Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP 6H 3.5X84MM 245.061

Facility

$1,751.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$980.56
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: MDX Hawaii PPO	$1,698.47
Rate for Payer: University Health Alliance Commercial	$980.56

PLATE LCP 6H 3.5X85MM 223.561

Facility

$1,280.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$652.80
Max. Negotiated Rate	$1,241.60
Rate for Payer: Cash Price	$768.00
Rate for Payer: Hawaii Western Management Group Commercial	$896.00
Rate for Payer: Health Management Network Commercial	$1,088.00
Rate for Payer: Kaiser Permanente Commercial	$806.40
Rate for Payer: Kaiser Permanente Medicaid	$652.80
Rate for Payer: MDX Hawaii PPO	$1,241.60
Rate for Payer: University Health Alliance Commercial	$716.80

PLATE LCP 6H 3.5X85MM 223.561

Facility

$1,280.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$716.80
Max. Negotiated Rate	$1,241.60
Rate for Payer: Cash Price	$768.00
Rate for Payer: Hawaii Western Management Group Commercial	$896.00
Rate for Payer: Health Management Network Commercial	$1,088.00
Rate for Payer: MDX Hawaii PPO	$1,241.60
Rate for Payer: University Health Alliance Commercial	$716.80

PLATE LCP 6H 4.5X116MM 224.561

Facility

$1,731.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$882.81
Max. Negotiated Rate	$1,679.07
Rate for Payer: Cash Price	$1,038.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,211.70
Rate for Payer: Health Management Network Commercial	$1,471.35
Rate for Payer: Kaiser Permanente Commercial	$1,090.53
Rate for Payer: Kaiser Permanente Medicaid	$882.81
Rate for Payer: MDX Hawaii PPO	$1,679.07
Rate for Payer: University Health Alliance Commercial	$969.36

PLATE LCP 6H 4.5X116MM 224.561

Facility

$1,731.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$969.36
Max. Negotiated Rate	$1,679.07
Rate for Payer: Cash Price	$1,038.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,211.70
Rate for Payer: Health Management Network Commercial	$1,471.35
Rate for Payer: MDX Hawaii PPO	$1,679.07
Rate for Payer: University Health Alliance Commercial	$969.36

PLATE LCP 6H 4.5X116MM 226.561

Facility

$1,848.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$942.48
Max. Negotiated Rate	$1,792.56
Rate for Payer: Cash Price	$1,108.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,293.60
Rate for Payer: Health Management Network Commercial	$1,570.80
Rate for Payer: Kaiser Permanente Commercial	$1,164.24
Rate for Payer: Kaiser Permanente Medicaid	$942.48
Rate for Payer: MDX Hawaii PPO	$1,792.56
Rate for Payer: University Health Alliance Commercial	$1,034.88

PLATE LCP 6H 4.5X116MM 226.561

Facility

$1,848.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,034.88
Max. Negotiated Rate	$1,792.56
Rate for Payer: Cash Price	$1,108.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,293.60
Rate for Payer: Health Management Network Commercial	$1,570.80
Rate for Payer: MDX Hawaii PPO	$1,792.56
Rate for Payer: University Health Alliance Commercial	$1,034.88

PLATE LCP 6H 4.5X118MM 240.038

Facility

$3,751.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,100.56
Max. Negotiated Rate	$3,638.47
Rate for Payer: Cash Price	$2,250.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.70
Rate for Payer: Health Management Network Commercial	$3,188.35
Rate for Payer: MDX Hawaii PPO	$3,638.47
Rate for Payer: University Health Alliance Commercial	$2,100.56

PLATE LCP 6H 4.5X118MM 240.038

Facility

$3,751.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,913.01
Max. Negotiated Rate	$3,638.47
Rate for Payer: Cash Price	$2,250.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.70
Rate for Payer: Health Management Network Commercial	$3,188.35
Rate for Payer: Kaiser Permanente Commercial	$2,363.13
Rate for Payer: Kaiser Permanente Medicaid	$1,913.01
Rate for Payer: MDX Hawaii PPO	$3,638.47
Rate for Payer: University Health Alliance Commercial	$2,100.56

PLATE LCP 6H 4.5X118MM 240.039

Facility

$3,751.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,913.01
Max. Negotiated Rate	$3,638.47
Rate for Payer: Cash Price	$2,250.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.70
Rate for Payer: Health Management Network Commercial	$3,188.35
Rate for Payer: Kaiser Permanente Commercial	$2,363.13
Rate for Payer: Kaiser Permanente Medicaid	$1,913.01
Rate for Payer: MDX Hawaii PPO	$3,638.47
Rate for Payer: University Health Alliance Commercial	$2,100.56

PLATE LCP 6H 4.5X118MM 240.039

Facility

$3,751.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,100.56
Max. Negotiated Rate	$3,638.47
Rate for Payer: Cash Price	$2,250.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,625.70
Rate for Payer: Health Management Network Commercial	$3,188.35
Rate for Payer: MDX Hawaii PPO	$3,638.47
Rate for Payer: University Health Alliance Commercial	$2,100.56

PLATE LCP 7H 1/3T 81MM 241.371

Facility

$756.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$423.36
Max. Negotiated Rate	$733.32
Rate for Payer: Cash Price	$453.60
Rate for Payer: Hawaii Western Management Group Commercial	$529.20
Rate for Payer: Health Management Network Commercial	$642.60
Rate for Payer: MDX Hawaii PPO	$733.32
Rate for Payer: University Health Alliance Commercial	$423.36

PLATE LCP 7H 1/3T 81MM 241.371

Facility

$756.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$385.56
Max. Negotiated Rate	$733.32
Rate for Payer: Cash Price	$453.60
Rate for Payer: Hawaii Western Management Group Commercial	$529.20
Rate for Payer: Health Management Network Commercial	$642.60
Rate for Payer: Kaiser Permanente Commercial	$476.28
Rate for Payer: Kaiser Permanente Medicaid	$385.56
Rate for Payer: MDX Hawaii PPO	$733.32
Rate for Payer: University Health Alliance Commercial	$423.36

PLATE LCP 7H 3.5X98MM 223.571

Facility

$1,328.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$743.68
Max. Negotiated Rate	$1,288.16
Rate for Payer: Cash Price	$796.80
Rate for Payer: Hawaii Western Management Group Commercial	$929.60
Rate for Payer: Health Management Network Commercial	$1,128.80
Rate for Payer: MDX Hawaii PPO	$1,288.16
Rate for Payer: University Health Alliance Commercial	$743.68

PLATE LCP 7H 3.5X98MM 223.571

Facility

$1,328.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$677.28
Max. Negotiated Rate	$1,288.16
Rate for Payer: Cash Price	$796.80
Rate for Payer: Hawaii Western Management Group Commercial	$929.60
Rate for Payer: Health Management Network Commercial	$1,128.80
Rate for Payer: Kaiser Permanente Commercial	$836.64
Rate for Payer: Kaiser Permanente Medicaid	$677.28
Rate for Payer: MDX Hawaii PPO	$1,288.16
Rate for Payer: University Health Alliance Commercial	$743.68

PLATE LCP 7H 3.5X98MM 245.071

Facility

$1,836.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,028.16
Max. Negotiated Rate	$1,780.92
Rate for Payer: Cash Price	$1,101.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,285.20
Rate for Payer: Health Management Network Commercial	$1,560.60
Rate for Payer: MDX Hawaii PPO	$1,780.92
Rate for Payer: University Health Alliance Commercial	$1,028.16

PLATE LCP 7H 3.5X98MM 245.071

Facility

$1,836.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$936.36
Max. Negotiated Rate	$1,780.92
Rate for Payer: Cash Price	$1,101.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,285.20
Rate for Payer: Health Management Network Commercial	$1,560.60
Rate for Payer: Kaiser Permanente Commercial	$1,156.68
Rate for Payer: Kaiser Permanente Medicaid	$936.36
Rate for Payer: MDX Hawaii PPO	$1,780.92
Rate for Payer: University Health Alliance Commercial	$1,028.16

PLATE LCP 7H 4.5X134MM 224.571

Facility

$2,004.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,122.24
Max. Negotiated Rate	$1,943.88
Rate for Payer: Cash Price	$1,202.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,402.80
Rate for Payer: Health Management Network Commercial	$1,703.40
Rate for Payer: MDX Hawaii PPO	$1,943.88
Rate for Payer: University Health Alliance Commercial	$1,122.24

PLATE LCP 7H 4.5X134MM 224.571

Facility

$2,004.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,022.04
Max. Negotiated Rate	$1,943.88
Rate for Payer: Cash Price	$1,202.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,402.80
Rate for Payer: Health Management Network Commercial	$1,703.40
Rate for Payer: Kaiser Permanente Commercial	$1,262.52
Rate for Payer: Kaiser Permanente Medicaid	$1,022.04
Rate for Payer: MDX Hawaii PPO	$1,943.88
Rate for Payer: University Health Alliance Commercial	$1,122.24

PLATE LCP 7H 4.5X134MM 226.571

Facility

$1,962.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,000.62
Max. Negotiated Rate	$1,903.14
Rate for Payer: Cash Price	$1,177.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,373.40
Rate for Payer: Health Management Network Commercial	$1,667.70
Rate for Payer: Kaiser Permanente Commercial	$1,236.06
Rate for Payer: Kaiser Permanente Medicaid	$1,000.62
Rate for Payer: MDX Hawaii PPO	$1,903.14
Rate for Payer: University Health Alliance Commercial	$1,098.72

PLATE LCP 7H 4.5X134MM 226.571

Facility

$1,962.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,098.72
Max. Negotiated Rate	$1,903.14
Rate for Payer: Cash Price	$1,177.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,373.40
Rate for Payer: Health Management Network Commercial	$1,667.70
Rate for Payer: MDX Hawaii PPO	$1,903.14
Rate for Payer: University Health Alliance Commercial	$1,098.72

PLATE LCP 8H 1/3T 93MM 241.381

Facility

$800.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$408.00
Max. Negotiated Rate	$776.00
Rate for Payer: Cash Price	$480.00
Rate for Payer: Hawaii Western Management Group Commercial	$560.00
Rate for Payer: Health Management Network Commercial	$680.00
Rate for Payer: Kaiser Permanente Commercial	$504.00
Rate for Payer: Kaiser Permanente Medicaid	$408.00
Rate for Payer: MDX Hawaii PPO	$776.00
Rate for Payer: University Health Alliance Commercial	$448.00

PLATE LCP 8H 1/3T 93MM 241.381

Facility

$800.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$448.00
Max. Negotiated Rate	$776.00
Rate for Payer: Cash Price	$480.00
Rate for Payer: Hawaii Western Management Group Commercial	$560.00
Rate for Payer: Health Management Network Commercial	$680.00
Rate for Payer: MDX Hawaii PPO	$776.00
Rate for Payer: University Health Alliance Commercial	$448.00

PLATE LCP 8H 3.5X111MM 223.581

Facility

$1,396.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$781.76
Max. Negotiated Rate	$1,354.12
Rate for Payer: Cash Price	$837.60
Rate for Payer: Hawaii Western Management Group Commercial	$977.20
Rate for Payer: Health Management Network Commercial	$1,186.60
Rate for Payer: MDX Hawaii PPO	$1,354.12
Rate for Payer: University Health Alliance Commercial	$781.76

PLATE LCP 8H 3.5X111MM 223.581

Facility

$1,396.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$711.96
Max. Negotiated Rate	$1,354.12
Rate for Payer: Cash Price	$837.60
Rate for Payer: Hawaii Western Management Group Commercial	$977.20
Rate for Payer: Health Management Network Commercial	$1,186.60
Rate for Payer: Kaiser Permanente Commercial	$879.48
Rate for Payer: Kaiser Permanente Medicaid	$711.96
Rate for Payer: MDX Hawaii PPO	$1,354.12
Rate for Payer: University Health Alliance Commercial	$781.76

Know your out-of-pocket cost for care.

All Charges