Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

DRSG 4X6 MEPILEX AG ANTIMICRO

Facility

$122.00

Service Code	HCPCS A6212
Hospital Revenue Code	272
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$118.34
Rate for Payer: Cash Price	$73.20
Rate for Payer: Cash Price	$73.20
Rate for Payer: Hawaii Western Management Group Commercial	$115.90
Rate for Payer: Health Management Network Commercial	$103.70
Rate for Payer: Kaiser Permanente Commercial	$76.86
Rate for Payer: Kaiser Permanente Medicaid	$62.22
Rate for Payer: MDX Hawaii PPO	$118.34
Rate for Payer: UnitedHealthcare Medicaid	$10.11
Rate for Payer: University Health Alliance Commercial	$88.93

DRSG 4X8 MEPILEX AG ANTIMICRO

Facility

$141.00

Service Code	HCPCS A6212
Hospital Revenue Code	272
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cash Price	$84.60
Rate for Payer: Hawaii Western Management Group Commercial	$133.95
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: Kaiser Permanente Commercial	$88.83
Rate for Payer: Kaiser Permanente Medicaid	$71.91
Rate for Payer: MDX Hawaii PPO	$136.77
Rate for Payer: UnitedHealthcare Medicaid	$10.11
Rate for Payer: University Health Alliance Commercial	$102.77

DRSG 4X8 MEPILEX AG ANTIMICRO

Facility

$141.00

Service Code	HCPCS A6212
Hospital Revenue Code	272
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$136.77
Rate for Payer: Cash Price	$84.60
Rate for Payer: Health Management Network Commercial	$119.85
Rate for Payer: MDX Hawaii PPO	$136.77

DRSG 6X6 HYDROFERA BLUE

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

DRSG 6X6 HYDROFERA BLUE

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

DRSG 6X6 HYDROFERA COMFORTCEL

Facility

$156.00

Service Code	HCPCS A6210
Hospital Revenue Code	272
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: MDX Hawaii PPO	$151.32

DRSG 6X6 HYDROFERA COMFORTCEL

Facility

$156.00

Service Code	HCPCS A6210
Hospital Revenue Code	272
Min. Negotiated Rate	$16.82
Max. Negotiated Rate	$151.32
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Hawaii Western Management Group Commercial	$148.20
Rate for Payer: Health Management Network Commercial	$132.60
Rate for Payer: Kaiser Permanente Commercial	$98.28
Rate for Payer: Kaiser Permanente Medicaid	$79.56
Rate for Payer: MDX Hawaii PPO	$151.32
Rate for Payer: UnitedHealthcare Medicaid	$16.82
Rate for Payer: University Health Alliance Commercial	$113.71

DRSG 8X8 HYDROFERA READY

Facility

$95.00

Service Code	HCPCS A6211
Hospital Revenue Code	272
Min. Negotiated Rate	$80.75
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: MDX Hawaii PPO	$92.15

DRSG 8X8 HYDROFERA READY

Facility

$95.00

Service Code	HCPCS A6211
Hospital Revenue Code	272
Min. Negotiated Rate	$30.61
Max. Negotiated Rate	$92.15
Rate for Payer: Cash Price	$57.00
Rate for Payer: Cash Price	$57.00
Rate for Payer: Hawaii Western Management Group Commercial	$90.25
Rate for Payer: Health Management Network Commercial	$80.75
Rate for Payer: Kaiser Permanente Commercial	$59.85
Rate for Payer: Kaiser Permanente Medicaid	$48.45
Rate for Payer: MDX Hawaii PPO	$92.15
Rate for Payer: UnitedHealthcare Medicaid	$30.61
Rate for Payer: University Health Alliance Commercial	$69.25

DRSG LG VAC PEEL

Facility

$573.00

Hospital Revenue Code	272
Min. Negotiated Rate	$292.23
Max. Negotiated Rate	$555.81
Rate for Payer: Cash Price	$343.80
Rate for Payer: Hawaii Western Management Group Commercial	$544.35
Rate for Payer: Health Management Network Commercial	$487.05
Rate for Payer: Kaiser Permanente Commercial	$360.99
Rate for Payer: Kaiser Permanente Medicaid	$292.23
Rate for Payer: MDX Hawaii PPO	$555.81
Rate for Payer: University Health Alliance Commercial	$417.66

DRSG LG VAC PEEL

Facility

$573.00

Hospital Revenue Code	272
Min. Negotiated Rate	$487.05
Max. Negotiated Rate	$555.81
Rate for Payer: Cash Price	$343.80
Rate for Payer: Health Management Network Commercial	$487.05
Rate for Payer: MDX Hawaii PPO	$555.81

DRSG MED VAC PEEL

Facility

$465.00

Hospital Revenue Code	272
Min. Negotiated Rate	$237.15
Max. Negotiated Rate	$451.05
Rate for Payer: Cash Price	$279.00
Rate for Payer: Hawaii Western Management Group Commercial	$441.75
Rate for Payer: Health Management Network Commercial	$395.25
Rate for Payer: Kaiser Permanente Commercial	$292.95
Rate for Payer: Kaiser Permanente Medicaid	$237.15
Rate for Payer: MDX Hawaii PPO	$451.05
Rate for Payer: University Health Alliance Commercial	$338.94

DRSG MED VAC PEEL

Facility

$465.00

Hospital Revenue Code	272
Min. Negotiated Rate	$395.25
Max. Negotiated Rate	$451.05
Rate for Payer: Cash Price	$279.00
Rate for Payer: Health Management Network Commercial	$395.25
Rate for Payer: MDX Hawaii PPO	$451.05

DRSG SENSATRAC VAC

Facility

$220.00

Hospital Revenue Code	272
Min. Negotiated Rate	$187.00
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: MDX Hawaii PPO	$213.40

DRSG SENSATRAC VAC

Facility

$220.00

Hospital Revenue Code	272
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Hawaii Western Management Group Commercial	$209.00
Rate for Payer: Health Management Network Commercial	$187.00
Rate for Payer: Kaiser Permanente Commercial	$138.60
Rate for Payer: Kaiser Permanente Medicaid	$112.20
Rate for Payer: MDX Hawaii PPO	$213.40
Rate for Payer: University Health Alliance Commercial	$160.36

DRSG SM VAC PEEL

Facility

$377.00

Hospital Revenue Code	272
Min. Negotiated Rate	$320.45
Max. Negotiated Rate	$365.69
Rate for Payer: Cash Price	$226.20
Rate for Payer: Health Management Network Commercial	$320.45
Rate for Payer: MDX Hawaii PPO	$365.69

DRSG SM VAC PEEL

Facility

$377.00

Hospital Revenue Code	272
Min. Negotiated Rate	$192.27
Max. Negotiated Rate	$365.69
Rate for Payer: Cash Price	$226.20
Rate for Payer: Hawaii Western Management Group Commercial	$358.15
Rate for Payer: Health Management Network Commercial	$320.45
Rate for Payer: Kaiser Permanente Commercial	$237.51
Rate for Payer: Kaiser Permanente Medicaid	$192.27
Rate for Payer: MDX Hawaii PPO	$365.69
Rate for Payer: University Health Alliance Commercial	$274.80

DRSG SURGICEL 3X2

Facility

$255.00

Hospital Revenue Code	272
Min. Negotiated Rate	$130.05
Max. Negotiated Rate	$247.35
Rate for Payer: Cash Price	$153.00
Rate for Payer: Hawaii Western Management Group Commercial	$242.25
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: Kaiser Permanente Commercial	$160.65
Rate for Payer: Kaiser Permanente Medicaid	$130.05
Rate for Payer: MDX Hawaii PPO	$247.35
Rate for Payer: University Health Alliance Commercial	$185.87

DRSG SURGICEL 3X2

Facility

$255.00

Hospital Revenue Code	272
Min. Negotiated Rate	$216.75
Max. Negotiated Rate	$247.35
Rate for Payer: Cash Price	$153.00
Rate for Payer: Health Management Network Commercial	$216.75
Rate for Payer: MDX Hawaii PPO	$247.35

DRSG SURGICEL 4X8

Facility

$432.00

Hospital Revenue Code	272
Min. Negotiated Rate	$220.32
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$259.20
Rate for Payer: Hawaii Western Management Group Commercial	$410.40
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: Kaiser Permanente Commercial	$272.16
Rate for Payer: Kaiser Permanente Medicaid	$220.32
Rate for Payer: MDX Hawaii PPO	$419.04
Rate for Payer: University Health Alliance Commercial	$314.88

DRSG SURGICEL 4X8

Facility

$432.00

Hospital Revenue Code	272
Min. Negotiated Rate	$367.20
Max. Negotiated Rate	$419.04
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Management Network Commercial	$367.20
Rate for Payer: MDX Hawaii PPO	$419.04

DRSG SURGICEL .5X2

Facility

$165.00

Hospital Revenue Code	272
Min. Negotiated Rate	$140.25
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$99.00
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: MDX Hawaii PPO	$160.05

DRSG SURGICEL .5X2

Facility

$165.00

Hospital Revenue Code	272
Min. Negotiated Rate	$84.15
Max. Negotiated Rate	$160.05
Rate for Payer: Cash Price	$99.00
Rate for Payer: Hawaii Western Management Group Commercial	$156.75
Rate for Payer: Health Management Network Commercial	$140.25
Rate for Payer: Kaiser Permanente Commercial	$103.95
Rate for Payer: Kaiser Permanente Medicaid	$84.15
Rate for Payer: MDX Hawaii PPO	$160.05
Rate for Payer: University Health Alliance Commercial	$120.27

DRSG WOUND VAC LG

Facility

$208.00

Hospital Revenue Code	272
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: MDX Hawaii PPO	$201.76

DRSG WOUND VAC LG

Facility

$208.00

Hospital Revenue Code	272
Min. Negotiated Rate	$106.08
Max. Negotiated Rate	$201.76
Rate for Payer: Cash Price	$124.80
Rate for Payer: Hawaii Western Management Group Commercial	$197.60
Rate for Payer: Health Management Network Commercial	$176.80
Rate for Payer: Kaiser Permanente Commercial	$131.04
Rate for Payer: Kaiser Permanente Medicaid	$106.08
Rate for Payer: MDX Hawaii PPO	$201.76
Rate for Payer: University Health Alliance Commercial	$151.61

Know your out-of-pocket cost for care.

All Charges