Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE TIBIA 189MM 10H

Facility

$6,772.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,453.72
Max. Negotiated Rate	$6,568.84
Rate for Payer: Cash Price	$4,063.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,740.40
Rate for Payer: Health Management Network Commercial	$5,756.20
Rate for Payer: Kaiser Permanente Commercial	$4,266.36
Rate for Payer: Kaiser Permanente Medicaid	$3,453.72
Rate for Payer: MDX Hawaii PPO	$6,568.84
Rate for Payer: University Health Alliance Commercial	$3,792.32

PLATE TIBIA 189MM 10H

Facility

$6,772.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,792.32
Max. Negotiated Rate	$6,568.84
Rate for Payer: Cash Price	$4,063.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,740.40
Rate for Payer: Health Management Network Commercial	$5,756.20
Rate for Payer: MDX Hawaii PPO	$6,568.84
Rate for Payer: University Health Alliance Commercial	$3,792.32

PLATE TIBIA3.5MM SM 02.127.241

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,174.13
Max. Negotiated Rate	$4,135.11
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: Kaiser Permanente Commercial	$2,685.69
Rate for Payer: Kaiser Permanente Medicaid	$2,174.13
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE TIBIA3.5MM SM 02.127.241

Facility

$4,263.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,387.28
Max. Negotiated Rate	$4,135.11
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,984.10
Rate for Payer: Health Management Network Commercial	$3,623.55
Rate for Payer: MDX Hawaii PPO	$4,135.11
Rate for Payer: University Health Alliance Commercial	$2,387.28

PLATE TIBIAL 4H 121MM 627334

Facility

$3,712.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,893.12
Max. Negotiated Rate	$3,600.64
Rate for Payer: Cash Price	$2,227.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,598.40
Rate for Payer: Health Management Network Commercial	$3,155.20
Rate for Payer: Kaiser Permanente Commercial	$2,338.56
Rate for Payer: Kaiser Permanente Medicaid	$1,893.12
Rate for Payer: MDX Hawaii PPO	$3,600.64
Rate for Payer: University Health Alliance Commercial	$2,078.72

PLATE TIBIAL 4H 121MM 627334

Facility

$3,712.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,078.72
Max. Negotiated Rate	$3,600.64
Rate for Payer: Cash Price	$2,227.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,598.40
Rate for Payer: Health Management Network Commercial	$3,155.20
Rate for Payer: MDX Hawaii PPO	$3,600.64
Rate for Payer: University Health Alliance Commercial	$2,078.72

PLATE TIBIAL 6HOLE 336-4006

Facility

$3,528.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,975.68
Max. Negotiated Rate	$3,422.16
Rate for Payer: Cash Price	$2,116.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,469.60
Rate for Payer: Health Management Network Commercial	$2,998.80
Rate for Payer: MDX Hawaii PPO	$3,422.16
Rate for Payer: University Health Alliance Commercial	$1,975.68

PLATE TIBIAL 6HOLE 336-4006

Facility

$3,528.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,799.28
Max. Negotiated Rate	$3,422.16
Rate for Payer: Cash Price	$2,116.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,469.60
Rate for Payer: Health Management Network Commercial	$2,998.80
Rate for Payer: Kaiser Permanente Commercial	$2,222.64
Rate for Payer: Kaiser Permanente Medicaid	$1,799.28
Rate for Payer: MDX Hawaii PPO	$3,422.16
Rate for Payer: University Health Alliance Commercial	$1,975.68

PLATE TIBIAL LEFT 4MM 6H

Facility

$3,414.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,741.14
Max. Negotiated Rate	$3,311.58
Rate for Payer: Cash Price	$2,048.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,389.80
Rate for Payer: Health Management Network Commercial	$2,901.90
Rate for Payer: Kaiser Permanente Commercial	$2,150.82
Rate for Payer: Kaiser Permanente Medicaid	$1,741.14
Rate for Payer: MDX Hawaii PPO	$3,311.58
Rate for Payer: University Health Alliance Commercial	$1,911.84

PLATE TIBIAL LEFT 4MM 6H

Facility

$3,414.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,911.84
Max. Negotiated Rate	$3,311.58
Rate for Payer: Cash Price	$2,048.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,389.80
Rate for Payer: Health Management Network Commercial	$2,901.90
Rate for Payer: MDX Hawaii PPO	$3,311.58
Rate for Payer: University Health Alliance Commercial	$1,911.84

PLATE TIBIAL LF DISTAL 627404

Facility

$4,686.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,624.16
Max. Negotiated Rate	$4,545.42
Rate for Payer: Cash Price	$2,811.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,280.20
Rate for Payer: Health Management Network Commercial	$3,983.10
Rate for Payer: MDX Hawaii PPO	$4,545.42
Rate for Payer: University Health Alliance Commercial	$2,624.16

PLATE TIBIAL LF DISTAL 627404

Facility

$4,686.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,389.86
Max. Negotiated Rate	$4,545.42
Rate for Payer: Cash Price	$2,811.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,280.20
Rate for Payer: Health Management Network Commercial	$3,983.10
Rate for Payer: Kaiser Permanente Commercial	$2,952.18
Rate for Payer: Kaiser Permanente Medicaid	$2,389.86
Rate for Payer: MDX Hawaii PPO	$4,545.42
Rate for Payer: University Health Alliance Commercial	$2,624.16

PLATE TIBIAL RT 8H 627338

Facility

$5,204.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,914.24
Max. Negotiated Rate	$5,047.88
Rate for Payer: Cash Price	$3,122.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,642.80
Rate for Payer: Health Management Network Commercial	$4,423.40
Rate for Payer: MDX Hawaii PPO	$5,047.88
Rate for Payer: University Health Alliance Commercial	$2,914.24

PLATE TIBIAL RT 8H 627338

Facility

$5,204.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,654.04
Max. Negotiated Rate	$5,047.88
Rate for Payer: Cash Price	$3,122.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,642.80
Rate for Payer: Health Management Network Commercial	$4,423.40
Rate for Payer: Kaiser Permanente Commercial	$3,278.52
Rate for Payer: Kaiser Permanente Medicaid	$2,654.04
Rate for Payer: MDX Hawaii PPO	$5,047.88
Rate for Payer: University Health Alliance Commercial	$2,914.24

PLATE TIBIAL RT DISTAL 627440

Facility

$3,787.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,120.72
Max. Negotiated Rate	$3,673.39
Rate for Payer: Cash Price	$2,272.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,650.90
Rate for Payer: Health Management Network Commercial	$3,218.95
Rate for Payer: MDX Hawaii PPO	$3,673.39
Rate for Payer: University Health Alliance Commercial	$2,120.72

PLATE TIBIAL RT DISTAL 627440

Facility

$3,787.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,931.37
Max. Negotiated Rate	$3,673.39
Rate for Payer: Cash Price	$2,272.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,650.90
Rate for Payer: Health Management Network Commercial	$3,218.95
Rate for Payer: Kaiser Permanente Commercial	$2,385.81
Rate for Payer: Kaiser Permanente Medicaid	$1,931.37
Rate for Payer: MDX Hawaii PPO	$3,673.39
Rate for Payer: University Health Alliance Commercial	$2,120.72

PLATE TI MATRIX 04.503.396

Facility

$2,892.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,619.52
Max. Negotiated Rate	$2,805.24
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: University Health Alliance Commercial	$1,619.52

PLATE TI MATRIX 04.503.396

Facility

$2,892.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,474.92
Max. Negotiated Rate	$2,805.24
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Hawaii Western Management Group Commercial	$2,024.40
Rate for Payer: Health Management Network Commercial	$2,458.20
Rate for Payer: Kaiser Permanente Commercial	$1,821.96
Rate for Payer: Kaiser Permanente Medicaid	$1,474.92
Rate for Payer: MDX Hawaii PPO	$2,805.24
Rate for Payer: University Health Alliance Commercial	$1,619.52

PLATE TIT MANDI 12H 04.503.729

Facility

$2,770.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,551.20
Max. Negotiated Rate	$2,686.90
Rate for Payer: Cash Price	$1,662.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,939.00
Rate for Payer: Health Management Network Commercial	$2,354.50
Rate for Payer: MDX Hawaii PPO	$2,686.90
Rate for Payer: University Health Alliance Commercial	$1,551.20

PLATE TIT MANDI 12H 04.503.729

Facility

$2,770.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,412.70
Max. Negotiated Rate	$2,686.90
Rate for Payer: Cash Price	$1,662.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,939.00
Rate for Payer: Health Management Network Commercial	$2,354.50
Rate for Payer: Kaiser Permanente Commercial	$1,745.10
Rate for Payer: Kaiser Permanente Medicaid	$1,412.70
Rate for Payer: MDX Hawaii PPO	$2,686.90
Rate for Payer: University Health Alliance Commercial	$1,551.20

PLATE TIT MANDI 6H 04.503.728

Facility

$2,770.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,551.20
Max. Negotiated Rate	$2,686.90
Rate for Payer: Cash Price	$1,662.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,939.00
Rate for Payer: Health Management Network Commercial	$2,354.50
Rate for Payer: MDX Hawaii PPO	$2,686.90
Rate for Payer: University Health Alliance Commercial	$1,551.20

PLATE TIT MANDI 6H 04.503.728

Facility

$2,770.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,412.70
Max. Negotiated Rate	$2,686.90
Rate for Payer: Cash Price	$1,662.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,939.00
Rate for Payer: Health Management Network Commercial	$2,354.50
Rate for Payer: Kaiser Permanente Commercial	$1,745.10
Rate for Payer: Kaiser Permanente Medicaid	$1,412.70
Rate for Payer: MDX Hawaii PPO	$2,686.90
Rate for Payer: University Health Alliance Commercial	$1,551.20

PLATE T NARR LCK 2.0

Facility

$2,083.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,062.33
Max. Negotiated Rate	$2,020.51
Rate for Payer: Cash Price	$1,249.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,458.10
Rate for Payer: Health Management Network Commercial	$1,770.55
Rate for Payer: Kaiser Permanente Commercial	$1,312.29
Rate for Payer: Kaiser Permanente Medicaid	$1,062.33
Rate for Payer: MDX Hawaii PPO	$2,020.51
Rate for Payer: University Health Alliance Commercial	$1,166.48

PLATE T NARR LCK 2.0

Facility

$2,083.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,166.48
Max. Negotiated Rate	$2,020.51
Rate for Payer: Cash Price	$1,249.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,458.10
Rate for Payer: Health Management Network Commercial	$1,770.55
Rate for Payer: MDX Hawaii PPO	$2,020.51
Rate for Payer: University Health Alliance Commercial	$1,166.48

PLATE TUB 1/3 6H/73MM 241.36

Facility

$435.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$421.95
Rate for Payer: Cash Price	$261.00
Rate for Payer: Hawaii Western Management Group Commercial	$304.50
Rate for Payer: Health Management Network Commercial	$369.75
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: University Health Alliance Commercial	$243.60

Know your out-of-pocket cost for care.

All Charges