Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLT CLASS 140D 4H 100MM 124132

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 140D 4H 100MM 124132

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 140D 6H 140MM 124142

Facility

$1,617.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$905.52
Max. Negotiated Rate	$1,568.49
Rate for Payer: Cash Price	$970.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,131.90
Rate for Payer: Health Management Network Commercial	$1,374.45
Rate for Payer: MDX Hawaii PPO	$1,568.49
Rate for Payer: University Health Alliance Commercial	$905.52

PLT CLASS 140D 6H 140MM 124142

Facility

$1,617.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$824.67
Max. Negotiated Rate	$1,568.49
Rate for Payer: Cash Price	$970.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,131.90
Rate for Payer: Health Management Network Commercial	$1,374.45
Rate for Payer: Kaiser Permanente Commercial	$1,018.71
Rate for Payer: Kaiser Permanente Medicaid	$824.67
Rate for Payer: MDX Hawaii PPO	$1,568.49
Rate for Payer: University Health Alliance Commercial	$905.52

PLT CLASS 145D 4H 100MM 124133

Facility

$2,337.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,308.72
Max. Negotiated Rate	$2,266.89
Rate for Payer: Cash Price	$1,402.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,635.90
Rate for Payer: Health Management Network Commercial	$1,986.45
Rate for Payer: MDX Hawaii PPO	$2,266.89
Rate for Payer: University Health Alliance Commercial	$1,308.72

PLT CLASS 145D 4H 100MM 124133

Facility

$2,337.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,191.87
Max. Negotiated Rate	$2,266.89
Rate for Payer: Cash Price	$1,402.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,635.90
Rate for Payer: Health Management Network Commercial	$1,986.45
Rate for Payer: Kaiser Permanente Commercial	$1,472.31
Rate for Payer: Kaiser Permanente Medicaid	$1,191.87
Rate for Payer: MDX Hawaii PPO	$2,266.89
Rate for Payer: University Health Alliance Commercial	$1,308.72

PLT CLASS 145D 6H 140MM 124143

Facility

$2,568.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,438.08
Max. Negotiated Rate	$2,490.96
Rate for Payer: Cash Price	$1,540.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,797.60
Rate for Payer: Health Management Network Commercial	$2,182.80
Rate for Payer: MDX Hawaii PPO	$2,490.96
Rate for Payer: University Health Alliance Commercial	$1,438.08

PLT CLASS 145D 6H 140MM 124143

Facility

$2,568.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,309.68
Max. Negotiated Rate	$2,490.96
Rate for Payer: Cash Price	$1,540.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,797.60
Rate for Payer: Health Management Network Commercial	$2,182.80
Rate for Payer: Kaiser Permanente Commercial	$1,617.84
Rate for Payer: Kaiser Permanente Medicaid	$1,309.68
Rate for Payer: MDX Hawaii PPO	$2,490.96
Rate for Payer: University Health Alliance Commercial	$1,438.08

PLT CLASS 150D 4H 100MM 124134

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

PLT CLASS 150D 4H 100MM 124134

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

PLT COMP 10H 3.5X121MM 4935-10

Facility

$600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$306.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Hawaii Western Management Group Commercial	$420.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: Kaiser Permanente Commercial	$378.00
Rate for Payer: Kaiser Permanente Medicaid	$306.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: University Health Alliance Commercial	$336.00

PLT COMP 10H 3.5X121MM 4935-10

Facility

$600.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$582.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Hawaii Western Management Group Commercial	$420.00
Rate for Payer: Health Management Network Commercial	$510.00
Rate for Payer: MDX Hawaii PPO	$582.00
Rate for Payer: University Health Alliance Commercial	$336.00

PLT COMP 12H 3.5X145MM 4935-12

Facility

$926.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$472.26
Max. Negotiated Rate	$898.22
Rate for Payer: Cash Price	$555.60
Rate for Payer: Hawaii Western Management Group Commercial	$648.20
Rate for Payer: Health Management Network Commercial	$787.10
Rate for Payer: Kaiser Permanente Commercial	$583.38
Rate for Payer: Kaiser Permanente Medicaid	$472.26
Rate for Payer: MDX Hawaii PPO	$898.22
Rate for Payer: University Health Alliance Commercial	$518.56

PLT COMP 12H 3.5X145MM 4935-12

Facility

$926.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$518.56
Max. Negotiated Rate	$898.22
Rate for Payer: Cash Price	$555.60
Rate for Payer: Hawaii Western Management Group Commercial	$648.20
Rate for Payer: Health Management Network Commercial	$787.10
Rate for Payer: MDX Hawaii PPO	$898.22
Rate for Payer: University Health Alliance Commercial	$518.56

PLT COMP 14H 3.5X169MM 4935-14

Facility

$1,544.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$864.64
Max. Negotiated Rate	$1,497.68
Rate for Payer: Cash Price	$926.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,080.80
Rate for Payer: Health Management Network Commercial	$1,312.40
Rate for Payer: MDX Hawaii PPO	$1,497.68
Rate for Payer: University Health Alliance Commercial	$864.64

PLT COMP 14H 3.5X169MM 4935-14

Facility

$1,544.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$787.44
Max. Negotiated Rate	$1,497.68
Rate for Payer: Cash Price	$926.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,080.80
Rate for Payer: Health Management Network Commercial	$1,312.40
Rate for Payer: Kaiser Permanente Commercial	$972.72
Rate for Payer: Kaiser Permanente Medicaid	$787.44
Rate for Payer: MDX Hawaii PPO	$1,497.68
Rate for Payer: University Health Alliance Commercial	$864.64

PLT COMP 16H 3.5X194MM 4935-16

Facility

$1,530.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,484.10
Rate for Payer: Cash Price	$918.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: University Health Alliance Commercial	$856.80

PLT COMP 16H 3.5X194MM 4935-16

Facility

$1,530.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$780.30
Max. Negotiated Rate	$1,484.10
Rate for Payer: Cash Price	$918.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,071.00
Rate for Payer: Health Management Network Commercial	$1,300.50
Rate for Payer: Kaiser Permanente Commercial	$963.90
Rate for Payer: Kaiser Permanente Medicaid	$780.30
Rate for Payer: MDX Hawaii PPO	$1,484.10
Rate for Payer: University Health Alliance Commercial	$856.80

PLT COMP 18H 3.5X217MM 4935-18

Facility

$1,719.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$876.69
Max. Negotiated Rate	$1,667.43
Rate for Payer: Cash Price	$1,031.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,203.30
Rate for Payer: Health Management Network Commercial	$1,461.15
Rate for Payer: Kaiser Permanente Commercial	$1,082.97
Rate for Payer: Kaiser Permanente Medicaid	$876.69
Rate for Payer: MDX Hawaii PPO	$1,667.43
Rate for Payer: University Health Alliance Commercial	$962.64

PLT COMP 18H 3.5X217MM 4935-18

Facility

$1,719.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$962.64
Max. Negotiated Rate	$1,667.43
Rate for Payer: Cash Price	$1,031.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,203.30
Rate for Payer: Health Management Network Commercial	$1,461.15
Rate for Payer: MDX Hawaii PPO	$1,667.43
Rate for Payer: University Health Alliance Commercial	$962.64

PLT COMP 20H 3.5X242MM 4935-20

Facility

$1,875.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,050.00
Max. Negotiated Rate	$1,818.75
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,312.50
Rate for Payer: Health Management Network Commercial	$1,593.75
Rate for Payer: MDX Hawaii PPO	$1,818.75
Rate for Payer: University Health Alliance Commercial	$1,050.00

PLT COMP 20H 3.5X242MM 4935-20

Facility

$1,875.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$956.25
Max. Negotiated Rate	$1,818.75
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,312.50
Rate for Payer: Health Management Network Commercial	$1,593.75
Rate for Payer: Kaiser Permanente Commercial	$1,181.25
Rate for Payer: Kaiser Permanente Medicaid	$956.25
Rate for Payer: MDX Hawaii PPO	$1,818.75
Rate for Payer: University Health Alliance Commercial	$1,050.00

PLT COMP 22H 3.5X265MM 4935-22

Facility

$2,034.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,037.34
Max. Negotiated Rate	$1,972.98
Rate for Payer: Cash Price	$1,220.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,423.80
Rate for Payer: Health Management Network Commercial	$1,728.90
Rate for Payer: Kaiser Permanente Commercial	$1,281.42
Rate for Payer: Kaiser Permanente Medicaid	$1,037.34
Rate for Payer: MDX Hawaii PPO	$1,972.98
Rate for Payer: University Health Alliance Commercial	$1,139.04

PLT COMP 22H 3.5X265MM 4935-22

Facility

$2,034.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,139.04
Max. Negotiated Rate	$1,972.98
Rate for Payer: Cash Price	$1,220.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,423.80
Rate for Payer: Health Management Network Commercial	$1,728.90
Rate for Payer: MDX Hawaii PPO	$1,972.98
Rate for Payer: University Health Alliance Commercial	$1,139.04

PLT COMP 2H 3.5X25MM 4935-02

Facility

$394.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$220.64
Max. Negotiated Rate	$382.18
Rate for Payer: Cash Price	$236.40
Rate for Payer: Hawaii Western Management Group Commercial	$275.80
Rate for Payer: Health Management Network Commercial	$334.90
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

Know your out-of-pocket cost for care.

All Charges