Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LATERAL TIBIA 540304

Facility

$6,710.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,757.60
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: MDX Hawaii PPO	$6,508.70
Rate for Payer: University Health Alliance Commercial	$3,757.60

PLATE LCDCP 3.5/6H/77MM 223.56

Facility

$1,369.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$698.19
Max. Negotiated Rate	$1,327.93
Rate for Payer: Cash Price	$821.40
Rate for Payer: Hawaii Western Management Group Commercial	$958.30
Rate for Payer: Health Management Network Commercial	$1,163.65
Rate for Payer: Kaiser Permanente Commercial	$862.47
Rate for Payer: Kaiser Permanente Medicaid	$698.19
Rate for Payer: MDX Hawaii PPO	$1,327.93
Rate for Payer: University Health Alliance Commercial	$766.64

PLATE LCDCP 3.5/6H/77MM 223.56

Facility

$1,369.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$766.64
Max. Negotiated Rate	$1,327.93
Rate for Payer: Cash Price	$821.40
Rate for Payer: Hawaii Western Management Group Commercial	$958.30
Rate for Payer: Health Management Network Commercial	$1,163.65
Rate for Payer: MDX Hawaii PPO	$1,327.93
Rate for Payer: University Health Alliance Commercial	$766.64

PLATE LC-DCP 3.5MM/10-H 223.60

Facility

$1,594.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$812.94
Max. Negotiated Rate	$1,546.18
Rate for Payer: Cash Price	$956.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,115.80
Rate for Payer: Health Management Network Commercial	$1,354.90
Rate for Payer: Kaiser Permanente Commercial	$1,004.22
Rate for Payer: Kaiser Permanente Medicaid	$812.94
Rate for Payer: MDX Hawaii PPO	$1,546.18
Rate for Payer: University Health Alliance Commercial	$892.64

PLATE LC-DCP 3.5MM/10-H 223.60

Facility

$1,594.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$892.64
Max. Negotiated Rate	$1,546.18
Rate for Payer: Cash Price	$956.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,115.80
Rate for Payer: Health Management Network Commercial	$1,354.90
Rate for Payer: MDX Hawaii PPO	$1,546.18
Rate for Payer: University Health Alliance Commercial	$892.64

PLATE LC-DCP 3.5MM/8-HL 223.58

Facility

$1,495.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$762.45
Max. Negotiated Rate	$1,450.15
Rate for Payer: Cash Price	$897.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,046.50
Rate for Payer: Health Management Network Commercial	$1,270.75
Rate for Payer: Kaiser Permanente Commercial	$941.85
Rate for Payer: Kaiser Permanente Medicaid	$762.45
Rate for Payer: MDX Hawaii PPO	$1,450.15
Rate for Payer: University Health Alliance Commercial	$837.20

PLATE LC-DCP 3.5MM/8-HL 223.58

Facility

$1,495.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$837.20
Max. Negotiated Rate	$1,450.15
Rate for Payer: Cash Price	$897.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,046.50
Rate for Payer: Health Management Network Commercial	$1,270.75
Rate for Payer: MDX Hawaii PPO	$1,450.15
Rate for Payer: University Health Alliance Commercial	$837.20

PLATE LC-DCP 3.5MM/9-HL 223.59

Facility

$660.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$336.60
Max. Negotiated Rate	$640.20
Rate for Payer: Cash Price	$396.00
Rate for Payer: Hawaii Western Management Group Commercial	$462.00
Rate for Payer: Health Management Network Commercial	$561.00
Rate for Payer: Kaiser Permanente Commercial	$415.80
Rate for Payer: Kaiser Permanente Medicaid	$336.60
Rate for Payer: MDX Hawaii PPO	$640.20
Rate for Payer: University Health Alliance Commercial	$369.60

PLATE LC-DCP 3.5MM/9-HL 223.59

Facility

$660.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$369.60
Max. Negotiated Rate	$640.20
Rate for Payer: Cash Price	$396.00
Rate for Payer: Hawaii Western Management Group Commercial	$462.00
Rate for Payer: Health Management Network Commercial	$561.00
Rate for Payer: MDX Hawaii PPO	$640.20
Rate for Payer: University Health Alliance Commercial	$369.60

PLATE LCK 1.7MM 57-10395

Facility

$2,335.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,307.60
Max. Negotiated Rate	$2,264.95
Rate for Payer: Cash Price	$1,401.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.50
Rate for Payer: Health Management Network Commercial	$1,984.75
Rate for Payer: MDX Hawaii PPO	$2,264.95
Rate for Payer: University Health Alliance Commercial	$1,307.60

PLATE LCK 1.7MM 57-10395

Facility

$2,335.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,190.85
Max. Negotiated Rate	$2,264.95
Rate for Payer: Cash Price	$1,401.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,634.50
Rate for Payer: Health Management Network Commercial	$1,984.75
Rate for Payer: Kaiser Permanente Commercial	$1,471.05
Rate for Payer: Kaiser Permanente Medicaid	$1,190.85
Rate for Payer: MDX Hawaii PPO	$2,264.95
Rate for Payer: University Health Alliance Commercial	$1,307.60

PLATE LCK 2.7MM 6H

Facility

$2,614.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,333.14
Max. Negotiated Rate	$2,535.58
Rate for Payer: Cash Price	$1,568.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,829.80
Rate for Payer: Health Management Network Commercial	$2,221.90
Rate for Payer: Kaiser Permanente Commercial	$1,646.82
Rate for Payer: Kaiser Permanente Medicaid	$1,333.14
Rate for Payer: MDX Hawaii PPO	$2,535.58
Rate for Payer: University Health Alliance Commercial	$1,463.84

PLATE LCK 2.7MM 6H

Facility

$2,614.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,463.84
Max. Negotiated Rate	$2,535.58
Rate for Payer: Cash Price	$1,568.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,829.80
Rate for Payer: Health Management Network Commercial	$2,221.90
Rate for Payer: MDX Hawaii PPO	$2,535.58
Rate for Payer: University Health Alliance Commercial	$1,463.84

PLATE LCK 3RD TUB AR-8943T-06

Facility

$882.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$493.92
Max. Negotiated Rate	$855.54
Rate for Payer: Cash Price	$529.20
Rate for Payer: Hawaii Western Management Group Commercial	$617.40
Rate for Payer: Health Management Network Commercial	$749.70
Rate for Payer: MDX Hawaii PPO	$855.54
Rate for Payer: University Health Alliance Commercial	$493.92

PLATE LCK 3RD TUB AR-8943T-06

Facility

$882.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$449.82
Max. Negotiated Rate	$855.54
Rate for Payer: Cash Price	$529.20
Rate for Payer: Hawaii Western Management Group Commercial	$617.40
Rate for Payer: Health Management Network Commercial	$749.70
Rate for Payer: Kaiser Permanente Commercial	$555.66
Rate for Payer: Kaiser Permanente Medicaid	$449.82
Rate for Payer: MDX Hawaii PPO	$855.54
Rate for Payer: University Health Alliance Commercial	$493.92

PLATE LCK 4H NARRW 32MM 629724

Facility

$2,291.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,168.41
Max. Negotiated Rate	$2,222.27
Rate for Payer: Cash Price	$1,374.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,603.70
Rate for Payer: Health Management Network Commercial	$1,947.35
Rate for Payer: Kaiser Permanente Commercial	$1,443.33
Rate for Payer: Kaiser Permanente Medicaid	$1,168.41
Rate for Payer: MDX Hawaii PPO	$2,222.27
Rate for Payer: University Health Alliance Commercial	$1,282.96

PLATE LCK 4H NARRW 32MM 629724

Facility

$2,291.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,282.96
Max. Negotiated Rate	$2,222.27
Rate for Payer: Cash Price	$1,374.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,603.70
Rate for Payer: Health Management Network Commercial	$1,947.35
Rate for Payer: MDX Hawaii PPO	$2,222.27
Rate for Payer: University Health Alliance Commercial	$1,282.96

PLATE LCK DIST RT AR-8943DR-06

Facility

$2,520.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,285.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Commercial	$1,587.60
Rate for Payer: Kaiser Permanente Medicaid	$1,285.20
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: University Health Alliance Commercial	$1,411.20

PLATE LCK DIST RT AR-8943DR-06

Facility

$2,520.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: University Health Alliance Commercial	$1,411.20

PLATE LCK ELBOW LT DIST 629248

Facility

$4,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,050.20
Max. Negotiated Rate	$3,899.40
Rate for Payer: Cash Price	$2,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,814.00
Rate for Payer: Health Management Network Commercial	$3,417.00
Rate for Payer: Kaiser Permanente Commercial	$2,532.60
Rate for Payer: Kaiser Permanente Medicaid	$2,050.20
Rate for Payer: MDX Hawaii PPO	$3,899.40
Rate for Payer: University Health Alliance Commercial	$2,251.20

PLATE LCK ELBOW LT DIST 629248

Facility

$4,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,251.20
Max. Negotiated Rate	$3,899.40
Rate for Payer: Cash Price	$2,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,814.00
Rate for Payer: Health Management Network Commercial	$3,417.00
Rate for Payer: MDX Hawaii PPO	$3,899.40
Rate for Payer: University Health Alliance Commercial	$2,251.20

PLATE LCK HOOK 3H AR-8943H-03

Facility

$2,599.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,455.44
Max. Negotiated Rate	$2,521.03
Rate for Payer: Cash Price	$1,559.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,819.30
Rate for Payer: Health Management Network Commercial	$2,209.15
Rate for Payer: MDX Hawaii PPO	$2,521.03
Rate for Payer: University Health Alliance Commercial	$1,455.44

PLATE LCK HOOK 3H AR-8943H-03

Facility

$2,599.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,325.49
Max. Negotiated Rate	$2,521.03
Rate for Payer: Cash Price	$1,559.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,819.30
Rate for Payer: Health Management Network Commercial	$2,209.15
Rate for Payer: Kaiser Permanente Commercial	$1,637.37
Rate for Payer: Kaiser Permanente Medicaid	$1,325.49
Rate for Payer: MDX Hawaii PPO	$2,521.03
Rate for Payer: University Health Alliance Commercial	$1,455.44

PLATE LCK HUMERAL LF 627208

Facility

$5,866.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,991.66
Max. Negotiated Rate	$5,690.02
Rate for Payer: Cash Price	$3,519.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,106.20
Rate for Payer: Health Management Network Commercial	$4,986.10
Rate for Payer: Kaiser Permanente Commercial	$3,695.58
Rate for Payer: Kaiser Permanente Medicaid	$2,991.66
Rate for Payer: MDX Hawaii PPO	$5,690.02
Rate for Payer: University Health Alliance Commercial	$3,284.96

PLATE LCK HUMERAL LF 627208

Facility

$5,866.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,284.96
Max. Negotiated Rate	$5,690.02
Rate for Payer: Cash Price	$3,519.60
Rate for Payer: Hawaii Western Management Group Commercial	$4,106.20
Rate for Payer: Health Management Network Commercial	$4,986.10
Rate for Payer: MDX Hawaii PPO	$5,690.02
Rate for Payer: University Health Alliance Commercial	$3,284.96

Know your out-of-pocket cost for care.

All Charges