Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

WIRE PRECUT 0.6X175 291.240.98

Facility

$121.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$61.71
Max. Negotiated Rate	$117.37
Rate for Payer: Cash Price	$72.60
Rate for Payer: Hawaii Western Management Group Commercial	$84.70
Rate for Payer: Health Management Network Commercial	$102.85
Rate for Payer: Kaiser Permanente Commercial	$76.23
Rate for Payer: Kaiser Permanente Medicaid	$61.71
Rate for Payer: MDX Hawaii PPO	$117.37
Rate for Payer: University Health Alliance Commercial	$67.76

WIRE STD STR TIP

Facility

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$155.55
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: MDX Hawaii PPO	$177.51

WIRE STD STR TIP

Facility

$183.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$93.33
Max. Negotiated Rate	$177.51
Rate for Payer: Cash Price	$109.80
Rate for Payer: Hawaii Western Management Group Commercial	$173.85
Rate for Payer: Health Management Network Commercial	$155.55
Rate for Payer: Kaiser Permanente Commercial	$115.29
Rate for Payer: Kaiser Permanente Medicaid	$93.33
Rate for Payer: MDX Hawaii PPO	$177.51
Rate for Payer: University Health Alliance Commercial	$133.39

WIRE STRAIGHT 300 V14 CONTROL

Facility

$599.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$509.15
Max. Negotiated Rate	$581.03
Rate for Payer: Cash Price	$359.40
Rate for Payer: Health Management Network Commercial	$509.15
Rate for Payer: MDX Hawaii PPO	$581.03

WIRE STRAIGHT 300 V14 CONTROL

Facility

$599.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$305.49
Max. Negotiated Rate	$581.03
Rate for Payer: Cash Price	$359.40
Rate for Payer: Hawaii Western Management Group Commercial	$569.05
Rate for Payer: Health Management Network Commercial	$509.15
Rate for Payer: Kaiser Permanente Commercial	$377.37
Rate for Payer: Kaiser Permanente Medicaid	$305.49
Rate for Payer: MDX Hawaii PPO	$581.03
Rate for Payer: University Health Alliance Commercial	$436.61

WIRE THREADED 70/15 1.6MM M420

Facility

$641.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$326.91
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$384.60
Rate for Payer: Hawaii Western Management Group Commercial	$608.95
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: Kaiser Permanente Commercial	$403.83
Rate for Payer: Kaiser Permanente Medicaid	$326.91
Rate for Payer: MDX Hawaii PPO	$621.77
Rate for Payer: University Health Alliance Commercial	$467.22

WIRE THREADED 70/15 1.6MM M420

Facility

$641.00

Service Code	HCPCS C1769
Hospital Revenue Code	272
Min. Negotiated Rate	$544.85
Max. Negotiated Rate	$621.77
Rate for Payer: Cash Price	$384.60
Rate for Payer: Health Management Network Commercial	$544.85
Rate for Payer: MDX Hawaii PPO	$621.77

WOLVERINE CB 2.25X10

Facility

$2,805.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,430.55
Max. Negotiated Rate	$2,720.85
Rate for Payer: Cash Price	$1,683.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,664.75
Rate for Payer: Health Management Network Commercial	$2,384.25
Rate for Payer: Kaiser Permanente Commercial	$1,767.15
Rate for Payer: Kaiser Permanente Medicaid	$1,430.55
Rate for Payer: MDX Hawaii PPO	$2,720.85
Rate for Payer: University Health Alliance Commercial	$2,044.56

WOLVERINE CB 2.25X10

Facility

$2,805.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$2,384.25
Max. Negotiated Rate	$2,720.85
Rate for Payer: Cash Price	$1,683.00
Rate for Payer: Health Management Network Commercial	$2,384.25
Rate for Payer: MDX Hawaii PPO	$2,720.85

WOLVERINE CB 4X15

Facility

$2,550.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$2,167.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: MDX Hawaii PPO	$2,473.50

WOLVERINE CB 4X15

Facility

$2,550.00

Service Code	HCPCS C1725
Hospital Revenue Code	272
Min. Negotiated Rate	$1,300.50
Max. Negotiated Rate	$2,473.50
Rate for Payer: Cash Price	$1,530.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,422.50
Rate for Payer: Health Management Network Commercial	$2,167.50
Rate for Payer: Kaiser Permanente Commercial	$1,606.50
Rate for Payer: Kaiser Permanente Medicaid	$1,300.50
Rate for Payer: MDX Hawaii PPO	$2,473.50
Rate for Payer: University Health Alliance Commercial	$1,858.69

WOUND CLOSURE SYL-WC-32-050

Facility

$260.00

Hospital Revenue Code	272
Min. Negotiated Rate	$221.00
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: MDX Hawaii PPO	$252.20

WOUND CLOSURE SYL-WC-32-050

Facility

$260.00

Hospital Revenue Code	272
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$247.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: Kaiser Permanente Commercial	$163.80
Rate for Payer: Kaiser Permanente Medicaid	$132.60
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$189.51

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$103,543.02

Service Code	MSDRG 464
Min. Negotiated Rate	$35,427.39
Max. Negotiated Rate	$103,543.02
Rate for Payer: AlohaCare Medicare	$35,427.39
Rate for Payer: Devoted Health Medicare	$38,970.13
Rate for Payer: Hawaii Medical Service Association Commercial	$103,543.02
Rate for Payer: Hawaii Medical Service Association Medicare	$35,427.39
Rate for Payer: Humana Medicare	$35,427.39
Rate for Payer: Kaiser Permanente Commercial	$53,728.57
Rate for Payer: Kaiser Permanente Medicare	$35,427.39
Rate for Payer: Ohana Health Plan Medicare	$35,427.39
Rate for Payer: UnitedHealthcare Medicare	$35,427.39

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$103,543.02

Service Code	MSDRG 463
Min. Negotiated Rate	$64,827.56
Max. Negotiated Rate	$103,543.02
Rate for Payer: AlohaCare Medicare	$64,827.56
Rate for Payer: Devoted Health Medicare	$71,310.32
Rate for Payer: Hawaii Medical Service Association Commercial	$103,543.02
Rate for Payer: Hawaii Medical Service Association Medicare	$64,827.56
Rate for Payer: Humana Medicare	$64,827.56
Rate for Payer: Kaiser Permanente Commercial	$98,316.38
Rate for Payer: Kaiser Permanente Medicare	$64,827.56
Rate for Payer: Ohana Health Plan Medicare	$64,827.56
Rate for Payer: UnitedHealthcare Medicare	$64,827.56

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$103,543.02

Service Code	MSDRG 465
Min. Negotiated Rate	$20,743.21
Max. Negotiated Rate	$103,543.02
Rate for Payer: AlohaCare Medicare	$20,743.21
Rate for Payer: Devoted Health Medicare	$22,817.53
Rate for Payer: Hawaii Medical Service Association Commercial	$103,543.02
Rate for Payer: Hawaii Medical Service Association Medicare	$20,743.21
Rate for Payer: Humana Medicare	$20,743.21
Rate for Payer: Kaiser Permanente Commercial	$31,458.83
Rate for Payer: Kaiser Permanente Medicare	$20,743.21
Rate for Payer: Ohana Health Plan Medicare	$20,743.21
Rate for Payer: UnitedHealthcare Medicare	$20,743.21

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$33,025.12

Service Code	MSDRG 902
Min. Negotiated Rate	$21,776.01
Max. Negotiated Rate	$33,025.12
Rate for Payer: AlohaCare Medicare	$21,776.01
Rate for Payer: Devoted Health Medicare	$23,953.61
Rate for Payer: Hawaii Medical Service Association Commercial	$28,755.21
Rate for Payer: Hawaii Medical Service Association Medicare	$21,776.01
Rate for Payer: Humana Medicare	$21,776.01
Rate for Payer: Kaiser Permanente Commercial	$33,025.12
Rate for Payer: Kaiser Permanente Medicare	$21,776.01
Rate for Payer: Ohana Health Plan Medicare	$21,776.01
Rate for Payer: UnitedHealthcare Medicare	$21,776.01

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$72,391.35

Service Code	MSDRG 901
Min. Negotiated Rate	$28,755.21
Max. Negotiated Rate	$72,391.35
Rate for Payer: AlohaCare Medicare	$47,733.21
Rate for Payer: Devoted Health Medicare	$52,506.53
Rate for Payer: Hawaii Medical Service Association Commercial	$28,755.21
Rate for Payer: Hawaii Medical Service Association Medicare	$47,733.21
Rate for Payer: Humana Medicare	$47,733.21
Rate for Payer: Kaiser Permanente Commercial	$72,391.35
Rate for Payer: Kaiser Permanente Medicare	$47,733.21
Rate for Payer: Ohana Health Plan Medicare	$47,733.21
Rate for Payer: UnitedHealthcare Medicare	$47,733.21

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$28,755.21

Service Code	MSDRG 903
Min. Negotiated Rate	$13,303.33
Max. Negotiated Rate	$28,755.21
Rate for Payer: AlohaCare Medicare	$13,303.33
Rate for Payer: Devoted Health Medicare	$14,633.66
Rate for Payer: Hawaii Medical Service Association Commercial	$28,755.21
Rate for Payer: Hawaii Medical Service Association Medicare	$13,303.33
Rate for Payer: Humana Medicare	$13,303.33
Rate for Payer: Kaiser Permanente Commercial	$20,175.60
Rate for Payer: Kaiser Permanente Medicare	$13,303.33
Rate for Payer: Ohana Health Plan Medicare	$13,303.33
Rate for Payer: UnitedHealthcare Medicare	$13,303.33

WOUND LAVAGE WW 00-8887-002-00

Facility

$2,363.00

Hospital Revenue Code	272
Min. Negotiated Rate	$2,008.55
Max. Negotiated Rate	$2,292.11
Rate for Payer: Cash Price	$1,417.80
Rate for Payer: Health Management Network Commercial	$2,008.55
Rate for Payer: MDX Hawaii PPO	$2,292.11

WOUND LAVAGE WW 00-8887-002-00

Facility

$2,363.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,205.13
Max. Negotiated Rate	$2,292.11
Rate for Payer: Cash Price	$1,417.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,244.85
Rate for Payer: Health Management Network Commercial	$2,008.55
Rate for Payer: Kaiser Permanente Commercial	$1,488.69
Rate for Payer: Kaiser Permanente Medicaid	$1,205.13
Rate for Payer: MDX Hawaii PPO	$2,292.11
Rate for Payer: University Health Alliance Commercial	$1,722.39

WOUNDVAC CANISTER

Facility

$145.00

Hospital Revenue Code	272
Min. Negotiated Rate	$123.25
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$87.00
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: MDX Hawaii PPO	$140.65

WOUNDVAC CANISTER

Facility

$145.00

Hospital Revenue Code	272
Min. Negotiated Rate	$73.95
Max. Negotiated Rate	$140.65
Rate for Payer: Cash Price	$87.00
Rate for Payer: Hawaii Western Management Group Commercial	$137.75
Rate for Payer: Health Management Network Commercial	$123.25
Rate for Payer: Kaiser Permanente Commercial	$91.35
Rate for Payer: Kaiser Permanente Medicaid	$73.95
Rate for Payer: MDX Hawaii PPO	$140.65
Rate for Payer: University Health Alliance Commercial	$105.69

WOUNDVAC CANISTER VERAFLO 1000

Facility

$214.00

Hospital Revenue Code	271
Min. Negotiated Rate	$181.90
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$128.40
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: MDX Hawaii PPO	$207.58

WOUNDVAC CANISTER VERAFLO 1000

Facility

$214.00

Hospital Revenue Code	271
Min. Negotiated Rate	$109.14
Max. Negotiated Rate	$207.58
Rate for Payer: Cash Price	$128.40
Rate for Payer: Hawaii Western Management Group Commercial	$203.30
Rate for Payer: Health Management Network Commercial	$181.90
Rate for Payer: Kaiser Permanente Commercial	$134.82
Rate for Payer: Kaiser Permanente Medicaid	$109.14
Rate for Payer: MDX Hawaii PPO	$207.58
Rate for Payer: University Health Alliance Commercial	$155.98

Know your out-of-pocket cost for care.

All Charges