Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLT COMP 2H 3.5X25MM 4935-02

Facility

$394.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$200.94
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: Kaiser Permanente Commercial	$248.22
Rate for Payer: Kaiser Permanente Medicaid	$200.94
Rate for Payer: MDX Hawaii PPO	$382.18
Rate for Payer: University Health Alliance Commercial	$220.64

PLT COMP 3H 3.5X37MM 4935-03

Facility

$420.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$407.40
Rate for Payer: Cash Price	$252.00
Rate for Payer: Hawaii Western Management Group Commercial	$294.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: MDX Hawaii PPO	$407.40
Rate for Payer: University Health Alliance Commercial	$235.20

PLT COMP 3H 3.5X37MM 4935-03

Facility

$420.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$407.40
Rate for Payer: Cash Price	$252.00
Rate for Payer: Hawaii Western Management Group Commercial	$294.00
Rate for Payer: Health Management Network Commercial	$357.00
Rate for Payer: Kaiser Permanente Commercial	$264.60
Rate for Payer: Kaiser Permanente Medicaid	$214.20
Rate for Payer: MDX Hawaii PPO	$407.40
Rate for Payer: University Health Alliance Commercial	$235.20

PLT COMP 4H 3.5X49MM 4935-04

Facility

$446.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$227.46
Max. Negotiated Rate	$432.62
Rate for Payer: Cash Price	$267.60
Rate for Payer: Hawaii Western Management Group Commercial	$312.20
Rate for Payer: Health Management Network Commercial	$379.10
Rate for Payer: Kaiser Permanente Commercial	$280.98
Rate for Payer: Kaiser Permanente Medicaid	$227.46
Rate for Payer: MDX Hawaii PPO	$432.62
Rate for Payer: University Health Alliance Commercial	$249.76

PLT COMP 4H 3.5X49MM 4935-04

Facility

$446.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$249.76
Max. Negotiated Rate	$432.62
Rate for Payer: Cash Price	$267.60
Rate for Payer: Hawaii Western Management Group Commercial	$312.20
Rate for Payer: Health Management Network Commercial	$379.10
Rate for Payer: MDX Hawaii PPO	$432.62
Rate for Payer: University Health Alliance Commercial	$249.76

PLT COMP 5H 3.5X61MM 4935-05

Facility

$750.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

PLT COMP 5H 3.5X61MM 4935-05

Facility

$750.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$525.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$420.00

PLT COMP 8H 3.5X97MM 4935-08

Facility

$531.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$270.81
Max. Negotiated Rate	$515.07
Rate for Payer: Cash Price	$318.60
Rate for Payer: Hawaii Western Management Group Commercial	$371.70
Rate for Payer: Health Management Network Commercial	$451.35
Rate for Payer: Kaiser Permanente Commercial	$334.53
Rate for Payer: Kaiser Permanente Medicaid	$270.81
Rate for Payer: MDX Hawaii PPO	$515.07
Rate for Payer: University Health Alliance Commercial	$297.36

PLT COMP 8H 3.5X97MM 4935-08

Facility

$531.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$297.36
Max. Negotiated Rate	$515.07
Rate for Payer: Cash Price	$318.60
Rate for Payer: Hawaii Western Management Group Commercial	$371.70
Rate for Payer: Health Management Network Commercial	$451.35
Rate for Payer: MDX Hawaii PPO	$515.07
Rate for Payer: University Health Alliance Commercial	$297.36

PLT COMP 9H 3.5X109MM 4935-09

Facility

$863.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$483.28
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Hawaii Western Management Group Commercial	$604.10
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: University Health Alliance Commercial	$483.28

PLT COMP 9H 3.5X109MM 4935-09

Facility

$863.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$440.13
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Hawaii Western Management Group Commercial	$604.10
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Kaiser Permanente Commercial	$543.69
Rate for Payer: Kaiser Permanente Medicaid	$440.13
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: University Health Alliance Commercial	$483.28

PLT LCDCP 14H 4.5X250MM 226.64

Facility

$1,470.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$823.20
Max. Negotiated Rate	$1,425.90
Rate for Payer: Cash Price	$882.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,029.00
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: MDX Hawaii PPO	$1,425.90
Rate for Payer: University Health Alliance Commercial	$823.20

PLT LCDCP 14H 4.5X250MM 226.64

Facility

$1,470.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$749.70
Max. Negotiated Rate	$1,425.90
Rate for Payer: Cash Price	$882.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,029.00
Rate for Payer: Health Management Network Commercial	$1,249.50
Rate for Payer: Kaiser Permanente Commercial	$926.10
Rate for Payer: Kaiser Permanente Medicaid	$749.70
Rate for Payer: MDX Hawaii PPO	$1,425.90
Rate for Payer: University Health Alliance Commercial	$823.20

PLT LCP 10H 1/3T 117MM 241.401

Facility

$1,082.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$605.92
Max. Negotiated Rate	$1,049.54
Rate for Payer: Cash Price	$649.20
Rate for Payer: Hawaii Western Management Group Commercial	$757.40
Rate for Payer: Health Management Network Commercial	$919.70
Rate for Payer: MDX Hawaii PPO	$1,049.54
Rate for Payer: University Health Alliance Commercial	$605.92

PLT LCP 10H 1/3T 117MM 241.401

Facility

$1,082.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$551.82
Max. Negotiated Rate	$1,049.54
Rate for Payer: Cash Price	$649.20
Rate for Payer: Hawaii Western Management Group Commercial	$757.40
Rate for Payer: Health Management Network Commercial	$919.70
Rate for Payer: Kaiser Permanente Commercial	$681.66
Rate for Payer: Kaiser Permanente Medicaid	$551.82
Rate for Payer: MDX Hawaii PPO	$1,049.54
Rate for Payer: University Health Alliance Commercial	$605.92

PLT LCP 12H 4.5X229MM 226.622

Facility

$2,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,147.50
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: Kaiser Permanente Commercial	$1,417.50
Rate for Payer: Kaiser Permanente Medicaid	$1,147.50
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

PLT LCP 12H 4.5X229MM 226.622

Facility

$2,250.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$2,182.50
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,575.00
Rate for Payer: Health Management Network Commercial	$1,912.50
Rate for Payer: MDX Hawaii PPO	$2,182.50
Rate for Payer: University Health Alliance Commercial	$1,260.00

PLT LCP 13H 4.5X247MM 226.632

Facility

$2,652.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,352.52
Max. Negotiated Rate	$2,572.44
Rate for Payer: Cash Price	$1,591.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,856.40
Rate for Payer: Health Management Network Commercial	$2,254.20
Rate for Payer: Kaiser Permanente Commercial	$1,670.76
Rate for Payer: Kaiser Permanente Medicaid	$1,352.52
Rate for Payer: MDX Hawaii PPO	$2,572.44
Rate for Payer: University Health Alliance Commercial	$1,485.12

PLT LCP 13H 4.5X247MM 226.632

Facility

$2,652.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,485.12
Max. Negotiated Rate	$2,572.44
Rate for Payer: Cash Price	$1,591.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,856.40
Rate for Payer: Health Management Network Commercial	$2,254.20
Rate for Payer: MDX Hawaii PPO	$2,572.44
Rate for Payer: University Health Alliance Commercial	$1,485.12

PLT LCP 14H 4.5X265MM 226.642

Facility

$2,340.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,193.40
Max. Negotiated Rate	$2,269.80
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,638.00
Rate for Payer: Health Management Network Commercial	$1,989.00
Rate for Payer: Kaiser Permanente Commercial	$1,474.20
Rate for Payer: Kaiser Permanente Medicaid	$1,193.40
Rate for Payer: MDX Hawaii PPO	$2,269.80
Rate for Payer: University Health Alliance Commercial	$1,310.40

PLT LCP 14H 4.5X265MM 226.642

Facility

$2,340.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,310.40
Max. Negotiated Rate	$2,269.80
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,638.00
Rate for Payer: Health Management Network Commercial	$1,989.00
Rate for Payer: MDX Hawaii PPO	$2,269.80
Rate for Payer: University Health Alliance Commercial	$1,310.40

PLT LCP 15H 4.5X282MM 226.652

Facility

$2,598.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,324.98
Max. Negotiated Rate	$2,520.06
Rate for Payer: Cash Price	$1,558.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,818.60
Rate for Payer: Health Management Network Commercial	$2,208.30
Rate for Payer: Kaiser Permanente Commercial	$1,636.74
Rate for Payer: Kaiser Permanente Medicaid	$1,324.98
Rate for Payer: MDX Hawaii PPO	$2,520.06
Rate for Payer: University Health Alliance Commercial	$1,454.88

PLT LCP 15H 4.5X282MM 226.652

Facility

$2,598.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,454.88
Max. Negotiated Rate	$2,520.06
Rate for Payer: Cash Price	$1,558.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,818.60
Rate for Payer: Health Management Network Commercial	$2,208.30
Rate for Payer: MDX Hawaii PPO	$2,520.06
Rate for Payer: University Health Alliance Commercial	$1,454.88

PLT LCP 16H 4.5X300MM 226.662

Facility

$2,256.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,150.56
Max. Negotiated Rate	$2,188.32
Rate for Payer: Cash Price	$1,353.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,579.20
Rate for Payer: Health Management Network Commercial	$1,917.60
Rate for Payer: Kaiser Permanente Commercial	$1,421.28
Rate for Payer: Kaiser Permanente Medicaid	$1,150.56
Rate for Payer: MDX Hawaii PPO	$2,188.32
Rate for Payer: University Health Alliance Commercial	$1,263.36

PLT LCP 16H 4.5X300MM 226.662

Facility

$2,256.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,263.36
Max. Negotiated Rate	$2,188.32
Rate for Payer: Cash Price	$1,353.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,579.20
Rate for Payer: Health Management Network Commercial	$1,917.60
Rate for Payer: MDX Hawaii PPO	$2,188.32
Rate for Payer: University Health Alliance Commercial	$1,263.36

Know your out-of-pocket cost for care.

All Charges