Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP 3.5/8H/RT 02.112.020

Facility

$3,160.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,611.60
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/RT 02.112.030

Facility

$2,277.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.12
Max. Negotiated Rate	$2,208.69
Rate for Payer: Cash Price	$1,366.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.90
Rate for Payer: Health Management Network Commercial	$1,935.45
Rate for Payer: MDX Hawaii PPO	$2,208.69
Rate for Payer: University Health Alliance Commercial	$1,275.12

PLATE LCP 3.5/8H/RT 02.112.030

Facility

$2,277.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,161.27
Max. Negotiated Rate	$2,208.69
Rate for Payer: Cash Price	$1,366.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.90
Rate for Payer: Health Management Network Commercial	$1,935.45
Rate for Payer: Kaiser Permanente Commercial	$1,434.51
Rate for Payer: Kaiser Permanente Medicaid	$1,161.27
Rate for Payer: MDX Hawaii PPO	$2,208.69
Rate for Payer: University Health Alliance Commercial	$1,275.12

PLATE LCP 3.5/8H/RT 02.112.084

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/RT 02.112.084

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/RT 02.127.230

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 02.127.230

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 CLAVICLE HOOK

Facility

$2,995.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,677.20
Max. Negotiated Rate	$2,905.15
Rate for Payer: Cash Price	$1,797.00
Rate for Payer: Cash Price	$1,484.40
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Cash Price	$1,597.20
Rate for Payer: Cash Price	$1,664.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,941.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,863.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,731.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,096.50
Rate for Payer: Health Management Network Commercial	$2,545.75
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: Health Management Network Commercial	$2,357.90
Rate for Payer: Health Management Network Commercial	$2,102.90
Rate for Payer: Health Management Network Commercial	$2,262.70
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: MDX Hawaii PPO	$2,399.78
Rate for Payer: MDX Hawaii PPO	$2,582.14
Rate for Payer: MDX Hawaii PPO	$2,690.78
Rate for Payer: MDX Hawaii PPO	$2,905.15
Rate for Payer: University Health Alliance Commercial	$1,490.72
Rate for Payer: University Health Alliance Commercial	$1,449.28
Rate for Payer: University Health Alliance Commercial	$1,385.44
Rate for Payer: University Health Alliance Commercial	$1,677.20
Rate for Payer: University Health Alliance Commercial	$1,553.44

PLATE LCP 3.5 CLAVICLE HOOK

Facility

$2,662.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,357.62
Max. Negotiated Rate	$2,582.14
Rate for Payer: Cash Price	$1,597.20
Rate for Payer: Cash Price	$1,484.40
Rate for Payer: Cash Price	$1,797.00
Rate for Payer: Cash Price	$1,552.80
Rate for Payer: Cash Price	$1,664.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,863.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,811.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,941.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,731.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,096.50
Rate for Payer: Health Management Network Commercial	$2,545.75
Rate for Payer: Health Management Network Commercial	$2,199.80
Rate for Payer: Health Management Network Commercial	$2,102.90
Rate for Payer: Health Management Network Commercial	$2,262.70
Rate for Payer: Health Management Network Commercial	$2,357.90
Rate for Payer: Kaiser Permanente Commercial	$1,677.06
Rate for Payer: Kaiser Permanente Commercial	$1,558.62
Rate for Payer: Kaiser Permanente Commercial	$1,630.44
Rate for Payer: Kaiser Permanente Commercial	$1,747.62
Rate for Payer: Kaiser Permanente Commercial	$1,886.85
Rate for Payer: Kaiser Permanente Medicaid	$1,261.74
Rate for Payer: Kaiser Permanente Medicaid	$1,527.45
Rate for Payer: Kaiser Permanente Medicaid	$1,357.62
Rate for Payer: Kaiser Permanente Medicaid	$1,414.74
Rate for Payer: Kaiser Permanente Medicaid	$1,319.88
Rate for Payer: MDX Hawaii PPO	$2,399.78
Rate for Payer: MDX Hawaii PPO	$2,905.15
Rate for Payer: MDX Hawaii PPO	$2,690.78
Rate for Payer: MDX Hawaii PPO	$2,510.36
Rate for Payer: MDX Hawaii PPO	$2,582.14
Rate for Payer: University Health Alliance Commercial	$1,553.44
Rate for Payer: University Health Alliance Commercial	$1,449.28
Rate for Payer: University Health Alliance Commercial	$1,490.72
Rate for Payer: University Health Alliance Commercial	$1,385.44
Rate for Payer: University Health Alliance Commercial	$1,677.20

PLATE LCP 3.5M 02.112.042

Facility

$2,277.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,161.27
Max. Negotiated Rate	$2,208.69
Rate for Payer: Cash Price	$1,366.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.90
Rate for Payer: Health Management Network Commercial	$1,935.45
Rate for Payer: Kaiser Permanente Commercial	$1,434.51
Rate for Payer: Kaiser Permanente Medicaid	$1,161.27
Rate for Payer: MDX Hawaii PPO	$2,208.69
Rate for Payer: University Health Alliance Commercial	$1,275.12

PLATE LCP 3.5M 02.112.042

Facility

$2,277.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.12
Max. Negotiated Rate	$2,208.69
Rate for Payer: Cash Price	$1,366.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.90
Rate for Payer: Health Management Network Commercial	$1,935.45
Rate for Payer: MDX Hawaii PPO	$2,208.69
Rate for Payer: University Health Alliance Commercial	$1,275.12

PLATE LCP 3.5X86MM RT 236.502

Facility

$2,073.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,057.23
Max. Negotiated Rate	$2,010.81
Rate for Payer: Cash Price	$1,243.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,451.10
Rate for Payer: Health Management Network Commercial	$1,762.05
Rate for Payer: Kaiser Permanente Commercial	$1,305.99
Rate for Payer: Kaiser Permanente Medicaid	$1,057.23
Rate for Payer: MDX Hawaii PPO	$2,010.81
Rate for Payer: University Health Alliance Commercial	$1,160.88

PLATE LCP 3.5X86MM RT 236.502

Facility

$2,073.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,160.88
Max. Negotiated Rate	$2,010.81
Rate for Payer: Cash Price	$1,243.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,451.10
Rate for Payer: Health Management Network Commercial	$1,762.05
Rate for Payer: MDX Hawaii PPO	$2,010.81
Rate for Payer: University Health Alliance Commercial	$1,160.88

PLATE LCP 3H 3.5X90MM 241.901

Facility

$3,409.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,909.04
Max. Negotiated Rate	$3,306.73
Rate for Payer: Cash Price	$2,045.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,386.30
Rate for Payer: Health Management Network Commercial	$2,897.65
Rate for Payer: MDX Hawaii PPO	$3,306.73
Rate for Payer: University Health Alliance Commercial	$1,909.04

PLATE LCP 3H 3.5X90MM 241.901

Facility

$3,409.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,738.59
Max. Negotiated Rate	$3,306.73
Rate for Payer: Cash Price	$2,045.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,386.30
Rate for Payer: Health Management Network Commercial	$2,897.65
Rate for Payer: Kaiser Permanente Commercial	$2,147.67
Rate for Payer: Kaiser Permanente Medicaid	$1,738.59
Rate for Payer: MDX Hawaii PPO	$3,306.73
Rate for Payer: University Health Alliance Commercial	$1,909.04

PLATE LCP 3H 4.5X62MM 224.531

Facility

$1,694.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$863.94
Max. Negotiated Rate	$1,643.18
Rate for Payer: Cash Price	$1,016.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.80
Rate for Payer: Health Management Network Commercial	$1,439.90
Rate for Payer: Kaiser Permanente Commercial	$1,067.22
Rate for Payer: Kaiser Permanente Medicaid	$863.94
Rate for Payer: MDX Hawaii PPO	$1,643.18
Rate for Payer: University Health Alliance Commercial	$948.64

PLATE LCP 3H 4.5X62MM 224.531

Facility

$1,694.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$948.64
Max. Negotiated Rate	$1,643.18
Rate for Payer: Cash Price	$1,016.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,185.80
Rate for Payer: Health Management Network Commercial	$1,439.90
Rate for Payer: MDX Hawaii PPO	$1,643.18
Rate for Payer: University Health Alliance Commercial	$948.64

PLATE LCP 4.5X266MM 02.124.413

Facility

$4,419.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,474.64
Max. Negotiated Rate	$4,286.43
Rate for Payer: Cash Price	$2,651.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,093.30
Rate for Payer: Health Management Network Commercial	$3,756.15
Rate for Payer: MDX Hawaii PPO	$4,286.43
Rate for Payer: University Health Alliance Commercial	$2,474.64

PLATE LCP 4.5X266MM 02.124.413

Facility

$4,419.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,253.69
Max. Negotiated Rate	$4,286.43
Rate for Payer: Cash Price	$2,651.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,093.30
Rate for Payer: Health Management Network Commercial	$3,756.15
Rate for Payer: Kaiser Permanente Commercial	$2,783.97
Rate for Payer: Kaiser Permanente Medicaid	$2,253.69
Rate for Payer: MDX Hawaii PPO	$4,286.43
Rate for Payer: University Health Alliance Commercial	$2,474.64

PLATE LCP 4.5X3.5 12H 224.757

Facility

$2,923.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,636.88
Max. Negotiated Rate	$2,835.31
Rate for Payer: Cash Price	$1,753.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,046.10
Rate for Payer: Health Management Network Commercial	$2,484.55
Rate for Payer: MDX Hawaii PPO	$2,835.31
Rate for Payer: University Health Alliance Commercial	$1,636.88

PLATE LCP 4.5X3.5 12H 224.757

Facility

$2,923.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,490.73
Max. Negotiated Rate	$2,835.31
Rate for Payer: Cash Price	$1,753.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,046.10
Rate for Payer: Health Management Network Commercial	$2,484.55
Rate for Payer: Kaiser Permanente Commercial	$1,841.49
Rate for Payer: Kaiser Permanente Medicaid	$1,490.73
Rate for Payer: MDX Hawaii PPO	$2,835.31
Rate for Payer: University Health Alliance Commercial	$1,636.88

PLATE LCP 4H 109MM 04.112.510

Facility

$3,542.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,806.42
Max. Negotiated Rate	$3,435.74
Rate for Payer: Cash Price	$2,125.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,479.40
Rate for Payer: Health Management Network Commercial	$3,010.70
Rate for Payer: Kaiser Permanente Commercial	$2,231.46
Rate for Payer: Kaiser Permanente Medicaid	$1,806.42
Rate for Payer: MDX Hawaii PPO	$3,435.74
Rate for Payer: University Health Alliance Commercial	$1,983.52

PLATE LCP 4H 109MM 04.112.510

Facility

$3,542.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,983.52
Max. Negotiated Rate	$3,435.74
Rate for Payer: Cash Price	$2,125.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,479.40
Rate for Payer: Health Management Network Commercial	$3,010.70
Rate for Payer: MDX Hawaii PPO	$3,435.74
Rate for Payer: University Health Alliance Commercial	$1,983.52

PLATE LCP 4H 3.5X81MM #239.934

Facility

$4,472.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,504.32
Max. Negotiated Rate	$4,337.84
Rate for Payer: Cash Price	$2,683.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,130.40
Rate for Payer: Health Management Network Commercial	$3,801.20
Rate for Payer: MDX Hawaii PPO	$4,337.84
Rate for Payer: University Health Alliance Commercial	$2,504.32

PLATE LCP 4H 3.5X81MM #239.934

Facility

$4,472.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,280.72
Max. Negotiated Rate	$4,337.84
Rate for Payer: Cash Price	$2,683.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,130.40
Rate for Payer: Health Management Network Commercial	$3,801.20
Rate for Payer: Kaiser Permanente Commercial	$2,817.36
Rate for Payer: Kaiser Permanente Medicaid	$2,280.72
Rate for Payer: MDX Hawaii PPO	$4,337.84
Rate for Payer: University Health Alliance Commercial	$2,504.32

Know your out-of-pocket cost for care.

All Charges