Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLT LCP 17H 4.5X318MM 226.672

Facility

$2,978.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,518.78
Max. Negotiated Rate	$2,888.66
Rate for Payer: Cash Price	$1,786.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.60
Rate for Payer: Health Management Network Commercial	$2,531.30
Rate for Payer: Kaiser Permanente Commercial	$1,876.14
Rate for Payer: Kaiser Permanente Medicaid	$1,518.78
Rate for Payer: MDX Hawaii PPO	$2,888.66
Rate for Payer: University Health Alliance Commercial	$1,667.68

PLT LCP 17H 4.5X318MM 226.672

Facility

$2,978.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,667.68
Max. Negotiated Rate	$2,888.66
Rate for Payer: Cash Price	$1,786.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,084.60
Rate for Payer: Health Management Network Commercial	$2,531.30
Rate for Payer: MDX Hawaii PPO	$2,888.66
Rate for Payer: University Health Alliance Commercial	$1,667.68

PLT LCP 18H 4.5X336MM 226.682

Facility

$3,246.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,817.76
Max. Negotiated Rate	$3,148.62
Rate for Payer: Cash Price	$1,947.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,272.20
Rate for Payer: Health Management Network Commercial	$2,759.10
Rate for Payer: MDX Hawaii PPO	$3,148.62
Rate for Payer: University Health Alliance Commercial	$1,817.76

PLT LCP 18H 4.5X336MM 226.682

Facility

$3,246.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,655.46
Max. Negotiated Rate	$3,148.62
Rate for Payer: Cash Price	$1,947.60
Rate for Payer: Hawaii Western Management Group Commercial	$2,272.20
Rate for Payer: Health Management Network Commercial	$2,759.10
Rate for Payer: Kaiser Permanente Commercial	$2,044.98
Rate for Payer: Kaiser Permanente Medicaid	$1,655.46
Rate for Payer: MDX Hawaii PPO	$3,148.62
Rate for Payer: University Health Alliance Commercial	$1,817.76

PLT LCP-T 6H 4.5X115MM 240.161

Facility

$2,436.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,242.36
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,705.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: Kaiser Permanente Commercial	$1,534.68
Rate for Payer: Kaiser Permanente Medicaid	$1,242.36
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: University Health Alliance Commercial	$1,364.16

PLT LCP-T 6H 4.5X115MM 240.161

Facility

$2,436.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,364.16
Max. Negotiated Rate	$2,362.92
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,705.20
Rate for Payer: Health Management Network Commercial	$2,070.60
Rate for Payer: MDX Hawaii PPO	$2,362.92
Rate for Payer: University Health Alliance Commercial	$1,364.16

PLT LCP-T 8H 4.5X147MM 240.181

Facility

$2,364.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,323.84
Max. Negotiated Rate	$2,293.08
Rate for Payer: Cash Price	$1,418.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,654.80
Rate for Payer: Health Management Network Commercial	$2,009.40
Rate for Payer: MDX Hawaii PPO	$2,293.08
Rate for Payer: University Health Alliance Commercial	$1,323.84

PLT LCP-T 8H 4.5X147MM 240.181

Facility

$2,364.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,205.64
Max. Negotiated Rate	$2,293.08
Rate for Payer: Cash Price	$1,418.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,654.80
Rate for Payer: Health Management Network Commercial	$2,009.40
Rate for Payer: Kaiser Permanente Commercial	$1,489.32
Rate for Payer: Kaiser Permanente Medicaid	$1,205.64
Rate for Payer: MDX Hawaii PPO	$2,293.08
Rate for Payer: University Health Alliance Commercial	$1,323.84

PLT LCP TIB 4H "T" 02.118.306

Facility

$2,110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,076.10
Max. Negotiated Rate	$2,046.70
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,477.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Kaiser Permanente Commercial	$1,329.30
Rate for Payer: Kaiser Permanente Medicaid	$1,076.10
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: University Health Alliance Commercial	$1,181.60

PLT LCP TIB 4H "T" 02.118.306

Facility

$2,110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.60
Max. Negotiated Rate	$2,046.70
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,477.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: University Health Alliance Commercial	$1,181.60

PLT LCP TIB 6H "T" 02.118.207

Facility

$2,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,229.76
Max. Negotiated Rate	$2,130.12
Rate for Payer: Cash Price	$1,317.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,537.20
Rate for Payer: Health Management Network Commercial	$1,866.60
Rate for Payer: MDX Hawaii PPO	$2,130.12
Rate for Payer: University Health Alliance Commercial	$1,229.76

PLT LCP TIB 6H "T" 02.118.207

Facility

$2,196.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.96
Max. Negotiated Rate	$2,130.12
Rate for Payer: Cash Price	$1,317.60
Rate for Payer: Hawaii Western Management Group Commercial	$1,537.20
Rate for Payer: Health Management Network Commercial	$1,866.60
Rate for Payer: Kaiser Permanente Commercial	$1,383.48
Rate for Payer: Kaiser Permanente Medicaid	$1,119.96
Rate for Payer: MDX Hawaii PPO	$2,130.12
Rate for Payer: University Health Alliance Commercial	$1,229.76

PLT LCP TIB-L 12H 02.118.111S

Facility

$5,374.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,740.74
Max. Negotiated Rate	$5,212.78
Rate for Payer: Cash Price	$3,224.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,761.80
Rate for Payer: Health Management Network Commercial	$4,567.90
Rate for Payer: Kaiser Permanente Commercial	$3,385.62
Rate for Payer: Kaiser Permanente Medicaid	$2,740.74
Rate for Payer: MDX Hawaii PPO	$5,212.78
Rate for Payer: University Health Alliance Commercial	$3,009.44

PLT LCP TIB-L 12H 02.118.111S

Facility

$5,374.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,009.44
Max. Negotiated Rate	$5,212.78
Rate for Payer: Cash Price	$3,224.40
Rate for Payer: Hawaii Western Management Group Commercial	$3,761.80
Rate for Payer: Health Management Network Commercial	$4,567.90
Rate for Payer: MDX Hawaii PPO	$5,212.78
Rate for Payer: University Health Alliance Commercial	$3,009.44

PLT LCP TIB-L 16H 02.118.015

Facility

$5,972.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,045.72
Max. Negotiated Rate	$5,792.84
Rate for Payer: Cash Price	$3,583.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,180.40
Rate for Payer: Health Management Network Commercial	$5,076.20
Rate for Payer: Kaiser Permanente Commercial	$3,762.36
Rate for Payer: Kaiser Permanente Medicaid	$3,045.72
Rate for Payer: MDX Hawaii PPO	$5,792.84
Rate for Payer: University Health Alliance Commercial	$3,344.32

PLT LCP TIB-L 16H 02.118.015

Facility

$5,972.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,344.32
Max. Negotiated Rate	$5,792.84
Rate for Payer: Cash Price	$3,583.20
Rate for Payer: Hawaii Western Management Group Commercial	$4,180.40
Rate for Payer: Health Management Network Commercial	$5,076.20
Rate for Payer: MDX Hawaii PPO	$5,792.84
Rate for Payer: University Health Alliance Commercial	$3,344.32

PLT LCP TIB-L 16H 02.118.115S

Facility

$6,578.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,683.68
Max. Negotiated Rate	$6,380.66
Rate for Payer: Cash Price	$3,946.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,604.60
Rate for Payer: Health Management Network Commercial	$5,591.30
Rate for Payer: MDX Hawaii PPO	$6,380.66
Rate for Payer: University Health Alliance Commercial	$3,683.68

PLT LCP TIB-L 16H 02.118.115S

Facility

$6,578.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$3,354.78
Max. Negotiated Rate	$6,380.66
Rate for Payer: Cash Price	$3,946.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,604.60
Rate for Payer: Health Management Network Commercial	$5,591.30
Rate for Payer: Kaiser Permanente Commercial	$4,144.14
Rate for Payer: Kaiser Permanente Medicaid	$3,354.78
Rate for Payer: MDX Hawaii PPO	$6,380.66
Rate for Payer: University Health Alliance Commercial	$3,683.68

PLT LCP TIB-L 4H 02.118.103S

Facility

$5,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,558.16
Max. Negotiated Rate	$4,865.52
Rate for Payer: Cash Price	$3,009.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,511.20
Rate for Payer: Health Management Network Commercial	$4,263.60
Rate for Payer: Kaiser Permanente Commercial	$3,160.08
Rate for Payer: Kaiser Permanente Medicaid	$2,558.16
Rate for Payer: MDX Hawaii PPO	$4,865.52
Rate for Payer: University Health Alliance Commercial	$2,808.96

PLT LCP TIB-L 4H 02.118.103S

Facility

$5,016.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,808.96
Max. Negotiated Rate	$4,865.52
Rate for Payer: Cash Price	$3,009.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,511.20
Rate for Payer: Health Management Network Commercial	$4,263.60
Rate for Payer: MDX Hawaii PPO	$4,865.52
Rate for Payer: University Health Alliance Commercial	$2,808.96

PLT LCP TIB-L 4H "L"02.118.303

Facility

$2,110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,181.60
Max. Negotiated Rate	$2,046.70
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,477.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: University Health Alliance Commercial	$1,181.60

PLT LCP TIB-L 4H "L"02.118.303

Facility

$2,110.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,076.10
Max. Negotiated Rate	$2,046.70
Rate for Payer: Cash Price	$1,266.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,477.00
Rate for Payer: Health Management Network Commercial	$1,793.50
Rate for Payer: Kaiser Permanente Commercial	$1,329.30
Rate for Payer: Kaiser Permanente Medicaid	$1,076.10
Rate for Payer: MDX Hawaii PPO	$2,046.70
Rate for Payer: University Health Alliance Commercial	$1,181.60

PLT LCP TIB-L 6H 02.118.105S

Facility

$5,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,836.96
Max. Negotiated Rate	$4,914.02
Rate for Payer: Cash Price	$3,039.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,546.20
Rate for Payer: Health Management Network Commercial	$4,306.10
Rate for Payer: MDX Hawaii PPO	$4,914.02
Rate for Payer: University Health Alliance Commercial	$2,836.96

PLT LCP TIB-L 6H 02.118.105S

Facility

$5,066.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,583.66
Max. Negotiated Rate	$4,914.02
Rate for Payer: Cash Price	$3,039.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,546.20
Rate for Payer: Health Management Network Commercial	$4,306.10
Rate for Payer: Kaiser Permanente Commercial	$3,191.58
Rate for Payer: Kaiser Permanente Medicaid	$2,583.66
Rate for Payer: MDX Hawaii PPO	$4,914.02
Rate for Payer: University Health Alliance Commercial	$2,836.96

PLT LCP TIB-L 6H "L"02.118.305

Facility

$2,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,461.60
Max. Negotiated Rate	$2,531.70
Rate for Payer: Cash Price	$1,566.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,827.00
Rate for Payer: Health Management Network Commercial	$2,218.50
Rate for Payer: MDX Hawaii PPO	$2,531.70
Rate for Payer: University Health Alliance Commercial	$1,461.60

Know your out-of-pocket cost for care.

All Charges