Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$6,490.16

Service Code	APR-DRG 3612
Min. Negotiated Rate	$6,490.16
Max. Negotiated Rate	$6,490.16
Rate for Payer: AlohaCare Medicaid	$6,490.16
Rate for Payer: Hawaii Medical Service Association ABD	$6,490.16
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,490.16
Rate for Payer: Kaiser Permanente Medicaid	$6,490.16
Rate for Payer: Ohana Health Plan Medicaid	$6,490.16
Rate for Payer: UnitedHealthcare Medicaid	$6,490.16

SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$21,199.65

Service Code	APR-DRG 3614
Min. Negotiated Rate	$21,199.65
Max. Negotiated Rate	$21,199.65
Rate for Payer: AlohaCare Medicaid	$21,199.65
Rate for Payer: Hawaii Medical Service Association ABD	$21,199.65
Rate for Payer: Hawaii Medical Service Association Non-ABD	$21,199.65
Rate for Payer: Kaiser Permanente Medicaid	$21,199.65
Rate for Payer: Ohana Health Plan Medicaid	$21,199.65
Rate for Payer: UnitedHealthcare Medicaid	$21,199.65

SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$5,608.93

Service Code	APR-DRG 3611
Min. Negotiated Rate	$5,608.93
Max. Negotiated Rate	$5,608.93
Rate for Payer: AlohaCare Medicaid	$5,608.93
Rate for Payer: Hawaii Medical Service Association ABD	$5,608.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,608.93
Rate for Payer: Kaiser Permanente Medicaid	$5,608.93
Rate for Payer: Ohana Health Plan Medicaid	$5,608.93
Rate for Payer: UnitedHealthcare Medicaid	$5,608.93

SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$9,691.53

Service Code	APR-DRG 3613
Min. Negotiated Rate	$9,691.53
Max. Negotiated Rate	$9,691.53
Rate for Payer: AlohaCare Medicaid	$9,691.53
Rate for Payer: Hawaii Medical Service Association ABD	$9,691.53
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,691.53
Rate for Payer: Kaiser Permanente Medicaid	$9,691.53
Rate for Payer: Ohana Health Plan Medicaid	$9,691.53
Rate for Payer: UnitedHealthcare Medicaid	$9,691.53

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$59,881.65

Service Code	MSDRG 574
Min. Negotiated Rate	$39,484.60
Max. Negotiated Rate	$59,881.65
Rate for Payer: AlohaCare Medicare	$39,484.60
Rate for Payer: Devoted Health Medicare	$43,433.06
Rate for Payer: Hawaii Medical Service Association Commercial	$59,111.98
Rate for Payer: Hawaii Medical Service Association Medicare	$39,484.60
Rate for Payer: Humana Medicare	$39,484.60
Rate for Payer: Kaiser Permanente Commercial	$59,881.65
Rate for Payer: Kaiser Permanente Medicare	$39,484.60
Rate for Payer: Ohana Health Plan Medicare	$39,484.60
Rate for Payer: UnitedHealthcare Medicare	$39,484.60

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$113,011.65

Service Code	MSDRG 573
Min. Negotiated Rate	$62,339.35
Max. Negotiated Rate	$113,011.65
Rate for Payer: AlohaCare Medicare	$74,517.30
Rate for Payer: Devoted Health Medicare	$81,969.03
Rate for Payer: Hawaii Medical Service Association Commercial	$62,339.35
Rate for Payer: Hawaii Medical Service Association Medicare	$74,517.30
Rate for Payer: Humana Medicare	$74,517.30
Rate for Payer: Kaiser Permanente Commercial	$113,011.65
Rate for Payer: Kaiser Permanente Medicare	$74,517.30
Rate for Payer: Ohana Health Plan Medicare	$74,517.30
Rate for Payer: UnitedHealthcare Medicare	$74,517.30

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$35,816.62

Service Code	MSDRG 575
Min. Negotiated Rate	$20,439.53
Max. Negotiated Rate	$35,816.62
Rate for Payer: AlohaCare Medicare	$20,439.53
Rate for Payer: Devoted Health Medicare	$22,483.48
Rate for Payer: Hawaii Medical Service Association Commercial	$35,816.62
Rate for Payer: Hawaii Medical Service Association Medicare	$20,439.53
Rate for Payer: Humana Medicare	$20,439.53
Rate for Payer: Kaiser Permanente Commercial	$28,179.60
Rate for Payer: Kaiser Permanente Medicare	$20,439.53
Rate for Payer: Ohana Health Plan Medicare	$20,439.53
Rate for Payer: UnitedHealthcare Medicare	$20,439.53

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$47,173.10

Service Code	MSDRG 623
Min. Negotiated Rate	$20,404.27
Max. Negotiated Rate	$47,173.10
Rate for Payer: AlohaCare Medicare	$20,404.27
Rate for Payer: Devoted Health Medicare	$22,444.70
Rate for Payer: Hawaii Medical Service Association Commercial	$47,173.10
Rate for Payer: Hawaii Medical Service Association Medicare	$20,404.27
Rate for Payer: Humana Medicare	$20,404.27
Rate for Payer: Kaiser Permanente Commercial	$30,944.78
Rate for Payer: Kaiser Permanente Medicare	$20,404.27
Rate for Payer: Ohana Health Plan Medicare	$20,404.27
Rate for Payer: UnitedHealthcare Medicare	$20,404.27

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$61,396.20

Service Code	MSDRG 622
Min. Negotiated Rate	$40,483.25
Max. Negotiated Rate	$61,396.20
Rate for Payer: AlohaCare Medicare	$40,483.25
Rate for Payer: Devoted Health Medicare	$44,531.57
Rate for Payer: Hawaii Medical Service Association Commercial	$47,173.10
Rate for Payer: Hawaii Medical Service Association Medicare	$40,483.25
Rate for Payer: Humana Medicare	$40,483.25
Rate for Payer: Kaiser Permanente Commercial	$61,396.20
Rate for Payer: Kaiser Permanente Medicare	$40,483.25
Rate for Payer: Ohana Health Plan Medicare	$40,483.25
Rate for Payer: UnitedHealthcare Medicare	$40,483.25

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$47,173.10

Service Code	MSDRG 624
Min. Negotiated Rate	$14,239.43
Max. Negotiated Rate	$47,173.10
Rate for Payer: AlohaCare Medicare	$14,239.43
Rate for Payer: Devoted Health Medicare	$15,663.37
Rate for Payer: Hawaii Medical Service Association Commercial	$47,173.10
Rate for Payer: Hawaii Medical Service Association Medicare	$14,239.43
Rate for Payer: Humana Medicare	$14,239.43
Rate for Payer: Kaiser Permanente Commercial	$21,595.28
Rate for Payer: Kaiser Permanente Medicare	$14,239.43
Rate for Payer: Ohana Health Plan Medicare	$14,239.43
Rate for Payer: UnitedHealthcare Medicare	$14,239.43

SKIN GRAFTS FOR INJURIES WITH CC/MCC

Facility

$66,610.17

Service Code	MSDRG 904
Min. Negotiated Rate	$41,778.79
Max. Negotiated Rate	$66,610.17
Rate for Payer: AlohaCare Medicare	$41,778.79
Rate for Payer: Devoted Health Medicare	$45,956.67
Rate for Payer: Hawaii Medical Service Association Commercial	$66,610.17
Rate for Payer: Hawaii Medical Service Association Medicare	$41,778.79
Rate for Payer: Humana Medicare	$41,778.79
Rate for Payer: Kaiser Permanente Commercial	$63,360.97
Rate for Payer: Kaiser Permanente Medicare	$41,778.79
Rate for Payer: Ohana Health Plan Medicare	$41,778.79
Rate for Payer: UnitedHealthcare Medicare	$41,778.79

SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC

Facility

$66,610.17

Service Code	MSDRG 905
Min. Negotiated Rate	$16,872.57
Max. Negotiated Rate	$66,610.17
Rate for Payer: AlohaCare Medicare	$16,872.57
Rate for Payer: Devoted Health Medicare	$18,559.83
Rate for Payer: Hawaii Medical Service Association Commercial	$66,610.17
Rate for Payer: Hawaii Medical Service Association Medicare	$16,872.57
Rate for Payer: Humana Medicare	$16,872.57
Rate for Payer: Kaiser Permanente Commercial	$24,698.55
Rate for Payer: Kaiser Permanente Medicare	$16,872.57
Rate for Payer: Ohana Health Plan Medicare	$16,872.57
Rate for Payer: UnitedHealthcare Medicare	$16,872.57

SKIN ULCERS

Facility

$4,982.74

Service Code	APR-DRG 3803
Min. Negotiated Rate	$4,982.74
Max. Negotiated Rate	$4,982.74
Rate for Payer: AlohaCare Medicaid	$4,982.74
Rate for Payer: Hawaii Medical Service Association ABD	$4,982.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,982.74
Rate for Payer: Kaiser Permanente Medicaid	$4,982.74
Rate for Payer: Ohana Health Plan Medicaid	$4,982.74
Rate for Payer: UnitedHealthcare Medicaid	$4,982.74

SKIN ULCERS

Facility

$2,865.45

Service Code	APR-DRG 3801
Min. Negotiated Rate	$2,865.45
Max. Negotiated Rate	$2,865.45
Rate for Payer: AlohaCare Medicaid	$2,865.45
Rate for Payer: Hawaii Medical Service Association ABD	$2,865.45
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,865.45
Rate for Payer: Kaiser Permanente Medicaid	$2,865.45
Rate for Payer: Ohana Health Plan Medicaid	$2,865.45
Rate for Payer: UnitedHealthcare Medicaid	$2,865.45

SKIN ULCERS

Facility

$9,328.21

Service Code	APR-DRG 3804
Min. Negotiated Rate	$9,328.21
Max. Negotiated Rate	$9,328.21
Rate for Payer: AlohaCare Medicaid	$9,328.21
Rate for Payer: Hawaii Medical Service Association ABD	$9,328.21
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,328.21
Rate for Payer: Kaiser Permanente Medicaid	$9,328.21
Rate for Payer: Ohana Health Plan Medicaid	$9,328.21
Rate for Payer: UnitedHealthcare Medicaid	$9,328.21

SKIN ULCERS

Facility

$3,614.92

Service Code	APR-DRG 3802
Min. Negotiated Rate	$3,614.92
Max. Negotiated Rate	$3,614.92
Rate for Payer: AlohaCare Medicaid	$3,614.92
Rate for Payer: Hawaii Medical Service Association ABD	$3,614.92
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,614.92
Rate for Payer: Kaiser Permanente Medicaid	$3,614.92
Rate for Payer: Ohana Health Plan Medicaid	$3,614.92
Rate for Payer: UnitedHealthcare Medicaid	$3,614.92

SKIN ULCERS WITH CC

Facility

$23,586.55

Service Code	MSDRG 593
Min. Negotiated Rate	$13,493.27
Max. Negotiated Rate	$23,586.55
Rate for Payer: AlohaCare Medicare	$13,493.27
Rate for Payer: Devoted Health Medicare	$14,842.60
Rate for Payer: Hawaii Medical Service Association Commercial	$23,586.55
Rate for Payer: Hawaii Medical Service Association Medicare	$13,493.27
Rate for Payer: Humana Medicare	$13,493.27
Rate for Payer: Kaiser Permanente Commercial	$20,463.67
Rate for Payer: Kaiser Permanente Medicare	$13,493.27
Rate for Payer: Ohana Health Plan Medicare	$13,493.27
Rate for Payer: UnitedHealthcare Medicare	$13,493.27

SKIN ULCERS WITH MCC

Facility

$33,383.93

Service Code	MSDRG 592
Min. Negotiated Rate	$22,012.59
Max. Negotiated Rate	$33,383.93
Rate for Payer: AlohaCare Medicare	$22,012.59
Rate for Payer: Devoted Health Medicare	$24,213.85
Rate for Payer: Hawaii Medical Service Association Commercial	$23,586.55
Rate for Payer: Hawaii Medical Service Association Medicare	$22,012.59
Rate for Payer: Humana Medicare	$22,012.59
Rate for Payer: Kaiser Permanente Commercial	$33,383.93
Rate for Payer: Kaiser Permanente Medicare	$22,012.59
Rate for Payer: Ohana Health Plan Medicare	$22,012.59
Rate for Payer: UnitedHealthcare Medicare	$22,012.59

SKIN ULCERS WITHOUT CC/MCC

Facility

$23,586.55

Service Code	MSDRG 594
Min. Negotiated Rate	$9,859.20
Max. Negotiated Rate	$23,586.55
Rate for Payer: AlohaCare Medicare	$9,859.20
Rate for Payer: Devoted Health Medicare	$10,845.12
Rate for Payer: Hawaii Medical Service Association Commercial	$23,586.55
Rate for Payer: Hawaii Medical Service Association Medicare	$9,859.20
Rate for Payer: Humana Medicare	$9,859.20
Rate for Payer: Kaiser Permanente Commercial	$14,952.30
Rate for Payer: Kaiser Permanente Medicare	$9,859.20
Rate for Payer: Ohana Health Plan Medicare	$9,859.20
Rate for Payer: UnitedHealthcare Medicare	$9,859.20

SLED OLECRANON OSN-70

Facility

$2,775.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,554.00
Max. Negotiated Rate	$2,691.75
Rate for Payer: Cash Price	$1,665.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,942.50
Rate for Payer: Health Management Network Commercial	$2,358.75
Rate for Payer: MDX Hawaii PPO	$2,691.75
Rate for Payer: University Health Alliance Commercial	$1,554.00

SLED OLECRANON OSN-70

Facility

$2,775.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,415.25
Max. Negotiated Rate	$2,691.75
Rate for Payer: Cash Price	$1,665.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,942.50
Rate for Payer: Health Management Network Commercial	$2,358.75
Rate for Payer: Kaiser Permanente Commercial	$1,748.25
Rate for Payer: Kaiser Permanente Medicaid	$1,415.25
Rate for Payer: MDX Hawaii PPO	$2,691.75
Rate for Payer: University Health Alliance Commercial	$1,554.00

SLEEVE 12.0MM ST 03.010.437S

Facility

$476.00

Hospital Revenue Code	272
Min. Negotiated Rate	$242.76
Max. Negotiated Rate	$461.72
Rate for Payer: Cash Price	$285.60
Rate for Payer: Hawaii Western Management Group Commercial	$452.20
Rate for Payer: Health Management Network Commercial	$404.60
Rate for Payer: Kaiser Permanente Commercial	$299.88
Rate for Payer: Kaiser Permanente Medicaid	$242.76
Rate for Payer: MDX Hawaii PPO	$461.72
Rate for Payer: University Health Alliance Commercial	$346.96

SLEEVE 12.0MM ST 03.010.437S

Facility

$476.00

Hospital Revenue Code	272
Min. Negotiated Rate	$404.60
Max. Negotiated Rate	$461.72
Rate for Payer: Cash Price	$285.60
Rate for Payer: Health Management Network Commercial	$404.60
Rate for Payer: MDX Hawaii PPO	$461.72

SLEEVE LG SCD THIGH

Facility

$131.00

Hospital Revenue Code	271
Min. Negotiated Rate	$111.35
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$78.60
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: MDX Hawaii PPO	$127.07

SLEEVE LG SCD THIGH

Facility

$131.00

Hospital Revenue Code	271
Min. Negotiated Rate	$66.81
Max. Negotiated Rate	$127.07
Rate for Payer: Cash Price	$78.60
Rate for Payer: Hawaii Western Management Group Commercial	$124.45
Rate for Payer: Health Management Network Commercial	$111.35
Rate for Payer: Kaiser Permanente Commercial	$82.53
Rate for Payer: Kaiser Permanente Medicaid	$66.81
Rate for Payer: MDX Hawaii PPO	$127.07
Rate for Payer: University Health Alliance Commercial	$95.49

Know your out-of-pocket cost for care.

All Charges