Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SIZER RND SILI GS10610-500LP

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

SIZER SALINE RND 510CC SZ68510

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$110.25
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER SALINE RND 510CC SZ68510

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER SALINE RND SZ10621-235MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER SALINE RND SZ10621-235MP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
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	$182.00
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	$145.60

SIZER SALINE RND SZ10621-565HP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
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	$182.00
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	$145.60

SIZER SALINE RND SZ10621-565HP

Facility

$260.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$252.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Hawaii Western Management Group Commercial	$182.00
Rate for Payer: Health Management Network Commercial	$221.00
Rate for Payer: MDX Hawaii PPO	$252.20
Rate for Payer: University Health Alliance Commercial	$145.60

SIZER SALINE RND SZ68650

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$110.25
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER SALINE RND SZ68650

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER SALINE ROUND SZHP68750

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$89.25
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: Kaiser Permanente Commercial	$110.25
Rate for Payer: Kaiser Permanente Medicaid	$89.25
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER SALINE ROUND SZHP68750

Facility

$175.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$169.75
Rate for Payer: Cash Price	$105.00
Rate for Payer: Hawaii Western Management Group Commercial	$122.50
Rate for Payer: Health Management Network Commercial	$148.75
Rate for Payer: MDX Hawaii PPO	$169.75
Rate for Payer: University Health Alliance Commercial	$98.00

SIZER SILICONE GS10621-235MP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$388.64
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: University Health Alliance Commercial	$388.64

SIZER SILICONE GS10621-235MP

Facility

$694.00

Service Code	HCPCS C1789
Hospital Revenue Code	278
Min. Negotiated Rate	$353.94
Max. Negotiated Rate	$673.18
Rate for Payer: Cash Price	$416.40
Rate for Payer: Hawaii Western Management Group Commercial	$485.80
Rate for Payer: Health Management Network Commercial	$589.90
Rate for Payer: Kaiser Permanente Commercial	$437.22
Rate for Payer: Kaiser Permanente Medicaid	$353.94
Rate for Payer: MDX Hawaii PPO	$673.18
Rate for Payer: University Health Alliance Commercial	$388.64

SIZER X-HI PRO GS10621-420XP

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

SIZER X-HI PRO GS10621-420XP

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

SKIN DEBRIDEMENT WITH CC

Facility

$59,330.37

Service Code	MSDRG 571
Min. Negotiated Rate	$19,216.79
Max. Negotiated Rate	$59,330.37
Rate for Payer: AlohaCare Medicare	$19,216.79
Rate for Payer: Devoted Health Medicare	$21,138.47
Rate for Payer: Hawaii Medical Service Association Commercial	$59,330.37
Rate for Payer: Hawaii Medical Service Association Medicare	$19,216.79
Rate for Payer: Humana Medicare	$19,216.79
Rate for Payer: Kaiser Permanente Commercial	$29,143.88
Rate for Payer: Kaiser Permanente Medicare	$19,216.79
Rate for Payer: Ohana Health Plan Medicare	$19,216.79
Rate for Payer: UnitedHealthcare Medicare	$19,216.79

SKIN DEBRIDEMENT WITH MCC

Facility

$62,242.29

Service Code	MSDRG 570
Min. Negotiated Rate	$33,452.83
Max. Negotiated Rate	$62,242.29
Rate for Payer: AlohaCare Medicare	$33,452.83
Rate for Payer: Devoted Health Medicare	$36,798.11
Rate for Payer: Hawaii Medical Service Association Commercial	$62,242.29
Rate for Payer: Hawaii Medical Service Association Medicare	$33,452.83
Rate for Payer: Humana Medicare	$33,452.83
Rate for Payer: Kaiser Permanente Commercial	$50,733.97
Rate for Payer: Kaiser Permanente Medicare	$33,452.83
Rate for Payer: Ohana Health Plan Medicare	$33,452.83
Rate for Payer: UnitedHealthcare Medicare	$33,452.83

SKIN DEBRIDEMENT WITHOUT CC/MCC

Facility

$30,696.49

Service Code	MSDRG 572
Min. Negotiated Rate	$13,038.30
Max. Negotiated Rate	$30,696.49
Rate for Payer: AlohaCare Medicare	$13,038.30
Rate for Payer: Devoted Health Medicare	$14,342.13
Rate for Payer: Hawaii Medical Service Association Commercial	$30,696.49
Rate for Payer: Hawaii Medical Service Association Medicare	$13,038.30
Rate for Payer: Humana Medicare	$13,038.30
Rate for Payer: Kaiser Permanente Commercial	$19,773.67
Rate for Payer: Kaiser Permanente Medicare	$13,038.30
Rate for Payer: Ohana Health Plan Medicare	$13,038.30
Rate for Payer: UnitedHealthcare Medicare	$13,038.30

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$61,320.18

Service Code	MSDRG 577
Min. Negotiated Rate	$30,149.75
Max. Negotiated Rate	$61,320.18
Rate for Payer: AlohaCare Medicare	$30,149.75
Rate for Payer: Devoted Health Medicare	$33,164.72
Rate for Payer: Hawaii Medical Service Association Commercial	$61,320.18
Rate for Payer: Hawaii Medical Service Association Medicare	$30,149.75
Rate for Payer: Humana Medicare	$30,149.75
Rate for Payer: Kaiser Permanente Commercial	$45,724.57
Rate for Payer: Kaiser Permanente Medicare	$30,149.75
Rate for Payer: Ohana Health Plan Medicare	$30,149.75
Rate for Payer: UnitedHealthcare Medicare	$30,149.75

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$84,545.70

Service Code	MSDRG 576
Min. Negotiated Rate	$55,747.50
Max. Negotiated Rate	$84,545.70
Rate for Payer: AlohaCare Medicare	$55,747.50
Rate for Payer: Devoted Health Medicare	$61,322.25
Rate for Payer: Hawaii Medical Service Association Commercial	$61,320.18
Rate for Payer: Hawaii Medical Service Association Medicare	$55,747.50
Rate for Payer: Humana Medicare	$55,747.50
Rate for Payer: Kaiser Permanente Commercial	$84,545.70
Rate for Payer: Kaiser Permanente Medicare	$55,747.50
Rate for Payer: Ohana Health Plan Medicare	$55,747.50
Rate for Payer: UnitedHealthcare Medicare	$55,747.50

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$27,710.40

Service Code	MSDRG 578
Min. Negotiated Rate	$14,486.80
Max. Negotiated Rate	$27,710.40
Rate for Payer: AlohaCare Medicare	$18,271.60
Rate for Payer: Devoted Health Medicare	$20,098.76
Rate for Payer: Hawaii Medical Service Association Commercial	$14,486.80
Rate for Payer: Hawaii Medical Service Association Medicare	$18,271.60
Rate for Payer: Humana Medicare	$18,271.60
Rate for Payer: Kaiser Permanente Commercial	$27,710.40
Rate for Payer: Kaiser Permanente Medicare	$18,271.60
Rate for Payer: Ohana Health Plan Medicare	$18,271.60
Rate for Payer: UnitedHealthcare Medicare	$18,271.60

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES

Facility

$6,024.43

Service Code	APR-DRG 3121
Min. Negotiated Rate	$6,024.43
Max. Negotiated Rate	$6,024.43
Rate for Payer: AlohaCare Medicaid	$6,024.43
Rate for Payer: Hawaii Medical Service Association ABD	$6,024.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,024.43
Rate for Payer: Kaiser Permanente Medicaid	$6,024.43
Rate for Payer: Ohana Health Plan Medicaid	$6,024.43
Rate for Payer: UnitedHealthcare Medicaid	$6,024.43

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES

Facility

$26,822.28

Service Code	APR-DRG 3124
Min. Negotiated Rate	$26,822.28
Max. Negotiated Rate	$26,822.28
Rate for Payer: AlohaCare Medicaid	$26,822.28
Rate for Payer: Hawaii Medical Service Association ABD	$26,822.28
Rate for Payer: Hawaii Medical Service Association Non-ABD	$26,822.28
Rate for Payer: Kaiser Permanente Medicaid	$26,822.28
Rate for Payer: Ohana Health Plan Medicaid	$26,822.28
Rate for Payer: UnitedHealthcare Medicaid	$26,822.28

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES

Facility

$7,730.13

Service Code	APR-DRG 3122
Min. Negotiated Rate	$7,730.13
Max. Negotiated Rate	$7,730.13
Rate for Payer: AlohaCare Medicaid	$7,730.13
Rate for Payer: Hawaii Medical Service Association ABD	$7,730.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$7,730.13
Rate for Payer: Kaiser Permanente Medicaid	$7,730.13
Rate for Payer: Ohana Health Plan Medicaid	$7,730.13
Rate for Payer: UnitedHealthcare Medicaid	$7,730.13

SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL & CONNECTIVE TISSUE DIAGNOSES

Facility

$12,715.49

Service Code	APR-DRG 3123
Min. Negotiated Rate	$12,715.49
Max. Negotiated Rate	$12,715.49
Rate for Payer: AlohaCare Medicaid	$12,715.49
Rate for Payer: Hawaii Medical Service Association ABD	$12,715.49
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,715.49
Rate for Payer: Kaiser Permanente Medicaid	$12,715.49
Rate for Payer: Ohana Health Plan Medicaid	$12,715.49
Rate for Payer: UnitedHealthcare Medicaid	$12,715.49

Know your out-of-pocket cost for care.

All Charges