Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE SIDEWINDER RT 7H SWOR-7N

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 7H SWOR-7N

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-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 RT 7H SWOR-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 SMALL FRAGMENT 131217003

Facility

$1,671.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$935.76
Max. Negotiated Rate	$1,620.87
Rate for Payer: Cash Price	$1,002.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,169.70
Rate for Payer: Health Management Network Commercial	$1,420.35
Rate for Payer: MDX Hawaii PPO	$1,620.87
Rate for Payer: University Health Alliance Commercial	$935.76

PLATE SMALL FRAGMENT 131217003

Facility

$1,671.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$852.21
Max. Negotiated Rate	$1,620.87
Rate for Payer: Cash Price	$1,002.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,169.70
Rate for Payer: Health Management Network Commercial	$1,420.35
Rate for Payer: Kaiser Permanente Commercial	$1,052.73
Rate for Payer: Kaiser Permanente Medicaid	$852.21
Rate for Payer: MDX Hawaii PPO	$1,620.87
Rate for Payer: University Health Alliance Commercial	$935.76

PLATE SPOON 5HOLE/100MM 240.05

Facility

$914.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$466.14
Max. Negotiated Rate	$886.58
Rate for Payer: Cash Price	$548.40
Rate for Payer: Hawaii Western Management Group Commercial	$639.80
Rate for Payer: Health Management Network Commercial	$776.90
Rate for Payer: Kaiser Permanente Commercial	$575.82
Rate for Payer: Kaiser Permanente Medicaid	$466.14
Rate for Payer: MDX Hawaii PPO	$886.58
Rate for Payer: University Health Alliance Commercial	$511.84

PLATE SPOON 5HOLE/100MM 240.05

Facility

$914.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$511.84
Max. Negotiated Rate	$886.58
Rate for Payer: Cash Price	$548.40
Rate for Payer: Hawaii Western Management Group Commercial	$639.80
Rate for Payer: Health Management Network Commercial	$776.90
Rate for Payer: MDX Hawaii PPO	$886.58
Rate for Payer: University Health Alliance Commercial	$511.84

PLATE SPOON 6HOLE/120MM 240.06

Facility

$914.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$466.14
Max. Negotiated Rate	$886.58
Rate for Payer: Cash Price	$548.40
Rate for Payer: Hawaii Western Management Group Commercial	$639.80
Rate for Payer: Health Management Network Commercial	$776.90
Rate for Payer: Kaiser Permanente Commercial	$575.82
Rate for Payer: Kaiser Permanente Medicaid	$466.14
Rate for Payer: MDX Hawaii PPO	$886.58
Rate for Payer: University Health Alliance Commercial	$511.84

PLATE SPOON 6HOLE/120MM 240.06

Facility

$914.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$511.84
Max. Negotiated Rate	$886.58
Rate for Payer: Cash Price	$548.40
Rate for Payer: Hawaii Western Management Group Commercial	$639.80
Rate for Payer: Health Management Network Commercial	$776.90
Rate for Payer: MDX Hawaii PPO	$886.58
Rate for Payer: University Health Alliance Commercial	$511.84

PLATE STANDARD RIGHT DVRA-R

Facility

$2,235.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,251.60
Max. Negotiated Rate	$2,167.95
Rate for Payer: Cash Price	$1,341.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,564.50
Rate for Payer: Health Management Network Commercial	$1,899.75
Rate for Payer: MDX Hawaii PPO	$2,167.95
Rate for Payer: University Health Alliance Commercial	$1,251.60

PLATE STANDARD RIGHT DVRA-R

Facility

$2,235.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,139.85
Max. Negotiated Rate	$2,167.95
Rate for Payer: Cash Price	$1,341.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,564.50
Rate for Payer: Health Management Network Commercial	$1,899.75
Rate for Payer: Kaiser Permanente Commercial	$1,408.05
Rate for Payer: Kaiser Permanente Medicaid	$1,139.85
Rate for Payer: MDX Hawaii PPO	$2,167.95
Rate for Payer: University Health Alliance Commercial	$1,251.60

PLATE STD LFT 3H AR-8916VSL-03

Facility

$2,272.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.72
Max. Negotiated Rate	$2,203.84
Rate for Payer: Cash Price	$1,363.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,590.40
Rate for Payer: Health Management Network Commercial	$1,931.20
Rate for Payer: Kaiser Permanente Commercial	$1,431.36
Rate for Payer: Kaiser Permanente Medicaid	$1,158.72
Rate for Payer: MDX Hawaii PPO	$2,203.84
Rate for Payer: University Health Alliance Commercial	$1,272.32

PLATE STD LFT 3H AR-8916VSL-03

Facility

$2,272.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,272.32
Max. Negotiated Rate	$2,203.84
Rate for Payer: Cash Price	$1,363.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,590.40
Rate for Payer: Health Management Network Commercial	$1,931.20
Rate for Payer: MDX Hawaii PPO	$2,203.84
Rate for Payer: University Health Alliance Commercial	$1,272.32

PLATE STD RT ANKLE 28.14.102

Facility

$3,800.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,128.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

PLATE STD RT ANKLE 28.14.102

Facility

$3,800.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,938.00
Max. Negotiated Rate	$3,686.00
Rate for Payer: Cash Price	$2,280.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,660.00
Rate for Payer: Health Management Network Commercial	$3,230.00
Rate for Payer: Kaiser Permanente Commercial	$2,394.00
Rate for Payer: Kaiser Permanente Medicaid	$1,938.00
Rate for Payer: MDX Hawaii PPO	$3,686.00
Rate for Payer: University Health Alliance Commercial	$2,128.00

PLATE STR 103MM 8H 629548

Facility

$2,900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,479.00
Max. Negotiated Rate	$2,813.00
Rate for Payer: Cash Price	$1,740.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,030.00
Rate for Payer: Health Management Network Commercial	$2,465.00
Rate for Payer: Kaiser Permanente Commercial	$1,827.00
Rate for Payer: Kaiser Permanente Medicaid	$1,479.00
Rate for Payer: MDX Hawaii PPO	$2,813.00
Rate for Payer: University Health Alliance Commercial	$1,624.00

PLATE STR 103MM 8H 629548

Facility

$2,900.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,624.00
Max. Negotiated Rate	$2,813.00
Rate for Payer: Cash Price	$1,740.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,030.00
Rate for Payer: Health Management Network Commercial	$2,465.00
Rate for Payer: MDX Hawaii PPO	$2,813.00
Rate for Payer: University Health Alliance Commercial	$1,624.00

PLATE STRAIGHT 2.3X16 57-15316

Facility

$2,476.00

Service Code	HCPCS C1776
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 STRAIGHT 2.3X16 57-15316

Facility

$2,476.00

Service Code	HCPCS C1776
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 STR NARR 114MM 9H 629509

Facility

$2,225.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,134.75
Max. Negotiated Rate	$2,158.25
Rate for Payer: Cash Price	$1,335.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,557.50
Rate for Payer: Health Management Network Commercial	$1,891.25
Rate for Payer: Kaiser Permanente Commercial	$1,401.75
Rate for Payer: Kaiser Permanente Medicaid	$1,134.75
Rate for Payer: MDX Hawaii PPO	$2,158.25
Rate for Payer: University Health Alliance Commercial	$1,246.00

PLATE STR NARR 114MM 9H 629509

Facility

$2,225.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,246.00
Max. Negotiated Rate	$2,158.25
Rate for Payer: Cash Price	$1,335.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,557.50
Rate for Payer: Health Management Network Commercial	$1,891.25
Rate for Payer: MDX Hawaii PPO	$2,158.25
Rate for Payer: University Health Alliance Commercial	$1,246.00

PLATE STR NARR 90MM 7H 629527

Facility

$1,514.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$772.14
Max. Negotiated Rate	$1,468.58
Rate for Payer: Cash Price	$908.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,059.80
Rate for Payer: Health Management Network Commercial	$1,286.90
Rate for Payer: Kaiser Permanente Commercial	$953.82
Rate for Payer: Kaiser Permanente Medicaid	$772.14
Rate for Payer: MDX Hawaii PPO	$1,468.58
Rate for Payer: University Health Alliance Commercial	$847.84

PLATE STR NARR 90MM 7H 629527

Facility

$1,514.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$847.84
Max. Negotiated Rate	$1,468.58
Rate for Payer: Cash Price	$908.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,059.80
Rate for Payer: Health Management Network Commercial	$1,286.90
Rate for Payer: MDX Hawaii PPO	$1,468.58
Rate for Payer: University Health Alliance Commercial	$847.84

PLATE STR NARROW 54MM 4H

Facility

$1,331.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$678.81
Max. Negotiated Rate	$1,291.07
Rate for Payer: Cash Price	$798.60
Rate for Payer: Hawaii Western Management Group Commercial	$931.70
Rate for Payer: Health Management Network Commercial	$1,131.35
Rate for Payer: Kaiser Permanente Commercial	$838.53
Rate for Payer: Kaiser Permanente Medicaid	$678.81
Rate for Payer: MDX Hawaii PPO	$1,291.07
Rate for Payer: University Health Alliance Commercial	$745.36

Know your out-of-pocket cost for care.

All Charges