Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

FRN/GT 10X380MM 04.033.069S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 10X380MM 04.033.069S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 10X400MM 04.033.070S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 10X400MM 04.033.070S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 10X400MM LF 04.033.071S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 10X400MM LF 04.033.071S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 10X420MM LF 04.033.073S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 10X420MM LF 04.033.073S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 10X420MM RT 04.033.072S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 10X420MM RT 04.033.072S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X300MM LF 04.033.161S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X300MM LF 04.033.161S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X300MM RT 04.033.160S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X300MM RT 04.033.160S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X320MM LF 04.033.163S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X320MM LF 04.033.163S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X320MM RT 04.033.162S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X320MM RT 04.033.162S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X340MM LF 04.033.165S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X340MM LF 04.033.165S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X360MM LF 04.033.167S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X360MM LF 04.033.167S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X360MM RT 04.033.166S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X360MM RT 04.033.166S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 11X380MM LF 04.033.169S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

Know your out-of-pocket cost for care.

All Charges