Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLAT LCP 12H 3.5X220MM 238.709

Facility

$3,724.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,085.44
Max. Negotiated Rate	$3,612.28
Rate for Payer: Cash Price	$2,234.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,606.80
Rate for Payer: Health Management Network Commercial	$3,165.40
Rate for Payer: MDX Hawaii PPO	$3,612.28
Rate for Payer: University Health Alliance Commercial	$2,085.44

PLAT LCP 12H 3.5X220MM 238.709

Facility

$3,724.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,899.24
Max. Negotiated Rate	$3,612.28
Rate for Payer: Cash Price	$2,234.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,606.80
Rate for Payer: Health Management Network Commercial	$3,165.40
Rate for Payer: Kaiser Permanente Commercial	$2,346.12
Rate for Payer: Kaiser Permanente Medicaid	$1,899.24
Rate for Payer: MDX Hawaii PPO	$3,612.28
Rate for Payer: University Health Alliance Commercial	$2,085.44

PLAT LCP 12H 4.5X224MM 224.621

Facility

$2,217.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,241.52
Max. Negotiated Rate	$2,150.49
Rate for Payer: Cash Price	$1,330.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,551.90
Rate for Payer: Health Management Network Commercial	$1,884.45
Rate for Payer: MDX Hawaii PPO	$2,150.49
Rate for Payer: University Health Alliance Commercial	$1,241.52

PLAT LCP 12H 4.5X224MM 224.621

Facility

$2,217.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,130.67
Max. Negotiated Rate	$2,150.49
Rate for Payer: Cash Price	$1,330.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,551.90
Rate for Payer: Health Management Network Commercial	$1,884.45
Rate for Payer: Kaiser Permanente Commercial	$1,396.71
Rate for Payer: Kaiser Permanente Medicaid	$1,130.67
Rate for Payer: MDX Hawaii PPO	$2,150.49
Rate for Payer: University Health Alliance Commercial	$1,241.52

PLAT LCP 12H 4.5X224MM 226.621

Facility

$2,102.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,177.12
Max. Negotiated Rate	$2,038.94
Rate for Payer: Cash Price	$1,261.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,471.40
Rate for Payer: Health Management Network Commercial	$1,786.70
Rate for Payer: MDX Hawaii PPO	$2,038.94
Rate for Payer: University Health Alliance Commercial	$1,177.12

PLAT LCP 12H 4.5X224MM 226.621

Facility

$2,102.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,072.02
Max. Negotiated Rate	$2,038.94
Rate for Payer: Cash Price	$1,261.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,471.40
Rate for Payer: Health Management Network Commercial	$1,786.70
Rate for Payer: Kaiser Permanente Commercial	$1,324.26
Rate for Payer: Kaiser Permanente Medicaid	$1,072.02
Rate for Payer: MDX Hawaii PPO	$2,038.94
Rate for Payer: University Health Alliance Commercial	$1,177.12

PLAT LCP 13H 4.5X242MM 224.631

Facility

$2,739.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,533.84
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: MDX Hawaii PPO	$2,656.83
Rate for Payer: University Health Alliance Commercial	$1,533.84

PLAT LCP 13H 4.5X242MM 224.631

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

PLAT LCP 14H 3.5X189MM 223.641

Facility

$2,124.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,189.44
Max. Negotiated Rate	$2,060.28
Rate for Payer: Cash Price	$1,274.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.80
Rate for Payer: Health Management Network Commercial	$1,805.40
Rate for Payer: MDX Hawaii PPO	$2,060.28
Rate for Payer: University Health Alliance Commercial	$1,189.44

PLAT LCP 14H 3.5X189MM 223.641

Facility

$2,124.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,083.24
Max. Negotiated Rate	$2,060.28
Rate for Payer: Cash Price	$1,274.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,486.80
Rate for Payer: Health Management Network Commercial	$1,805.40
Rate for Payer: Kaiser Permanente Commercial	$1,338.12
Rate for Payer: Kaiser Permanente Medicaid	$1,083.24
Rate for Payer: MDX Hawaii PPO	$2,060.28
Rate for Payer: University Health Alliance Commercial	$1,189.44

PLAT LCP 14H 4.5X260MM 224.641

Facility

$2,086.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,168.16
Max. Negotiated Rate	$2,023.42
Rate for Payer: Cash Price	$1,251.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,460.20
Rate for Payer: Health Management Network Commercial	$1,773.10
Rate for Payer: MDX Hawaii PPO	$2,023.42
Rate for Payer: University Health Alliance Commercial	$1,168.16

PLAT LCP 14H 4.5X260MM 224.641

Facility

$2,086.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,063.86
Max. Negotiated Rate	$2,023.42
Rate for Payer: Cash Price	$1,251.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,460.20
Rate for Payer: Health Management Network Commercial	$1,773.10
Rate for Payer: Kaiser Permanente Commercial	$1,314.18
Rate for Payer: Kaiser Permanente Medicaid	$1,063.86
Rate for Payer: MDX Hawaii PPO	$2,023.42
Rate for Payer: University Health Alliance Commercial	$1,168.16

PLAT LCP 14H 4.5X260MM 226.641

Facility

$2,786.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,420.86
Max. Negotiated Rate	$2,702.42
Rate for Payer: Cash Price	$1,671.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,950.20
Rate for Payer: Health Management Network Commercial	$2,368.10
Rate for Payer: Kaiser Permanente Commercial	$1,755.18
Rate for Payer: Kaiser Permanente Medicaid	$1,420.86
Rate for Payer: MDX Hawaii PPO	$2,702.42
Rate for Payer: University Health Alliance Commercial	$1,560.16

PLAT LCP 14H 4.5X260MM 226.641

Facility

$2,786.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,560.16
Max. Negotiated Rate	$2,702.42
Rate for Payer: Cash Price	$1,671.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,950.20
Rate for Payer: Health Management Network Commercial	$2,368.10
Rate for Payer: MDX Hawaii PPO	$2,702.42
Rate for Payer: University Health Alliance Commercial	$1,560.16

PLAT LCP 16H 4.5X296MM 224.661

Facility

$2,438.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,243.38
Max. Negotiated Rate	$2,364.86
Rate for Payer: Cash Price	$1,462.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,706.60
Rate for Payer: Health Management Network Commercial	$2,072.30
Rate for Payer: Kaiser Permanente Commercial	$1,535.94
Rate for Payer: Kaiser Permanente Medicaid	$1,243.38
Rate for Payer: MDX Hawaii PPO	$2,364.86
Rate for Payer: University Health Alliance Commercial	$1,365.28

PLAT LCP 16H 4.5X296MM 224.661

Facility

$2,438.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,365.28
Max. Negotiated Rate	$2,364.86
Rate for Payer: Cash Price	$1,462.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,706.60
Rate for Payer: Health Management Network Commercial	$2,072.30
Rate for Payer: MDX Hawaii PPO	$2,364.86
Rate for Payer: University Health Alliance Commercial	$1,365.28

PLAT LCP 16H 4.5X296MM 226.661

Facility

$2,842.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,591.52
Max. Negotiated Rate	$2,756.74
Rate for Payer: Cash Price	$1,705.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,989.40
Rate for Payer: Health Management Network Commercial	$2,415.70
Rate for Payer: MDX Hawaii PPO	$2,756.74
Rate for Payer: University Health Alliance Commercial	$1,591.52

PLAT LCP 16H 4.5X296MM 226.661

Facility

$2,842.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,449.42
Max. Negotiated Rate	$2,756.74
Rate for Payer: Cash Price	$1,705.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,989.40
Rate for Payer: Health Management Network Commercial	$2,415.70
Rate for Payer: Kaiser Permanente Commercial	$1,790.46
Rate for Payer: Kaiser Permanente Medicaid	$1,449.42
Rate for Payer: MDX Hawaii PPO	$2,756.74
Rate for Payer: University Health Alliance Commercial	$1,591.52

PLAT LCP 18H 4.5X332MM 224.681

Facility

$2,960.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,657.60
Max. Negotiated Rate	$2,871.20
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,072.00
Rate for Payer: Health Management Network Commercial	$2,516.00
Rate for Payer: MDX Hawaii PPO	$2,871.20
Rate for Payer: University Health Alliance Commercial	$1,657.60

PLAT LCP 18H 4.5X332MM 224.681

Facility

$2,960.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,509.60
Max. Negotiated Rate	$2,871.20
Rate for Payer: Cash Price	$1,776.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,072.00
Rate for Payer: Health Management Network Commercial	$2,516.00
Rate for Payer: Kaiser Permanente Commercial	$1,864.80
Rate for Payer: Kaiser Permanente Medicaid	$1,509.60
Rate for Payer: MDX Hawaii PPO	$2,871.20
Rate for Payer: University Health Alliance Commercial	$1,657.60

PLAT LCP 18H 4.5X332MM 226.681

Facility

$3,460.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,937.60
Max. Negotiated Rate	$3,356.20
Rate for Payer: Cash Price	$2,076.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,422.00
Rate for Payer: Health Management Network Commercial	$2,941.00
Rate for Payer: MDX Hawaii PPO	$3,356.20
Rate for Payer: University Health Alliance Commercial	$1,937.60

PLAT LCP 18H 4.5X332MM 226.681

Facility

$3,460.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,764.60
Max. Negotiated Rate	$3,356.20
Rate for Payer: Cash Price	$2,076.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,422.00
Rate for Payer: Health Management Network Commercial	$2,941.00
Rate for Payer: Kaiser Permanente Commercial	$2,179.80
Rate for Payer: Kaiser Permanente Medicaid	$1,764.60
Rate for Payer: MDX Hawaii PPO	$3,356.20
Rate for Payer: University Health Alliance Commercial	$1,937.60

PLAT LCP 20H 4.5X368MM 224.701

Facility

$3,764.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,107.84
Max. Negotiated Rate	$3,651.08
Rate for Payer: Cash Price	$2,258.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,634.80
Rate for Payer: Health Management Network Commercial	$3,199.40
Rate for Payer: MDX Hawaii PPO	$3,651.08
Rate for Payer: University Health Alliance Commercial	$2,107.84

PLAT LCP 20H 4.5X368MM 224.701

Facility

$3,764.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,919.64
Max. Negotiated Rate	$3,651.08
Rate for Payer: Cash Price	$2,258.40
Rate for Payer: Hawaii Western Management Group Commercial	$2,634.80
Rate for Payer: Health Management Network Commercial	$3,199.40
Rate for Payer: Kaiser Permanente Commercial	$2,371.32
Rate for Payer: Kaiser Permanente Medicaid	$1,919.64
Rate for Payer: MDX Hawaii PPO	$3,651.08
Rate for Payer: University Health Alliance Commercial	$2,107.84

PLAT LCP 20H 4.5X368MM 226.701

Facility

$3,820.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,948.20
Max. Negotiated Rate	$3,705.40
Rate for Payer: Cash Price	$2,292.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,674.00
Rate for Payer: Health Management Network Commercial	$3,247.00
Rate for Payer: Kaiser Permanente Commercial	$2,406.60
Rate for Payer: Kaiser Permanente Medicaid	$1,948.20
Rate for Payer: MDX Hawaii PPO	$3,705.40
Rate for Payer: University Health Alliance Commercial	$2,139.20

Know your out-of-pocket cost for care.

All Charges