Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

PSN ASF CR 10MM PLY L 3-9CD

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY L 7-12GH

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY L 7-12GH

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY L 9-12J

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY L 9-12J

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY, R 3-11EF

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY, R 3-11EF

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY, R 3-9CD

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY, R 3-9CD

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY, R 7-12GH

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY, R 7-12GH

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY, R 9-12J

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 10MM PLY, R 9-12J

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 11MM PLY L 3-11EF

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 11MM PLY L 3-11EF

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 11MM PLY L 3-9CD

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 11MM PLY L 3-9CD

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 11MM PLY L 7-12GH

Facility

$1,815.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,016.40
Max. Negotiated Rate	$1,760.55
Rate for Payer: Cash Price	$1,089.00
Rate for Payer: Cash Price	$1,200.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,270.50
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Health Management Network Commercial	$1,542.75
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: MDX Hawaii PPO	$1,760.55
Rate for Payer: University Health Alliance Commercial	$1,016.40
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 11MM PLY L 7-12GH

Facility

$2,000.00

Service Code	HCPCS C1776
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: Cash Price	$1,089.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,400.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,270.50
Rate for Payer: Health Management Network Commercial	$1,700.00
Rate for Payer: Health Management Network Commercial	$1,542.75
Rate for Payer: Kaiser Permanente Commercial	$1,143.45
Rate for Payer: Kaiser Permanente Commercial	$1,260.00
Rate for Payer: Kaiser Permanente Medicaid	$925.65
Rate for Payer: Kaiser Permanente Medicaid	$1,020.00
Rate for Payer: MDX Hawaii PPO	$1,940.00
Rate for Payer: MDX Hawaii PPO	$1,760.55
Rate for Payer: University Health Alliance Commercial	$1,016.40
Rate for Payer: University Health Alliance Commercial	$1,120.00

PSN ASF CR 11MM PLY L 9-12J

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 11MM PLY L 9-12J

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 11MM PLY, R 3-11EF

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 11MM PLY, R 3-11EF

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 11MM PLY, R 3-9CD

Facility

$2,000.00

Service Code	HCPCS C1776
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

PSN ASF CR 11MM PLY, R 3-9CD

Facility

$2,000.00

Service Code	HCPCS C1776
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

Know your out-of-pocket cost for care.

All Charges