Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCKIGN 3.5, 7 HOLE

Facility

$774.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$433.44
Max. Negotiated Rate	$750.78
Rate for Payer: Cash Price	$464.40
Rate for Payer: Hawaii Western Management Group Commercial	$541.80
Rate for Payer: Health Management Network Commercial	$657.90
Rate for Payer: MDX Hawaii PPO	$750.78
Rate for Payer: University Health Alliance Commercial	$433.44

PLATE LCKIGN 3.5, 7 HOLE

Facility

$774.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$394.74
Max. Negotiated Rate	$750.78
Rate for Payer: Cash Price	$464.40
Rate for Payer: Hawaii Western Management Group Commercial	$541.80
Rate for Payer: Health Management Network Commercial	$657.90
Rate for Payer: Kaiser Permanente Commercial	$487.62
Rate for Payer: Kaiser Permanente Medicaid	$394.74
Rate for Payer: MDX Hawaii PPO	$750.78
Rate for Payer: University Health Alliance Commercial	$433.44

PLATE LCKING COUNTOUR DUAL 3.5

Facility

$1,535.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$782.85
Max. Negotiated Rate	$1,488.95
Rate for Payer: Cash Price	$921.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,074.50
Rate for Payer: Health Management Network Commercial	$1,304.75
Rate for Payer: Kaiser Permanente Commercial	$967.05
Rate for Payer: Kaiser Permanente Medicaid	$782.85
Rate for Payer: MDX Hawaii PPO	$1,488.95
Rate for Payer: University Health Alliance Commercial	$859.60

PLATE LCKING COUNTOUR DUAL 3.5

Facility

$1,535.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$859.60
Max. Negotiated Rate	$1,488.95
Rate for Payer: Cash Price	$921.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,074.50
Rate for Payer: Health Management Network Commercial	$1,304.75
Rate for Payer: MDX Hawaii PPO	$1,488.95
Rate for Payer: University Health Alliance Commercial	$859.60

PLATE LCKING DUAL COMPRESS 3.5

Facility

$1,488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$758.88
Max. Negotiated Rate	$1,443.36
Rate for Payer: Cash Price	$892.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,041.60
Rate for Payer: Health Management Network Commercial	$1,264.80
Rate for Payer: Kaiser Permanente Commercial	$937.44
Rate for Payer: Kaiser Permanente Medicaid	$758.88
Rate for Payer: MDX Hawaii PPO	$1,443.36
Rate for Payer: University Health Alliance Commercial	$833.28

PLATE LCKING DUAL COMPRESS 3.5

Facility

$1,488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$833.28
Max. Negotiated Rate	$1,443.36
Rate for Payer: Cash Price	$892.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,041.60
Rate for Payer: Health Management Network Commercial	$1,264.80
Rate for Payer: MDX Hawaii PPO	$1,443.36
Rate for Payer: University Health Alliance Commercial	$833.28

PLATE LCK LAT HK AR-8943TH-03

Facility

$2,205.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,124.55
Max. Negotiated Rate	$2,138.85
Rate for Payer: Cash Price	$1,323.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,543.50
Rate for Payer: Health Management Network Commercial	$1,874.25
Rate for Payer: Kaiser Permanente Commercial	$1,389.15
Rate for Payer: Kaiser Permanente Medicaid	$1,124.55
Rate for Payer: MDX Hawaii PPO	$2,138.85
Rate for Payer: University Health Alliance Commercial	$1,234.80

PLATE LCK LAT HK AR-8943TH-03

Facility

$2,205.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,234.80
Max. Negotiated Rate	$2,138.85
Rate for Payer: Cash Price	$1,323.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,543.50
Rate for Payer: Health Management Network Commercial	$1,874.25
Rate for Payer: MDX Hawaii PPO	$2,138.85
Rate for Payer: University Health Alliance Commercial	$1,234.80

PLATE LCKNG 2.3MM 3D 57-15392

Facility

$2,476.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.76
Max. Negotiated Rate	$2,401.72
Rate for Payer: Cash Price	$1,485.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,733.20
Rate for Payer: Health Management Network Commercial	$2,104.60
Rate for Payer: Kaiser Permanente Commercial	$1,559.88
Rate for Payer: Kaiser Permanente Medicaid	$1,262.76
Rate for Payer: MDX Hawaii PPO	$2,401.72
Rate for Payer: University Health Alliance Commercial	$1,386.56

PLATE LCKNG 2.3MM 3D 57-15392

Facility

$2,476.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,386.56
Max. Negotiated Rate	$2,401.72
Rate for Payer: Cash Price	$1,485.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,733.20
Rate for Payer: Health Management Network Commercial	$2,104.60
Rate for Payer: MDX Hawaii PPO	$2,401.72
Rate for Payer: University Health Alliance Commercial	$1,386.56

PLATE LCK RT 3 HOLE 627233

Facility

$5,084.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,592.84
Max. Negotiated Rate	$4,931.48
Rate for Payer: Cash Price	$3,050.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,558.80
Rate for Payer: Health Management Network Commercial	$4,321.40
Rate for Payer: Kaiser Permanente Commercial	$3,202.92
Rate for Payer: Kaiser Permanente Medicaid	$2,592.84
Rate for Payer: MDX Hawaii PPO	$4,931.48
Rate for Payer: University Health Alliance Commercial	$2,847.04

PLATE LCK RT 3 HOLE 627233

Facility

$5,084.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,847.04
Max. Negotiated Rate	$4,931.48
Rate for Payer: Cash Price	$3,050.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,558.80
Rate for Payer: Health Management Network Commercial	$4,321.40
Rate for Payer: MDX Hawaii PPO	$4,931.48
Rate for Payer: University Health Alliance Commercial	$2,847.04

PLATE LCK ST 10H AR-8943C-10

Facility

$1,874.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,049.44
Max. Negotiated Rate	$1,817.78
Rate for Payer: Cash Price	$1,124.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,311.80
Rate for Payer: Health Management Network Commercial	$1,592.90
Rate for Payer: MDX Hawaii PPO	$1,817.78
Rate for Payer: University Health Alliance Commercial	$1,049.44

PLATE LCK ST 10H AR-8943C-10

Facility

$1,874.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$955.74
Max. Negotiated Rate	$1,817.78
Rate for Payer: Cash Price	$1,124.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,311.80
Rate for Payer: Health Management Network Commercial	$1,592.90
Rate for Payer: Kaiser Permanente Commercial	$1,180.62
Rate for Payer: Kaiser Permanente Medicaid	$955.74
Rate for Payer: MDX Hawaii PPO	$1,817.78
Rate for Payer: University Health Alliance Commercial	$1,049.44

PLATE LCK STR 7H AR-8943C-06

Facility

$1,746.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$890.46
Max. Negotiated Rate	$1,693.62
Rate for Payer: Cash Price	$1,047.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,222.20
Rate for Payer: Health Management Network Commercial	$1,484.10
Rate for Payer: Kaiser Permanente Commercial	$1,099.98
Rate for Payer: Kaiser Permanente Medicaid	$890.46
Rate for Payer: MDX Hawaii PPO	$1,693.62
Rate for Payer: University Health Alliance Commercial	$977.76

PLATE LCK STR 7H AR-8943C-06

Facility

$1,746.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$977.76
Max. Negotiated Rate	$1,693.62
Rate for Payer: Cash Price	$1,047.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,222.20
Rate for Payer: Health Management Network Commercial	$1,484.10
Rate for Payer: MDX Hawaii PPO	$1,693.62
Rate for Payer: University Health Alliance Commercial	$977.76

PLATE LCK STR 8H AR-8943C-08

Facility

$1,650.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

PLATE LCK STR 8H AR-8943C-08

Facility

$1,650.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$841.50
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$841.50
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

PLATE LCK THIRD 4H AR-8943T-04

Facility

$886.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$451.86
Max. Negotiated Rate	$859.42
Rate for Payer: Cash Price	$531.60
Rate for Payer: Hawaii Western Management Group Commercial	$620.20
Rate for Payer: Health Management Network Commercial	$753.10
Rate for Payer: Kaiser Permanente Commercial	$558.18
Rate for Payer: Kaiser Permanente Medicaid	$451.86
Rate for Payer: MDX Hawaii PPO	$859.42
Rate for Payer: University Health Alliance Commercial	$496.16

PLATE LCK THIRD 4H AR-8943T-04

Facility

$886.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$496.16
Max. Negotiated Rate	$859.42
Rate for Payer: Cash Price	$531.60
Rate for Payer: Hawaii Western Management Group Commercial	$620.20
Rate for Payer: Health Management Network Commercial	$753.10
Rate for Payer: MDX Hawaii PPO	$859.42
Rate for Payer: University Health Alliance Commercial	$496.16

PLATE LCK TIBIAL LF 5H 627705

Facility

$4,456.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,272.56
Max. Negotiated Rate	$4,322.32
Rate for Payer: Cash Price	$2,673.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,119.20
Rate for Payer: Health Management Network Commercial	$3,787.60
Rate for Payer: Kaiser Permanente Commercial	$2,807.28
Rate for Payer: Kaiser Permanente Medicaid	$2,272.56
Rate for Payer: MDX Hawaii PPO	$4,322.32
Rate for Payer: University Health Alliance Commercial	$2,495.36

PLATE LCK TIBIAL LF 5H 627705

Facility

$4,456.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,495.36
Max. Negotiated Rate	$4,322.32
Rate for Payer: Cash Price	$2,673.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,119.20
Rate for Payer: Health Management Network Commercial	$3,787.60
Rate for Payer: MDX Hawaii PPO	$4,322.32
Rate for Payer: University Health Alliance Commercial	$2,495.36

PLATE LCK TIBIAL RT 2H 627332

Facility

$4,894.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,740.64
Max. Negotiated Rate	$4,747.18
Rate for Payer: Cash Price	$2,936.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,425.80
Rate for Payer: Health Management Network Commercial	$4,159.90
Rate for Payer: MDX Hawaii PPO	$4,747.18
Rate for Payer: University Health Alliance Commercial	$2,740.64

PLATE LCK TIBIAL RT 2H 627332

Facility

$4,894.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,495.94
Max. Negotiated Rate	$4,747.18
Rate for Payer: Cash Price	$2,936.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,425.80
Rate for Payer: Health Management Network Commercial	$4,159.90
Rate for Payer: Kaiser Permanente Commercial	$3,083.22
Rate for Payer: Kaiser Permanente Medicaid	$2,495.94
Rate for Payer: MDX Hawaii PPO	$4,747.18
Rate for Payer: University Health Alliance Commercial	$2,740.64

PLATE LCK TIB LT DIST 627412

Facility

$3,890.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,983.90
Max. Negotiated Rate	$3,773.30
Rate for Payer: Cash Price	$2,334.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,723.00
Rate for Payer: Health Management Network Commercial	$3,306.50
Rate for Payer: Kaiser Permanente Commercial	$2,450.70
Rate for Payer: Kaiser Permanente Medicaid	$1,983.90
Rate for Payer: MDX Hawaii PPO	$3,773.30
Rate for Payer: University Health Alliance Commercial	$2,178.40

Know your out-of-pocket cost for care.

All Charges