Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP FIB-L 6H 02.118.407

Facility

$2,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,030.20
Max. Negotiated Rate	$1,959.40
Rate for Payer: Cash Price	$1,212.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,414.00
Rate for Payer: Health Management Network Commercial	$1,717.00
Rate for Payer: Kaiser Permanente Commercial	$1,272.60
Rate for Payer: Kaiser Permanente Medicaid	$1,030.20
Rate for Payer: MDX Hawaii PPO	$1,959.40
Rate for Payer: University Health Alliance Commercial	$1,131.20

PLATE LCP FIB-L 7H 02.118.409

Facility

$2,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,079.16
Max. Negotiated Rate	$2,052.52
Rate for Payer: Cash Price	$1,269.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,481.20
Rate for Payer: Health Management Network Commercial	$1,798.60
Rate for Payer: Kaiser Permanente Commercial	$1,333.08
Rate for Payer: Kaiser Permanente Medicaid	$1,079.16
Rate for Payer: MDX Hawaii PPO	$2,052.52
Rate for Payer: University Health Alliance Commercial	$1,184.96

PLATE LCP FIB-L 7H 02.118.409

Facility

$2,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,184.96
Max. Negotiated Rate	$2,052.52
Rate for Payer: Cash Price	$1,269.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,481.20
Rate for Payer: Health Management Network Commercial	$1,798.60
Rate for Payer: MDX Hawaii PPO	$2,052.52
Rate for Payer: University Health Alliance Commercial	$1,184.96

PLATE LCP FIB-L 9H 02.118.411

Facility

$2,996.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,677.76
Max. Negotiated Rate	$2,906.12
Rate for Payer: Cash Price	$1,797.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,097.20
Rate for Payer: Health Management Network Commercial	$2,546.60
Rate for Payer: MDX Hawaii PPO	$2,906.12
Rate for Payer: University Health Alliance Commercial	$1,677.76

PLATE LCP FIB-L 9H 02.118.411

Facility

$2,996.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,527.96
Max. Negotiated Rate	$2,906.12
Rate for Payer: Cash Price	$1,797.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,097.20
Rate for Payer: Health Management Network Commercial	$2,546.60
Rate for Payer: Kaiser Permanente Commercial	$1,887.48
Rate for Payer: Kaiser Permanente Medicaid	$1,527.96
Rate for Payer: MDX Hawaii PPO	$2,906.12
Rate for Payer: University Health Alliance Commercial	$1,677.76

PLATE LCP FIB-R 11H 02.118.412

Facility

$3,140.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,758.40
Max. Negotiated Rate	$3,045.80
Rate for Payer: Cash Price	$1,884.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,198.00
Rate for Payer: Health Management Network Commercial	$2,669.00
Rate for Payer: MDX Hawaii PPO	$3,045.80
Rate for Payer: University Health Alliance Commercial	$1,758.40

PLATE LCP FIB-R 11H 02.118.412

Facility

$3,140.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,601.40
Max. Negotiated Rate	$3,045.80
Rate for Payer: Cash Price	$1,884.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,198.00
Rate for Payer: Health Management Network Commercial	$2,669.00
Rate for Payer: Kaiser Permanente Commercial	$1,978.20
Rate for Payer: Kaiser Permanente Medicaid	$1,601.40
Rate for Payer: MDX Hawaii PPO	$3,045.80
Rate for Payer: University Health Alliance Commercial	$1,758.40

PLATE LCP FIB-R 13H 02.118.414

Facility

$3,378.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,891.68
Max. Negotiated Rate	$3,276.66
Rate for Payer: Cash Price	$2,026.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,364.60
Rate for Payer: Health Management Network Commercial	$2,871.30
Rate for Payer: MDX Hawaii PPO	$3,276.66
Rate for Payer: University Health Alliance Commercial	$1,891.68

PLATE LCP FIB-R 13H 02.118.414

Facility

$3,378.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,722.78
Max. Negotiated Rate	$3,276.66
Rate for Payer: Cash Price	$2,026.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,364.60
Rate for Payer: Health Management Network Commercial	$2,871.30
Rate for Payer: Kaiser Permanente Commercial	$2,128.14
Rate for Payer: Kaiser Permanente Medicaid	$1,722.78
Rate for Payer: MDX Hawaii PPO	$3,276.66
Rate for Payer: University Health Alliance Commercial	$1,891.68

PLATE LCP FIB-R 3H 02.118.400

Facility

$2,629.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,472.24
Max. Negotiated Rate	$2,550.13
Rate for Payer: Cash Price	$1,577.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,840.30
Rate for Payer: Health Management Network Commercial	$2,234.65
Rate for Payer: MDX Hawaii PPO	$2,550.13
Rate for Payer: University Health Alliance Commercial	$1,472.24

PLATE LCP FIB-R 3H 02.118.400

Facility

$2,629.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,340.79
Max. Negotiated Rate	$2,550.13
Rate for Payer: Cash Price	$1,577.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,840.30
Rate for Payer: Health Management Network Commercial	$2,234.65
Rate for Payer: Kaiser Permanente Commercial	$1,656.27
Rate for Payer: Kaiser Permanente Medicaid	$1,340.79
Rate for Payer: MDX Hawaii PPO	$2,550.13
Rate for Payer: University Health Alliance Commercial	$1,472.24

PLATE LCP FIB-R 4H 02.118.402

Facility

$2,747.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,538.32
Max. Negotiated Rate	$2,664.59
Rate for Payer: Cash Price	$1,648.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,922.90
Rate for Payer: Health Management Network Commercial	$2,334.95
Rate for Payer: MDX Hawaii PPO	$2,664.59
Rate for Payer: University Health Alliance Commercial	$1,538.32

PLATE LCP FIB-R 4H 02.118.402

Facility

$2,747.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,400.97
Max. Negotiated Rate	$2,664.59
Rate for Payer: Cash Price	$1,648.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,922.90
Rate for Payer: Health Management Network Commercial	$2,334.95
Rate for Payer: Kaiser Permanente Commercial	$1,730.61
Rate for Payer: Kaiser Permanente Medicaid	$1,400.97
Rate for Payer: MDX Hawaii PPO	$2,664.59
Rate for Payer: University Health Alliance Commercial	$1,538.32

PLATE LCP FIB-R 5H 02.118.404

Facility

$2,886.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,616.16
Max. Negotiated Rate	$2,799.42
Rate for Payer: Cash Price	$1,731.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,020.20
Rate for Payer: Health Management Network Commercial	$2,453.10
Rate for Payer: MDX Hawaii PPO	$2,799.42
Rate for Payer: University Health Alliance Commercial	$1,616.16

PLATE LCP FIB-R 5H 02.118.404

Facility

$2,886.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,471.86
Max. Negotiated Rate	$2,799.42
Rate for Payer: Cash Price	$1,731.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,020.20
Rate for Payer: Health Management Network Commercial	$2,453.10
Rate for Payer: Kaiser Permanente Commercial	$1,818.18
Rate for Payer: Kaiser Permanente Medicaid	$1,471.86
Rate for Payer: MDX Hawaii PPO	$2,799.42
Rate for Payer: University Health Alliance Commercial	$1,616.16

PLATE LCP FIB-R 6H 02.118.406

Facility

$2,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,131.20
Max. Negotiated Rate	$1,959.40
Rate for Payer: Cash Price	$1,212.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,414.00
Rate for Payer: Health Management Network Commercial	$1,717.00
Rate for Payer: MDX Hawaii PPO	$1,959.40
Rate for Payer: University Health Alliance Commercial	$1,131.20

PLATE LCP FIB-R 6H 02.118.406

Facility

$2,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,030.20
Max. Negotiated Rate	$1,959.40
Rate for Payer: Cash Price	$1,212.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,414.00
Rate for Payer: Health Management Network Commercial	$1,717.00
Rate for Payer: Kaiser Permanente Commercial	$1,272.60
Rate for Payer: Kaiser Permanente Medicaid	$1,030.20
Rate for Payer: MDX Hawaii PPO	$1,959.40
Rate for Payer: University Health Alliance Commercial	$1,131.20

PLATE LCP FIB-R 7H 02.118.408

Facility

$2,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,184.96
Max. Negotiated Rate	$2,052.52
Rate for Payer: Cash Price	$1,269.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,481.20
Rate for Payer: Health Management Network Commercial	$1,798.60
Rate for Payer: MDX Hawaii PPO	$2,052.52
Rate for Payer: University Health Alliance Commercial	$1,184.96

PLATE LCP FIB-R 7H 02.118.408

Facility

$2,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,079.16
Max. Negotiated Rate	$2,052.52
Rate for Payer: Cash Price	$1,269.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,481.20
Rate for Payer: Health Management Network Commercial	$1,798.60
Rate for Payer: Kaiser Permanente Commercial	$1,333.08
Rate for Payer: Kaiser Permanente Medicaid	$1,079.16
Rate for Payer: MDX Hawaii PPO	$2,052.52
Rate for Payer: University Health Alliance Commercial	$1,184.96

PLATE LCP-LT 10H 4.5MM 222.661

Facility

$3,709.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,891.59
Max. Negotiated Rate	$3,597.73
Rate for Payer: Cash Price	$2,225.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,596.30
Rate for Payer: Health Management Network Commercial	$3,152.65
Rate for Payer: Kaiser Permanente Commercial	$2,336.67
Rate for Payer: Kaiser Permanente Medicaid	$1,891.59
Rate for Payer: MDX Hawaii PPO	$3,597.73
Rate for Payer: University Health Alliance Commercial	$2,077.04

PLATE LCP-LT 10H 4.5MM 222.661

Facility

$3,709.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,077.04
Max. Negotiated Rate	$3,597.73
Rate for Payer: Cash Price	$2,225.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,596.30
Rate for Payer: Health Management Network Commercial	$3,152.65
Rate for Payer: MDX Hawaii PPO	$3,597.73
Rate for Payer: University Health Alliance Commercial	$2,077.04

PLATE LCP-LT 10H 4.5MM 240.043

Facility

$4,328.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,423.68
Max. Negotiated Rate	$4,198.16
Rate for Payer: Cash Price	$2,596.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,029.60
Rate for Payer: Health Management Network Commercial	$3,678.80
Rate for Payer: MDX Hawaii PPO	$4,198.16
Rate for Payer: University Health Alliance Commercial	$2,423.68

PLATE LCP-LT 10H 4.5MM 240.043

Facility

$4,328.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,207.28
Max. Negotiated Rate	$4,198.16
Rate for Payer: Cash Price	$2,596.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,029.60
Rate for Payer: Health Management Network Commercial	$3,678.80
Rate for Payer: Kaiser Permanente Commercial	$2,726.64
Rate for Payer: Kaiser Permanente Medicaid	$2,207.28
Rate for Payer: MDX Hawaii PPO	$4,198.16
Rate for Payer: University Health Alliance Commercial	$2,423.68

PLATE LCP-LT 12H 4.5MM 222.663

Facility

$5,221.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,662.71
Max. Negotiated Rate	$5,064.37
Rate for Payer: Cash Price	$3,132.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,654.70
Rate for Payer: Health Management Network Commercial	$4,437.85
Rate for Payer: Kaiser Permanente Commercial	$3,289.23
Rate for Payer: Kaiser Permanente Medicaid	$2,662.71
Rate for Payer: MDX Hawaii PPO	$5,064.37
Rate for Payer: University Health Alliance Commercial	$2,923.76

PLATE LCP-LT 12H 4.5MM 222.663

Facility

$5,221.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,923.76
Max. Negotiated Rate	$5,064.37
Rate for Payer: Cash Price	$3,132.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,654.70
Rate for Payer: Health Management Network Commercial	$4,437.85
Rate for Payer: MDX Hawaii PPO	$5,064.37
Rate for Payer: University Health Alliance Commercial	$2,923.76

Know your out-of-pocket cost for care.

All Charges