Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DRAIN BLAKE RND 15FR

Facility

$116.00

Hospital Revenue Code	272
Min. Negotiated Rate	$98.60
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: MDX Hawaii PPO	$112.52

DRAIN BLAKE RND 15FR

Facility

$116.00

Hospital Revenue Code	272
Min. Negotiated Rate	$59.16
Max. Negotiated Rate	$112.52
Rate for Payer: Cash Price	$69.60
Rate for Payer: Hawaii Western Management Group Commercial	$110.20
Rate for Payer: Health Management Network Commercial	$98.60
Rate for Payer: Kaiser Permanente Commercial	$73.08
Rate for Payer: Kaiser Permanente Medicaid	$59.16
Rate for Payer: MDX Hawaii PPO	$112.52
Rate for Payer: University Health Alliance Commercial	$84.55

DRAIN FLUTED ROUND 19FR

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: MDX Hawaii PPO	$102.82

DRAIN FLUTED ROUND 19FR

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$54.06
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$66.78
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: University Health Alliance Commercial	$77.26

DRAIN RND HUBLESS 28FR

Facility

$146.00

Hospital Revenue Code	272
Min. Negotiated Rate	$124.10
Max. Negotiated Rate	$141.62
Rate for Payer: Cash Price	$87.60
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: MDX Hawaii PPO	$141.62

DRAIN RND HUBLESS 28FR

Facility

$146.00

Hospital Revenue Code	272
Min. Negotiated Rate	$74.46
Max. Negotiated Rate	$141.62
Rate for Payer: Cash Price	$87.60
Rate for Payer: Hawaii Western Management Group Commercial	$138.70
Rate for Payer: Health Management Network Commercial	$124.10
Rate for Payer: Kaiser Permanente Commercial	$91.98
Rate for Payer: Kaiser Permanente Medicaid	$74.46
Rate for Payer: MDX Hawaii PPO	$141.62
Rate for Payer: University Health Alliance Commercial	$106.42

DRAIN T-TUBE 12FR SU130-1238

Facility

$938.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$797.30
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: MDX Hawaii PPO	$909.86

DRAIN T-TUBE 12FR SU130-1238

Facility

$938.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$478.38
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Hawaii Western Management Group Commercial	$891.10
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: Kaiser Permanente Commercial	$590.94
Rate for Payer: Kaiser Permanente Medicaid	$478.38
Rate for Payer: MDX Hawaii PPO	$909.86
Rate for Payer: University Health Alliance Commercial	$683.71

DRAIN T-TUBE 14FR

Facility

$938.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$478.38
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Hawaii Western Management Group Commercial	$891.10
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: Kaiser Permanente Commercial	$590.94
Rate for Payer: Kaiser Permanente Medicaid	$478.38
Rate for Payer: MDX Hawaii PPO	$909.86
Rate for Payer: University Health Alliance Commercial	$683.71

DRAIN T-TUBE 14FR

Facility

$938.00

Service Code	HCPCS A4649
Hospital Revenue Code	272
Min. Negotiated Rate	$797.30
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: MDX Hawaii PPO	$909.86

DRAIN T-TUBE 16FR

Facility

$938.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$478.38
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Hawaii Western Management Group Commercial	$891.10
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: Kaiser Permanente Commercial	$590.94
Rate for Payer: Kaiser Permanente Medicaid	$478.38
Rate for Payer: MDX Hawaii PPO	$909.86
Rate for Payer: University Health Alliance Commercial	$683.71

DRAIN T-TUBE 16FR

Facility

$938.00

Service Code	HCPCS C1729
Hospital Revenue Code	272
Min. Negotiated Rate	$797.30
Max. Negotiated Rate	$909.86
Rate for Payer: Cash Price	$562.80
Rate for Payer: Health Management Network Commercial	$797.30
Rate for Payer: MDX Hawaii PPO	$909.86

DRAIN VALVE HEIMLICK CHEST

Facility

$195.00

Hospital Revenue Code	272
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$117.00
Rate for Payer: Hawaii Western Management Group Commercial	$185.25
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: Kaiser Permanente Commercial	$122.85
Rate for Payer: Kaiser Permanente Medicaid	$99.45
Rate for Payer: MDX Hawaii PPO	$189.15
Rate for Payer: University Health Alliance Commercial	$142.14

DRAIN VALVE HEIMLICK CHEST

Facility

$195.00

Hospital Revenue Code	272
Min. Negotiated Rate	$165.75
Max. Negotiated Rate	$189.15
Rate for Payer: Cash Price	$117.00
Rate for Payer: Health Management Network Commercial	$165.75
Rate for Payer: MDX Hawaii PPO	$189.15

DRESSING LG VERAFLO KIT

Facility

$880.00

Hospital Revenue Code	271
Min. Negotiated Rate	$448.80
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$528.00
Rate for Payer: Hawaii Western Management Group Commercial	$836.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: Kaiser Permanente Commercial	$554.40
Rate for Payer: Kaiser Permanente Medicaid	$448.80
Rate for Payer: MDX Hawaii PPO	$853.60
Rate for Payer: University Health Alliance Commercial	$641.43

DRESSING LG VERAFLO KIT

Facility

$880.00

Hospital Revenue Code	271
Min. Negotiated Rate	$748.00
Max. Negotiated Rate	$853.60
Rate for Payer: Cash Price	$528.00
Rate for Payer: Health Management Network Commercial	$748.00
Rate for Payer: MDX Hawaii PPO	$853.60

DRESSING MED VERAFLO KIT

Facility

$502.00

Hospital Revenue Code	271
Min. Negotiated Rate	$426.70
Max. Negotiated Rate	$486.94
Rate for Payer: Cash Price	$301.20
Rate for Payer: Health Management Network Commercial	$426.70
Rate for Payer: MDX Hawaii PPO	$486.94

DRESSING MED VERAFLO KIT

Facility

$502.00

Hospital Revenue Code	271
Min. Negotiated Rate	$256.02
Max. Negotiated Rate	$486.94
Rate for Payer: Cash Price	$301.20
Rate for Payer: Hawaii Western Management Group Commercial	$476.90
Rate for Payer: Health Management Network Commercial	$426.70
Rate for Payer: Kaiser Permanente Commercial	$316.26
Rate for Payer: Kaiser Permanente Medicaid	$256.02
Rate for Payer: MDX Hawaii PPO	$486.94
Rate for Payer: University Health Alliance Commercial	$365.91

DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)

Facility

$2,837.00

Service Code	CPT 16020
Hospital Revenue Code	360
Min. Negotiated Rate	$34.39
Max. Negotiated Rate	$2,837.00
Rate for Payer: AlohaCare Medicaid	$237.02
Rate for Payer: AlohaCare Medicare	$237.02
Rate for Payer: Devoted Health Medicare	$260.72
Rate for Payer: Hawaii Medical Service Association Commercial	$296.27
Rate for Payer: Hawaii Medical Service Association Medicare	$237.02
Rate for Payer: Humana Medicare	$237.02
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$237.02
Rate for Payer: Ohana Health Plan Medicaid	$260.72
Rate for Payer: Ohana Health Plan Medicare	$237.02
Rate for Payer: UnitedHealthcare Medicaid	$34.39
Rate for Payer: UnitedHealthcare Medicare	$237.02

DRILL

Facility

$825.00

Hospital Revenue Code	272
Min. Negotiated Rate	$701.25
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: MDX Hawaii PPO	$800.25

DRILL

Facility

$825.00

Hospital Revenue Code	272
Min. Negotiated Rate	$420.75
Max. Negotiated Rate	$800.25
Rate for Payer: Cash Price	$495.00
Rate for Payer: Hawaii Western Management Group Commercial	$783.75
Rate for Payer: Health Management Network Commercial	$701.25
Rate for Payer: Kaiser Permanente Commercial	$519.75
Rate for Payer: Kaiser Permanente Medicaid	$420.75
Rate for Payer: MDX Hawaii PPO	$800.25
Rate for Payer: University Health Alliance Commercial	$601.34

DRILL 12MM CANN 03.010.439

Facility

$1,679.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,427.15
Max. Negotiated Rate	$1,628.63
Rate for Payer: Cash Price	$1,007.40
Rate for Payer: Health Management Network Commercial	$1,427.15
Rate for Payer: MDX Hawaii PPO	$1,628.63

DRILL 12MM CANN 03.010.439

Facility

$1,679.00

Hospital Revenue Code	272
Min. Negotiated Rate	$856.29
Max. Negotiated Rate	$1,628.63
Rate for Payer: Cash Price	$1,007.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,595.05
Rate for Payer: Health Management Network Commercial	$1,427.15
Rate for Payer: Kaiser Permanente Commercial	$1,057.77
Rate for Payer: Kaiser Permanente Medicaid	$856.29
Rate for Payer: MDX Hawaii PPO	$1,628.63
Rate for Payer: University Health Alliance Commercial	$1,223.82

DRILL 1.3X100MM P99-100-1310

Facility

$872.00

Hospital Revenue Code	272
Min. Negotiated Rate	$444.72
Max. Negotiated Rate	$845.84
Rate for Payer: Cash Price	$523.20
Rate for Payer: Hawaii Western Management Group Commercial	$828.40
Rate for Payer: Health Management Network Commercial	$741.20
Rate for Payer: Kaiser Permanente Commercial	$549.36
Rate for Payer: Kaiser Permanente Medicaid	$444.72
Rate for Payer: MDX Hawaii PPO	$845.84
Rate for Payer: University Health Alliance Commercial	$635.60

DRILL 1.3X100MM P99-100-1310

Facility

$872.00

Hospital Revenue Code	272
Min. Negotiated Rate	$741.20
Max. Negotiated Rate	$845.84
Rate for Payer: Cash Price	$523.20
Rate for Payer: Health Management Network Commercial	$741.20
Rate for Payer: MDX Hawaii PPO	$845.84

Know your out-of-pocket cost for care.

All Charges