Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE MATRIX 20 H 03.503.174

Facility

$540.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$523.80
Rate for Payer: Cash Price	$324.00
Rate for Payer: Hawaii Western Management Group Commercial	$378.00
Rate for Payer: Health Management Network Commercial	$459.00
Rate for Payer: MDX Hawaii PPO	$523.80
Rate for Payer: University Health Alliance Commercial	$302.40

PLATE MATRIX 2X2 H 04.503.723

Facility

$2,558.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,432.48
Max. Negotiated Rate	$2,481.26
Rate for Payer: Cash Price	$1,534.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,790.60
Rate for Payer: Health Management Network Commercial	$2,174.30
Rate for Payer: MDX Hawaii PPO	$2,481.26
Rate for Payer: University Health Alliance Commercial	$1,432.48

PLATE MATRIX 2X2 H 04.503.723

Facility

$2,558.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,304.58
Max. Negotiated Rate	$2,481.26
Rate for Payer: Cash Price	$1,534.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,790.60
Rate for Payer: Health Management Network Commercial	$2,174.30
Rate for Payer: Kaiser Permanente Commercial	$1,611.54
Rate for Payer: Kaiser Permanente Medicaid	$1,304.58
Rate for Payer: MDX Hawaii PPO	$2,481.26
Rate for Payer: University Health Alliance Commercial	$1,432.48

PLATE MATRIX 3X3 04.503.704

Facility

$2,040.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,040.40
Max. Negotiated Rate	$1,978.80
Rate for Payer: Cash Price	$1,224.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,428.00
Rate for Payer: Health Management Network Commercial	$1,734.00
Rate for Payer: Kaiser Permanente Commercial	$1,285.20
Rate for Payer: Kaiser Permanente Medicaid	$1,040.40
Rate for Payer: MDX Hawaii PPO	$1,978.80
Rate for Payer: University Health Alliance Commercial	$1,142.40

PLATE MATRIX 3X3 04.503.704

Facility

$2,040.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,142.40
Max. Negotiated Rate	$1,978.80
Rate for Payer: Cash Price	$1,224.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,428.00
Rate for Payer: Health Management Network Commercial	$1,734.00
Rate for Payer: MDX Hawaii PPO	$1,978.80
Rate for Payer: University Health Alliance Commercial	$1,142.40

PLATE MATRIXMIDFACE 04.503.346

Facility

$2,892.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,619.52
Max. Negotiated Rate	$2,805.24
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: University Health Alliance Commercial	$1,619.52

PLATE MATRIXMIDFACE 04.503.346

Facility

$2,892.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,474.92
Max. Negotiated Rate	$2,805.24
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: Kaiser Permanente Commercial	$1,821.96
Rate for Payer: Kaiser Permanente Medicaid	$1,474.92
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: University Health Alliance Commercial	$1,619.52

PLATE MATRX 12H 1.5 04.503.717

Facility

$2,770.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,412.70
Max. Negotiated Rate	$2,686.90
Rate for Payer: Cash Price	$1,662.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,939.00
Rate for Payer: Health Management Network Commercial	$2,354.50
Rate for Payer: Kaiser Permanente Commercial	$1,745.10
Rate for Payer: Kaiser Permanente Medicaid	$1,412.70
Rate for Payer: MDX Hawaii PPO	$2,686.90
Rate for Payer: University Health Alliance Commercial	$1,551.20

PLATE MATRX 12H 1.5 04.503.717

Facility

$2,770.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,551.20
Max. Negotiated Rate	$2,686.90
Rate for Payer: Cash Price	$1,662.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,939.00
Rate for Payer: Health Management Network Commercial	$2,354.50
Rate for Payer: MDX Hawaii PPO	$2,686.90
Rate for Payer: University Health Alliance Commercial	$1,551.20

PLATE MED DIST 6H RT 627436

Facility

$4,824.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,701.44
Max. Negotiated Rate	$4,679.28
Rate for Payer: Cash Price	$2,894.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,376.80
Rate for Payer: Health Management Network Commercial	$4,100.40
Rate for Payer: MDX Hawaii PPO	$4,679.28
Rate for Payer: University Health Alliance Commercial	$2,701.44

PLATE MED DIST 6H RT 627436

Facility

$4,824.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,460.24
Max. Negotiated Rate	$4,679.28
Rate for Payer: Cash Price	$2,894.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,376.80
Rate for Payer: Health Management Network Commercial	$4,100.40
Rate for Payer: Kaiser Permanente Commercial	$3,039.12
Rate for Payer: Kaiser Permanente Medicaid	$2,460.24
Rate for Payer: MDX Hawaii PPO	$4,679.28
Rate for Payer: University Health Alliance Commercial	$2,701.44

PLATE MEDIAL DIST HUM 2.7/3.5

Facility

$3,042.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,703.52
Max. Negotiated Rate	$2,950.74
Rate for Payer: Cash Price	$1,825.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,129.40
Rate for Payer: Health Management Network Commercial	$2,585.70
Rate for Payer: MDX Hawaii PPO	$2,950.74
Rate for Payer: University Health Alliance Commercial	$1,703.52

PLATE MEDIAL DIST HUM 2.7/3.5

Facility

$3,042.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,551.42
Max. Negotiated Rate	$2,950.74
Rate for Payer: Cash Price	$1,825.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,129.40
Rate for Payer: Health Management Network Commercial	$2,585.70
Rate for Payer: Kaiser Permanente Commercial	$1,916.46
Rate for Payer: Kaiser Permanente Medicaid	$1,551.42
Rate for Payer: MDX Hawaii PPO	$2,950.74
Rate for Payer: University Health Alliance Commercial	$1,703.52

PLATE MESH 56MM CALC 336-3530

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,493.52
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE MESH 56MM CALC 336-3530

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.17
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: Kaiser Permanente Commercial	$1,680.21
Rate for Payer: Kaiser Permanente Medicaid	$1,360.17
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE MESH 65MM CALC 336-3531

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,360.17
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: Kaiser Permanente Commercial	$1,680.21
Rate for Payer: Kaiser Permanente Medicaid	$1,360.17
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE MESH 65MM CALC 336-3531

Facility

$2,667.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,493.52
Max. Negotiated Rate	$2,586.99
Rate for Payer: Cash Price	$1,600.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,866.90
Rate for Payer: Health Management Network Commercial	$2,266.95
Rate for Payer: MDX Hawaii PPO	$2,586.99
Rate for Payer: University Health Alliance Commercial	$1,493.52

PLATE MINI 1.0MM RT 04.503.780

Facility

$2,382.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,214.82
Max. Negotiated Rate	$2,310.54
Rate for Payer: Cash Price	$1,429.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,667.40
Rate for Payer: Health Management Network Commercial	$2,024.70
Rate for Payer: Kaiser Permanente Commercial	$1,500.66
Rate for Payer: Kaiser Permanente Medicaid	$1,214.82
Rate for Payer: MDX Hawaii PPO	$2,310.54
Rate for Payer: University Health Alliance Commercial	$1,333.92

PLATE MINI 1.0MM RT 04.503.780

Facility

$2,382.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,333.92
Max. Negotiated Rate	$2,310.54
Rate for Payer: Cash Price	$1,429.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,667.40
Rate for Payer: Health Management Network Commercial	$2,024.70
Rate for Payer: MDX Hawaii PPO	$2,310.54
Rate for Payer: University Health Alliance Commercial	$1,333.92

PLATE MINI 2X2 HOLE 04.503.750

Facility

$2,276.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,274.56
Max. Negotiated Rate	$2,207.72
Rate for Payer: Cash Price	$1,365.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.20
Rate for Payer: Health Management Network Commercial	$1,934.60
Rate for Payer: MDX Hawaii PPO	$2,207.72
Rate for Payer: University Health Alliance Commercial	$1,274.56

PLATE MINI 2X2 HOLE 04.503.750

Facility

$2,276.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,160.76
Max. Negotiated Rate	$2,207.72
Rate for Payer: Cash Price	$1,365.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,593.20
Rate for Payer: Health Management Network Commercial	$1,934.60
Rate for Payer: Kaiser Permanente Commercial	$1,433.88
Rate for Payer: Kaiser Permanente Medicaid	$1,160.76
Rate for Payer: MDX Hawaii PPO	$2,207.72
Rate for Payer: University Health Alliance Commercial	$1,274.56

PLATE MINI 2X2 HOLE 04.503.781

Facility

$2,550.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,428.00
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,785.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: University Health Alliance Commercial	$1,428.00

PLATE MINI 2X2 HOLE 04.503.781

Facility

$2,550.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,300.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,785.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$1,300.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: University Health Alliance Commercial	$1,428.00

PLATE MINI FRAG 2.0 4H 629604

Facility

$1,564.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$875.84
Max. Negotiated Rate	$1,517.08
Rate for Payer: Cash Price	$938.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,094.80
Rate for Payer: Health Management Network Commercial	$1,329.40
Rate for Payer: MDX Hawaii PPO	$1,517.08
Rate for Payer: University Health Alliance Commercial	$875.84

PLATE MINI FRAG 2.0 4H 629604

Facility

$1,564.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$797.64
Max. Negotiated Rate	$1,517.08
Rate for Payer: Cash Price	$938.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,094.80
Rate for Payer: Health Management Network Commercial	$1,329.40
Rate for Payer: Kaiser Permanente Commercial	$985.32
Rate for Payer: Kaiser Permanente Medicaid	$797.64
Rate for Payer: MDX Hawaii PPO	$1,517.08
Rate for Payer: University Health Alliance Commercial	$875.84

Know your out-of-pocket cost for care.

All Charges