Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLAT LCP-T 4H 4.5X83MM 240.141

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,500.24
Max. Negotiated Rate	$2,598.63
Rate for Payer: Cash Price	$1,607.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: University Health Alliance Commercial	$1,500.24

PLAT LCP-T 4H 4.5X83MM 240.141

Facility

$2,679.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,366.29
Max. Negotiated Rate	$2,598.63
Rate for Payer: Cash Price	$1,607.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,875.30
Rate for Payer: Health Management Network Commercial	$2,277.15
Rate for Payer: Kaiser Permanente Commercial	$1,687.77
Rate for Payer: Kaiser Permanente Medicaid	$1,366.29
Rate for Payer: MDX Hawaii PPO	$2,598.63
Rate for Payer: University Health Alliance Commercial	$1,500.24

PLAT LCP-T 5H 3.5X67MM 241.151

Facility

$1,569.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$878.64
Max. Negotiated Rate	$1,521.93
Rate for Payer: Cash Price	$941.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,098.30
Rate for Payer: Health Management Network Commercial	$1,333.65
Rate for Payer: MDX Hawaii PPO	$1,521.93
Rate for Payer: University Health Alliance Commercial	$878.64

PLAT LCP-T 5H 3.5X67MM 241.151

Facility

$1,569.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$800.19
Max. Negotiated Rate	$1,521.93
Rate for Payer: Cash Price	$941.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,098.30
Rate for Payer: Health Management Network Commercial	$1,333.65
Rate for Payer: Kaiser Permanente Commercial	$988.47
Rate for Payer: Kaiser Permanente Medicaid	$800.19
Rate for Payer: MDX Hawaii PPO	$1,521.93
Rate for Payer: University Health Alliance Commercial	$878.64

PLAT LCP-T 5H 3.5X74MM 214.051

Facility

$1,740.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$974.40
Max. Negotiated Rate	$1,687.80
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,218.00
Rate for Payer: Health Management Network Commercial	$1,479.00
Rate for Payer: MDX Hawaii PPO	$1,687.80
Rate for Payer: University Health Alliance Commercial	$974.40

PLAT LCP-T 5H 3.5X74MM 214.051

Facility

$1,740.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$887.40
Max. Negotiated Rate	$1,687.80
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,218.00
Rate for Payer: Health Management Network Commercial	$1,479.00
Rate for Payer: Kaiser Permanente Commercial	$1,096.20
Rate for Payer: Kaiser Permanente Medicaid	$887.40
Rate for Payer: MDX Hawaii PPO	$1,687.80
Rate for Payer: University Health Alliance Commercial	$974.40

PLAT LCP-T 5H 3.5X74MM 241.951

Facility

$1,747.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$890.97
Max. Negotiated Rate	$1,694.59
Rate for Payer: Cash Price	$1,048.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,222.90
Rate for Payer: Health Management Network Commercial	$1,484.95
Rate for Payer: Kaiser Permanente Commercial	$1,100.61
Rate for Payer: Kaiser Permanente Medicaid	$890.97
Rate for Payer: MDX Hawaii PPO	$1,694.59
Rate for Payer: University Health Alliance Commercial	$978.32

PLAT LCP-T 5H 3.5X74MM 241.951

Facility

$1,747.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$978.32
Max. Negotiated Rate	$1,694.59
Rate for Payer: Cash Price	$1,048.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,222.90
Rate for Payer: Health Management Network Commercial	$1,484.95
Rate for Payer: MDX Hawaii PPO	$1,694.59
Rate for Payer: University Health Alliance Commercial	$978.32

PLAT LCP-T 6H 3.5X78MM 241.161

Facility

$1,710.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$872.10
Max. Negotiated Rate	$1,658.70
Rate for Payer: Cash Price	$1,026.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,197.00
Rate for Payer: Health Management Network Commercial	$1,453.50
Rate for Payer: Kaiser Permanente Commercial	$1,077.30
Rate for Payer: Kaiser Permanente Medicaid	$872.10
Rate for Payer: MDX Hawaii PPO	$1,658.70
Rate for Payer: University Health Alliance Commercial	$957.60

PLAT LCP-T 6H 3.5X78MM 241.161

Facility

$1,710.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$957.60
Max. Negotiated Rate	$1,658.70
Rate for Payer: Cash Price	$1,026.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,197.00
Rate for Payer: Health Management Network Commercial	$1,453.50
Rate for Payer: MDX Hawaii PPO	$1,658.70
Rate for Payer: University Health Alliance Commercial	$957.60

PLAT LCP-T 7H 3.5X87MM 241.171

Facility

$2,022.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,132.32
Max. Negotiated Rate	$1,961.34
Rate for Payer: Cash Price	$1,213.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,415.40
Rate for Payer: Health Management Network Commercial	$1,718.70
Rate for Payer: MDX Hawaii PPO	$1,961.34
Rate for Payer: University Health Alliance Commercial	$1,132.32

PLAT LCP-T 7H 3.5X87MM 241.171

Facility

$2,022.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,031.22
Max. Negotiated Rate	$1,961.34
Rate for Payer: Cash Price	$1,213.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,415.40
Rate for Payer: Health Management Network Commercial	$1,718.70
Rate for Payer: Kaiser Permanente Commercial	$1,273.86
Rate for Payer: Kaiser Permanente Medicaid	$1,031.22
Rate for Payer: MDX Hawaii PPO	$1,961.34
Rate for Payer: University Health Alliance Commercial	$1,132.32

PLAT LCP-T 7H 3.5X96MM 241.071

Facility

$1,620.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$907.20
Max. Negotiated Rate	$1,571.40
Rate for Payer: Cash Price	$972.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,134.00
Rate for Payer: Health Management Network Commercial	$1,377.00
Rate for Payer: MDX Hawaii PPO	$1,571.40
Rate for Payer: University Health Alliance Commercial	$907.20

PLAT LCP-T 7H 3.5X96MM 241.071

Facility

$1,620.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$826.20
Max. Negotiated Rate	$1,571.40
Rate for Payer: Cash Price	$972.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,134.00
Rate for Payer: Health Management Network Commercial	$1,377.00
Rate for Payer: Kaiser Permanente Commercial	$1,020.60
Rate for Payer: Kaiser Permanente Medicaid	$826.20
Rate for Payer: MDX Hawaii PPO	$1,571.40
Rate for Payer: University Health Alliance Commercial	$907.20

PLAT LCP-T 7H 3.5X96MM 241.971

Facility

$1,623.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$908.88
Max. Negotiated Rate	$1,574.31
Rate for Payer: Cash Price	$973.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,136.10
Rate for Payer: Health Management Network Commercial	$1,379.55
Rate for Payer: MDX Hawaii PPO	$1,574.31
Rate for Payer: University Health Alliance Commercial	$908.88

PLAT LCP-T 7H 3.5X96MM 241.971

Facility

$1,623.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$827.73
Max. Negotiated Rate	$1,574.31
Rate for Payer: Cash Price	$973.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,136.10
Rate for Payer: Health Management Network Commercial	$1,379.55
Rate for Payer: Kaiser Permanente Commercial	$1,022.49
Rate for Payer: Kaiser Permanente Medicaid	$827.73
Rate for Payer: MDX Hawaii PPO	$1,574.31
Rate for Payer: University Health Alliance Commercial	$908.88

PLEURAL EFFUSION WITH CC

Facility

$28,221.36

Service Code	MSDRG 187
Min. Negotiated Rate	$11,250.28
Max. Negotiated Rate	$28,221.36
Rate for Payer: AlohaCare Medicare	$11,250.28
Rate for Payer: Devoted Health Medicare	$12,375.31
Rate for Payer: Hawaii Medical Service Association Commercial	$28,221.36
Rate for Payer: Hawaii Medical Service Association Medicare	$11,250.28
Rate for Payer: Humana Medicare	$11,250.28
Rate for Payer: Kaiser Permanente Commercial	$17,061.97
Rate for Payer: Kaiser Permanente Medicare	$11,250.28
Rate for Payer: Ohana Health Plan Medicare	$11,250.28
Rate for Payer: UnitedHealthcare Medicare	$11,250.28

PLEURAL EFFUSION WITH MCC

Facility

$28,876.54

Service Code	MSDRG 186
Min. Negotiated Rate	$17,726.78
Max. Negotiated Rate	$28,876.54
Rate for Payer: AlohaCare Medicare	$17,726.78
Rate for Payer: Devoted Health Medicare	$19,499.46
Rate for Payer: Hawaii Medical Service Association Commercial	$28,876.54
Rate for Payer: Hawaii Medical Service Association Medicare	$17,726.78
Rate for Payer: Humana Medicare	$17,726.78
Rate for Payer: Kaiser Permanente Commercial	$26,884.12
Rate for Payer: Kaiser Permanente Medicare	$17,726.78
Rate for Payer: Ohana Health Plan Medicare	$17,726.78
Rate for Payer: UnitedHealthcare Medicare	$17,726.78

PLEURAL EFFUSION WITHOUT CC/MCC

Facility

$23,052.70

Service Code	MSDRG 188
Min. Negotiated Rate	$8,157.63
Max. Negotiated Rate	$23,052.70
Rate for Payer: AlohaCare Medicare	$8,157.63
Rate for Payer: Devoted Health Medicare	$8,973.39
Rate for Payer: Hawaii Medical Service Association Commercial	$23,052.70
Rate for Payer: Hawaii Medical Service Association Medicare	$8,157.63
Rate for Payer: Humana Medicare	$8,157.63
Rate for Payer: Kaiser Permanente Commercial	$12,371.70
Rate for Payer: Kaiser Permanente Medicare	$8,157.63
Rate for Payer: Ohana Health Plan Medicare	$8,157.63
Rate for Payer: UnitedHealthcare Medicare	$8,157.63

PLEURIX CATHETER ABDOMEN DRAIN

Facility

$2,028.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,723.80
Max. Negotiated Rate	$1,967.16
Rate for Payer: Cash Price	$1,216.80
Rate for Payer: Health Management Network Commercial	$1,723.80
Rate for Payer: MDX Hawaii PPO	$1,967.16

PLEURIX CATHETER ABDOMEN DRAIN

Facility

$2,028.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,034.28
Max. Negotiated Rate	$1,967.16
Rate for Payer: Cash Price	$1,216.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,926.60
Rate for Payer: Health Management Network Commercial	$1,723.80
Rate for Payer: Kaiser Permanente Commercial	$1,277.64
Rate for Payer: Kaiser Permanente Medicaid	$1,034.28
Rate for Payer: MDX Hawaii PPO	$1,967.16
Rate for Payer: University Health Alliance Commercial	$1,478.21

PLT CLASS 135D 4H 100MM 124131

Facility

$2,688.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,505.28
Max. Negotiated Rate	$2,607.36
Rate for Payer: Cash Price	$1,612.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,881.60
Rate for Payer: Health Management Network Commercial	$2,284.80
Rate for Payer: MDX Hawaii PPO	$2,607.36
Rate for Payer: University Health Alliance Commercial	$1,505.28

PLT CLASS 135D 4H 100MM 124131

Facility

$2,688.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,370.88
Max. Negotiated Rate	$2,607.36
Rate for Payer: Cash Price	$1,612.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,881.60
Rate for Payer: Health Management Network Commercial	$2,284.80
Rate for Payer: Kaiser Permanente Commercial	$1,693.44
Rate for Payer: Kaiser Permanente Medicaid	$1,370.88
Rate for Payer: MDX Hawaii PPO	$2,607.36
Rate for Payer: University Health Alliance Commercial	$1,505.28

PLT CLASS 135D 8H 180MM 124146

Facility

$2,223.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,244.88
Max. Negotiated Rate	$2,156.31
Rate for Payer: Cash Price	$1,333.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,556.10
Rate for Payer: Health Management Network Commercial	$1,889.55
Rate for Payer: MDX Hawaii PPO	$2,156.31
Rate for Payer: University Health Alliance Commercial	$1,244.88

PLT CLASS 135D 8H 180MM 124146

Facility

$2,223.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,133.73
Max. Negotiated Rate	$2,156.31
Rate for Payer: Cash Price	$1,333.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,556.10
Rate for Payer: Health Management Network Commercial	$1,889.55
Rate for Payer: Kaiser Permanente Commercial	$1,400.49
Rate for Payer: Kaiser Permanente Medicaid	$1,133.73
Rate for Payer: MDX Hawaii PPO	$2,156.31
Rate for Payer: University Health Alliance Commercial	$1,244.88

Know your out-of-pocket cost for care.

All Charges