Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP-LT 12H 4.5MM 240.045

Facility

$4,380.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,452.80
Max. Negotiated Rate	$4,248.60
Rate for Payer: Cash Price	$2,628.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,066.00
Rate for Payer: Health Management Network Commercial	$3,723.00
Rate for Payer: MDX Hawaii PPO	$4,248.60
Rate for Payer: University Health Alliance Commercial	$2,452.80

PLATE LCP-LT 12H 4.5MM 240.045

Facility

$4,380.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,233.80
Max. Negotiated Rate	$4,248.60
Rate for Payer: Cash Price	$2,628.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,066.00
Rate for Payer: Health Management Network Commercial	$3,723.00
Rate for Payer: Kaiser Permanente Commercial	$2,759.40
Rate for Payer: Kaiser Permanente Medicaid	$2,233.80
Rate for Payer: MDX Hawaii PPO	$4,248.60
Rate for Payer: University Health Alliance Commercial	$2,452.80

PLATE LCP-LT 14H 4.5MM 222.665

Facility

$5,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,882.88
Max. Negotiated Rate	$4,993.56
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: University Health Alliance Commercial	$2,882.88

PLATE LCP-LT 14H 4.5MM 222.665

Facility

$5,148.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,625.48
Max. Negotiated Rate	$4,993.56
Rate for Payer: Cash Price	$3,088.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,603.60
Rate for Payer: Health Management Network Commercial	$4,375.80
Rate for Payer: Kaiser Permanente Commercial	$3,243.24
Rate for Payer: Kaiser Permanente Medicaid	$2,625.48
Rate for Payer: MDX Hawaii PPO	$4,993.56
Rate for Payer: University Health Alliance Commercial	$2,882.88

PLATE LCP-LT 14H 4.5MM 240.047

Facility

$4,426.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,478.56
Max. Negotiated Rate	$4,293.22
Rate for Payer: Cash Price	$2,655.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,098.20
Rate for Payer: Health Management Network Commercial	$3,762.10
Rate for Payer: MDX Hawaii PPO	$4,293.22
Rate for Payer: University Health Alliance Commercial	$2,478.56

PLATE LCP-LT 14H 4.5MM 240.047

Facility

$4,426.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,257.26
Max. Negotiated Rate	$4,293.22
Rate for Payer: Cash Price	$2,655.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,098.20
Rate for Payer: Health Management Network Commercial	$3,762.10
Rate for Payer: Kaiser Permanente Commercial	$2,788.38
Rate for Payer: Kaiser Permanente Medicaid	$2,257.26
Rate for Payer: MDX Hawaii PPO	$4,293.22
Rate for Payer: University Health Alliance Commercial	$2,478.56

PLATE LCP-LT 16H 4.5MM 222.667

Facility

$4,031.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,257.36
Max. Negotiated Rate	$3,910.07
Rate for Payer: Cash Price	$2,418.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,821.70
Rate for Payer: Health Management Network Commercial	$3,426.35
Rate for Payer: MDX Hawaii PPO	$3,910.07
Rate for Payer: University Health Alliance Commercial	$2,257.36

PLATE LCP-LT 16H 4.5MM 222.667

Facility

$4,031.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$2,055.81
Max. Negotiated Rate	$3,910.07
Rate for Payer: Cash Price	$2,418.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,821.70
Rate for Payer: Health Management Network Commercial	$3,426.35
Rate for Payer: Kaiser Permanente Commercial	$2,539.53
Rate for Payer: Kaiser Permanente Medicaid	$2,055.81
Rate for Payer: MDX Hawaii PPO	$3,910.07
Rate for Payer: University Health Alliance Commercial	$2,257.36

PLATE LCP-LT 18H 4.5MM 222.669

Facility

$5,356.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,999.36
Max. Negotiated Rate	$5,195.32
Rate for Payer: Cash Price	$3,213.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,749.20
Rate for Payer: Health Management Network Commercial	$4,552.60
Rate for Payer: MDX Hawaii PPO	$5,195.32
Rate for Payer: University Health Alliance Commercial	$2,999.36

PLATE LCP-LT 18H 4.5MM 222.669

Facility

$5,356.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,731.56
Max. Negotiated Rate	$5,195.32
Rate for Payer: Cash Price	$3,213.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,749.20
Rate for Payer: Health Management Network Commercial	$4,552.60
Rate for Payer: Kaiser Permanente Commercial	$3,374.28
Rate for Payer: Kaiser Permanente Medicaid	$2,731.56
Rate for Payer: MDX Hawaii PPO	$5,195.32
Rate for Payer: University Health Alliance Commercial	$2,999.36

PLATE LCP-LT 8H 4.5MM 240.041

Facility

$4,284.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,399.04
Max. Negotiated Rate	$4,155.48
Rate for Payer: Cash Price	$2,570.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,998.80
Rate for Payer: Health Management Network Commercial	$3,641.40
Rate for Payer: MDX Hawaii PPO	$4,155.48
Rate for Payer: University Health Alliance Commercial	$2,399.04

PLATE LCP-LT 8H 4.5MM 240.041

Facility

$4,284.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,184.84
Max. Negotiated Rate	$4,155.48
Rate for Payer: Cash Price	$2,570.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,998.80
Rate for Payer: Health Management Network Commercial	$3,641.40
Rate for Payer: Kaiser Permanente Commercial	$2,698.92
Rate for Payer: Kaiser Permanente Medicaid	$2,184.84
Rate for Payer: MDX Hawaii PPO	$4,155.48
Rate for Payer: University Health Alliance Commercial	$2,399.04

PLATE LCP PERIART PROX 3.5

Facility

$4,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,073.66
Max. Negotiated Rate	$3,944.02
Rate for Payer: Cash Price	$2,439.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.20
Rate for Payer: Health Management Network Commercial	$3,456.10
Rate for Payer: Kaiser Permanente Commercial	$2,561.58
Rate for Payer: Kaiser Permanente Medicaid	$2,073.66
Rate for Payer: MDX Hawaii PPO	$3,944.02
Rate for Payer: University Health Alliance Commercial	$2,276.96

PLATE LCP PERIART PROX 3.5

Facility

$4,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,276.96
Max. Negotiated Rate	$3,944.02
Rate for Payer: Cash Price	$2,439.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,846.20
Rate for Payer: Health Management Network Commercial	$3,456.10
Rate for Payer: MDX Hawaii PPO	$3,944.02
Rate for Payer: University Health Alliance Commercial	$2,276.96

PLATE LCP PROXI TIB 3.5MM

Facility

$3,836.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,148.16
Max. Negotiated Rate	$3,720.92
Rate for Payer: Cash Price	$2,301.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,685.20
Rate for Payer: Health Management Network Commercial	$3,260.60
Rate for Payer: MDX Hawaii PPO	$3,720.92
Rate for Payer: University Health Alliance Commercial	$2,148.16

PLATE LCP PROXI TIB 3.5MM

Facility

$3,836.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,956.36
Max. Negotiated Rate	$3,720.92
Rate for Payer: Cash Price	$2,301.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,685.20
Rate for Payer: Health Management Network Commercial	$3,260.60
Rate for Payer: Kaiser Permanente Commercial	$2,416.68
Rate for Payer: Kaiser Permanente Medicaid	$1,956.36
Rate for Payer: MDX Hawaii PPO	$3,720.92
Rate for Payer: University Health Alliance Commercial	$2,148.16

PLATE LCP-RT 10H 4.5MM 222.660

Facility

$4,786.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,680.16
Max. Negotiated Rate	$4,642.42
Rate for Payer: Cash Price	$2,871.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,350.20
Rate for Payer: Health Management Network Commercial	$4,068.10
Rate for Payer: MDX Hawaii PPO	$4,642.42
Rate for Payer: University Health Alliance Commercial	$2,680.16

PLATE LCP-RT 10H 4.5MM 222.660

Facility

$4,786.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,440.86
Max. Negotiated Rate	$4,642.42
Rate for Payer: Cash Price	$2,871.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,350.20
Rate for Payer: Health Management Network Commercial	$4,068.10
Rate for Payer: Kaiser Permanente Commercial	$3,015.18
Rate for Payer: Kaiser Permanente Medicaid	$2,440.86
Rate for Payer: MDX Hawaii PPO	$4,642.42
Rate for Payer: University Health Alliance Commercial	$2,680.16

PLATE LCP-RT 10H 4.5MM 240.042

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-RT 10H 4.5MM 240.042

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-RT 12H 4.5MM 222.662

Facility

$3,748.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,098.88
Max. Negotiated Rate	$3,635.56
Rate for Payer: Cash Price	$2,248.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,623.60
Rate for Payer: Health Management Network Commercial	$3,185.80
Rate for Payer: MDX Hawaii PPO	$3,635.56
Rate for Payer: University Health Alliance Commercial	$2,098.88

PLATE LCP-RT 12H 4.5MM 222.662

Facility

$3,748.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,911.48
Max. Negotiated Rate	$3,635.56
Rate for Payer: Cash Price	$2,248.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,623.60
Rate for Payer: Health Management Network Commercial	$3,185.80
Rate for Payer: Kaiser Permanente Commercial	$2,361.24
Rate for Payer: Kaiser Permanente Medicaid	$1,911.48
Rate for Payer: MDX Hawaii PPO	$3,635.56
Rate for Payer: University Health Alliance Commercial	$2,098.88

PLATE LCP-RT 12H 4.5MM 240.044

Facility

$4,380.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,452.80
Max. Negotiated Rate	$4,248.60
Rate for Payer: Cash Price	$2,628.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,066.00
Rate for Payer: Health Management Network Commercial	$3,723.00
Rate for Payer: MDX Hawaii PPO	$4,248.60
Rate for Payer: University Health Alliance Commercial	$2,452.80

PLATE LCP-RT 12H 4.5MM 240.044

Facility

$4,380.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,233.80
Max. Negotiated Rate	$4,248.60
Rate for Payer: Cash Price	$2,628.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,066.00
Rate for Payer: Health Management Network Commercial	$3,723.00
Rate for Payer: Kaiser Permanente Commercial	$2,759.40
Rate for Payer: Kaiser Permanente Medicaid	$2,233.80
Rate for Payer: MDX Hawaii PPO	$4,248.60
Rate for Payer: University Health Alliance Commercial	$2,452.80

PLATE LCP-RT 14H 4.5MM 222.664

Facility

$5,147.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,882.32
Max. Negotiated Rate	$4,992.59
Rate for Payer: Cash Price	$3,088.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,602.90
Rate for Payer: Health Management Network Commercial	$4,374.95
Rate for Payer: MDX Hawaii PPO	$4,992.59
Rate for Payer: University Health Alliance Commercial	$2,882.32

Know your out-of-pocket cost for care.

All Charges