Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP 3.5/10H/R 02.127.240

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,387.28
Max. Negotiated Rate	$4,135.11
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE LCP 3.5/10H/R 02.127.240

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,174.13
Max. Negotiated Rate	$4,135.11
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Kaiser Permanente Commercial	$2,685.69
Rate for Payer: Kaiser Permanente Medicaid	$2,174.13
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE LCP 3.5/10H/R 02.127.340

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,174.13
Max. Negotiated Rate	$4,135.11
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Kaiser Permanente Commercial	$2,685.69
Rate for Payer: Kaiser Permanente Medicaid	$2,174.13
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE LCP 3.5/10H/R 02.127.340

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,387.28
Max. Negotiated Rate	$4,135.11
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE LCP 3.5/12H/L 02.127.251

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,662.80
Max. Negotiated Rate	$4,612.35
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/12H/L 02.127.251

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,425.05
Max. Negotiated Rate	$4,612.35
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: Kaiser Permanente Commercial	$2,995.65
Rate for Payer: Kaiser Permanente Medicaid	$2,425.05
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/12H/L 02.127.351

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,425.05
Max. Negotiated Rate	$4,612.35
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: Kaiser Permanente Commercial	$2,995.65
Rate for Payer: Kaiser Permanente Medicaid	$2,425.05
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/12H/L 02.127.351

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,662.80
Max. Negotiated Rate	$4,612.35
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/12H/R 02.127.250

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,425.05
Max. Negotiated Rate	$4,612.35
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: Kaiser Permanente Commercial	$2,995.65
Rate for Payer: Kaiser Permanente Medicaid	$2,425.05
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/12H/R 02.127.250

Facility

$4,755.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,662.80
Max. Negotiated Rate	$4,612.35
Rate for Payer: Cash Price	$2,853.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,328.50
Rate for Payer: Health Management Network Commercial	$4,041.75
Rate for Payer: MDX Hawaii PPO	$4,612.35
Rate for Payer: University Health Alliance Commercial	$2,662.80

PLATE LCP 3.5/14H/L 02.127.261

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,531.64
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: Kaiser Permanente Commercial	$3,127.32
Rate for Payer: Kaiser Permanente Medicaid	$2,531.64
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/L 02.127.261

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,779.84
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/L 02.127.361

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,531.64
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: Kaiser Permanente Commercial	$3,127.32
Rate for Payer: Kaiser Permanente Medicaid	$2,531.64
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/L 02.127.361

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,779.84
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/R 02.127.260

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,779.84
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/R 02.127.260

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,531.64
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: Kaiser Permanente Commercial	$3,127.32
Rate for Payer: Kaiser Permanente Medicaid	$2,531.64
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/R 02.127.360

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,531.64
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: Kaiser Permanente Commercial	$3,127.32
Rate for Payer: Kaiser Permanente Medicaid	$2,531.64
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/14H/R 02.127.360

Facility

$4,964.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,779.84
Max. Negotiated Rate	$4,815.08
Rate for Payer: Cash Price	$2,978.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,474.80
Rate for Payer: Health Management Network Commercial	$4,219.40
Rate for Payer: MDX Hawaii PPO	$4,815.08
Rate for Payer: University Health Alliance Commercial	$2,779.84

PLATE LCP 3.5/3H/LT 02.112.007

Facility

$2,888.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,617.28
Max. Negotiated Rate	$2,801.36
Rate for Payer: Cash Price	$1,732.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,021.60
Rate for Payer: Health Management Network Commercial	$2,454.80
Rate for Payer: MDX Hawaii PPO	$2,801.36
Rate for Payer: University Health Alliance Commercial	$1,617.28

PLATE LCP 3.5/3H/LT 02.112.007

Facility

$2,888.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,472.88
Max. Negotiated Rate	$2,801.36
Rate for Payer: Cash Price	$1,732.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,021.60
Rate for Payer: Health Management Network Commercial	$2,454.80
Rate for Payer: Kaiser Permanente Commercial	$1,819.44
Rate for Payer: Kaiser Permanente Medicaid	$1,472.88
Rate for Payer: MDX Hawaii PPO	$2,801.36
Rate for Payer: University Health Alliance Commercial	$1,617.28

PLATE LCP 3.5/3H/RT 02.112.006

Facility

$2,888.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,617.28
Max. Negotiated Rate	$2,801.36
Rate for Payer: Cash Price	$1,732.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,021.60
Rate for Payer: Health Management Network Commercial	$2,454.80
Rate for Payer: MDX Hawaii PPO	$2,801.36
Rate for Payer: University Health Alliance Commercial	$1,617.28

PLATE LCP 3.5/3H/RT 02.112.006

Facility

$2,888.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,472.88
Max. Negotiated Rate	$2,801.36
Rate for Payer: Cash Price	$1,732.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,021.60
Rate for Payer: Health Management Network Commercial	$2,454.80
Rate for Payer: Kaiser Permanente Commercial	$1,819.44
Rate for Payer: Kaiser Permanente Medicaid	$1,472.88
Rate for Payer: MDX Hawaii PPO	$2,801.36
Rate for Payer: University Health Alliance Commercial	$1,617.28

PLATE LCP 3.5/4H/L 02.127.311

Facility

$3,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,051.84
Max. Negotiated Rate	$3,554.08
Rate for Payer: Cash Price	$2,198.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,564.80
Rate for Payer: Health Management Network Commercial	$3,114.40
Rate for Payer: MDX Hawaii PPO	$3,554.08
Rate for Payer: University Health Alliance Commercial	$2,051.84

PLATE LCP 3.5/4H/L 02.127.311

Facility

$3,664.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,868.64
Max. Negotiated Rate	$3,554.08
Rate for Payer: Cash Price	$2,198.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,564.80
Rate for Payer: Health Management Network Commercial	$3,114.40
Rate for Payer: Kaiser Permanente Commercial	$2,308.32
Rate for Payer: Kaiser Permanente Medicaid	$1,868.64
Rate for Payer: MDX Hawaii PPO	$3,554.08
Rate for Payer: University Health Alliance Commercial	$2,051.84

PLATE LCP 3.5/4H/LT 02.112.011

Facility

$2,930.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,640.80
Max. Negotiated Rate	$2,842.10
Rate for Payer: Cash Price	$1,758.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,051.00
Rate for Payer: Health Management Network Commercial	$2,490.50
Rate for Payer: MDX Hawaii PPO	$2,842.10
Rate for Payer: University Health Alliance Commercial	$1,640.80

Know your out-of-pocket cost for care.

All Charges