Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE LCP TIB-R 16H 02.118.214

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-R 18H 02.118.216

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

PLATE LCP TIB-R 18H 02.118.216

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-R 4H 02.118.002

Facility

$3,685.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,063.60
Max. Negotiated Rate	$3,574.45
Rate for Payer: Cash Price	$2,211.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,579.50
Rate for Payer: Health Management Network Commercial	$3,132.25
Rate for Payer: MDX Hawaii PPO	$3,574.45
Rate for Payer: University Health Alliance Commercial	$2,063.60

PLATE LCP TIB-R 4H 02.118.002

Facility

$3,685.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,879.35
Max. Negotiated Rate	$3,574.45
Rate for Payer: Cash Price	$2,211.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,579.50
Rate for Payer: Health Management Network Commercial	$3,132.25
Rate for Payer: Kaiser Permanente Commercial	$2,321.55
Rate for Payer: Kaiser Permanente Medicaid	$1,879.35
Rate for Payer: MDX Hawaii PPO	$3,574.45
Rate for Payer: University Health Alliance Commercial	$2,063.60

PLATE LCP TIB-R 4H 02.118.202

Facility

$4,616.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,584.96
Max. Negotiated Rate	$4,477.52
Rate for Payer: Cash Price	$2,769.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,231.20
Rate for Payer: Health Management Network Commercial	$3,923.60
Rate for Payer: MDX Hawaii PPO	$4,477.52
Rate for Payer: University Health Alliance Commercial	$2,584.96

PLATE LCP TIB-R 4H 02.118.202

Facility

$4,616.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,354.16
Max. Negotiated Rate	$4,477.52
Rate for Payer: Cash Price	$2,769.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,231.20
Rate for Payer: Health Management Network Commercial	$3,923.60
Rate for Payer: Kaiser Permanente Commercial	$2,908.08
Rate for Payer: Kaiser Permanente Medicaid	$2,354.16
Rate for Payer: MDX Hawaii PPO	$4,477.52
Rate for Payer: University Health Alliance Commercial	$2,584.96

PLATE LCP TIB-R 6H 02.118.004

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-R 6H 02.118.004

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-R 6H 02.118.204

Facility

$3,966.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,220.96
Max. Negotiated Rate	$3,847.02
Rate for Payer: Cash Price	$2,379.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,776.20
Rate for Payer: Health Management Network Commercial	$3,371.10
Rate for Payer: MDX Hawaii PPO	$3,847.02
Rate for Payer: University Health Alliance Commercial	$2,220.96

PLATE LCP TIB-R 6H 02.118.204

Facility

$3,966.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,022.66
Max. Negotiated Rate	$3,847.02
Rate for Payer: Cash Price	$2,379.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,776.20
Rate for Payer: Health Management Network Commercial	$3,371.10
Rate for Payer: Kaiser Permanente Commercial	$2,498.58
Rate for Payer: Kaiser Permanente Medicaid	$2,022.66
Rate for Payer: MDX Hawaii PPO	$3,847.02
Rate for Payer: University Health Alliance Commercial	$2,220.96

PLATE LCP TIB-R 8H 02.118.006

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-R 8H 02.118.006

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-R 8H 02.118.206

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 8H 02.118.206

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 LEFT 3H 74MM 2358-108-03

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,579.20
Max. Negotiated Rate	$2,735.40
Rate for Payer: Cash Price	$1,692.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: University Health Alliance Commercial	$1,579.20

PLATE LEFT 3H 74MM 2358-108-03

Facility

$2,820.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,438.20
Max. Negotiated Rate	$2,735.40
Rate for Payer: Cash Price	$1,692.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,974.00
Rate for Payer: Health Management Network Commercial	$2,397.00
Rate for Payer: Kaiser Permanente Commercial	$1,776.60
Rate for Payer: Kaiser Permanente Medicaid	$1,438.20
Rate for Payer: MDX Hawaii PPO	$2,735.40
Rate for Payer: University Health Alliance Commercial	$1,579.20

PLATE LEFT STD 4HOLE DVRAL

Facility

$2,660.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,489.60
Max. Negotiated Rate	$2,580.20
Rate for Payer: Cash Price	$1,596.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,862.00
Rate for Payer: Health Management Network Commercial	$2,261.00
Rate for Payer: MDX Hawaii PPO	$2,580.20
Rate for Payer: University Health Alliance Commercial	$1,489.60

PLATE LEFT STD 4HOLE DVRAL

Facility

$2,660.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,356.60
Max. Negotiated Rate	$2,580.20
Rate for Payer: Cash Price	$1,596.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,862.00
Rate for Payer: Health Management Network Commercial	$2,261.00
Rate for Payer: Kaiser Permanente Commercial	$1,675.80
Rate for Payer: Kaiser Permanente Medicaid	$1,356.60
Rate for Payer: MDX Hawaii PPO	$2,580.20
Rate for Payer: University Health Alliance Commercial	$1,489.60

PLATE LF 10H 120MM AR-2653CL

Facility

$2,678.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,365.78
Max. Negotiated Rate	$2,597.66
Rate for Payer: Cash Price	$1,606.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,874.60
Rate for Payer: Health Management Network Commercial	$2,276.30
Rate for Payer: Kaiser Permanente Commercial	$1,687.14
Rate for Payer: Kaiser Permanente Medicaid	$1,365.78
Rate for Payer: MDX Hawaii PPO	$2,597.66
Rate for Payer: University Health Alliance Commercial	$1,499.68

PLATE LF 10H 120MM AR-2653CL

Facility

$2,678.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,499.68
Max. Negotiated Rate	$2,597.66
Rate for Payer: Cash Price	$1,606.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,874.60
Rate for Payer: Health Management Network Commercial	$2,276.30
Rate for Payer: MDX Hawaii PPO	$2,597.66
Rate for Payer: University Health Alliance Commercial	$1,499.68

PLATE LF 3.5/4.0X58MM 336-3540

Facility

$2,884.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,615.04
Max. Negotiated Rate	$2,797.48
Rate for Payer: Cash Price	$1,730.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,018.80
Rate for Payer: Health Management Network Commercial	$2,451.40
Rate for Payer: MDX Hawaii PPO	$2,797.48
Rate for Payer: University Health Alliance Commercial	$1,615.04

PLATE LF 3.5/4.0X58MM 336-3540

Facility

$2,884.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,470.84
Max. Negotiated Rate	$2,797.48
Rate for Payer: Cash Price	$1,730.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,018.80
Rate for Payer: Health Management Network Commercial	$2,451.40
Rate for Payer: Kaiser Permanente Commercial	$1,816.92
Rate for Payer: Kaiser Permanente Medicaid	$1,470.84
Rate for Payer: MDX Hawaii PPO	$2,797.48
Rate for Payer: University Health Alliance Commercial	$1,615.04

PLATE LF 4X6 0.5MM 04.503.334

Facility

$1,941.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,086.96
Max. Negotiated Rate	$1,882.77
Rate for Payer: Cash Price	$1,164.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,358.70
Rate for Payer: Health Management Network Commercial	$1,649.85
Rate for Payer: MDX Hawaii PPO	$1,882.77
Rate for Payer: University Health Alliance Commercial	$1,086.96

PLATE LF 4X6 0.5MM 04.503.334

Facility

$1,941.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$989.91
Max. Negotiated Rate	$1,882.77
Rate for Payer: Cash Price	$1,164.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,358.70
Rate for Payer: Health Management Network Commercial	$1,649.85
Rate for Payer: Kaiser Permanente Commercial	$1,222.83
Rate for Payer: Kaiser Permanente Medicaid	$989.91
Rate for Payer: MDX Hawaii PPO	$1,882.77
Rate for Payer: University Health Alliance Commercial	$1,086.96

Know your out-of-pocket cost for care.

All Charges