Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

GEL SILVER ANTIMICROBIAL WOUND

Facility

$94.00

Service Code	HCPCS A6261
Hospital Revenue Code	272
Min. Negotiated Rate	$47.94
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Hawaii Western Management Group Commercial	$89.30
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: Kaiser Permanente Commercial	$59.22
Rate for Payer: Kaiser Permanente Medicaid	$47.94
Rate for Payer: MDX Hawaii PPO	$91.18
Rate for Payer: University Health Alliance Commercial	$68.52

GEL SILVER ANTIMICROBIAL WOUND

Facility

$94.00

Service Code	HCPCS A6261
Hospital Revenue Code	272
Min. Negotiated Rate	$79.90
Max. Negotiated Rate	$91.18
Rate for Payer: Cash Price	$56.40
Rate for Payer: Health Management Network Commercial	$79.90
Rate for Payer: MDX Hawaii PPO	$91.18

GEL SIZER 305CC

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 305CC

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 350CC

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 350CC

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 350CC GS10512-350MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 350CC GS10512-350MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 410CC GS10512-410MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 410CC GS10512-410MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 525CC GS10621-525MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 525CC GS10621-525MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 565CC GS10621-565HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 565CC GS10621-565HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 575CC GS10621-575MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 575CC GS10621-575MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 695CC GS10621-695MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER 695CC GS10621-695MP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER GS10621-505HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER GS10621-505HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER RND GS10621-385HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER RND GS10621-385HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER RND GS10621-415HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$430.44
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: Kaiser Permanente Commercial	$531.72
Rate for Payer: Kaiser Permanente Medicaid	$430.44
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER RND GS10621-415HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

GEL SIZER RND GS10621-440HP

Facility

$844.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$472.64
Max. Negotiated Rate	$818.68
Rate for Payer: Cash Price	$506.40
Rate for Payer: Hawaii Western Management Group Commercial	$590.80
Rate for Payer: Health Management Network Commercial	$717.40
Rate for Payer: MDX Hawaii PPO	$818.68
Rate for Payer: University Health Alliance Commercial	$472.64

Know your out-of-pocket cost for care.

All Charges