rate for Payer: Cash Price	$945.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,102.50
Rate for Payer: Health Management Network Commercial	$1,338.75
Rate for Payer: Kaiser Permanente Commercial	$992.25
Rate for Payer: Kaiser Permanente Medicaid	$803.25
Rate for Payer: MDX Hawaii PPO	$1,527.75
Rate for Payer: University Health Alliance Commercial	$882.00

PLATE FOOT TL+ 160MM 56-13630

Facility

$1,553.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$792.03
Max. Negotiated Rate	$1,506.41
Rate for Payer: Cash Price	$931.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,087.10
Rate for Payer: Health Management Network Commercial	$1,320.05
Rate for Payer: Kaiser Permanente Commercial	$978.39
Rate for Payer: Kaiser Permanente Medicaid	$792.03
Rate for Payer: MDX Hawaii PPO	$1,506.41
Rate for Payer: University Health Alliance Commercial	$869.68

PLATE FOOT TL+ 160MM 56-13630

Facility

$1,553.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$869.68
Max. Negotiated Rate	$1,506.41
Rate for Payer: Cash Price	$931.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,087.10
Rate for Payer: Health Management Network Commercial	$1,320.05
Rate for Payer: MDX Hawaii PPO	$1,506.41
Rate for Payer: University Health Alliance Commercial	$869.68

PLATE FOOT TL+ 170MM 56-13640

Facility

$1,620.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$907.20
Max. Negotiated Rate	$1,571.40
Rate for Payer: Cash Price	$972.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,134.00
Rate for Payer: Health Management Network Commercial	$1,377.00
Rate for Payer: MDX Hawaii PPO	$1,571.40
Rate for Payer: University Health Alliance Commercial	$907.20

PLATE FOOT TL+ 170MM 56-13640

Facility

$1,620.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$826.20
Max. Negotiated Rate	$1,571.40
Rate for Payer: Cash Price	$972.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,134.00
Rate for Payer: Health Management Network Commercial	$1,377.00
Rate for Payer: Kaiser Permanente Commercial	$1,020.60
Rate for Payer: Kaiser Permanente Medicaid	$826.20
Rate for Payer: MDX Hawaii PPO	$1,571.40
Rate for Payer: University Health Alliance Commercial	$907.20

PLATE FOOT TL+ 180MM 56-13650

Facility

$1,688.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$945.28
Max. Negotiated Rate	$1,637.36
Rate for Payer: Cash Price	$1,012.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,181.60
Rate for Payer: Health Management Network Commercial	$1,434.80
Rate for Payer: MDX Hawaii PPO	$1,637.36
Rate for Payer: University Health Alliance Commercial	$945.28

PLATE FOOT TL+ 180MM 56-13650

Facility

$1,688.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$860.88
Max. Negotiated Rate	$1,637.36
Rate for Payer: Cash Price	$1,012.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,181.60
Rate for Payer: Health Management Network Commercial	$1,434.80
Rate for Payer: Kaiser Permanente Commercial	$1,063.44
Rate for Payer: Kaiser Permanente Medicaid	$860.88
Rate for Payer: MDX Hawaii PPO	$1,637.36
Rate for Payer: University Health Alliance Commercial	$945.28

PLATE FOOT TL+ 200MM 56-13660

Facility

$1,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$982.80
Max. Negotiated Rate	$1,702.35
Rate for Payer: Cash Price	$1,053.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,228.50
Rate for Payer: Health Management Network Commercial	$1,491.75
Rate for Payer: MDX Hawaii PPO	$1,702.35
Rate for Payer: University Health Alliance Commercial	$982.80

PLATE FOOT TL+ 200MM 56-13660

Facility

$1,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$895.05
Max. Negotiated Rate	$1,702.35
Rate for Payer: Cash Price	$1,053.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,228.50
Rate for Payer: Health Management Network Commercial	$1,491.75
Rate for Payer: Kaiser Permanente Commercial	$1,105.65
Rate for Payer: Kaiser Permanente Medicaid	$895.05
Rate for Payer: MDX Hawaii PPO	$1,702.35
Rate for Payer: University Health Alliance Commercial	$982.80

PLATE FUSION 4.0 LONG 336-3564

Facility

$3,640.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,856.40
Max. Negotiated Rate	$3,530.80
Rate for Payer: Cash Price	$2,184.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,548.00
Rate for Payer: Health Management Network Commercial	$3,094.00
Rate for Payer: Kaiser Permanente Commercial	$2,293.20
Rate for Payer: Kaiser Permanente Medicaid	$1,856.40
Rate for Payer: MDX Hawaii PPO	$3,530.80
Rate for Payer: University Health Alliance Commercial	$2,038.40

PLATE FUSION 4.0 LONG 336-3564

Facility

$3,640.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,038.40
Max. Negotiated Rate	$3,530.80
Rate for Payer: Cash Price	$2,184.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,548.00
Rate for Payer: Health Management Network Commercial	$3,094.00
Rate for Payer: MDX Hawaii PPO	$3,530.80
Rate for Payer: University Health Alliance Commercial	$2,038.40

PLATE FUSION 4.0 MED 336-3563

Facility

$3,640.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,038.40
Max. Negotiated Rate	$3,530.80
Rate for Payer: Cash Price	$2,184.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,548.00
Rate for Payer: Health Management Network Commercial	$3,094.00
Rate for Payer: MDX Hawaii PPO	$3,530.80
Rate for Payer: University Health Alliance Commercial	$2,038.40

PLATE FUSION 4.0 MED 336-3563

Facility

$3,640.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,856.40
Max. Negotiated Rate	$3,530.80
Rate for Payer: Cash Price	$2,184.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,548.00
Rate for Payer: Health Management Network Commercial	$3,094.00
Rate for Payer: Kaiser Permanente Commercial	$2,293.20
Rate for Payer: Kaiser Permanente Medicaid	$1,856.40
Rate for Payer: MDX Hawaii PPO	$3,530.80
Rate for Payer: University Health Alliance Commercial	$2,038.40

PLATE GLENOID AS 01.04223.200

Facility

$4,064.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,072.64
Max. Negotiated Rate	$3,942.08
Rate for Payer: Cash Price	$2,438.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,844.80
Rate for Payer: Health Management Network Commercial	$3,454.40
Rate for Payer: Kaiser Permanente Commercial	$2,560.32
Rate for Payer: Kaiser Permanente Medicaid	$2,072.64
Rate for Payer: MDX Hawaii PPO	$3,942.08
Rate for Payer: University Health Alliance Commercial	$2,275.84

PLATE GLENOID AS 01.04223.200

Facility

$4,064.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,275.84
Max. Negotiated Rate	$3,942.08
Rate for Payer: Cash Price	$2,438.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,844.80
Rate for Payer: Health Management Network Commercial	$3,454.40
Rate for Payer: MDX Hawaii PPO	$3,942.08
Rate for Payer: University Health Alliance Commercial	$2,275.84

PLATE H 3.5X15MM 336-3500

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,493.52
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE H 3.5X15MM 336-3500

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.17
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: Kaiser Permanente Commercial	$1,680.21
Rate for Payer: Kaiser Permanente Medicaid	$1,360.17
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE H 3.5X30MM 336-3502

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,493.52
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE H 3.5X30MM 336-3502

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.17
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: Kaiser Permanente Commercial	$1,680.21
Rate for Payer: Kaiser Permanente Medicaid	$1,360.17
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE HOLDING TAKS 16 337-0001

Facility

$252.00

Hospital Revenue Code	272
Min. Negotiated Rate	$128.52
Max. Negotiated Rate	$244.44
Rate for Payer: Cash Price	$151.20
Rate for Payer: Hawaii Western Management Group Commercial	$239.40
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: Kaiser Permanente Commercial	$158.76
Rate for Payer: Kaiser Permanente Medicaid	$128.52
Rate for Payer: MDX Hawaii PPO	$244.44
Rate for Payer: University Health Alliance Commercial	$183.68

PLATE HOLDING TAKS 16 337-0001

Facility

$252.00

Hospital Revenue Code	272
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$244.44
Rate for Payer: Cash Price	$151.20
Rate for Payer: Health Management Network Commercial	$214.20
Rate for Payer: MDX Hawaii PPO	$244.44

Know your out-of-pocket cost for care.

All Charges