Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

FRN/GT 9X420 LF 04.033.973S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 9X420 RT 04.033.972S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN/GT 9X420 RT 04.033.972S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN LF 9X300MM 04.033.961S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN LF 9X300MM 04.033.961S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN LF 9X320MM 04.033.963S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN LF 9X320MM 04.033.963S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN LF 9X340MM 04.033.965S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN LF 9X340MM 04.033.965S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN LF 9X380MM 04.033.969S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN LF 9X380MM 04.033.969S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN RT 9X300MM 04.033.960S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN RT 9X300MM 04.033.960S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN RT 9X340MM 04.033.964S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,801.12
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FRN RT 9X340MM 04.033.964S

Facility

$5,002.00

Service Code	HCPCS C1713
Hospital Revenue Code	278
Min. Negotiated Rate	$2,551.02
Max. Negotiated Rate	$4,851.94
Rate for Payer: Cash Price	$3,001.20
Rate for Payer: Hawaii Western Management Group Commercial	$3,501.40
Rate for Payer: Health Management Network Commercial	$4,251.70
Rate for Payer: Kaiser Permanente Commercial	$3,151.26
Rate for Payer: Kaiser Permanente Medicaid	$2,551.02
Rate for Payer: MDX Hawaii PPO	$4,851.94
Rate for Payer: University Health Alliance Commercial	$2,801.12

FULL CURVE A/V ACCESS TUNNELER

Facility

$257.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$218.45
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$154.20
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: MDX Hawaii PPO	$249.29

FULL CURVE A/V ACCESS TUNNELER

Facility

$257.00

Service Code	HCPCS C1894
Hospital Revenue Code	272
Min. Negotiated Rate	$131.07
Max. Negotiated Rate	$249.29
Rate for Payer: Cash Price	$154.20
Rate for Payer: Hawaii Western Management Group Commercial	$244.15
Rate for Payer: Health Management Network Commercial	$218.45
Rate for Payer: Kaiser Permanente Commercial	$161.91
Rate for Payer: Kaiser Permanente Medicaid	$131.07
Rate for Payer: MDX Hawaii PPO	$249.29
Rate for Payer: University Health Alliance Commercial	$187.33

FULL TERM NEONATE WITH MAJOR PROBLEMS

Facility

$71,925.60

Service Code	MSDRG 793
Min. Negotiated Rate	$19,437.07
Max. Negotiated Rate	$71,925.60
Rate for Payer: AlohaCare Medicare	$47,426.09
Rate for Payer: Devoted Health Medicare	$52,168.70
Rate for Payer: Hawaii Medical Service Association Commercial	$19,437.07
Rate for Payer: Hawaii Medical Service Association Medicare	$47,426.09
Rate for Payer: Humana Medicare	$47,426.09
Rate for Payer: Kaiser Permanente Commercial	$71,925.60
Rate for Payer: Kaiser Permanente Medicare	$47,426.09
Rate for Payer: Ohana Health Plan Medicare	$47,426.09
Rate for Payer: UnitedHealthcare Medicare	$47,426.09

FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY

Facility

$38,132.85

Service Code	MSDRG 934
Min. Negotiated Rate	$25,143.94
Max. Negotiated Rate	$38,132.85
Rate for Payer: AlohaCare Medicare	$25,143.94
Rate for Payer: Devoted Health Medicare	$27,658.33
Rate for Payer: Hawaii Medical Service Association Medicare	$25,143.94
Rate for Payer: Humana Medicare	$25,143.94
Rate for Payer: Kaiser Permanente Commercial	$38,132.85
Rate for Payer: Kaiser Permanente Medicare	$25,143.94
Rate for Payer: Ohana Health Plan Medicare	$25,143.94
Rate for Payer: UnitedHealthcare Medicare	$25,143.94

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC

Facility

$123,729.07

Service Code	MSDRG 928
Min. Negotiated Rate	$81,584.13
Max. Negotiated Rate	$123,729.07
Rate for Payer: AlohaCare Medicare	$81,584.13
Rate for Payer: Devoted Health Medicare	$89,742.54
Rate for Payer: Hawaii Medical Service Association Medicare	$81,584.13
Rate for Payer: Humana Medicare	$81,584.13
Rate for Payer: Kaiser Permanente Commercial	$123,729.07
Rate for Payer: Kaiser Permanente Medicare	$81,584.13
Rate for Payer: Ohana Health Plan Medicare	$81,584.13
Rate for Payer: UnitedHealthcare Medicare	$81,584.13

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC

Facility

$55,558.80

Service Code	MSDRG 929
Min. Negotiated Rate	$36,634.21
Max. Negotiated Rate	$55,558.80
Rate for Payer: AlohaCare Medicare	$36,634.21
Rate for Payer: Devoted Health Medicare	$40,297.63
Rate for Payer: Hawaii Medical Service Association Medicare	$36,634.21
Rate for Payer: Humana Medicare	$36,634.21
Rate for Payer: Kaiser Permanente Commercial	$55,558.80
Rate for Payer: Kaiser Permanente Medicare	$36,634.21
Rate for Payer: Ohana Health Plan Medicare	$36,634.21
Rate for Payer: UnitedHealthcare Medicare	$36,634.21

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS

Facility

$8,270.00

Service Code	CPT 15240
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$6,743.44

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15241
Hospital Revenue Code	360
Min. Negotiated Rate	$102.79
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$102.79

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS

Facility

$8,270.00

Service Code	CPT 15260
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$5,160.40

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS

Facility

$8,270.00

Service Code	CPT 15220
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$8,270.00
Rate for Payer: AlohaCare Medicaid	$2,437.45
Rate for Payer: AlohaCare Medicare	$2,437.45
Rate for Payer: Devoted Health Medicare	$2,681.20
Rate for Payer: Hawaii Medical Service Association ABD	$848.00
Rate for Payer: Hawaii Medical Service Association Commercial	$8,270.00
Rate for Payer: Hawaii Medical Service Association Medicare	$2,437.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,427.62
Rate for Payer: Humana Medicare	$2,437.45
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,437.45
Rate for Payer: Ohana Health Plan Medicaid	$2,681.20
Rate for Payer: Ohana Health Plan Medicare	$2,437.45
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,437.45
Rate for Payer: University Health Alliance Commercial	$5,160.40

Know your out-of-pocket cost for care.

All Charges