Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GORE T-IPSI 12/14CM RLT231214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,220.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$13,860.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/14CM RLT231214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/14CM RLT261214

Facility

$22,550.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,500.50
Max. Negotiated Rate	$21,873.50
Rate for Payer: Cash Price	$13,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,785.00
Rate for Payer: Health Management Network Commercial	$19,167.50
Rate for Payer: Kaiser Permanente Commercial	$14,206.50
Rate for Payer: Kaiser Permanente Medicaid	$11,500.50
Rate for Payer: MDX Hawaii PPO	$21,873.50
Rate for Payer: University Health Alliance Commercial	$12,628.00

GORE T-IPSI 12/14CM RLT261214

Facility

$22,550.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,628.00
Max. Negotiated Rate	$21,873.50
Rate for Payer: Cash Price	$13,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,785.00
Rate for Payer: Health Management Network Commercial	$19,167.50
Rate for Payer: MDX Hawaii PPO	$21,873.50
Rate for Payer: University Health Alliance Commercial	$12,628.00

GORE T-IPSI 12/14CM RLT281214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/14CM RLT281214

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,220.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$13,860.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/16CM RLT231216

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/16CM RLT231216

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,220.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$13,860.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/16CM RLT261216

Facility

$26,024.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$14,573.44
Max. Negotiated Rate	$25,243.28
Rate for Payer: Cash Price	$15,614.40
Rate for Payer: Hawaii Western Management Group Commercial	$18,216.80
Rate for Payer: Health Management Network Commercial	$22,120.40
Rate for Payer: MDX Hawaii PPO	$25,243.28
Rate for Payer: University Health Alliance Commercial	$14,573.44

GORE T-IPSI 12/16CM RLT261216

Facility

$26,024.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$13,272.24
Max. Negotiated Rate	$25,243.28
Rate for Payer: Cash Price	$15,614.40
Rate for Payer: Hawaii Western Management Group Commercial	$18,216.80
Rate for Payer: Health Management Network Commercial	$22,120.40
Rate for Payer: Kaiser Permanente Commercial	$16,395.12
Rate for Payer: Kaiser Permanente Medicaid	$13,272.24
Rate for Payer: MDX Hawaii PPO	$25,243.28
Rate for Payer: University Health Alliance Commercial	$14,573.44

GORE T-IPSI 12/18CM RLT231218

Facility

$25,266.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,885.66
Max. Negotiated Rate	$24,508.02
Rate for Payer: Cash Price	$15,159.60
Rate for Payer: Hawaii Western Management Group Commercial	$17,686.20
Rate for Payer: Health Management Network Commercial	$21,476.10
Rate for Payer: Kaiser Permanente Commercial	$15,917.58
Rate for Payer: Kaiser Permanente Medicaid	$12,885.66
Rate for Payer: MDX Hawaii PPO	$24,508.02
Rate for Payer: University Health Alliance Commercial	$14,148.96

GORE T-IPSI 12/18CM RLT231218

Facility

$25,266.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$14,148.96
Max. Negotiated Rate	$24,508.02
Rate for Payer: Cash Price	$15,159.60
Rate for Payer: Hawaii Western Management Group Commercial	$17,686.20
Rate for Payer: Health Management Network Commercial	$21,476.10
Rate for Payer: MDX Hawaii PPO	$24,508.02
Rate for Payer: University Health Alliance Commercial	$14,148.96

GORE T-IPSI 12/18CM RLT281218

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/18CM RLT281218

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,220.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$13,860.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/18 RLT261218

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 12/18 RLT261218

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,220.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$13,860.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 14.5/12 RLT231412

Facility

$21,500.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,040.00
Max. Negotiated Rate	$20,855.00
Rate for Payer: Cash Price	$12,900.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,050.00
Rate for Payer: Health Management Network Commercial	$18,275.00
Rate for Payer: MDX Hawaii PPO	$20,855.00
Rate for Payer: University Health Alliance Commercial	$12,040.00

GORE T-IPSI 14.5/12 RLT231412

Facility

$21,500.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$10,965.00
Max. Negotiated Rate	$20,855.00
Rate for Payer: Cash Price	$12,900.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,050.00
Rate for Payer: Health Management Network Commercial	$18,275.00
Rate for Payer: Kaiser Permanente Commercial	$13,545.00
Rate for Payer: Kaiser Permanente Medicaid	$10,965.00
Rate for Payer: MDX Hawaii PPO	$20,855.00
Rate for Payer: University Health Alliance Commercial	$12,040.00

GORE T-IPSI 14.5/12 RLT261412

Facility

$24,770.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,632.70
Max. Negotiated Rate	$24,026.90
Rate for Payer: Cash Price	$14,862.00
Rate for Payer: Hawaii Western Management Group Commercial	$17,339.00
Rate for Payer: Health Management Network Commercial	$21,054.50
Rate for Payer: Kaiser Permanente Commercial	$15,605.10
Rate for Payer: Kaiser Permanente Medicaid	$12,632.70
Rate for Payer: MDX Hawaii PPO	$24,026.90
Rate for Payer: University Health Alliance Commercial	$13,871.20

GORE T-IPSI 14.5/12 RLT261412

Facility

$24,770.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$13,871.20
Max. Negotiated Rate	$24,026.90
Rate for Payer: Cash Price	$14,862.00
Rate for Payer: Hawaii Western Management Group Commercial	$17,339.00
Rate for Payer: Health Management Network Commercial	$21,054.50
Rate for Payer: MDX Hawaii PPO	$24,026.90
Rate for Payer: University Health Alliance Commercial	$13,871.20

GORE T-IPSI 14.5/12 RLT281412

Facility

$27,420.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$13,984.20
Max. Negotiated Rate	$26,597.40
Rate for Payer: Cash Price	$16,452.00
Rate for Payer: Hawaii Western Management Group Commercial	$19,194.00
Rate for Payer: Health Management Network Commercial	$23,307.00
Rate for Payer: Kaiser Permanente Commercial	$17,274.60
Rate for Payer: Kaiser Permanente Medicaid	$13,984.20
Rate for Payer: MDX Hawaii PPO	$26,597.40
Rate for Payer: University Health Alliance Commercial	$15,355.20

GORE T-IPSI 14.5/12 RLT281412

Facility

$27,420.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$15,355.20
Max. Negotiated Rate	$26,597.40
Rate for Payer: Cash Price	$16,452.00
Rate for Payer: Hawaii Western Management Group Commercial	$19,194.00
Rate for Payer: Health Management Network Commercial	$23,307.00
Rate for Payer: MDX Hawaii PPO	$26,597.40
Rate for Payer: University Health Alliance Commercial	$15,355.20

GORE T-IPSI 14.5/13 RLT311413

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,220.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$13,860.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 14.5/13 RLT311413

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,320.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

GORE T-IPSI 14.5/14 RLT231414

Facility

$22,000.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$11,220.00
Max. Negotiated Rate	$21,340.00
Rate for Payer: Cash Price	$13,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$15,400.00
Rate for Payer: Health Management Network Commercial	$18,700.00
Rate for Payer: Kaiser Permanente Commercial	$13,860.00
Rate for Payer: Kaiser Permanente Medicaid	$11,220.00
Rate for Payer: MDX Hawaii PPO	$21,340.00
Rate for Payer: University Health Alliance Commercial	$12,320.00

Know your out-of-pocket cost for care.

All Charges