Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP TIB-L 4H 02.118.003

Facility

$4,644.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,368.44
Max. Negotiated Rate	$4,504.68
Rate for Payer: Cash Price	$2,786.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,250.80
Rate for Payer: Health Management Network Commercial	$3,947.40
Rate for Payer: Kaiser Permanente Commercial	$2,925.72
Rate for Payer: Kaiser Permanente Medicaid	$2,368.44
Rate for Payer: MDX Hawaii PPO	$4,504.68
Rate for Payer: University Health Alliance Commercial	$2,600.64

PLATE LCP TIB-L 4H 02.118.003

Facility

$4,644.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,600.64
Max. Negotiated Rate	$4,504.68
Rate for Payer: Cash Price	$2,786.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,250.80
Rate for Payer: Health Management Network Commercial	$3,947.40
Rate for Payer: MDX Hawaii PPO	$4,504.68
Rate for Payer: University Health Alliance Commercial	$2,600.64

PLATE LCP TIB-L 4H 02.118.203

Facility

$3,921.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,999.71
Max. Negotiated Rate	$3,803.37
Rate for Payer: Cash Price	$2,352.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,744.70
Rate for Payer: Health Management Network Commercial	$3,332.85
Rate for Payer: Kaiser Permanente Commercial	$2,470.23
Rate for Payer: Kaiser Permanente Medicaid	$1,999.71
Rate for Payer: MDX Hawaii PPO	$3,803.37
Rate for Payer: University Health Alliance Commercial	$2,195.76

PLATE LCP TIB-L 4H 02.118.203

Facility

$3,921.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,195.76
Max. Negotiated Rate	$3,803.37
Rate for Payer: Cash Price	$2,352.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,744.70
Rate for Payer: Health Management Network Commercial	$3,332.85
Rate for Payer: MDX Hawaii PPO	$3,803.37
Rate for Payer: University Health Alliance Commercial	$2,195.76

PLATE LCP TIB-L 6H 02.118.005

Facility

$3,726.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,086.56
Max. Negotiated Rate	$3,614.22
Rate for Payer: Cash Price	$2,235.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,608.20
Rate for Payer: Health Management Network Commercial	$3,167.10
Rate for Payer: MDX Hawaii PPO	$3,614.22
Rate for Payer: University Health Alliance Commercial	$2,086.56

PLATE LCP TIB-L 6H 02.118.005

Facility

$3,726.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,900.26
Max. Negotiated Rate	$3,614.22
Rate for Payer: Cash Price	$2,235.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,608.20
Rate for Payer: Health Management Network Commercial	$3,167.10
Rate for Payer: Kaiser Permanente Commercial	$2,347.38
Rate for Payer: Kaiser Permanente Medicaid	$1,900.26
Rate for Payer: MDX Hawaii PPO	$3,614.22
Rate for Payer: University Health Alliance Commercial	$2,086.56

PLATE LCP TIB-L 6H 02.118.205

Facility

$4,670.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,615.20
Max. Negotiated Rate	$4,529.90
Rate for Payer: Cash Price	$2,802.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,269.00
Rate for Payer: Health Management Network Commercial	$3,969.50
Rate for Payer: MDX Hawaii PPO	$4,529.90
Rate for Payer: University Health Alliance Commercial	$2,615.20

PLATE LCP TIB-L 6H 02.118.205

Facility

$4,670.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,381.70
Max. Negotiated Rate	$4,529.90
Rate for Payer: Cash Price	$2,802.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,269.00
Rate for Payer: Health Management Network Commercial	$3,969.50
Rate for Payer: Kaiser Permanente Commercial	$2,942.10
Rate for Payer: Kaiser Permanente Medicaid	$2,381.70
Rate for Payer: MDX Hawaii PPO	$4,529.90
Rate for Payer: University Health Alliance Commercial	$2,615.20

PLATE LCP TIB-L 8H 02.118.007

Facility

$4,432.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,481.92
Max. Negotiated Rate	$4,299.04
Rate for Payer: Cash Price	$2,659.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,102.40
Rate for Payer: Health Management Network Commercial	$3,767.20
Rate for Payer: MDX Hawaii PPO	$4,299.04
Rate for Payer: University Health Alliance Commercial	$2,481.92

PLATE LCP TIB-L 8H 02.118.007

Facility

$4,432.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,260.32
Max. Negotiated Rate	$4,299.04
Rate for Payer: Cash Price	$2,659.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,102.40
Rate for Payer: Health Management Network Commercial	$3,767.20
Rate for Payer: Kaiser Permanente Commercial	$2,792.16
Rate for Payer: Kaiser Permanente Medicaid	$2,260.32
Rate for Payer: MDX Hawaii PPO	$4,299.04
Rate for Payer: University Health Alliance Commercial	$2,481.92

PLATE LCP TIB-L 8H 02.118.207

Facility

$4,009.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,044.59
Max. Negotiated Rate	$3,888.73
Rate for Payer: Cash Price	$2,405.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,806.30
Rate for Payer: Health Management Network Commercial	$3,407.65
Rate for Payer: Kaiser Permanente Commercial	$2,525.67
Rate for Payer: Kaiser Permanente Medicaid	$2,044.59
Rate for Payer: MDX Hawaii PPO	$3,888.73
Rate for Payer: University Health Alliance Commercial	$2,245.04

PLATE LCP TIB-L 8H 02.118.207

Facility

$4,009.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,245.04
Max. Negotiated Rate	$3,888.73
Rate for Payer: Cash Price	$2,405.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,806.30
Rate for Payer: Health Management Network Commercial	$3,407.65
Rate for Payer: MDX Hawaii PPO	$3,888.73
Rate for Payer: University Health Alliance Commercial	$2,245.04

PLATE LCP TIB-R 10H 02.118.008

Facility

$3,802.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,129.12
Max. Negotiated Rate	$3,687.94
Rate for Payer: Cash Price	$2,281.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,661.40
Rate for Payer: Health Management Network Commercial	$3,231.70
Rate for Payer: MDX Hawaii PPO	$3,687.94
Rate for Payer: University Health Alliance Commercial	$2,129.12

PLATE LCP TIB-R 10H 02.118.008

Facility

$3,802.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,939.02
Max. Negotiated Rate	$3,687.94
Rate for Payer: Cash Price	$2,281.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,661.40
Rate for Payer: Health Management Network Commercial	$3,231.70
Rate for Payer: Kaiser Permanente Commercial	$2,395.26
Rate for Payer: Kaiser Permanente Medicaid	$1,939.02
Rate for Payer: MDX Hawaii PPO	$3,687.94
Rate for Payer: University Health Alliance Commercial	$2,129.12

PLATE LCP TIB-R 10H 02.118.208

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-R 10H 02.118.208

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-R 12H 02.118.010

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-R 12H 02.118.010

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-R 12H 02.118.210

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-R 12H 02.118.210

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-R 14H 02.118.012

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-R 14H 02.118.012

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-R 14H 02.118.212

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-R 14H 02.118.212

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-R 16H 02.118.214

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

Know your out-of-pocket cost for care.

All Charges