Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP 3.5/6H/RT 02.112.080

Facility

$2,486.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,392.16
Max. Negotiated Rate	$2,411.42
Rate for Payer: Cash Price	$1,491.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,740.20
Rate for Payer: Health Management Network Commercial	$2,113.10
Rate for Payer: MDX Hawaii PPO	$2,411.42
Rate for Payer: University Health Alliance Commercial	$1,392.16

PLATE LCP 3.5/6H/RT 02.112.080

Facility

$2,486.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,267.86
Max. Negotiated Rate	$2,411.42
Rate for Payer: Cash Price	$1,491.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,740.20
Rate for Payer: Health Management Network Commercial	$2,113.10
Rate for Payer: Kaiser Permanente Commercial	$1,566.18
Rate for Payer: Kaiser Permanente Medicaid	$1,267.86
Rate for Payer: MDX Hawaii PPO	$2,411.42
Rate for Payer: University Health Alliance Commercial	$1,392.16

PLATE LCP 3.5/7H/LT 02.112.019

Facility

$3,084.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,572.84
Max. Negotiated Rate	$2,991.48
Rate for Payer: Cash Price	$1,850.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,158.80
Rate for Payer: Health Management Network Commercial	$2,621.40
Rate for Payer: Kaiser Permanente Commercial	$1,942.92
Rate for Payer: Kaiser Permanente Medicaid	$1,572.84
Rate for Payer: MDX Hawaii PPO	$2,991.48
Rate for Payer: University Health Alliance Commercial	$1,727.04

PLATE LCP 3.5/7H/LT 02.112.019

Facility

$3,084.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,727.04
Max. Negotiated Rate	$2,991.48
Rate for Payer: Cash Price	$1,850.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,158.80
Rate for Payer: Health Management Network Commercial	$2,621.40
Rate for Payer: MDX Hawaii PPO	$2,991.48
Rate for Payer: University Health Alliance Commercial	$1,727.04

PLATE LCP 3.5/7H/LT 02.112.029

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,131.69
Max. Negotiated Rate	$2,152.43
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: Kaiser Permanente Commercial	$1,397.97
Rate for Payer: Kaiser Permanente Medicaid	$1,131.69
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/7H/LT 02.112.029

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,242.64
Max. Negotiated Rate	$2,152.43
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/7H/LT 02.112.083

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,242.64
Max. Negotiated Rate	$2,152.43
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/7H/LT 02.112.083

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,131.69
Max. Negotiated Rate	$2,152.43
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: Kaiser Permanente Commercial	$1,397.97
Rate for Payer: Kaiser Permanente Medicaid	$1,131.69
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/7H/RT 02.112.028

Facility

$2,573.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,312.23
Max. Negotiated Rate	$2,495.81
Rate for Payer: Cash Price	$1,543.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,801.10
Rate for Payer: Health Management Network Commercial	$2,187.05
Rate for Payer: Kaiser Permanente Commercial	$1,620.99
Rate for Payer: Kaiser Permanente Medicaid	$1,312.23
Rate for Payer: MDX Hawaii PPO	$2,495.81
Rate for Payer: University Health Alliance Commercial	$1,440.88

PLATE LCP 3.5/7H/RT 02.112.028

Facility

$2,573.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,440.88
Max. Negotiated Rate	$2,495.81
Rate for Payer: Cash Price	$1,543.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,801.10
Rate for Payer: Health Management Network Commercial	$2,187.05
Rate for Payer: MDX Hawaii PPO	$2,495.81
Rate for Payer: University Health Alliance Commercial	$1,440.88

PLATE LCP 3.5/7H/RT 02.112.082

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,131.69
Max. Negotiated Rate	$2,152.43
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: Kaiser Permanente Commercial	$1,397.97
Rate for Payer: Kaiser Permanente Medicaid	$1,131.69
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/7H/RT 02.112.082

Facility

$2,219.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,242.64
Max. Negotiated Rate	$2,152.43
Rate for Payer: Cash Price	$1,331.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,553.30
Rate for Payer: Health Management Network Commercial	$1,886.15
Rate for Payer: MDX Hawaii PPO	$2,152.43
Rate for Payer: University Health Alliance Commercial	$1,242.64

PLATE LCP 3.5/8H/L 02.127.331

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,149.65
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Kaiser Permanente Commercial	$2,655.45
Rate for Payer: Kaiser Permanente Medicaid	$2,149.65
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/L 02.127.331

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.40
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/LT 02.112.021

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,611.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Kaiser Permanente Commercial	$1,990.80
Rate for Payer: Kaiser Permanente Medicaid	$1,611.60
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/LT 02.112.021

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/LT 02.112.031

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/LT 02.112.031

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,611.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: Kaiser Permanente Commercial	$1,990.80
Rate for Payer: Kaiser Permanente Medicaid	$1,611.60
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

PLATE LCP 3.5/8H/LT 02.112.085

Facility

$3,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.10
Max. Negotiated Rate	$3,501.70
Rate for Payer: Cash Price	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$3,068.50
Rate for Payer: Kaiser Permanente Commercial	$2,274.30
Rate for Payer: Kaiser Permanente Medicaid	$1,841.10
Rate for Payer: MDX Hawaii PPO	$3,501.70
Rate for Payer: University Health Alliance Commercial	$2,021.60

PLATE LCP 3.5/8H/LT 02.112.085

Facility

$3,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,021.60
Max. Negotiated Rate	$3,501.70
Rate for Payer: Cash Price	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$3,068.50
Rate for Payer: MDX Hawaii PPO	$3,501.70
Rate for Payer: University Health Alliance Commercial	$2,021.60

PLATE LCP 3.5/8H/LT 02.127.231

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,149.65
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Kaiser Permanente Commercial	$2,655.45
Rate for Payer: Kaiser Permanente Medicaid	$2,149.65
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/LT 02.127.231

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.40
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/R 02.127.330

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,149.65
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: Kaiser Permanente Commercial	$2,655.45
Rate for Payer: Kaiser Permanente Medicaid	$2,149.65
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/R 02.127.330

Facility

$4,215.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,360.40
Max. Negotiated Rate	$4,088.55
Rate for Payer: Cash Price	$2,529.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,950.50
Rate for Payer: Health Management Network Commercial	$3,582.75
Rate for Payer: MDX Hawaii PPO	$4,088.55
Rate for Payer: University Health Alliance Commercial	$2,360.40

PLATE LCP 3.5/8H/RT 02.112.020

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,769.60
Max. Negotiated Rate	$3,065.20
Rate for Payer: Cash Price	$1,896.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,212.00
Rate for Payer: Health Management Network Commercial	$2,686.00
Rate for Payer: MDX Hawaii PPO	$3,065.20
Rate for Payer: University Health Alliance Commercial	$1,769.60

Know your out-of-pocket cost for care.

All Charges