Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GORE T-IPSI 14.5/14 RLT231414

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 RLT261414

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 RLT261414

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 14.5/14 RLT281414

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 14.5/14 RLT281414

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 14.5/14 RLT351414

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 14.5/14 RLT351414

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 14.5/15 RLT311415

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 14.5/15 RLT311415

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 14.5/16 RLT231416

Facility

$26,882.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$15,053.92
Max. Negotiated Rate	$26,075.54
Rate for Payer: Cash Price	$16,129.20
Rate for Payer: Hawaii Western Management Group Commercial	$18,817.40
Rate for Payer: Health Management Network Commercial	$22,849.70
Rate for Payer: MDX Hawaii PPO	$26,075.54
Rate for Payer: University Health Alliance Commercial	$15,053.92

GORE T-IPSI 14.5/16 RLT231416

Facility

$26,882.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$13,709.82
Max. Negotiated Rate	$26,075.54
Rate for Payer: Cash Price	$16,129.20
Rate for Payer: Hawaii Western Management Group Commercial	$18,817.40
Rate for Payer: Health Management Network Commercial	$22,849.70
Rate for Payer: Kaiser Permanente Commercial	$16,935.66
Rate for Payer: Kaiser Permanente Medicaid	$13,709.82
Rate for Payer: MDX Hawaii PPO	$26,075.54
Rate for Payer: University Health Alliance Commercial	$15,053.92

GORE T-IPSI 14.5/16 RLT261416

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 14.5/16 RLT261416

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 14.5/16 RLT281416

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 14.5/16 RLT281416

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 14.5/16 RLT351416

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 14.5/16 RLT351416

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 14.5/17 RLT311417

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 14.5/17 RLT311417

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 14.5/18 RLT231418

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 14.5/18 RLT231418

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 14.5/18 RLT261418

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 14.5/18 RLT261418

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 14.5/18 RLT281418

Facility

$23,692.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$13,267.52
Max. Negotiated Rate	$22,981.24
Rate for Payer: Cash Price	$14,215.20
Rate for Payer: Hawaii Western Management Group Commercial	$16,584.40
Rate for Payer: Health Management Network Commercial	$20,138.20
Rate for Payer: MDX Hawaii PPO	$22,981.24
Rate for Payer: University Health Alliance Commercial	$13,267.52

GORE T-IPSI 14.5/18 RLT281418

Facility

$23,692.00

Service Code	HCPCS C1768
Hospital Revenue Code	278
Min. Negotiated Rate	$12,082.92
Max. Negotiated Rate	$22,981.24
Rate for Payer: Cash Price	$14,215.20
Rate for Payer: Hawaii Western Management Group Commercial	$16,584.40
Rate for Payer: Health Management Network Commercial	$20,138.20
Rate for Payer: Kaiser Permanente Commercial	$14,925.96
Rate for Payer: Kaiser Permanente Medicaid	$12,082.92
Rate for Payer: MDX Hawaii PPO	$22,981.24
Rate for Payer: University Health Alliance Commercial	$13,267.52

Know your out-of-pocket cost for care.

All Charges