Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLATE VOL LT/5H/5PEG VLBPL-5-5

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,691.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLATE VOL LT/5H/5PEG VLBPL-5-5

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,540.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: Kaiser Permanente Commercial	$1,902.60
Rate for Payer: Kaiser Permanente Medicaid	$1,540.20
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLATE VOL LT/5H/7PEG VLBPL-5-7

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,691.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLATE VOL LT/5H/7PEG VLBPL-5-7

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,540.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: Kaiser Permanente Commercial	$1,902.60
Rate for Payer: Kaiser Permanente Medicaid	$1,540.20
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

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

Facility

$3,320.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,859.20
Max. Negotiated Rate	$3,220.40
Rate for Payer: Cash Price	$1,992.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,324.00
Rate for Payer: Health Management Network Commercial	$2,822.00
Rate for Payer: MDX Hawaii PPO	$3,220.40
Rate for Payer: University Health Alliance Commercial	$1,859.20

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

Facility

$3,320.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,693.20
Max. Negotiated Rate	$3,220.40
Rate for Payer: Cash Price	$1,992.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,324.00
Rate for Payer: Health Management Network Commercial	$2,822.00
Rate for Payer: Kaiser Permanente Commercial	$2,091.60
Rate for Payer: Kaiser Permanente Medicaid	$1,693.20
Rate for Payer: MDX Hawaii PPO	$3,220.40
Rate for Payer: University Health Alliance Commercial	$1,859.20

PLATE VOL RT/3H/7PEG VLBPR-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 RT/3H/7PEG VLBPR-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

PLATE VOL RT/5H/7PEG VLBPR-5-7

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,691.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLATE VOL RT/5H/7PEG VLBPR-5-7

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,540.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: Kaiser Permanente Commercial	$1,902.60
Rate for Payer: Kaiser Permanente Medicaid	$1,540.20
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLATE VOL RT/7H/7PEG VLBPR-7-7

Facility

$3,320.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,693.20
Max. Negotiated Rate	$3,220.40
Rate for Payer: Cash Price	$1,992.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,324.00
Rate for Payer: Health Management Network Commercial	$2,822.00
Rate for Payer: Kaiser Permanente Commercial	$2,091.60
Rate for Payer: Kaiser Permanente Medicaid	$1,693.20
Rate for Payer: MDX Hawaii PPO	$3,220.40
Rate for Payer: University Health Alliance Commercial	$1,859.20

PLATE VOL RT/7H/7PEG VLBPR-7-7

Facility

$3,320.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,859.20
Max. Negotiated Rate	$3,220.40
Rate for Payer: Cash Price	$1,992.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,324.00
Rate for Payer: Health Management Network Commercial	$2,822.00
Rate for Payer: MDX Hawaii PPO	$3,220.40
Rate for Payer: University Health Alliance Commercial	$1,859.20

PLATE VOL RT/9H/7PEG VLBPR-9-7

Facility

$4,330.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,424.80
Max. Negotiated Rate	$4,200.10
Rate for Payer: Cash Price	$2,598.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,031.00
Rate for Payer: Health Management Network Commercial	$3,680.50
Rate for Payer: MDX Hawaii PPO	$4,200.10
Rate for Payer: University Health Alliance Commercial	$2,424.80

PLATE VOL RT/9H/7PEG VLBPR-9-7

Facility

$4,330.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,208.30
Max. Negotiated Rate	$4,200.10
Rate for Payer: Cash Price	$2,598.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,031.00
Rate for Payer: Health Management Network Commercial	$3,680.50
Rate for Payer: Kaiser Permanente Commercial	$2,727.90
Rate for Payer: Kaiser Permanente Medicaid	$2,208.30
Rate for Payer: MDX Hawaii PPO	$4,200.10
Rate for Payer: University Health Alliance Commercial	$2,424.80

PLATE WIRE FORM 3H WFP3

Facility

$1,650.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$841.50
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: Kaiser Permanente Commercial	$1,039.50
Rate for Payer: Kaiser Permanente Medicaid	$841.50
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

PLATE WIRE FORM 3H WFP3

Facility

$1,650.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,600.50
Rate for Payer: Cash Price	$990.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,155.00
Rate for Payer: Health Management Network Commercial	$1,402.50
Rate for Payer: MDX Hawaii PPO	$1,600.50
Rate for Payer: University Health Alliance Commercial	$924.00

PLATE WIRE FORM 5H WFP5

Facility

$1,680.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$940.80
Max. Negotiated Rate	$1,629.60
Rate for Payer: Cash Price	$1,008.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,176.00
Rate for Payer: Health Management Network Commercial	$1,428.00
Rate for Payer: MDX Hawaii PPO	$1,629.60
Rate for Payer: University Health Alliance Commercial	$940.80

PLATE WIRE FORM 5H WFP5

Facility

$1,680.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,629.60
Rate for Payer: Cash Price	$1,008.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,176.00
Rate for Payer: Health Management Network Commercial	$1,428.00
Rate for Payer: Kaiser Permanente Commercial	$1,058.40
Rate for Payer: Kaiser Permanente Medicaid	$856.80
Rate for Payer: MDX Hawaii PPO	$1,629.60
Rate for Payer: University Health Alliance Commercial	$940.80

PLATE WRIST FUSION RFP-SHB

Facility

$2,070.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,055.70
Max. Negotiated Rate	$2,007.90
Rate for Payer: Cash Price	$1,242.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,449.00
Rate for Payer: Health Management Network Commercial	$1,759.50
Rate for Payer: Kaiser Permanente Commercial	$1,304.10
Rate for Payer: Kaiser Permanente Medicaid	$1,055.70
Rate for Payer: MDX Hawaii PPO	$2,007.90
Rate for Payer: University Health Alliance Commercial	$1,159.20

PLATE WRIST FUSION RFP-SHB

Facility

$2,070.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,159.20
Max. Negotiated Rate	$2,007.90
Rate for Payer: Cash Price	$1,242.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,449.00
Rate for Payer: Health Management Network Commercial	$1,759.50
Rate for Payer: MDX Hawaii PPO	$2,007.90
Rate for Payer: University Health Alliance Commercial	$1,159.20

PLATE WRIST FUSION STR RFP-STR

Facility

$2,070.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,159.20
Max. Negotiated Rate	$2,007.90
Rate for Payer: Cash Price	$1,242.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,449.00
Rate for Payer: Health Management Network Commercial	$1,759.50
Rate for Payer: MDX Hawaii PPO	$2,007.90
Rate for Payer: University Health Alliance Commercial	$1,159.20

PLATE WRIST FUSION STR RFP-STR

Facility

$2,070.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,055.70
Max. Negotiated Rate	$2,007.90
Rate for Payer: Cash Price	$1,242.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,449.00
Rate for Payer: Health Management Network Commercial	$1,759.50
Rate for Payer: Kaiser Permanente Commercial	$1,304.10
Rate for Payer: Kaiser Permanente Medicaid	$1,055.70
Rate for Payer: MDX Hawaii PPO	$2,007.90
Rate for Payer: University Health Alliance Commercial	$1,159.20

PLATE WRIST SPANNING TI

Facility

$5,984.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,051.84
Max. Negotiated Rate	$5,804.48
Rate for Payer: Cash Price	$3,590.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,188.80
Rate for Payer: Health Management Network Commercial	$5,086.40
Rate for Payer: Kaiser Permanente Commercial	$3,769.92
Rate for Payer: Kaiser Permanente Medicaid	$3,051.84
Rate for Payer: MDX Hawaii PPO	$5,804.48
Rate for Payer: University Health Alliance Commercial	$3,351.04

PLATE WRIST SPANNING TI

Facility

$5,984.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,351.04
Max. Negotiated Rate	$5,804.48
Rate for Payer: Cash Price	$3,590.40
Rate for Payer: Hawaii Western Management Group Commercial	$4,188.80
Rate for Payer: Health Management Network Commercial	$5,086.40
Rate for Payer: MDX Hawaii PPO	$5,804.48
Rate for Payer: University Health Alliance Commercial	$3,351.04

PLATE Y 629770

Facility

$2,739.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,396.89
Max. Negotiated Rate	$2,656.83
Rate for Payer: Cash Price	$1,643.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,917.30
Rate for Payer: Health Management Network Commercial	$2,328.15
Rate for Payer: Kaiser Permanente Commercial	$1,725.57
Rate for Payer: Kaiser Permanente Medicaid	$1,396.89
Rate for Payer: MDX Hawaii PPO	$2,656.83
Rate for Payer: University Health Alliance Commercial	$1,533.84

Know your out-of-pocket cost for care.

All Charges