Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE RT X-SMALL CURVE 8 HOLE

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 SEMI-TUB 4H/71MM 222.04

Facility

$380.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$193.80
Max. Negotiated Rate	$368.60
Rate for Payer: Cash Price	$228.00
Rate for Payer: Hawaii Western Management Group Commercial	$266.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: Kaiser Permanente Commercial	$239.40
Rate for Payer: Kaiser Permanente Medicaid	$193.80
Rate for Payer: MDX Hawaii PPO	$368.60
Rate for Payer: University Health Alliance Commercial	$212.80

PLATE SEMI-TUB 4H/71MM 222.04

Facility

$380.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$368.60
Rate for Payer: Cash Price	$228.00
Rate for Payer: Hawaii Western Management Group Commercial	$266.00
Rate for Payer: Health Management Network Commercial	$323.00
Rate for Payer: MDX Hawaii PPO	$368.60
Rate for Payer: University Health Alliance Commercial	$212.80

PLATE SEMI-TUBULAR 5H SMTP-5

Facility

$1,260.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$705.60
Max. Negotiated Rate	$1,222.20
Rate for Payer: Cash Price	$756.00
Rate for Payer: Hawaii Western Management Group Commercial	$882.00
Rate for Payer: Health Management Network Commercial	$1,071.00
Rate for Payer: MDX Hawaii PPO	$1,222.20
Rate for Payer: University Health Alliance Commercial	$705.60

PLATE SEMI-TUBULAR 5H SMTP-5

Facility

$1,260.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$1,222.20
Rate for Payer: Cash Price	$756.00
Rate for Payer: Hawaii Western Management Group Commercial	$882.00
Rate for Payer: Health Management Network Commercial	$1,071.00
Rate for Payer: Kaiser Permanente Commercial	$793.80
Rate for Payer: Kaiser Permanente Medicaid	$642.60
Rate for Payer: MDX Hawaii PPO	$1,222.20
Rate for Payer: University Health Alliance Commercial	$705.60

PLATE SEMI-TUBULAR 8H SMTP-8

Facility

$1,418.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$794.08
Max. Negotiated Rate	$1,375.46
Rate for Payer: Cash Price	$850.80
Rate for Payer: Hawaii Western Management Group Commercial	$992.60
Rate for Payer: Health Management Network Commercial	$1,205.30
Rate for Payer: MDX Hawaii PPO	$1,375.46
Rate for Payer: University Health Alliance Commercial	$794.08

PLATE SEMI-TUBULAR 8H SMTP-8

Facility

$1,418.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$723.18
Max. Negotiated Rate	$1,375.46
Rate for Payer: Cash Price	$850.80
Rate for Payer: Hawaii Western Management Group Commercial	$992.60
Rate for Payer: Health Management Network Commercial	$1,205.30
Rate for Payer: Kaiser Permanente Commercial	$893.34
Rate for Payer: Kaiser Permanente Medicaid	$723.18
Rate for Payer: MDX Hawaii PPO	$1,375.46
Rate for Payer: University Health Alliance Commercial	$794.08

PLATE SIDEWINDER LT 6H SWOL-6M

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.45
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Kaiser Permanente Commercial	$1,823.85
Rate for Payer: Kaiser Permanente Medicaid	$1,476.45
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER LT 6H SWOL-6M

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,621.20
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER LT 6H SWOL-6N

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,621.20
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER LT 6H SWOL-6N

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.45
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Kaiser Permanente Commercial	$1,823.85
Rate for Payer: Kaiser Permanente Medicaid	$1,476.45
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER LT 6H SWOL-6W

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,621.20
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER LT 6H SWOL-6W

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.45
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Kaiser Permanente Commercial	$1,823.85
Rate for Payer: Kaiser Permanente Medicaid	$1,476.45
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER LT 7H SWOL-7M

Facility

$2,200.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,540.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,232.00

PLATE SIDEWINDER LT 7H SWOL-7M

Facility

$2,200.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,232.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,540.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,232.00

PLATE SIDEWINDER LT 7H SWOL-7W

Facility

$2,200.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,540.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,232.00

PLATE SIDEWINDER LT 7H SWOL-7W

Facility

$2,200.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,232.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,540.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,232.00

PLATE SIDEWINDER RT 6H SWOR-6M

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.45
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Kaiser Permanente Commercial	$1,823.85
Rate for Payer: Kaiser Permanente Medicaid	$1,476.45
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER RT 6H SWOR-6M

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,621.20
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER RT 6H SWOR-6N

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,621.20
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER RT 6H SWOR-6N

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.45
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Kaiser Permanente Commercial	$1,823.85
Rate for Payer: Kaiser Permanente Medicaid	$1,476.45
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER RT 6H SWOR-6W

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,621.20
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER RT 6H SWOR-6W

Facility

$2,895.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,476.45
Max. Negotiated Rate	$2,808.15
Rate for Payer: Cash Price	$1,737.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,026.50
Rate for Payer: Health Management Network Commercial	$2,460.75
Rate for Payer: Kaiser Permanente Commercial	$1,823.85
Rate for Payer: Kaiser Permanente Medicaid	$1,476.45
Rate for Payer: MDX Hawaii PPO	$2,808.15
Rate for Payer: University Health Alliance Commercial	$1,621.20

PLATE SIDEWINDER RT 7H SWOR-7M

Facility

$2,200.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,122.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,540.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: Kaiser Permanente Commercial	$1,386.00
Rate for Payer: Kaiser Permanente Medicaid	$1,122.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,232.00

PLATE SIDEWINDER RT 7H SWOR-7M

Facility

$2,200.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,232.00
Max. Negotiated Rate	$2,134.00
Rate for Payer: Cash Price	$1,320.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,540.00
Rate for Payer: Health Management Network Commercial	$1,870.00
Rate for Payer: MDX Hawaii PPO	$2,134.00
Rate for Payer: University Health Alliance Commercial	$1,232.00

Know your out-of-pocket cost for care.

All Charges