Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE PRMARY 2.7MM RT 336-2759

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 PROX HUMERUS 6H 627236

Facility

$5,532.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,097.92
Max. Negotiated Rate	$5,366.04
Rate for Payer: Cash Price	$3,319.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,872.40
Rate for Payer: Health Management Network Commercial	$4,702.20
Rate for Payer: MDX Hawaii PPO	$5,366.04
Rate for Payer: University Health Alliance Commercial	$3,097.92

PLATE PROX HUMERUS 6H 627236

Facility

$5,532.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,821.32
Max. Negotiated Rate	$5,366.04
Rate for Payer: Cash Price	$3,319.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,872.40
Rate for Payer: Health Management Network Commercial	$4,702.20
Rate for Payer: Kaiser Permanente Commercial	$3,485.16
Rate for Payer: Kaiser Permanente Medicaid	$2,821.32
Rate for Payer: MDX Hawaii PPO	$5,366.04
Rate for Payer: University Health Alliance Commercial	$3,097.92

PLATE PROX HUM LAT, 12HOLE

Facility

$5,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,800.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

PLATE PROX HUM LAT, 12HOLE

Facility

$5,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,550.00
Max. Negotiated Rate	$4,850.00
Rate for Payer: Cash Price	$3,000.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,500.00
Rate for Payer: Health Management Network Commercial	$4,250.00
Rate for Payer: Kaiser Permanente Commercial	$3,150.00
Rate for Payer: Kaiser Permanente Medicaid	$2,550.00
Rate for Payer: MDX Hawaii PPO	$4,850.00
Rate for Payer: University Health Alliance Commercial	$2,800.00

PLATE PROXIMAL HURMERUS 627204

Facility

$3,774.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,113.44
Max. Negotiated Rate	$3,660.78
Rate for Payer: Cash Price	$2,264.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,641.80
Rate for Payer: Health Management Network Commercial	$3,207.90
Rate for Payer: MDX Hawaii PPO	$3,660.78
Rate for Payer: University Health Alliance Commercial	$2,113.44

PLATE PROXIMAL HURMERUS 627204

Facility

$3,774.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,924.74
Max. Negotiated Rate	$3,660.78
Rate for Payer: Cash Price	$2,264.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,641.80
Rate for Payer: Health Management Network Commercial	$3,207.90
Rate for Payer: Kaiser Permanente Commercial	$2,377.62
Rate for Payer: Kaiser Permanente Medicaid	$1,924.74
Rate for Payer: MDX Hawaii PPO	$3,660.78
Rate for Payer: University Health Alliance Commercial	$2,113.44

PLATE PROXIMAL LATERAL 627242S

Facility

$6,127.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,431.12
Max. Negotiated Rate	$5,943.19
Rate for Payer: Cash Price	$3,676.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,288.90
Rate for Payer: Health Management Network Commercial	$5,207.95
Rate for Payer: MDX Hawaii PPO	$5,943.19
Rate for Payer: University Health Alliance Commercial	$3,431.12

PLATE PROXIMAL LATERAL 627242S

Facility

$6,127.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,124.77
Max. Negotiated Rate	$5,943.19
Rate for Payer: Cash Price	$3,676.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,288.90
Rate for Payer: Health Management Network Commercial	$5,207.95
Rate for Payer: Kaiser Permanente Commercial	$3,860.01
Rate for Payer: Kaiser Permanente Medicaid	$3,124.77
Rate for Payer: MDX Hawaii PPO	$5,943.19
Rate for Payer: University Health Alliance Commercial	$3,431.12

PLATE PROXIMAL LATERAL HUMERUS

Facility

$3,774.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,924.74
Max. Negotiated Rate	$3,660.78
Rate for Payer: Cash Price	$2,264.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,641.80
Rate for Payer: Health Management Network Commercial	$3,207.90
Rate for Payer: Kaiser Permanente Commercial	$2,377.62
Rate for Payer: Kaiser Permanente Medicaid	$1,924.74
Rate for Payer: MDX Hawaii PPO	$3,660.78
Rate for Payer: University Health Alliance Commercial	$2,113.44

PLATE PROXIMAL LATERAL HUMERUS

Facility

$3,774.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,113.44
Max. Negotiated Rate	$3,660.78
Rate for Payer: Cash Price	$2,264.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,641.80
Rate for Payer: Health Management Network Commercial	$3,207.90
Rate for Payer: MDX Hawaii PPO	$3,660.78
Rate for Payer: University Health Alliance Commercial	$2,113.44

PLATE PROX LATERAL RT 627234

Facility

$5,084.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,847.04
Max. Negotiated Rate	$4,931.48
Rate for Payer: Cash Price	$3,050.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,558.80
Rate for Payer: Health Management Network Commercial	$4,321.40
Rate for Payer: MDX Hawaii PPO	$4,931.48
Rate for Payer: University Health Alliance Commercial	$2,847.04

PLATE PROX LATERAL RT 627234

Facility

$5,084.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,592.84
Max. Negotiated Rate	$4,931.48
Rate for Payer: Cash Price	$3,050.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,558.80
Rate for Payer: Health Management Network Commercial	$4,321.40
Rate for Payer: Kaiser Permanente Commercial	$3,202.92
Rate for Payer: Kaiser Permanente Medicaid	$2,592.84
Rate for Payer: MDX Hawaii PPO	$4,931.48
Rate for Payer: University Health Alliance Commercial	$2,847.04

PLATE PROX LATERAL TIB 627302

Facility

$3,635.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,035.60
Max. Negotiated Rate	$3,525.95
Rate for Payer: Cash Price	$2,181.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,544.50
Rate for Payer: Health Management Network Commercial	$3,089.75
Rate for Payer: MDX Hawaii PPO	$3,525.95
Rate for Payer: University Health Alliance Commercial	$2,035.60

PLATE PROX LATERAL TIB 627302

Facility

$3,635.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,853.85
Max. Negotiated Rate	$3,525.95
Rate for Payer: Cash Price	$2,181.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,544.50
Rate for Payer: Health Management Network Commercial	$3,089.75
Rate for Payer: Kaiser Permanente Commercial	$2,290.05
Rate for Payer: Kaiser Permanente Medicaid	$1,853.85
Rate for Payer: MDX Hawaii PPO	$3,525.95
Rate for Payer: University Health Alliance Commercial	$2,035.60

PLATE PROX RADIUS LG 131218401

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 PROX RADIUS LG 131218401

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 PRX LT 4H 90MM 110030301

Facility

$4,832.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,464.32
Max. Negotiated Rate	$4,687.04
Rate for Payer: Cash Price	$2,899.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,382.40
Rate for Payer: Health Management Network Commercial	$4,107.20
Rate for Payer: Kaiser Permanente Commercial	$3,044.16
Rate for Payer: Kaiser Permanente Medicaid	$2,464.32
Rate for Payer: MDX Hawaii PPO	$4,687.04
Rate for Payer: University Health Alliance Commercial	$2,705.92

PLATE PRX LT 4H 90MM 110030301

Facility

$4,832.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,705.92
Max. Negotiated Rate	$4,687.04
Rate for Payer: Cash Price	$2,899.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,382.40
Rate for Payer: Health Management Network Commercial	$4,107.20
Rate for Payer: MDX Hawaii PPO	$4,687.04
Rate for Payer: University Health Alliance Commercial	$2,705.92

PLATE RADIAL COLUMN 3H RCP3

Facility

$2,385.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,216.35
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,669.50
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: Kaiser Permanente Commercial	$1,502.55
Rate for Payer: Kaiser Permanente Medicaid	$1,216.35
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: University Health Alliance Commercial	$1,335.60

PLATE RADIAL COLUMN 3H RCP3

Facility

$2,385.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,335.60
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,669.50
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: University Health Alliance Commercial	$1,335.60

PLATE RADIAL COLUMN 5H RCP5

Facility

$2,385.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,335.60
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,669.50
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: University Health Alliance Commercial	$1,335.60

PLATE RADIAL COLUMN 5H RCP5

Facility

$2,385.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,216.35
Max. Negotiated Rate	$2,313.45
Rate for Payer: Cash Price	$1,431.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,669.50
Rate for Payer: Health Management Network Commercial	$2,027.25
Rate for Payer: Kaiser Permanente Commercial	$1,502.55
Rate for Payer: Kaiser Permanente Medicaid	$1,216.35
Rate for Payer: MDX Hawaii PPO	$2,313.45
Rate for Payer: University Health Alliance Commercial	$1,335.60

PLATE RADIAL COLUMN 7H RCP7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLATE RADIAL COLUMN 7H RCP7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

Know your out-of-pocket cost for care.

All Charges