Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP 3.5/4H/LT 02.112.011

Facility

$2,930.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,494.30
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: Kaiser Permanente Commercial	$1,845.90
Rate for Payer: Kaiser Permanente Medicaid	$1,494.30
Rate for Payer: MDX Hawaii PPO	$2,842.10
Rate for Payer: University Health Alliance Commercial	$1,640.80

PLATE LCP 3.5/4H/LT 02.127.211

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 02.127.211

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/R 02.127.310

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/R 02.127.310

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/RT 02.112.010

Facility

$2,930.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,494.30
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: Kaiser Permanente Commercial	$1,845.90
Rate for Payer: Kaiser Permanente Medicaid	$1,494.30
Rate for Payer: MDX Hawaii PPO	$2,842.10
Rate for Payer: University Health Alliance Commercial	$1,640.80

PLATE LCP 3.5/4H/RT 02.112.010

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

PLATE LCP 3.5/5H/LT 02.112.013

Facility

$2,978.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,667.68
Max. Negotiated Rate	$2,888.66
Rate for Payer: Cash Price	$1,786.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.60
Rate for Payer: Health Management Network Commercial	$2,531.30
Rate for Payer: MDX Hawaii PPO	$2,888.66
Rate for Payer: University Health Alliance Commercial	$1,667.68

PLATE LCP 3.5/5H/LT 02.112.013

Facility

$2,978.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.78
Max. Negotiated Rate	$2,888.66
Rate for Payer: Cash Price	$1,786.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.60
Rate for Payer: Health Management Network Commercial	$2,531.30
Rate for Payer: Kaiser Permanente Commercial	$1,876.14
Rate for Payer: Kaiser Permanente Medicaid	$1,518.78
Rate for Payer: MDX Hawaii PPO	$2,888.66
Rate for Payer: University Health Alliance Commercial	$1,667.68

PLATE LCP 3.5/5H/RT 02.112.012

Facility

$2,978.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.78
Max. Negotiated Rate	$2,888.66
Rate for Payer: Cash Price	$1,786.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.60
Rate for Payer: Health Management Network Commercial	$2,531.30
Rate for Payer: Kaiser Permanente Commercial	$1,876.14
Rate for Payer: Kaiser Permanente Medicaid	$1,518.78
Rate for Payer: MDX Hawaii PPO	$2,888.66
Rate for Payer: University Health Alliance Commercial	$1,667.68

PLATE LCP 3.5/5H/RT 02.112.012

Facility

$2,978.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,667.68
Max. Negotiated Rate	$2,888.66
Rate for Payer: Cash Price	$1,786.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.60
Rate for Payer: Health Management Network Commercial	$2,531.30
Rate for Payer: MDX Hawaii PPO	$2,888.66
Rate for Payer: University Health Alliance Commercial	$1,667.68

PLATE LCP 3.5/6H/L 02.127.321

Facility

$3,714.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,894.14
Max. Negotiated Rate	$3,602.58
Rate for Payer: Cash Price	$2,228.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,599.80
Rate for Payer: Health Management Network Commercial	$3,156.90
Rate for Payer: Kaiser Permanente Commercial	$2,339.82
Rate for Payer: Kaiser Permanente Medicaid	$1,894.14
Rate for Payer: MDX Hawaii PPO	$3,602.58
Rate for Payer: University Health Alliance Commercial	$2,079.84

PLATE LCP 3.5/6H/L 02.127.321

Facility

$3,714.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,079.84
Max. Negotiated Rate	$3,602.58
Rate for Payer: Cash Price	$2,228.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,599.80
Rate for Payer: Health Management Network Commercial	$3,156.90
Rate for Payer: MDX Hawaii PPO	$3,602.58
Rate for Payer: University Health Alliance Commercial	$2,079.84

PLATE LCP 3.5/6H/LT 02.112.009

Facility

$3,010.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,535.10
Max. Negotiated Rate	$2,919.70
Rate for Payer: Cash Price	$1,806.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,107.00
Rate for Payer: Health Management Network Commercial	$2,558.50
Rate for Payer: Kaiser Permanente Commercial	$1,896.30
Rate for Payer: Kaiser Permanente Medicaid	$1,535.10
Rate for Payer: MDX Hawaii PPO	$2,919.70
Rate for Payer: University Health Alliance Commercial	$1,685.60

PLATE LCP 3.5/6H/LT 02.112.009

Facility

$3,010.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,685.60
Max. Negotiated Rate	$2,919.70
Rate for Payer: Cash Price	$1,806.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,107.00
Rate for Payer: Health Management Network Commercial	$2,558.50
Rate for Payer: MDX Hawaii PPO	$2,919.70
Rate for Payer: University Health Alliance Commercial	$1,685.60

PLATE LCP 3.5/6H/LT 02.112.027

Facility

$2,412.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,230.12
Max. Negotiated Rate	$2,339.64
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,688.40
Rate for Payer: Health Management Network Commercial	$2,050.20
Rate for Payer: Kaiser Permanente Commercial	$1,519.56
Rate for Payer: Kaiser Permanente Medicaid	$1,230.12
Rate for Payer: MDX Hawaii PPO	$2,339.64
Rate for Payer: University Health Alliance Commercial	$1,350.72

PLATE LCP 3.5/6H/LT 02.112.027

Facility

$2,412.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,350.72
Max. Negotiated Rate	$2,339.64
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,688.40
Rate for Payer: Health Management Network Commercial	$2,050.20
Rate for Payer: MDX Hawaii PPO	$2,339.64
Rate for Payer: University Health Alliance Commercial	$1,350.72

PLATE LCP 3.5/6H/LT 02.112.081

Facility

$2,164.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,211.84
Max. Negotiated Rate	$2,099.08
Rate for Payer: Cash Price	$1,298.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,514.80
Rate for Payer: Health Management Network Commercial	$1,839.40
Rate for Payer: MDX Hawaii PPO	$2,099.08
Rate for Payer: University Health Alliance Commercial	$1,211.84

PLATE LCP 3.5/6H/LT 02.112.081

Facility

$2,164.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,103.64
Max. Negotiated Rate	$2,099.08
Rate for Payer: Cash Price	$1,298.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,514.80
Rate for Payer: Health Management Network Commercial	$1,839.40
Rate for Payer: Kaiser Permanente Commercial	$1,363.32
Rate for Payer: Kaiser Permanente Medicaid	$1,103.64
Rate for Payer: MDX Hawaii PPO	$2,099.08
Rate for Payer: University Health Alliance Commercial	$1,211.84

PLATE LCP 3.5/6H/LT 02.127.221

Facility

$3,704.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,889.04
Max. Negotiated Rate	$3,592.88
Rate for Payer: Cash Price	$2,222.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,592.80
Rate for Payer: Health Management Network Commercial	$3,148.40
Rate for Payer: Kaiser Permanente Commercial	$2,333.52
Rate for Payer: Kaiser Permanente Medicaid	$1,889.04
Rate for Payer: MDX Hawaii PPO	$3,592.88
Rate for Payer: University Health Alliance Commercial	$2,074.24

PLATE LCP 3.5/6H/LT 02.127.221

Facility

$3,704.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,074.24
Max. Negotiated Rate	$3,592.88
Rate for Payer: Cash Price	$2,222.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,592.80
Rate for Payer: Health Management Network Commercial	$3,148.40
Rate for Payer: MDX Hawaii PPO	$3,592.88
Rate for Payer: University Health Alliance Commercial	$2,074.24

PLATE LCP 3.5/6H/R 02.127.320

Facility

$4,684.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,623.04
Max. Negotiated Rate	$4,543.48
Rate for Payer: Cash Price	$2,810.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,278.80
Rate for Payer: Health Management Network Commercial	$3,981.40
Rate for Payer: MDX Hawaii PPO	$4,543.48
Rate for Payer: University Health Alliance Commercial	$2,623.04

PLATE LCP 3.5/6H/R 02.127.320

Facility

$4,684.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,388.84
Max. Negotiated Rate	$4,543.48
Rate for Payer: Cash Price	$2,810.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,278.80
Rate for Payer: Health Management Network Commercial	$3,981.40
Rate for Payer: Kaiser Permanente Commercial	$2,950.92
Rate for Payer: Kaiser Permanente Medicaid	$2,388.84
Rate for Payer: MDX Hawaii PPO	$4,543.48
Rate for Payer: University Health Alliance Commercial	$2,623.04

PLATE LCP 3.5/6H/RT 02.112.026

Facility

$3,010.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,685.60
Max. Negotiated Rate	$2,919.70
Rate for Payer: Cash Price	$1,806.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,107.00
Rate for Payer: Health Management Network Commercial	$2,558.50
Rate for Payer: MDX Hawaii PPO	$2,919.70
Rate for Payer: University Health Alliance Commercial	$1,685.60

PLATE LCP 3.5/6H/RT 02.112.026

Facility

$3,010.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,535.10
Max. Negotiated Rate	$2,919.70
Rate for Payer: Cash Price	$1,806.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,107.00
Rate for Payer: Health Management Network Commercial	$2,558.50
Rate for Payer: Kaiser Permanente Commercial	$1,896.30
Rate for Payer: Kaiser Permanente Medicaid	$1,535.10
Rate for Payer: MDX Hawaii PPO	$2,919.70
Rate for Payer: University Health Alliance Commercial	$1,685.60

Know your out-of-pocket cost for care.

All Charges