Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE TUB 1/3 6H/73MM 241.36

Facility

$435.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$221.85
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: Kaiser Permanente Commercial	$274.05
Rate for Payer: Kaiser Permanente Medicaid	$221.85
Rate for Payer: MDX Hawaii PPO	$421.95
Rate for Payer: University Health Alliance Commercial	$243.60

PLATE TUBULAR 626674

Facility

$1,234.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$629.34
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$740.40
Rate for Payer: Hawaii Western Management Group Commercial	$863.80
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Kaiser Permanente Commercial	$777.42
Rate for Payer: Kaiser Permanente Medicaid	$629.34
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: University Health Alliance Commercial	$691.04

PLATE TUBULAR 626674

Facility

$1,234.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$691.04
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$740.40
Rate for Payer: Hawaii Western Management Group Commercial	$863.80
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: University Health Alliance Commercial	$691.04

PLATE TUBULAR 95MM 8 HOLES

Facility

$1,234.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$629.34
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$740.40
Rate for Payer: Hawaii Western Management Group Commercial	$863.80
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: Kaiser Permanente Commercial	$777.42
Rate for Payer: Kaiser Permanente Medicaid	$629.34
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: University Health Alliance Commercial	$691.04

PLATE TUBULAR 95MM 8 HOLES

Facility

$1,234.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$691.04
Max. Negotiated Rate	$1,196.98
Rate for Payer: Cash Price	$740.40
Rate for Payer: Hawaii Western Management Group Commercial	$863.80
Rate for Payer: Health Management Network Commercial	$1,048.90
Rate for Payer: MDX Hawaii PPO	$1,196.98
Rate for Payer: University Health Alliance Commercial	$691.04

PLATE ULNAR PEG 5H UPG-5

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 ULNAR PEG 5H UPG-5

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 ULNAR PEG 7H UPG-7

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 ULNAR PEG 7H UPG-7

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 VA-LCP 2.7X69 02.117.401

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,539.44
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

PLATE VA-LCP 2.7X69 02.117.401

Facility

$2,749.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,401.99
Max. Negotiated Rate	$2,666.53
Rate for Payer: Cash Price	$1,649.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,924.30
Rate for Payer: Health Management Network Commercial	$2,336.65
Rate for Payer: Kaiser Permanente Commercial	$1,731.87
Rate for Payer: Kaiser Permanente Medicaid	$1,401.99
Rate for Payer: MDX Hawaii PPO	$2,666.53
Rate for Payer: University Health Alliance Commercial	$1,539.44

PLATE VA-LCP RT SM 02.127.220

Facility

$3,704.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,889.04
Max. Negotiated Rate	$3,592.88
Rate for Payer: Cash Price	$2,222.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,592.80
Rate for Payer: Health Management Network Commercial	$3,148.40
Rate for Payer: Kaiser Permanente Commercial	$2,333.52
Rate for Payer: Kaiser Permanente Medicaid	$1,889.04
Rate for Payer: MDX Hawaii PPO	$3,592.88
Rate for Payer: University Health Alliance Commercial	$2,074.24

PLATE VA-LCP RT SM 02.127.220

Facility

$3,704.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,074.24
Max. Negotiated Rate	$3,592.88
Rate for Payer: Cash Price	$2,222.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,592.80
Rate for Payer: Health Management Network Commercial	$3,148.40
Rate for Payer: MDX Hawaii PPO	$3,592.88
Rate for Payer: University Health Alliance Commercial	$2,074.24

PLATE VOLAR DISTAL RAD RT 3H

Facility

$2,650.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,351.50
Max. Negotiated Rate	$2,570.50
Rate for Payer: Cash Price	$1,590.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,855.00
Rate for Payer: Health Management Network Commercial	$2,252.50
Rate for Payer: Kaiser Permanente Commercial	$1,669.50
Rate for Payer: Kaiser Permanente Medicaid	$1,351.50
Rate for Payer: MDX Hawaii PPO	$2,570.50
Rate for Payer: University Health Alliance Commercial	$1,484.00

PLATE VOLAR DISTAL RAD RT 3H

Facility

$2,650.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,484.00
Max. Negotiated Rate	$2,570.50
Rate for Payer: Cash Price	$1,590.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,855.00
Rate for Payer: Health Management Network Commercial	$2,252.50
Rate for Payer: MDX Hawaii PPO	$2,570.50
Rate for Payer: University Health Alliance Commercial	$1,484.00

PLATE VOLAR EXT LEFT DVRAX-L

Facility

$2,391.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,219.41
Max. Negotiated Rate	$2,319.27
Rate for Payer: Cash Price	$1,434.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,673.70
Rate for Payer: Health Management Network Commercial	$2,032.35
Rate for Payer: Kaiser Permanente Commercial	$1,506.33
Rate for Payer: Kaiser Permanente Medicaid	$1,219.41
Rate for Payer: MDX Hawaii PPO	$2,319.27
Rate for Payer: University Health Alliance Commercial	$1,338.96

PLATE VOLAR EXT LEFT DVRAX-L

Facility

$2,391.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,338.96
Max. Negotiated Rate	$2,319.27
Rate for Payer: Cash Price	$1,434.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,673.70
Rate for Payer: Health Management Network Commercial	$2,032.35
Rate for Payer: MDX Hawaii PPO	$2,319.27
Rate for Payer: University Health Alliance Commercial	$1,338.96

PLATE VOLAR EXT RIGHT DVRAX-R

Facility

$2,391.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,219.41
Max. Negotiated Rate	$2,319.27
Rate for Payer: Cash Price	$1,434.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,673.70
Rate for Payer: Health Management Network Commercial	$2,032.35
Rate for Payer: Kaiser Permanente Commercial	$1,506.33
Rate for Payer: Kaiser Permanente Medicaid	$1,219.41
Rate for Payer: MDX Hawaii PPO	$2,319.27
Rate for Payer: University Health Alliance Commercial	$1,338.96

PLATE VOLAR EXT RIGHT DVRAX-R

Facility

$2,391.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,338.96
Max. Negotiated Rate	$2,319.27
Rate for Payer: Cash Price	$1,434.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,673.70
Rate for Payer: Health Management Network Commercial	$2,032.35
Rate for Payer: MDX Hawaii PPO	$2,319.27
Rate for Payer: University Health Alliance Commercial	$1,338.96

PLATE VOLAR SHEAR LT VSP-L

Facility

$2,175.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,109.25
Max. Negotiated Rate	$2,109.75
Rate for Payer: Cash Price	$1,305.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,522.50
Rate for Payer: Health Management Network Commercial	$1,848.75
Rate for Payer: Kaiser Permanente Commercial	$1,370.25
Rate for Payer: Kaiser Permanente Medicaid	$1,109.25
Rate for Payer: MDX Hawaii PPO	$2,109.75
Rate for Payer: University Health Alliance Commercial	$1,218.00

PLATE VOLAR SHEAR LT VSP-L

Facility

$2,175.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,218.00
Max. Negotiated Rate	$2,109.75
Rate for Payer: Cash Price	$1,305.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,522.50
Rate for Payer: Health Management Network Commercial	$1,848.75
Rate for Payer: MDX Hawaii PPO	$2,109.75
Rate for Payer: University Health Alliance Commercial	$1,218.00

PLATE VOLAR SHEAR RT VSP-R

Facility

$2,175.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,218.00
Max. Negotiated Rate	$2,109.75
Rate for Payer: Cash Price	$1,305.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,522.50
Rate for Payer: Health Management Network Commercial	$1,848.75
Rate for Payer: MDX Hawaii PPO	$2,109.75
Rate for Payer: University Health Alliance Commercial	$1,218.00

PLATE VOLAR SHEAR RT VSP-R

Facility

$2,175.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,109.25
Max. Negotiated Rate	$2,109.75
Rate for Payer: Cash Price	$1,305.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,522.50
Rate for Payer: Health Management Network Commercial	$1,848.75
Rate for Payer: Kaiser Permanente Commercial	$1,370.25
Rate for Payer: Kaiser Permanente Medicaid	$1,109.25
Rate for Payer: MDX Hawaii PPO	$2,109.75
Rate for Payer: University Health Alliance Commercial	$1,218.00

PLATE VOL LT/3H/7PEG VLBPL-3-7

Facility

$2,760.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,545.60
Max. Negotiated Rate	$2,677.20
Rate for Payer: Cash Price	$1,656.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,932.00
Rate for Payer: Health Management Network Commercial	$2,346.00
Rate for Payer: MDX Hawaii PPO	$2,677.20
Rate for Payer: University Health Alliance Commercial	$1,545.60

PLATE VOL LT/3H/7PEG VLBPL-3-7

Facility

$2,760.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,407.60
Max. Negotiated Rate	$2,677.20
Rate for Payer: Cash Price	$1,656.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,932.00
Rate for Payer: Health Management Network Commercial	$2,346.00
Rate for Payer: Kaiser Permanente Commercial	$1,738.80
Rate for Payer: Kaiser Permanente Medicaid	$1,407.60
Rate for Payer: MDX Hawaii PPO	$2,677.20
Rate for Payer: University Health Alliance Commercial	$1,545.60

Know your out-of-pocket cost for care.

All Charges