Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE RAD PEG LT 10PEG RPGL-10

Facility

$3,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,683.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

PLATE RAD PEG LT 10PEG RPGL-10

Facility

$3,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

PLATE RAD PEG LT 7PEG RPGL-7

Facility

$2,480.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,388.80
Max. Negotiated Rate	$2,405.60
Rate for Payer: Cash Price	$1,488.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,736.00
Rate for Payer: Health Management Network Commercial	$2,108.00
Rate for Payer: MDX Hawaii PPO	$2,405.60
Rate for Payer: University Health Alliance Commercial	$1,388.80

PLATE RAD PEG LT 7PEG RPGL-7

Facility

$2,480.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,264.80
Max. Negotiated Rate	$2,405.60
Rate for Payer: Cash Price	$1,488.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,736.00
Rate for Payer: Health Management Network Commercial	$2,108.00
Rate for Payer: Kaiser Permanente Commercial	$1,562.40
Rate for Payer: Kaiser Permanente Medicaid	$1,264.80
Rate for Payer: MDX Hawaii PPO	$2,405.60
Rate for Payer: University Health Alliance Commercial	$1,388.80

PLATE RAD PEG RT 10PEG RPGR-10

Facility

$3,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,848.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

PLATE RAD PEG RT 10PEG RPGR-10

Facility

$3,300.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,683.00
Max. Negotiated Rate	$3,201.00
Rate for Payer: Cash Price	$1,980.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,310.00
Rate for Payer: Health Management Network Commercial	$2,805.00
Rate for Payer: Kaiser Permanente Commercial	$2,079.00
Rate for Payer: Kaiser Permanente Medicaid	$1,683.00
Rate for Payer: MDX Hawaii PPO	$3,201.00
Rate for Payer: University Health Alliance Commercial	$1,848.00

PLATE RAD PEG RT 7PEG RPGR-7

Facility

$2,910.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,484.10
Max. Negotiated Rate	$2,822.70
Rate for Payer: Cash Price	$1,746.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,037.00
Rate for Payer: Health Management Network Commercial	$2,473.50
Rate for Payer: Kaiser Permanente Commercial	$1,833.30
Rate for Payer: Kaiser Permanente Medicaid	$1,484.10
Rate for Payer: MDX Hawaii PPO	$2,822.70
Rate for Payer: University Health Alliance Commercial	$1,629.60

PLATE RAD PEG RT 7PEG RPGR-7

Facility

$2,910.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,629.60
Max. Negotiated Rate	$2,822.70
Rate for Payer: Cash Price	$1,746.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,037.00
Rate for Payer: Health Management Network Commercial	$2,473.50
Rate for Payer: MDX Hawaii PPO	$2,822.70
Rate for Payer: University Health Alliance Commercial	$1,629.60

PLATE RIGHT DVR SHORT DVRAS-R

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 RIGHT DVR SHORT DVRAS-R

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 RIGHT WIDE 4HOLE DVRAWR

Facility

$2,540.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,422.40
Max. Negotiated Rate	$2,463.80
Rate for Payer: Cash Price	$1,524.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,778.00
Rate for Payer: Health Management Network Commercial	$2,159.00
Rate for Payer: MDX Hawaii PPO	$2,463.80
Rate for Payer: University Health Alliance Commercial	$1,422.40

PLATE RIGHT WIDE 4HOLE DVRAWR

Facility

$2,540.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,295.40
Max. Negotiated Rate	$2,463.80
Rate for Payer: Cash Price	$1,524.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,778.00
Rate for Payer: Health Management Network Commercial	$2,159.00
Rate for Payer: Kaiser Permanente Commercial	$1,600.20
Rate for Payer: Kaiser Permanente Medicaid	$1,295.40
Rate for Payer: MDX Hawaii PPO	$2,463.80
Rate for Payer: University Health Alliance Commercial	$1,422.40

PLATE ROTATION W 5H 57-10185

Facility

$2,388.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,337.28
Max. Negotiated Rate	$2,316.36
Rate for Payer: Cash Price	$1,432.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,671.60
Rate for Payer: Health Management Network Commercial	$2,029.80
Rate for Payer: MDX Hawaii PPO	$2,316.36
Rate for Payer: University Health Alliance Commercial	$1,337.28

PLATE ROTATION W 5H 57-10185

Facility

$2,388.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,217.88
Max. Negotiated Rate	$2,316.36
Rate for Payer: Cash Price	$1,432.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,671.60
Rate for Payer: Health Management Network Commercial	$2,029.80
Rate for Payer: Kaiser Permanente Commercial	$1,504.44
Rate for Payer: Kaiser Permanente Medicaid	$1,217.88
Rate for Payer: MDX Hawaii PPO	$2,316.36
Rate for Payer: University Health Alliance Commercial	$1,337.28

PLATE RT 178MM 10H

Facility

$3,817.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,137.52
Max. Negotiated Rate	$3,702.49
Rate for Payer: Cash Price	$2,290.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,671.90
Rate for Payer: Health Management Network Commercial	$3,244.45
Rate for Payer: MDX Hawaii PPO	$3,702.49
Rate for Payer: University Health Alliance Commercial	$2,137.52

PLATE RT 178MM 10H

Facility

$3,817.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,946.67
Max. Negotiated Rate	$3,702.49
Rate for Payer: Cash Price	$2,290.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,671.90
Rate for Payer: Health Management Network Commercial	$3,244.45
Rate for Payer: Kaiser Permanente Commercial	$2,404.71
Rate for Payer: Kaiser Permanente Medicaid	$1,946.67
Rate for Payer: MDX Hawaii PPO	$3,702.49
Rate for Payer: University Health Alliance Commercial	$2,137.52

PLATE RT 3.5/4X58MM 336-3545

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 RT 3.5/4X58MM 336-3545

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 RT 4H 3.5X109 02.112.510

Facility

$3,221.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,642.71
Max. Negotiated Rate	$3,124.37
Rate for Payer: Cash Price	$1,932.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,254.70
Rate for Payer: Health Management Network Commercial	$2,737.85
Rate for Payer: Kaiser Permanente Commercial	$2,029.23
Rate for Payer: Kaiser Permanente Medicaid	$1,642.71
Rate for Payer: MDX Hawaii PPO	$3,124.37
Rate for Payer: University Health Alliance Commercial	$1,803.76

PLATE RT 4H 3.5X109 02.112.510

Facility

$3,221.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,803.76
Max. Negotiated Rate	$3,124.37
Rate for Payer: Cash Price	$1,932.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,254.70
Rate for Payer: Health Management Network Commercial	$2,737.85
Rate for Payer: MDX Hawaii PPO	$3,124.37
Rate for Payer: University Health Alliance Commercial	$1,803.76

PLATE RT MI 3.5X65MM 336-3546

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 RT MI 3.5X65MM 336-3546

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 RT XS CRV 8H AR-2654CR

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 RT XS CRV 8H AR-2654CR

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 RT X-SMALL CURVE 8 HOLE

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

Know your out-of-pocket cost for care.

All Charges