Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PLT TU 1/3 2H/25MM 4935-02-03

Facility

$488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$273.28
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$292.80
Rate for Payer: Hawaii Western Management Group Commercial	$341.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: University Health Alliance Commercial	$273.28

PLT TU 1/3 2H/25MM 4935-02-03

Facility

$488.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$248.88
Max. Negotiated Rate	$473.36
Rate for Payer: Cash Price	$292.80
Rate for Payer: Hawaii Western Management Group Commercial	$341.60
Rate for Payer: Health Management Network Commercial	$414.80
Rate for Payer: Kaiser Permanente Commercial	$307.44
Rate for Payer: Kaiser Permanente Medicaid	$248.88
Rate for Payer: MDX Hawaii PPO	$473.36
Rate for Payer: University Health Alliance Commercial	$273.28

PLT TU 1/3 6H/73MM 4935-06-03

Facility

$525.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$294.00
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$315.00
Rate for Payer: Hawaii Western Management Group Commercial	$367.50
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: University Health Alliance Commercial	$294.00

PLT TU 1/3 6H/73MM 4935-06-03

Facility

$525.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$509.25
Rate for Payer: Cash Price	$315.00
Rate for Payer: Hawaii Western Management Group Commercial	$367.50
Rate for Payer: Health Management Network Commercial	$446.25
Rate for Payer: Kaiser Permanente Commercial	$330.75
Rate for Payer: Kaiser Permanente Medicaid	$267.75
Rate for Payer: MDX Hawaii PPO	$509.25
Rate for Payer: University Health Alliance Commercial	$294.00

PLT TU 1/3 9H/109MM 4935-09-03

Facility

$450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: University Health Alliance Commercial	$252.00

PLT TU 1/3 9H/109MM 4935-09-03

Facility

$450.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$436.50
Rate for Payer: Cash Price	$270.00
Rate for Payer: Hawaii Western Management Group Commercial	$315.00
Rate for Payer: Health Management Network Commercial	$382.50
Rate for Payer: Kaiser Permanente Commercial	$283.50
Rate for Payer: Kaiser Permanente Medicaid	$229.50
Rate for Payer: MDX Hawaii PPO	$436.50
Rate for Payer: University Health Alliance Commercial	$252.00

PLT VO ANG LT/3H/7PEG VPPL-3-7

Facility

$2,595.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.20
Max. Negotiated Rate	$2,517.15
Rate for Payer: Cash Price	$1,557.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,816.50
Rate for Payer: Health Management Network Commercial	$2,205.75
Rate for Payer: MDX Hawaii PPO	$2,517.15
Rate for Payer: University Health Alliance Commercial	$1,453.20

PLT VO ANG LT/3H/7PEG VPPL-3-7

Facility

$2,595.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,323.45
Max. Negotiated Rate	$2,517.15
Rate for Payer: Cash Price	$1,557.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,816.50
Rate for Payer: Health Management Network Commercial	$2,205.75
Rate for Payer: Kaiser Permanente Commercial	$1,634.85
Rate for Payer: Kaiser Permanente Medicaid	$1,323.45
Rate for Payer: MDX Hawaii PPO	$2,517.15
Rate for Payer: University Health Alliance Commercial	$1,453.20

PLT VO ANG/LT/5H/7PEG VPPL-5-7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLT VO ANG/LT/5H/7PEG VPPL-5-7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLT VO ANG/RT/3H/7PEG VPPR-3-7

Facility

$2,595.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.20
Max. Negotiated Rate	$2,517.15
Rate for Payer: Cash Price	$1,557.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,816.50
Rate for Payer: Health Management Network Commercial	$2,205.75
Rate for Payer: MDX Hawaii PPO	$2,517.15
Rate for Payer: University Health Alliance Commercial	$1,453.20

PLT VO ANG/RT/3H/7PEG VPPR-3-7

Facility

$2,595.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,323.45
Max. Negotiated Rate	$2,517.15
Rate for Payer: Cash Price	$1,557.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,816.50
Rate for Payer: Health Management Network Commercial	$2,205.75
Rate for Payer: Kaiser Permanente Commercial	$1,634.85
Rate for Payer: Kaiser Permanente Medicaid	$1,323.45
Rate for Payer: MDX Hawaii PPO	$2,517.15
Rate for Payer: University Health Alliance Commercial	$1,453.20

PLT VO ANG/RT/5H/7PEG VPPR-5-7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLT VO ANG/RT/5H/7PEG VPPR-5-7

Facility

$2,000.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,020.00
Max. Negotiated Rate	$1,940.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: University Health Alliance Commercial	$1,120.00

PLT VOL LT/11H/7PEG VLBPL-11-7

Facility

$5,310.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,973.60
Max. Negotiated Rate	$5,150.70
Rate for Payer: Cash Price	$3,186.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,717.00
Rate for Payer: Health Management Network Commercial	$4,513.50
Rate for Payer: MDX Hawaii PPO	$5,150.70
Rate for Payer: University Health Alliance Commercial	$2,973.60

PLT VOL LT/11H/7PEG VLBPL-11-7

Facility

$5,310.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,708.10
Max. Negotiated Rate	$5,150.70
Rate for Payer: Cash Price	$3,186.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,717.00
Rate for Payer: Health Management Network Commercial	$4,513.50
Rate for Payer: Kaiser Permanente Commercial	$3,345.30
Rate for Payer: Kaiser Permanente Medicaid	$2,708.10
Rate for Payer: MDX Hawaii PPO	$5,150.70
Rate for Payer: University Health Alliance Commercial	$2,973.60

PLT VOL LT 3HOLE 7PEG NARROW

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,691.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLT VOL LT 3HOLE 7PEG NARROW

Facility

$3,020.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$1,540.20
Max. Negotiated Rate	$2,929.40
Rate for Payer: Cash Price	$1,812.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,114.00
Rate for Payer: Health Management Network Commercial	$2,567.00
Rate for Payer: Kaiser Permanente Commercial	$1,902.60
Rate for Payer: Kaiser Permanente Medicaid	$1,540.20
Rate for Payer: MDX Hawaii PPO	$2,929.40
Rate for Payer: University Health Alliance Commercial	$1,691.20

PLT VOL LT 9H 7PEG VLBPL-9-7

Facility

$4,330.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,424.80
Max. Negotiated Rate	$4,200.10
Rate for Payer: Cash Price	$2,598.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,031.00
Rate for Payer: Health Management Network Commercial	$3,680.50
Rate for Payer: MDX Hawaii PPO	$4,200.10
Rate for Payer: University Health Alliance Commercial	$2,424.80

PLT VOL LT 9H 7PEG VLBPL-9-7

Facility

$4,330.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,208.30
Max. Negotiated Rate	$4,200.10
Rate for Payer: Cash Price	$2,598.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,031.00
Rate for Payer: Health Management Network Commercial	$3,680.50
Rate for Payer: Kaiser Permanente Commercial	$2,727.90
Rate for Payer: Kaiser Permanente Medicaid	$2,208.30
Rate for Payer: MDX Hawaii PPO	$4,200.10
Rate for Payer: University Health Alliance Commercial	$2,424.80

PLT VOL RT/11H/7PEG VLBPR-11-7

Facility

$5,310.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,708.10
Max. Negotiated Rate	$5,150.70
Rate for Payer: Cash Price	$3,186.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,717.00
Rate for Payer: Health Management Network Commercial	$4,513.50
Rate for Payer: Kaiser Permanente Commercial	$3,345.30
Rate for Payer: Kaiser Permanente Medicaid	$2,708.10
Rate for Payer: MDX Hawaii PPO	$5,150.70
Rate for Payer: University Health Alliance Commercial	$2,973.60

PLT VOL RT/11H/7PEG VLBPR-11-7

Facility

$5,310.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,973.60
Max. Negotiated Rate	$5,150.70
Rate for Payer: Cash Price	$3,186.00
Rate for Payer: Hawaii Western Management Group Commercial	$3,717.00
Rate for Payer: Health Management Network Commercial	$4,513.50
Rate for Payer: MDX Hawaii PPO	$5,150.70
Rate for Payer: University Health Alliance Commercial	$2,973.60

PLUG

Facility

$392.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$219.52
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$235.20
Rate for Payer: Hawaii Western Management Group Commercial	$274.40
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: University Health Alliance Commercial	$219.52

PLUG

Facility

$392.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$199.92
Max. Negotiated Rate	$380.24
Rate for Payer: Cash Price	$235.20
Rate for Payer: Hawaii Western Management Group Commercial	$274.40
Rate for Payer: Health Management Network Commercial	$333.20
Rate for Payer: Kaiser Permanente Commercial	$246.96
Rate for Payer: Kaiser Permanente Medicaid	$199.92
Rate for Payer: MDX Hawaii PPO	$380.24
Rate for Payer: University Health Alliance Commercial	$219.52

PLUG 16MM/25MM 32-8105-038-00

Facility

$727.00

Hospital Revenue Code	272
Min. Negotiated Rate	$617.95
Max. Negotiated Rate	$705.19
Rate for Payer: Cash Price	$436.20
Rate for Payer: Health Management Network Commercial	$617.95
Rate for Payer: MDX Hawaii PPO	$705.19

Know your out-of-pocket cost for care.

All Charges