Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE HOOK DORS WRIST 4H WHD-4

Facility

$2,775.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,554.00
Max. Negotiated Rate	$2,691.75
Rate for Payer: Cash Price	$1,665.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,942.50
Rate for Payer: Health Management Network Commercial	$2,358.75
Rate for Payer: MDX Hawaii PPO	$2,691.75
Rate for Payer: University Health Alliance Commercial	$1,554.00

PLATE HOOK DORS WRIST 4H WHD-4

Facility

$2,775.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,415.25
Max. Negotiated Rate	$2,691.75
Rate for Payer: Cash Price	$1,665.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,942.50
Rate for Payer: Health Management Network Commercial	$2,358.75
Rate for Payer: Kaiser Permanente Commercial	$1,748.25
Rate for Payer: Kaiser Permanente Medicaid	$1,415.25
Rate for Payer: MDX Hawaii PPO	$2,691.75
Rate for Payer: University Health Alliance Commercial	$1,554.00

PLATE HOOK DORS WRIST 6H WHD-6

Facility

$2,120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,187.20
Max. Negotiated Rate	$2,056.40
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,484.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: MDX Hawaii PPO	$2,056.40
Rate for Payer: University Health Alliance Commercial	$1,187.20

PLATE HOOK DORS WRIST 6H WHD-6

Facility

$2,120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,081.20
Max. Negotiated Rate	$2,056.40
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,484.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: Kaiser Permanente Commercial	$1,335.60
Rate for Payer: Kaiser Permanente Medicaid	$1,081.20
Rate for Payer: MDX Hawaii PPO	$2,056.40
Rate for Payer: University Health Alliance Commercial	$1,187.20

PLATE HOOK VOLA WRIST 4H WHV-4

Facility

$2,775.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,415.25
Max. Negotiated Rate	$2,691.75
Rate for Payer: Cash Price	$1,665.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,942.50
Rate for Payer: Health Management Network Commercial	$2,358.75
Rate for Payer: Kaiser Permanente Commercial	$1,748.25
Rate for Payer: Kaiser Permanente Medicaid	$1,415.25
Rate for Payer: MDX Hawaii PPO	$2,691.75
Rate for Payer: University Health Alliance Commercial	$1,554.00

PLATE HOOK VOLA WRIST 4H WHV-4

Facility

$2,775.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,554.00
Max. Negotiated Rate	$2,691.75
Rate for Payer: Cash Price	$1,665.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,942.50
Rate for Payer: Health Management Network Commercial	$2,358.75
Rate for Payer: MDX Hawaii PPO	$2,691.75
Rate for Payer: University Health Alliance Commercial	$1,554.00

PLATE HOOK VOLA WRIST 6H WHV-6

Facility

$2,120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,187.20
Max. Negotiated Rate	$2,056.40
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,484.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: MDX Hawaii PPO	$2,056.40
Rate for Payer: University Health Alliance Commercial	$1,187.20

PLATE HOOK VOLA WRIST 6H WHV-6

Facility

$2,120.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,081.20
Max. Negotiated Rate	$2,056.40
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,484.00
Rate for Payer: Health Management Network Commercial	$1,802.00
Rate for Payer: Kaiser Permanente Commercial	$1,335.60
Rate for Payer: Kaiser Permanente Medicaid	$1,081.20
Rate for Payer: MDX Hawaii PPO	$2,056.40
Rate for Payer: University Health Alliance Commercial	$1,187.20

PLATE HUMERAL 2.7MM

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,401.99
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: Kaiser Permanente Commercial	$1,731.87
Rate for Payer: Kaiser Permanente Medicaid	$1,401.99
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

PLATE HUMERAL 2.7MM

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,539.44
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

PLATE HUMERAL 3.5MM 241.919

Facility

$3,692.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,882.92
Max. Negotiated Rate	$3,581.24
Rate for Payer: Cash Price	$2,215.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,584.40
Rate for Payer: Health Management Network Commercial	$3,138.20
Rate for Payer: Kaiser Permanente Commercial	$2,325.96
Rate for Payer: Kaiser Permanente Medicaid	$1,882.92
Rate for Payer: MDX Hawaii PPO	$3,581.24
Rate for Payer: University Health Alliance Commercial	$2,067.52

PLATE HUMERAL 3.5MM 241.919

Facility

$3,692.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,067.52
Max. Negotiated Rate	$3,581.24
Rate for Payer: Cash Price	$2,215.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,584.40
Rate for Payer: Health Management Network Commercial	$3,138.20
Rate for Payer: MDX Hawaii PPO	$3,581.24
Rate for Payer: University Health Alliance Commercial	$2,067.52

PLATE HUMERAL PROXIMAL LF

Facility

$6,560.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,345.60
Max. Negotiated Rate	$6,363.20
Rate for Payer: Cash Price	$3,936.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,592.00
Rate for Payer: Health Management Network Commercial	$5,576.00
Rate for Payer: Kaiser Permanente Commercial	$4,132.80
Rate for Payer: Kaiser Permanente Medicaid	$3,345.60
Rate for Payer: MDX Hawaii PPO	$6,363.20
Rate for Payer: University Health Alliance Commercial	$3,673.60

PLATE HUMERAL PROXIMAL LF

Facility

$6,560.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,673.60
Max. Negotiated Rate	$6,363.20
Rate for Payer: Cash Price	$3,936.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,592.00
Rate for Payer: Health Management Network Commercial	$5,576.00
Rate for Payer: MDX Hawaii PPO	$6,363.20
Rate for Payer: University Health Alliance Commercial	$3,673.60

PLATE HUMERUS DIST 4H

Facility

$2,418.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,354.08
Max. Negotiated Rate	$2,345.46
Rate for Payer: Cash Price	$1,450.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,692.60
Rate for Payer: Health Management Network Commercial	$2,055.30
Rate for Payer: MDX Hawaii PPO	$2,345.46
Rate for Payer: University Health Alliance Commercial	$1,354.08

PLATE HUMERUS DIST 4H

Facility

$2,418.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,233.18
Max. Negotiated Rate	$2,345.46
Rate for Payer: Cash Price	$1,450.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,692.60
Rate for Payer: Health Management Network Commercial	$2,055.30
Rate for Payer: Kaiser Permanente Commercial	$1,523.34
Rate for Payer: Kaiser Permanente Medicaid	$1,233.18
Rate for Payer: MDX Hawaii PPO	$2,345.46
Rate for Payer: University Health Alliance Commercial	$1,354.08

PLATE KNOTLESS DIS AR-2658TR

Facility

$2,069.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.64
Max. Negotiated Rate	$2,006.93
Rate for Payer: Cash Price	$1,241.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,448.30
Rate for Payer: Health Management Network Commercial	$1,758.65
Rate for Payer: MDX Hawaii PPO	$2,006.93
Rate for Payer: University Health Alliance Commercial	$1,158.64

PLATE KNOTLESS DIS AR-2658TR

Facility

$2,069.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,055.19
Max. Negotiated Rate	$2,006.93
Rate for Payer: Cash Price	$1,241.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,448.30
Rate for Payer: Health Management Network Commercial	$1,758.65
Rate for Payer: Kaiser Permanente Commercial	$1,303.47
Rate for Payer: Kaiser Permanente Medicaid	$1,055.19
Rate for Payer: MDX Hawaii PPO	$2,006.93
Rate for Payer: University Health Alliance Commercial	$1,158.64

PLATE LAT DIS HUMER 02.117.901

Facility

$2,942.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,647.52
Max. Negotiated Rate	$2,853.74
Rate for Payer: Cash Price	$1,765.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,059.40
Rate for Payer: Health Management Network Commercial	$2,500.70
Rate for Payer: MDX Hawaii PPO	$2,853.74
Rate for Payer: University Health Alliance Commercial	$1,647.52

PLATE LAT DIS HUMER 02.117.901

Facility

$2,942.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.42
Max. Negotiated Rate	$2,853.74
Rate for Payer: Cash Price	$1,765.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,059.40
Rate for Payer: Health Management Network Commercial	$2,500.70
Rate for Payer: Kaiser Permanente Commercial	$1,853.46
Rate for Payer: Kaiser Permanente Medicaid	$1,500.42
Rate for Payer: MDX Hawaii PPO	$2,853.74
Rate for Payer: University Health Alliance Commercial	$1,647.52

PLATE LATERAL 6HOLE 2347-17-06

Facility

$1,633.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$914.48
Max. Negotiated Rate	$1,584.01
Rate for Payer: Cash Price	$979.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,143.10
Rate for Payer: Health Management Network Commercial	$1,388.05
Rate for Payer: MDX Hawaii PPO	$1,584.01
Rate for Payer: University Health Alliance Commercial	$914.48

PLATE LATERAL 6HOLE 2347-17-06

Facility

$1,633.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$832.83
Max. Negotiated Rate	$1,584.01
Rate for Payer: Cash Price	$979.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,143.10
Rate for Payer: Health Management Network Commercial	$1,388.05
Rate for Payer: Kaiser Permanente Commercial	$1,028.79
Rate for Payer: Kaiser Permanente Medicaid	$832.83
Rate for Payer: MDX Hawaii PPO	$1,584.01
Rate for Payer: University Health Alliance Commercial	$914.48

PLATE LATERAL 8HOLE 2347-18-08

Facility

$1,686.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$944.16
Max. Negotiated Rate	$1,635.42
Rate for Payer: Cash Price	$1,011.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,180.20
Rate for Payer: Health Management Network Commercial	$1,433.10
Rate for Payer: MDX Hawaii PPO	$1,635.42
Rate for Payer: University Health Alliance Commercial	$944.16

PLATE LATERAL 8HOLE 2347-18-08

Facility

$1,686.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$859.86
Max. Negotiated Rate	$1,635.42
Rate for Payer: Cash Price	$1,011.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,180.20
Rate for Payer: Health Management Network Commercial	$1,433.10
Rate for Payer: Kaiser Permanente Commercial	$1,062.18
Rate for Payer: Kaiser Permanente Medicaid	$859.86
Rate for Payer: MDX Hawaii PPO	$1,635.42
Rate for Payer: University Health Alliance Commercial	$944.16

PLATE LATERAL TIBIA 540304

Facility

$6,710.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,422.10
Max. Negotiated Rate	$6,508.70
Rate for Payer: Cash Price	$4,026.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,697.00
Rate for Payer: Health Management Network Commercial	$5,703.50
Rate for Payer: Kaiser Permanente Commercial	$4,227.30
Rate for Payer: Kaiser Permanente Medicaid	$3,422.10
Rate for Payer: MDX Hawaii PPO	$6,508.70
Rate for Payer: University Health Alliance Commercial	$3,757.60

Know your out-of-pocket cost for care.

All Charges