Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLT LCP TIB-L 6H "L"02.118.305

Facility

$2,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,331.10
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: Kaiser Permanente Commercial	$1,644.30
Rate for Payer: Kaiser Permanente Medicaid	$1,331.10
Rate for Payer: MDX Hawaii PPO	$2,531.70
Rate for Payer: University Health Alliance Commercial	$1,461.60

PLT LCP TIB-L 8H 02.118.107S

Facility

$5,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,864.96
Max. Negotiated Rate	$4,962.52
Rate for Payer: Cash Price	$3,069.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.20
Rate for Payer: Health Management Network Commercial	$4,348.60
Rate for Payer: MDX Hawaii PPO	$4,962.52
Rate for Payer: University Health Alliance Commercial	$2,864.96

PLT LCP TIB-L 8H 02.118.107S

Facility

$5,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,609.16
Max. Negotiated Rate	$4,962.52
Rate for Payer: Cash Price	$3,069.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.20
Rate for Payer: Health Management Network Commercial	$4,348.60
Rate for Payer: Kaiser Permanente Commercial	$3,223.08
Rate for Payer: Kaiser Permanente Medicaid	$2,609.16
Rate for Payer: MDX Hawaii PPO	$4,962.52
Rate for Payer: University Health Alliance Commercial	$2,864.96

PLT LCP TIB-R 12H 02.118.110S

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-R 12H 02.118.110S

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-R 16H 02.118.014

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-R 16H 02.118.014

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-R 16H 02.118.114S

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-R 16H 02.118.114S

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-R 4H 02.118.102S

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-R 4H 02.118.102S

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-R 4H "L"02.118.302

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,405.60
Max. Negotiated Rate	$2,434.70
Rate for Payer: Cash Price	$1,506.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: University Health Alliance Commercial	$1,405.60

PLT LCP TIB-R 4H "L"02.118.302

Facility

$2,510.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,280.10
Max. Negotiated Rate	$2,434.70
Rate for Payer: Cash Price	$1,506.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,757.00
Rate for Payer: Health Management Network Commercial	$2,133.50
Rate for Payer: Kaiser Permanente Commercial	$1,581.30
Rate for Payer: Kaiser Permanente Medicaid	$1,280.10
Rate for Payer: MDX Hawaii PPO	$2,434.70
Rate for Payer: University Health Alliance Commercial	$1,405.60

PLT LCP TIB-R 6H 02.118.104S

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-R 6H 02.118.104S

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-R 6H "L"02.118.304

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

PLT LCP TIB-R 6H "L"02.118.304

Facility

$2,610.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,331.10
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: Kaiser Permanente Commercial	$1,644.30
Rate for Payer: Kaiser Permanente Medicaid	$1,331.10
Rate for Payer: MDX Hawaii PPO	$2,531.70
Rate for Payer: University Health Alliance Commercial	$1,461.60

PLT LCP TIB-R 8H 02.118.106S

Facility

$5,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,864.96
Max. Negotiated Rate	$4,962.52
Rate for Payer: Cash Price	$3,069.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.20
Rate for Payer: Health Management Network Commercial	$4,348.60
Rate for Payer: MDX Hawaii PPO	$4,962.52
Rate for Payer: University Health Alliance Commercial	$2,864.96

PLT LCP TIB-R 8H 02.118.106S

Facility

$5,116.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,609.16
Max. Negotiated Rate	$4,962.52
Rate for Payer: Cash Price	$3,069.60
Rate for Payer: Hawaii Western Management Group Commercial	$3,581.20
Rate for Payer: Health Management Network Commercial	$4,348.60
Rate for Payer: Kaiser Permanente Commercial	$3,223.08
Rate for Payer: Kaiser Permanente Medicaid	$2,609.16
Rate for Payer: MDX Hawaii PPO	$4,962.52
Rate for Payer: University Health Alliance Commercial	$2,864.96

PLT RECON 6H/70MM 1179-05-06

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$705.84
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$830.40
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$871.92
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: University Health Alliance Commercial	$775.04

PLT RECON 6H/70MM 1179-05-06

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$775.04
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$830.40
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: University Health Alliance Commercial	$775.04

PLT RECON 7H/82MM 1179-05-07

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$705.84
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$830.40
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: Kaiser Permanente Commercial	$871.92
Rate for Payer: Kaiser Permanente Medicaid	$705.84
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: University Health Alliance Commercial	$775.04

PLT RECON 7H/82MM 1179-05-07

Facility

$1,384.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$775.04
Max. Negotiated Rate	$1,342.48
Rate for Payer: Cash Price	$830.40
Rate for Payer: Hawaii Western Management Group Commercial	$968.80
Rate for Payer: Health Management Network Commercial	$1,176.40
Rate for Payer: MDX Hawaii PPO	$1,342.48
Rate for Payer: University Health Alliance Commercial	$775.04

PLT TU 1/3 10H/121M 4935-10-03

Facility

$288.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$146.88
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Hawaii Western Management Group Commercial	$201.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: Kaiser Permanente Commercial	$181.44
Rate for Payer: Kaiser Permanente Medicaid	$146.88
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: University Health Alliance Commercial	$161.28

PLT TU 1/3 10H/121M 4935-10-03

Facility

$288.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$161.28
Max. Negotiated Rate	$279.36
Rate for Payer: Cash Price	$172.80
Rate for Payer: Hawaii Western Management Group Commercial	$201.60
Rate for Payer: Health Management Network Commercial	$244.80
Rate for Payer: MDX Hawaii PPO	$279.36
Rate for Payer: University Health Alliance Commercial	$161.28

Know your out-of-pocket cost for care.

All Charges