Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE MINI LF DVR 131822040

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,631.28
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,747.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

PLATE MINI LF DVR 131822040

Facility

$2,913.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,485.63
Max. Negotiated Rate	$2,825.61
Rate for Payer: Cash Price	$1,747.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,039.10
Rate for Payer: Health Management Network Commercial	$2,476.05
Rate for Payer: Kaiser Permanente Commercial	$1,835.19
Rate for Payer: Kaiser Permanente Medicaid	$1,485.63
Rate for Payer: MDX Hawaii PPO	$2,825.61
Rate for Payer: University Health Alliance Commercial	$1,631.28

PLATE M LCK T REG 7H 57-15360

Facility

$2,476.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,262.76
Max. Negotiated Rate	$2,401.72
Rate for Payer: Cash Price	$1,485.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,733.20
Rate for Payer: Health Management Network Commercial	$2,104.60
Rate for Payer: Kaiser Permanente Commercial	$1,559.88
Rate for Payer: Kaiser Permanente Medicaid	$1,262.76
Rate for Payer: MDX Hawaii PPO	$2,401.72
Rate for Payer: University Health Alliance Commercial	$1,386.56

PLATE M LCK T REG 7H 57-15360

Facility

$2,476.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,386.56
Max. Negotiated Rate	$2,401.72
Rate for Payer: Cash Price	$1,485.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,733.20
Rate for Payer: Health Management Network Commercial	$2,104.60
Rate for Payer: MDX Hawaii PPO	$2,401.72
Rate for Payer: University Health Alliance Commercial	$1,386.56

PLATE NARR LCK 2.0

Facility

$1,907.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,067.92
Max. Negotiated Rate	$1,849.79
Rate for Payer: Cash Price	$1,144.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,334.90
Rate for Payer: Health Management Network Commercial	$1,620.95
Rate for Payer: MDX Hawaii PPO	$1,849.79
Rate for Payer: University Health Alliance Commercial	$1,067.92

PLATE NARR LCK 2.0

Facility

$1,907.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$972.57
Max. Negotiated Rate	$1,849.79
Rate for Payer: Cash Price	$1,144.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,334.90
Rate for Payer: Health Management Network Commercial	$1,620.95
Rate for Payer: Kaiser Permanente Commercial	$1,201.41
Rate for Payer: Kaiser Permanente Medicaid	$972.57
Rate for Payer: MDX Hawaii PPO	$1,849.79
Rate for Payer: University Health Alliance Commercial	$1,067.92

PLATE NARROW LEFT DVRAN-L

Facility

$2,460.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,254.60
Max. Negotiated Rate	$2,386.20
Rate for Payer: Cash Price	$1,476.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,722.00
Rate for Payer: Health Management Network Commercial	$2,091.00
Rate for Payer: Kaiser Permanente Commercial	$1,549.80
Rate for Payer: Kaiser Permanente Medicaid	$1,254.60
Rate for Payer: MDX Hawaii PPO	$2,386.20
Rate for Payer: University Health Alliance Commercial	$1,377.60

PLATE NARROW LEFT DVRAN-L

Facility

$2,460.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,377.60
Max. Negotiated Rate	$2,386.20
Rate for Payer: Cash Price	$1,476.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,722.00
Rate for Payer: Health Management Network Commercial	$2,091.00
Rate for Payer: MDX Hawaii PPO	$2,386.20
Rate for Payer: University Health Alliance Commercial	$1,377.60

PLATE NCB RT 12H 02.03264.012

Facility

$6,500.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,315.00
Max. Negotiated Rate	$6,305.00
Rate for Payer: Cash Price	$3,900.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,550.00
Rate for Payer: Health Management Network Commercial	$5,525.00
Rate for Payer: Kaiser Permanente Commercial	$4,095.00
Rate for Payer: Kaiser Permanente Medicaid	$3,315.00
Rate for Payer: MDX Hawaii PPO	$6,305.00
Rate for Payer: University Health Alliance Commercial	$3,640.00

PLATE NCB RT 12H 02.03264.012

Facility

$6,500.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,640.00
Max. Negotiated Rate	$6,305.00
Rate for Payer: Cash Price	$3,900.00
Rate for Payer: Hawaii Western Management Group Commercial	$4,550.00
Rate for Payer: Health Management Network Commercial	$5,525.00
Rate for Payer: MDX Hawaii PPO	$6,305.00
Rate for Payer: University Health Alliance Commercial	$3,640.00

PLATE NON COMP FEM LF 627610

Facility

$4,707.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,400.57
Max. Negotiated Rate	$4,565.79
Rate for Payer: Cash Price	$2,824.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,294.90
Rate for Payer: Health Management Network Commercial	$4,000.95
Rate for Payer: Kaiser Permanente Commercial	$2,965.41
Rate for Payer: Kaiser Permanente Medicaid	$2,400.57
Rate for Payer: MDX Hawaii PPO	$4,565.79
Rate for Payer: University Health Alliance Commercial	$2,635.92

PLATE NON COMP FEM LF 627610

Facility

$4,707.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,635.92
Max. Negotiated Rate	$4,565.79
Rate for Payer: Cash Price	$2,824.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,294.90
Rate for Payer: Health Management Network Commercial	$4,000.95
Rate for Payer: MDX Hawaii PPO	$4,565.79
Rate for Payer: University Health Alliance Commercial	$2,635.92

PLATE OLECRANON 12HOLE 629352S

Facility

$4,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,251.20
Max. Negotiated Rate	$3,899.40
Rate for Payer: Cash Price	$2,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,814.00
Rate for Payer: Health Management Network Commercial	$3,417.00
Rate for Payer: MDX Hawaii PPO	$3,899.40
Rate for Payer: University Health Alliance Commercial	$2,251.20

PLATE OLECRANON 12HOLE 629352S

Facility

$4,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,050.20
Max. Negotiated Rate	$3,899.40
Rate for Payer: Cash Price	$2,412.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,814.00
Rate for Payer: Health Management Network Commercial	$3,417.00
Rate for Payer: Kaiser Permanente Commercial	$2,532.60
Rate for Payer: Kaiser Permanente Medicaid	$2,050.20
Rate for Payer: MDX Hawaii PPO	$3,899.40
Rate for Payer: University Health Alliance Commercial	$2,251.20

PLATE OLECRANON 3H 65MM 629343

Facility

$2,193.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.08
Max. Negotiated Rate	$2,127.21
Rate for Payer: Cash Price	$1,315.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,535.10
Rate for Payer: Health Management Network Commercial	$1,864.05
Rate for Payer: MDX Hawaii PPO	$2,127.21
Rate for Payer: University Health Alliance Commercial	$1,228.08

PLATE OLECRANON 3H 65MM 629343

Facility

$2,193.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,118.43
Max. Negotiated Rate	$2,127.21
Rate for Payer: Cash Price	$1,315.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,535.10
Rate for Payer: Health Management Network Commercial	$1,864.05
Rate for Payer: Kaiser Permanente Commercial	$1,381.59
Rate for Payer: Kaiser Permanente Medicaid	$1,118.43
Rate for Payer: MDX Hawaii PPO	$2,127.21
Rate for Payer: University Health Alliance Commercial	$1,228.08

PLATE OLECRANON LF 629344

Facility

$2,418.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,354.08
Max. Negotiated Rate	$2,345.46
Rate for Payer: Cash Price	$1,450.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,692.60
Rate for Payer: Health Management Network Commercial	$2,055.30
Rate for Payer: MDX Hawaii PPO	$2,345.46
Rate for Payer: University Health Alliance Commercial	$1,354.08

PLATE OLECRANON LF 629344

Facility

$2,418.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,233.18
Max. Negotiated Rate	$2,345.46
Rate for Payer: Cash Price	$1,450.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,692.60
Rate for Payer: Health Management Network Commercial	$2,055.30
Rate for Payer: Kaiser Permanente Commercial	$1,523.34
Rate for Payer: Kaiser Permanente Medicaid	$1,233.18
Rate for Payer: MDX Hawaii PPO	$2,345.46
Rate for Payer: University Health Alliance Commercial	$1,354.08

PLATE ONE THIRD 7H 71MM 626676

Facility

$1,234.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$691.04
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$740.40
Rate for Payer: Hawaii Western Management Group Commercial	$863.80
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: University Health Alliance Commercial	$691.04

PLATE ONE THIRD 7H 71MM 626676

Facility

$1,234.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$629.34
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$740.40
Rate for Payer: Hawaii Western Management Group Commercial	$863.80
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Kaiser Permanente Commercial	$777.42
Rate for Payer: Kaiser Permanente Medicaid	$629.34
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: University Health Alliance Commercial	$691.04

PLATE PRIMARY 6 HOLE 336-3554

Facility

$3,605.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,838.55
Max. Negotiated Rate	$3,496.85
Rate for Payer: Cash Price	$2,163.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,523.50
Rate for Payer: Health Management Network Commercial	$3,064.25
Rate for Payer: Kaiser Permanente Commercial	$2,271.15
Rate for Payer: Kaiser Permanente Medicaid	$1,838.55
Rate for Payer: MDX Hawaii PPO	$3,496.85
Rate for Payer: University Health Alliance Commercial	$2,018.80

PLATE PRIMARY 6 HOLE 336-3554

Facility

$3,605.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,018.80
Max. Negotiated Rate	$3,496.85
Rate for Payer: Cash Price	$2,163.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,523.50
Rate for Payer: Health Management Network Commercial	$3,064.25
Rate for Payer: MDX Hawaii PPO	$3,496.85
Rate for Payer: University Health Alliance Commercial	$2,018.80

PLATE PRIMRY 2.7MM LT 336-2754

Facility

$3,605.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,018.80
Max. Negotiated Rate	$3,496.85
Rate for Payer: Cash Price	$2,163.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,523.50
Rate for Payer: Health Management Network Commercial	$3,064.25
Rate for Payer: MDX Hawaii PPO	$3,496.85
Rate for Payer: University Health Alliance Commercial	$2,018.80

PLATE PRIMRY 2.7MM LT 336-2754

Facility

$3,605.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,838.55
Max. Negotiated Rate	$3,496.85
Rate for Payer: Cash Price	$2,163.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,523.50
Rate for Payer: Health Management Network Commercial	$3,064.25
Rate for Payer: Kaiser Permanente Commercial	$2,271.15
Rate for Payer: Kaiser Permanente Medicaid	$1,838.55
Rate for Payer: MDX Hawaii PPO	$3,496.85
Rate for Payer: University Health Alliance Commercial	$2,018.80

PLATE PRMARY 2.7MM RT 336-2759

Facility

$3,605.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,018.80
Max. Negotiated Rate	$3,496.85
Rate for Payer: Cash Price	$2,163.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,523.50
Rate for Payer: Health Management Network Commercial	$3,064.25
Rate for Payer: MDX Hawaii PPO	$3,496.85
Rate for Payer: University Health Alliance Commercial	$2,018.80

Know your out-of-pocket cost for care.

All Charges