Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP-RT 14H 4.5MM 222.664

Facility

$5,147.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,624.97
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: Kaiser Permanente Commercial	$3,242.61
Rate for Payer: Kaiser Permanente Medicaid	$2,624.97
Rate for Payer: MDX Hawaii PPO	$4,992.59
Rate for Payer: University Health Alliance Commercial	$2,882.32

PLATE LCP-RT 14H 4.5MM 240.046

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-RT 14H 4.5MM 240.046

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-RT 16H 4.5MM 222.666

Facility

$5,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,940.00
Max. Negotiated Rate	$5,092.50
Rate for Payer: Cash Price	$3,150.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,675.00
Rate for Payer: Health Management Network Commercial	$4,462.50
Rate for Payer: MDX Hawaii PPO	$5,092.50
Rate for Payer: University Health Alliance Commercial	$2,940.00

PLATE LCP-RT 16H 4.5MM 222.666

Facility

$5,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,677.50
Max. Negotiated Rate	$5,092.50
Rate for Payer: Cash Price	$3,150.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,675.00
Rate for Payer: Health Management Network Commercial	$4,462.50
Rate for Payer: Kaiser Permanente Commercial	$3,307.50
Rate for Payer: Kaiser Permanente Medicaid	$2,677.50
Rate for Payer: MDX Hawaii PPO	$5,092.50
Rate for Payer: University Health Alliance Commercial	$2,940.00

PLATE LCP-RT 18H 4.5MM 222.668

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-RT 18H 4.5MM 222.668

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-RT 8H 4.5MM 240.040

Facility

$4,584.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,567.04
Max. Negotiated Rate	$4,446.48
Rate for Payer: Cash Price	$2,750.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,208.80
Rate for Payer: Health Management Network Commercial	$3,896.40
Rate for Payer: MDX Hawaii PPO	$4,446.48
Rate for Payer: University Health Alliance Commercial	$2,567.04

PLATE LCP-RT 8H 4.5MM 240.040

Facility

$4,584.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,337.84
Max. Negotiated Rate	$4,446.48
Rate for Payer: Cash Price	$2,750.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,208.80
Rate for Payer: Health Management Network Commercial	$3,896.40
Rate for Payer: Kaiser Permanente Commercial	$2,887.92
Rate for Payer: Kaiser Permanente Medicaid	$2,337.84
Rate for Payer: MDX Hawaii PPO	$4,446.48
Rate for Payer: University Health Alliance Commercial	$2,567.04

PLATE LCP TIB-L 10H 02.118.009

Facility

$4,478.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,283.78
Max. Negotiated Rate	$4,343.66
Rate for Payer: Cash Price	$2,686.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,134.60
Rate for Payer: Health Management Network Commercial	$3,806.30
Rate for Payer: Kaiser Permanente Commercial	$2,821.14
Rate for Payer: Kaiser Permanente Medicaid	$2,283.78
Rate for Payer: MDX Hawaii PPO	$4,343.66
Rate for Payer: University Health Alliance Commercial	$2,507.68

PLATE LCP TIB-L 10H 02.118.009

Facility

$4,478.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,507.68
Max. Negotiated Rate	$4,343.66
Rate for Payer: Cash Price	$2,686.80
Rate for Payer: Hawaii Western Management Group Commercial	$3,134.60
Rate for Payer: Health Management Network Commercial	$3,806.30
Rate for Payer: MDX Hawaii PPO	$4,343.66
Rate for Payer: University Health Alliance Commercial	$2,507.68

PLATE LCP TIB-L 10H 02.118.209

Facility

$4,764.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,429.64
Max. Negotiated Rate	$4,621.08
Rate for Payer: Cash Price	$2,858.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,334.80
Rate for Payer: Health Management Network Commercial	$4,049.40
Rate for Payer: Kaiser Permanente Commercial	$3,001.32
Rate for Payer: Kaiser Permanente Medicaid	$2,429.64
Rate for Payer: MDX Hawaii PPO	$4,621.08
Rate for Payer: University Health Alliance Commercial	$2,667.84

PLATE LCP TIB-L 10H 02.118.209

Facility

$4,764.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,667.84
Max. Negotiated Rate	$4,621.08
Rate for Payer: Cash Price	$2,858.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,334.80
Rate for Payer: Health Management Network Commercial	$4,049.40
Rate for Payer: MDX Hawaii PPO	$4,621.08
Rate for Payer: University Health Alliance Commercial	$2,667.84

PLATE LCP TIB-L 12H 02.118.011

Facility

$5,226.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,665.26
Max. Negotiated Rate	$5,069.22
Rate for Payer: Cash Price	$3,135.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,658.20
Rate for Payer: Health Management Network Commercial	$4,442.10
Rate for Payer: Kaiser Permanente Commercial	$3,292.38
Rate for Payer: Kaiser Permanente Medicaid	$2,665.26
Rate for Payer: MDX Hawaii PPO	$5,069.22
Rate for Payer: University Health Alliance Commercial	$2,926.56

PLATE LCP TIB-L 12H 02.118.011

Facility

$5,226.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,926.56
Max. Negotiated Rate	$5,069.22
Rate for Payer: Cash Price	$3,135.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,658.20
Rate for Payer: Health Management Network Commercial	$4,442.10
Rate for Payer: MDX Hawaii PPO	$5,069.22
Rate for Payer: University Health Alliance Commercial	$2,926.56

PLATE LCP TIB-L 12H 02.118.211

Facility

$5,406.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,757.06
Max. Negotiated Rate	$5,243.82
Rate for Payer: Cash Price	$3,243.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,784.20
Rate for Payer: Health Management Network Commercial	$4,595.10
Rate for Payer: Kaiser Permanente Commercial	$3,405.78
Rate for Payer: Kaiser Permanente Medicaid	$2,757.06
Rate for Payer: MDX Hawaii PPO	$5,243.82
Rate for Payer: University Health Alliance Commercial	$3,027.36

PLATE LCP TIB-L 12H 02.118.211

Facility

$5,406.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,027.36
Max. Negotiated Rate	$5,243.82
Rate for Payer: Cash Price	$3,243.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,784.20
Rate for Payer: Health Management Network Commercial	$4,595.10
Rate for Payer: MDX Hawaii PPO	$5,243.82
Rate for Payer: University Health Alliance Commercial	$3,027.36

PLATE LCP TIB-L 14H 02.118.013

Facility

$5,828.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,263.68
Max. Negotiated Rate	$5,653.16
Rate for Payer: Cash Price	$3,496.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,079.60
Rate for Payer: Health Management Network Commercial	$4,953.80
Rate for Payer: MDX Hawaii PPO	$5,653.16
Rate for Payer: University Health Alliance Commercial	$3,263.68

PLATE LCP TIB-L 14H 02.118.013

Facility

$5,828.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,972.28
Max. Negotiated Rate	$5,653.16
Rate for Payer: Cash Price	$3,496.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,079.60
Rate for Payer: Health Management Network Commercial	$4,953.80
Rate for Payer: Kaiser Permanente Commercial	$3,671.64
Rate for Payer: Kaiser Permanente Medicaid	$2,972.28
Rate for Payer: MDX Hawaii PPO	$5,653.16
Rate for Payer: University Health Alliance Commercial	$3,263.68

PLATE LCP TIB-L 14H 02.118.213

Facility

$6,034.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,379.04
Max. Negotiated Rate	$5,852.98
Rate for Payer: Cash Price	$3,620.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,223.80
Rate for Payer: Health Management Network Commercial	$5,128.90
Rate for Payer: MDX Hawaii PPO	$5,852.98
Rate for Payer: University Health Alliance Commercial	$3,379.04

PLATE LCP TIB-L 14H 02.118.213

Facility

$6,034.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,077.34
Max. Negotiated Rate	$5,852.98
Rate for Payer: Cash Price	$3,620.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,223.80
Rate for Payer: Health Management Network Commercial	$5,128.90
Rate for Payer: Kaiser Permanente Commercial	$3,801.42
Rate for Payer: Kaiser Permanente Medicaid	$3,077.34
Rate for Payer: MDX Hawaii PPO	$5,852.98
Rate for Payer: University Health Alliance Commercial	$3,379.04

PLATE LCP TIB-L 16H 02.118.215

Facility

$6,370.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,567.20
Max. Negotiated Rate	$6,178.90
Rate for Payer: Cash Price	$3,822.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,459.00
Rate for Payer: Health Management Network Commercial	$5,414.50
Rate for Payer: MDX Hawaii PPO	$6,178.90
Rate for Payer: University Health Alliance Commercial	$3,567.20

PLATE LCP TIB-L 16H 02.118.215

Facility

$6,370.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,248.70
Max. Negotiated Rate	$6,178.90
Rate for Payer: Cash Price	$3,822.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,459.00
Rate for Payer: Health Management Network Commercial	$5,414.50
Rate for Payer: Kaiser Permanente Commercial	$4,013.10
Rate for Payer: Kaiser Permanente Medicaid	$3,248.70
Rate for Payer: MDX Hawaii PPO	$6,178.90
Rate for Payer: University Health Alliance Commercial	$3,567.20

PLATE LCP TIB-L 18H 02.118.217

Facility

$6,488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,633.28
Max. Negotiated Rate	$6,293.36
Rate for Payer: Cash Price	$3,892.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,541.60
Rate for Payer: Health Management Network Commercial	$5,514.80
Rate for Payer: MDX Hawaii PPO	$6,293.36
Rate for Payer: University Health Alliance Commercial	$3,633.28

PLATE LCP TIB-L 18H 02.118.217

Facility

$6,488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,308.88
Max. Negotiated Rate	$6,293.36
Rate for Payer: Cash Price	$3,892.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,541.60
Rate for Payer: Health Management Network Commercial	$5,514.80
Rate for Payer: Kaiser Permanente Commercial	$4,087.44
Rate for Payer: Kaiser Permanente Medicaid	$3,308.88
Rate for Payer: MDX Hawaii PPO	$6,293.36
Rate for Payer: University Health Alliance Commercial	$3,633.28

Know your out-of-pocket cost for care.

All Charges