Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLAT LCP 20H 4.5X368MM 226.701

Facility

$3,820.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,139.20
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: MDX Hawaii PPO	$3,705.40
Rate for Payer: University Health Alliance Commercial	$2,139.20

PLAT LCP 22H 4.5X404MM 224.721

Facility

$4,108.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,095.08
Max. Negotiated Rate	$3,984.76
Rate for Payer: Cash Price	$2,464.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,875.60
Rate for Payer: Health Management Network Commercial	$3,491.80
Rate for Payer: Kaiser Permanente Commercial	$2,588.04
Rate for Payer: Kaiser Permanente Medicaid	$2,095.08
Rate for Payer: MDX Hawaii PPO	$3,984.76
Rate for Payer: University Health Alliance Commercial	$2,300.48

PLAT LCP 22H 4.5X404MM 224.721

Facility

$4,108.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,300.48
Max. Negotiated Rate	$3,984.76
Rate for Payer: Cash Price	$2,464.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,875.60
Rate for Payer: Health Management Network Commercial	$3,491.80
Rate for Payer: MDX Hawaii PPO	$3,984.76
Rate for Payer: University Health Alliance Commercial	$2,300.48

PLAT LCP 22H 4.5X404MM 226.721

Facility

$4,186.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,134.86
Max. Negotiated Rate	$4,060.42
Rate for Payer: Cash Price	$2,511.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,930.20
Rate for Payer: Health Management Network Commercial	$3,558.10
Rate for Payer: Kaiser Permanente Commercial	$2,637.18
Rate for Payer: Kaiser Permanente Medicaid	$2,134.86
Rate for Payer: MDX Hawaii PPO	$4,060.42
Rate for Payer: University Health Alliance Commercial	$2,344.16

PLAT LCP 22H 4.5X404MM 226.721

Facility

$4,186.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,344.16
Max. Negotiated Rate	$4,060.42
Rate for Payer: Cash Price	$2,511.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,930.20
Rate for Payer: Health Management Network Commercial	$3,558.10
Rate for Payer: MDX Hawaii PPO	$4,060.42
Rate for Payer: University Health Alliance Commercial	$2,344.16

PLAT LCP 4H 3.5X116MM 238.701

Facility

$3,570.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,999.20
Max. Negotiated Rate	$3,462.90
Rate for Payer: Cash Price	$2,142.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,499.00
Rate for Payer: Health Management Network Commercial	$3,034.50
Rate for Payer: MDX Hawaii PPO	$3,462.90
Rate for Payer: University Health Alliance Commercial	$1,999.20

PLAT LCP 4H 3.5X116MM 238.701

Facility

$3,570.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,820.70
Max. Negotiated Rate	$3,462.90
Rate for Payer: Cash Price	$2,142.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,499.00
Rate for Payer: Health Management Network Commercial	$3,034.50
Rate for Payer: Kaiser Permanente Commercial	$2,249.10
Rate for Payer: Kaiser Permanente Medicaid	$1,820.70
Rate for Payer: MDX Hawaii PPO	$3,462.90
Rate for Payer: University Health Alliance Commercial	$1,999.20

PLAT LCP 6H 3.5X142MM 238.702

Facility

$3,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.10
Max. Negotiated Rate	$3,501.70
Rate for Payer: Cash Price	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$3,068.50
Rate for Payer: Kaiser Permanente Commercial	$2,274.30
Rate for Payer: Kaiser Permanente Medicaid	$1,841.10
Rate for Payer: MDX Hawaii PPO	$3,501.70
Rate for Payer: University Health Alliance Commercial	$2,021.60

PLAT LCP 6H 3.5X142MM 238.702

Facility

$3,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,021.60
Max. Negotiated Rate	$3,501.70
Rate for Payer: Cash Price	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$3,068.50
Rate for Payer: MDX Hawaii PPO	$3,501.70
Rate for Payer: University Health Alliance Commercial	$2,021.60

PLAT LCP 6H 3.5X142MM 238.703

Facility

$3,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,841.10
Max. Negotiated Rate	$3,501.70
Rate for Payer: Cash Price	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$3,068.50
Rate for Payer: Kaiser Permanente Commercial	$2,274.30
Rate for Payer: Kaiser Permanente Medicaid	$1,841.10
Rate for Payer: MDX Hawaii PPO	$3,501.70
Rate for Payer: University Health Alliance Commercial	$2,021.60

PLAT LCP 6H 3.5X142MM 238.703

Facility

$3,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,021.60
Max. Negotiated Rate	$3,501.70
Rate for Payer: Cash Price	$2,166.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,527.00
Rate for Payer: Health Management Network Commercial	$3,068.50
Rate for Payer: MDX Hawaii PPO	$3,501.70
Rate for Payer: University Health Alliance Commercial	$2,021.60

PLAT LCP 8H 3.5X168MM 238.704

Facility

$3,646.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,041.76
Max. Negotiated Rate	$3,536.62
Rate for Payer: Cash Price	$2,187.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,552.20
Rate for Payer: Health Management Network Commercial	$3,099.10
Rate for Payer: MDX Hawaii PPO	$3,536.62
Rate for Payer: University Health Alliance Commercial	$2,041.76

PLAT LCP 8H 3.5X168MM 238.704

Facility

$3,646.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,859.46
Max. Negotiated Rate	$3,536.62
Rate for Payer: Cash Price	$2,187.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,552.20
Rate for Payer: Health Management Network Commercial	$3,099.10
Rate for Payer: Kaiser Permanente Commercial	$2,296.98
Rate for Payer: Kaiser Permanente Medicaid	$1,859.46
Rate for Payer: MDX Hawaii PPO	$3,536.62
Rate for Payer: University Health Alliance Commercial	$2,041.76

PLAT LCP-T 3H 3.5X50MM 241.131

Facility

$1,292.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$658.92
Max. Negotiated Rate	$1,253.24
Rate for Payer: Cash Price	$775.20
Rate for Payer: Hawaii Western Management Group Commercial	$904.40
Rate for Payer: Health Management Network Commercial	$1,098.20
Rate for Payer: Kaiser Permanente Commercial	$813.96
Rate for Payer: Kaiser Permanente Medicaid	$658.92
Rate for Payer: MDX Hawaii PPO	$1,253.24
Rate for Payer: University Health Alliance Commercial	$723.52

PLAT LCP-T 3H 3.5X50MM 241.131

Facility

$1,292.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$723.52
Max. Negotiated Rate	$1,253.24
Rate for Payer: Cash Price	$775.20
Rate for Payer: Hawaii Western Management Group Commercial	$904.40
Rate for Payer: Health Management Network Commercial	$1,098.20
Rate for Payer: MDX Hawaii PPO	$1,253.24
Rate for Payer: University Health Alliance Commercial	$723.52

PLAT LCP-T 3H 3.5X52MM 241.931

Facility

$1,596.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$813.96
Max. Negotiated Rate	$1,548.12
Rate for Payer: Cash Price	$957.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,117.20
Rate for Payer: Health Management Network Commercial	$1,356.60
Rate for Payer: Kaiser Permanente Commercial	$1,005.48
Rate for Payer: Kaiser Permanente Medicaid	$813.96
Rate for Payer: MDX Hawaii PPO	$1,548.12
Rate for Payer: University Health Alliance Commercial	$893.76

PLAT LCP-T 3H 3.5X52MM 241.931

Facility

$1,596.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$893.76
Max. Negotiated Rate	$1,548.12
Rate for Payer: Cash Price	$957.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,117.20
Rate for Payer: Health Management Network Commercial	$1,356.60
Rate for Payer: MDX Hawaii PPO	$1,548.12
Rate for Payer: University Health Alliance Commercial	$893.76

PLAT LCP-T 4H 3.5X52MM 241.031

Facility

$1,593.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$892.08
Max. Negotiated Rate	$1,545.21
Rate for Payer: Cash Price	$955.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,115.10
Rate for Payer: Health Management Network Commercial	$1,354.05
Rate for Payer: MDX Hawaii PPO	$1,545.21
Rate for Payer: University Health Alliance Commercial	$892.08

PLAT LCP-T 4H 3.5X52MM 241.031

Facility

$1,593.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$812.43
Max. Negotiated Rate	$1,545.21
Rate for Payer: Cash Price	$955.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,115.10
Rate for Payer: Health Management Network Commercial	$1,354.05
Rate for Payer: Kaiser Permanente Commercial	$1,003.59
Rate for Payer: Kaiser Permanente Medicaid	$812.43
Rate for Payer: MDX Hawaii PPO	$1,545.21
Rate for Payer: University Health Alliance Commercial	$892.08

PLAT LCP-T 4H 3.5X56MM 241.141

Facility

$1,335.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$747.60
Max. Negotiated Rate	$1,294.95
Rate for Payer: Cash Price	$801.00
Rate for Payer: Hawaii Western Management Group Commercial	$934.50
Rate for Payer: Health Management Network Commercial	$1,134.75
Rate for Payer: MDX Hawaii PPO	$1,294.95
Rate for Payer: University Health Alliance Commercial	$747.60

PLAT LCP-T 4H 3.5X56MM 241.141

Facility

$1,335.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$680.85
Max. Negotiated Rate	$1,294.95
Rate for Payer: Cash Price	$801.00
Rate for Payer: Hawaii Western Management Group Commercial	$934.50
Rate for Payer: Health Management Network Commercial	$1,134.75
Rate for Payer: Kaiser Permanente Commercial	$841.05
Rate for Payer: Kaiser Permanente Medicaid	$680.85
Rate for Payer: MDX Hawaii PPO	$1,294.95
Rate for Payer: University Health Alliance Commercial	$747.60

PLAT LCP-T 4H 3.5X63MM 241.041

Facility

$1,666.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$932.96
Max. Negotiated Rate	$1,616.02
Rate for Payer: Cash Price	$999.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,166.20
Rate for Payer: Health Management Network Commercial	$1,416.10
Rate for Payer: MDX Hawaii PPO	$1,616.02
Rate for Payer: University Health Alliance Commercial	$932.96

PLAT LCP-T 4H 3.5X63MM 241.041

Facility

$1,666.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$849.66
Max. Negotiated Rate	$1,616.02
Rate for Payer: Cash Price	$999.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,166.20
Rate for Payer: Health Management Network Commercial	$1,416.10
Rate for Payer: Kaiser Permanente Commercial	$1,049.58
Rate for Payer: Kaiser Permanente Medicaid	$849.66
Rate for Payer: MDX Hawaii PPO	$1,616.02
Rate for Payer: University Health Alliance Commercial	$932.96

PLAT LCP-T 4H 3.5X63MM 241.941

Facility

$1,673.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$936.88
Max. Negotiated Rate	$1,622.81
Rate for Payer: Cash Price	$1,003.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.10
Rate for Payer: Health Management Network Commercial	$1,422.05
Rate for Payer: MDX Hawaii PPO	$1,622.81
Rate for Payer: University Health Alliance Commercial	$936.88

PLAT LCP-T 4H 3.5X63MM 241.941

Facility

$1,673.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$853.23
Max. Negotiated Rate	$1,622.81
Rate for Payer: Cash Price	$1,003.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,171.10
Rate for Payer: Health Management Network Commercial	$1,422.05
Rate for Payer: Kaiser Permanente Commercial	$1,053.99
Rate for Payer: Kaiser Permanente Medicaid	$853.23
Rate for Payer: MDX Hawaii PPO	$1,622.81
Rate for Payer: University Health Alliance Commercial	$936.88

Know your out-of-pocket cost for care.

All Charges