Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP 4H 3.5X81MM #239.935

Facility

$3,302.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,849.12
Max. Negotiated Rate	$3,202.94
Rate for Payer: Cash Price	$1,981.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,311.40
Rate for Payer: Health Management Network Commercial	$2,806.70
Rate for Payer: MDX Hawaii PPO	$3,202.94
Rate for Payer: University Health Alliance Commercial	$1,849.12

PLATE LCP 4H 3.5X81MM #239.935

Facility

$3,302.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,684.02
Max. Negotiated Rate	$3,202.94
Rate for Payer: Cash Price	$1,981.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,311.40
Rate for Payer: Health Management Network Commercial	$2,806.70
Rate for Payer: Kaiser Permanente Commercial	$2,080.26
Rate for Payer: Kaiser Permanente Medicaid	$1,684.02
Rate for Payer: MDX Hawaii PPO	$3,202.94
Rate for Payer: University Health Alliance Commercial	$1,849.12

PLATE LCP 4H 4.5X82MM 240.036

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 4H 4.5X82MM 240.036

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 4H 4.5X82MM 240.037

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 4H 4.5X82MM 240.037

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 5H 1/3T 57MM 241.351

Facility

$743.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$416.08
Max. Negotiated Rate	$720.71
Rate for Payer: Cash Price	$445.80
Rate for Payer: Hawaii Western Management Group Commercial	$520.10
Rate for Payer: Health Management Network Commercial	$631.55
Rate for Payer: MDX Hawaii PPO	$720.71
Rate for Payer: University Health Alliance Commercial	$416.08

PLATE LCP 5H 1/3T 57MM 241.351

Facility

$743.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$378.93
Max. Negotiated Rate	$720.71
Rate for Payer: Cash Price	$445.80
Rate for Payer: Hawaii Western Management Group Commercial	$520.10
Rate for Payer: Health Management Network Commercial	$631.55
Rate for Payer: Kaiser Permanente Commercial	$468.09
Rate for Payer: Kaiser Permanente Medicaid	$378.93
Rate for Payer: MDX Hawaii PPO	$720.71
Rate for Payer: University Health Alliance Commercial	$416.08

PLATE LCP 5H 3.5X114MM 241.903

Facility

$3,516.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,968.96
Max. Negotiated Rate	$3,410.52
Rate for Payer: Cash Price	$2,109.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,461.20
Rate for Payer: Health Management Network Commercial	$2,988.60
Rate for Payer: MDX Hawaii PPO	$3,410.52
Rate for Payer: University Health Alliance Commercial	$1,968.96

PLATE LCP 5H 3.5X114MM 241.903

Facility

$3,516.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,793.16
Max. Negotiated Rate	$3,410.52
Rate for Payer: Cash Price	$2,109.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,461.20
Rate for Payer: Health Management Network Commercial	$2,988.60
Rate for Payer: Kaiser Permanente Commercial	$2,215.08
Rate for Payer: Kaiser Permanente Medicaid	$1,793.16
Rate for Payer: MDX Hawaii PPO	$3,410.52
Rate for Payer: University Health Alliance Commercial	$1,968.96

PLATE LCP 5H 3.5X70MM 245.051

Facility

$2,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,229.76
Max. Negotiated Rate	$2,130.12
Rate for Payer: Cash Price	$1,317.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,537.20
Rate for Payer: Health Management Network Commercial	$1,866.60
Rate for Payer: MDX Hawaii PPO	$2,130.12
Rate for Payer: University Health Alliance Commercial	$1,229.76

PLATE LCP 5H 3.5X70MM 245.051

Facility

$2,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.96
Max. Negotiated Rate	$2,130.12
Rate for Payer: Cash Price	$1,317.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,537.20
Rate for Payer: Health Management Network Commercial	$1,866.60
Rate for Payer: Kaiser Permanente Commercial	$1,383.48
Rate for Payer: Kaiser Permanente Medicaid	$1,119.96
Rate for Payer: MDX Hawaii PPO	$2,130.12
Rate for Payer: University Health Alliance Commercial	$1,229.76

PLATE LCP 5H 3.5X72MM 223.551

Facility

$1,512.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$846.72
Max. Negotiated Rate	$1,466.64
Rate for Payer: Cash Price	$907.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,058.40
Rate for Payer: Health Management Network Commercial	$1,285.20
Rate for Payer: MDX Hawaii PPO	$1,466.64
Rate for Payer: University Health Alliance Commercial	$846.72

PLATE LCP 5H 3.5X72MM 223.551

Facility

$1,512.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$771.12
Max. Negotiated Rate	$1,466.64
Rate for Payer: Cash Price	$907.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,058.40
Rate for Payer: Health Management Network Commercial	$1,285.20
Rate for Payer: Kaiser Permanente Commercial	$952.56
Rate for Payer: Kaiser Permanente Medicaid	$771.12
Rate for Payer: MDX Hawaii PPO	$1,466.64
Rate for Payer: University Health Alliance Commercial	$846.72

PLATE LCP 5H 4.5X98MM 224.551

Facility

$1,635.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$915.60
Max. Negotiated Rate	$1,585.95
Rate for Payer: Cash Price	$981.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,144.50
Rate for Payer: Health Management Network Commercial	$1,389.75
Rate for Payer: MDX Hawaii PPO	$1,585.95
Rate for Payer: University Health Alliance Commercial	$915.60

PLATE LCP 5H 4.5X98MM 224.551

Facility

$1,635.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$833.85
Max. Negotiated Rate	$1,585.95
Rate for Payer: Cash Price	$981.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,144.50
Rate for Payer: Health Management Network Commercial	$1,389.75
Rate for Payer: Kaiser Permanente Commercial	$1,030.05
Rate for Payer: Kaiser Permanente Medicaid	$833.85
Rate for Payer: MDX Hawaii PPO	$1,585.95
Rate for Payer: University Health Alliance Commercial	$915.60

PLATE LCP 6H 1/3T 69MM 241.361

Facility

$743.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$378.93
Max. Negotiated Rate	$720.71
Rate for Payer: Cash Price	$445.80
Rate for Payer: Hawaii Western Management Group Commercial	$520.10
Rate for Payer: Health Management Network Commercial	$631.55
Rate for Payer: Kaiser Permanente Commercial	$468.09
Rate for Payer: Kaiser Permanente Medicaid	$378.93
Rate for Payer: MDX Hawaii PPO	$720.71
Rate for Payer: University Health Alliance Commercial	$416.08

PLATE LCP 6H 1/3T 69MM 241.361

Facility

$743.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$416.08
Max. Negotiated Rate	$720.71
Rate for Payer: Cash Price	$445.80
Rate for Payer: Hawaii Western Management Group Commercial	$520.10
Rate for Payer: Health Management Network Commercial	$631.55
Rate for Payer: MDX Hawaii PPO	$720.71
Rate for Payer: University Health Alliance Commercial	$416.08

PLATE LCP 6H 145MM 02.111.681S

Facility

$4,333.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,209.83
Max. Negotiated Rate	$4,203.01
Rate for Payer: Cash Price	$2,599.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,033.10
Rate for Payer: Health Management Network Commercial	$3,683.05
Rate for Payer: Kaiser Permanente Commercial	$2,729.79
Rate for Payer: Kaiser Permanente Medicaid	$2,209.83
Rate for Payer: MDX Hawaii PPO	$4,203.01
Rate for Payer: University Health Alliance Commercial	$2,426.48

PLATE LCP 6H 145MM 02.111.681S

Facility

$4,333.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,426.48
Max. Negotiated Rate	$4,203.01
Rate for Payer: Cash Price	$2,599.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,033.10
Rate for Payer: Health Management Network Commercial	$3,683.05
Rate for Payer: MDX Hawaii PPO	$4,203.01
Rate for Payer: University Health Alliance Commercial	$2,426.48

PLATE LCP 6H 3.5X107MM 239.936

Facility

$3,342.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,871.52
Max. Negotiated Rate	$3,241.74
Rate for Payer: Cash Price	$2,005.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,339.40
Rate for Payer: Health Management Network Commercial	$2,840.70
Rate for Payer: MDX Hawaii PPO	$3,241.74
Rate for Payer: University Health Alliance Commercial	$1,871.52

PLATE LCP 6H 3.5X107MM 239.936

Facility

$3,342.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,704.42
Max. Negotiated Rate	$3,241.74
Rate for Payer: Cash Price	$2,005.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,339.40
Rate for Payer: Health Management Network Commercial	$2,840.70
Rate for Payer: Kaiser Permanente Commercial	$2,105.46
Rate for Payer: Kaiser Permanente Medicaid	$1,704.42
Rate for Payer: MDX Hawaii PPO	$3,241.74
Rate for Payer: University Health Alliance Commercial	$1,871.52

PLATE LCP 6H 3.5X107MM 239.937

Facility

$3,342.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,704.42
Max. Negotiated Rate	$3,241.74
Rate for Payer: Cash Price	$2,005.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,339.40
Rate for Payer: Health Management Network Commercial	$2,840.70
Rate for Payer: Kaiser Permanente Commercial	$2,105.46
Rate for Payer: Kaiser Permanente Medicaid	$1,704.42
Rate for Payer: MDX Hawaii PPO	$3,241.74
Rate for Payer: University Health Alliance Commercial	$1,871.52

PLATE LCP 6H 3.5X107MM 239.937

Facility

$3,342.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,871.52
Max. Negotiated Rate	$3,241.74
Rate for Payer: Cash Price	$2,005.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,339.40
Rate for Payer: Health Management Network Commercial	$2,840.70
Rate for Payer: MDX Hawaii PPO	$3,241.74
Rate for Payer: University Health Alliance Commercial	$1,871.52

PLATE LCP 6H 3.5X84MM 245.061

Facility

$1,751.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$893.01
Max. Negotiated Rate	$1,698.47
Rate for Payer: Cash Price	$1,050.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,225.70
Rate for Payer: Health Management Network Commercial	$1,488.35
Rate for Payer: Kaiser Permanente Commercial	$1,103.13
Rate for Payer: Kaiser Permanente Medicaid	$893.01
Rate for Payer: MDX Hawaii PPO	$1,698.47
Rate for Payer: University Health Alliance Commercial	$980.56

Know your out-of-pocket cost for care.

All Charges