Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

SUREFORM 45 4.6 BLACK 48345T

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$637.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: MDX Hawaii PPO	$727.50

SUREFORM 45 4.6 BLACK 48345T

Facility

$750.00

Hospital Revenue Code	272
Min. Negotiated Rate	$382.50
Max. Negotiated Rate	$727.50
Rate for Payer: Cash Price	$450.00
Rate for Payer: Hawaii Western Management Group Commercial	$712.50
Rate for Payer: Health Management Network Commercial	$637.50
Rate for Payer: Kaiser Permanente Commercial	$472.50
Rate for Payer: Kaiser Permanente Medicaid	$382.50
Rate for Payer: MDX Hawaii PPO	$727.50
Rate for Payer: University Health Alliance Commercial	$546.67

SUREFORM 60 2.5 WHITE 48360W

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$733.55
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: MDX Hawaii PPO	$837.11

SUREFORM 60 2.5 WHITE 48360W

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$440.13
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Hawaii Western Management Group Commercial	$819.85
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Kaiser Permanente Commercial	$543.69
Rate for Payer: Kaiser Permanente Medicaid	$440.13
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: University Health Alliance Commercial	$629.04

SUREFORM 60 3.5 BLUE 48360B

Facility

$906.00

Hospital Revenue Code	272
Min. Negotiated Rate	$462.06
Max. Negotiated Rate	$878.82
Rate for Payer: Cash Price	$543.60
Rate for Payer: Hawaii Western Management Group Commercial	$860.70
Rate for Payer: Health Management Network Commercial	$770.10
Rate for Payer: Kaiser Permanente Commercial	$570.78
Rate for Payer: Kaiser Permanente Medicaid	$462.06
Rate for Payer: MDX Hawaii PPO	$878.82
Rate for Payer: University Health Alliance Commercial	$660.38

SUREFORM 60 3.5 BLUE 48360B

Facility

$906.00

Hospital Revenue Code	272
Min. Negotiated Rate	$770.10
Max. Negotiated Rate	$878.82
Rate for Payer: Cash Price	$543.60
Rate for Payer: Health Management Network Commercial	$770.10
Rate for Payer: MDX Hawaii PPO	$878.82

SUREFORM 60 4.3 GREEN 48360G

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$733.55
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: MDX Hawaii PPO	$837.11

SUREFORM 60 4.3 GREEN 48360G

Facility

$863.00

Hospital Revenue Code	272
Min. Negotiated Rate	$440.13
Max. Negotiated Rate	$837.11
Rate for Payer: Cash Price	$517.80
Rate for Payer: Hawaii Western Management Group Commercial	$819.85
Rate for Payer: Health Management Network Commercial	$733.55
Rate for Payer: Kaiser Permanente Commercial	$543.69
Rate for Payer: Kaiser Permanente Medicaid	$440.13
Rate for Payer: MDX Hawaii PPO	$837.11
Rate for Payer: University Health Alliance Commercial	$629.04

SURFACE ART TIB 42-5121-008-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURFACE ART TIB 42-5121-008-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURFACE TIBIAL 42-5221-009-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,596.00
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURFACE TIBIAL 42-5221-009-10

Facility

$2,850.00

Service Code	HCPCS C1776
Hospital Revenue Code	278
Min. Negotiated Rate	$1,453.50
Max. Negotiated Rate	$2,764.50
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,995.00
Rate for Payer: Health Management Network Commercial	$2,422.50
Rate for Payer: Kaiser Permanente Commercial	$1,795.50
Rate for Payer: Kaiser Permanente Medicaid	$1,453.50
Rate for Payer: MDX Hawaii PPO	$2,764.50
Rate for Payer: University Health Alliance Commercial	$1,596.00

SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITHOUT PLASTIC REPAIR

Facility

$13,778.00

Service Code	CPT 31820
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$13,778.00
Rate for Payer: AlohaCare Medicaid	$3,916.70
Rate for Payer: AlohaCare Medicare	$3,916.70
Rate for Payer: Devoted Health Medicare	$4,308.37
Rate for Payer: Hawaii Medical Service Association ABD	$1,149.00
Rate for Payer: Hawaii Medical Service Association Commercial	$13,778.00
Rate for Payer: Hawaii Medical Service Association Medicare	$3,916.70
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.85
Rate for Payer: Humana Medicare	$3,916.70
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,916.70
Rate for Payer: Ohana Health Plan Medicaid	$4,308.37
Rate for Payer: Ohana Health Plan Medicare	$3,916.70
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,916.70
Rate for Payer: University Health Alliance Commercial	$4,035.20

SURGICAL MESH/TISSUE WSM1015

Facility

$3,690.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$3,579.30
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$20.85
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.85
Rate for Payer: Hawaii Western Management Group Commercial	$3,505.50
Rate for Payer: Health Management Network Commercial	$3,136.50
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$2,324.70
Rate for Payer: Kaiser Permanente Medicaid	$1,881.90
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$3,579.30
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$2,214.00
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$2,689.64

SURGICAL MESH/TISSUE WSM1015

Facility

$3,690.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$3,136.50
Max. Negotiated Rate	$3,579.30
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Health Management Network Commercial	$3,136.50
Rate for Payer: MDX Hawaii PPO	$3,579.30

SURGICAL MESH WSM0710

Facility

$2,050.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$1,742.50
Max. Negotiated Rate	$1,988.50
Rate for Payer: Cash Price	$1,230.00
Rate for Payer: Health Management Network Commercial	$1,742.50
Rate for Payer: MDX Hawaii PPO	$1,988.50

SURGICAL MESH WSM0710

Facility

$2,050.00

Service Code	HCPCS Q4166
Hospital Revenue Code	636
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$1,988.50
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$1,230.00
Rate for Payer: Cash Price	$1,230.00
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$20.85
Rate for Payer: Hawaii Medical Service Association Commercial	$183.76
Rate for Payer: Hawaii Medical Service Association Medicare	$147.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20.85
Rate for Payer: Hawaii Western Management Group Commercial	$1,947.50
Rate for Payer: Health Management Network Commercial	$1,742.50
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$1,291.50
Rate for Payer: Kaiser Permanente Medicaid	$1,045.50
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$1,988.50
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$1,230.00
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$1,494.24

SURGICAL POST BRA LG M5001-L

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$54.06
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$66.78
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: University Health Alliance Commercial	$77.26

SURGICAL POST BRA LG M5001-L

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: MDX Hawaii PPO	$102.82

SURGICAL POST BRA MED M5001-M

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$54.06
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$66.78
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: University Health Alliance Commercial	$77.26

SURGICAL POST BRA MED M5001-M

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: MDX Hawaii PPO	$102.82

SURGICAL POST BRA XLG M5001-XL

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$90.10
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: MDX Hawaii PPO	$102.82

SURGICAL POST BRA XLG M5001-XL

Facility

$106.00

Hospital Revenue Code	272
Min. Negotiated Rate	$54.06
Max. Negotiated Rate	$102.82
Rate for Payer: Cash Price	$63.60
Rate for Payer: Hawaii Western Management Group Commercial	$100.70
Rate for Payer: Health Management Network Commercial	$90.10
Rate for Payer: Kaiser Permanente Commercial	$66.78
Rate for Payer: Kaiser Permanente Medicaid	$54.06
Rate for Payer: MDX Hawaii PPO	$102.82
Rate for Payer: University Health Alliance Commercial	$77.26

SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR PART THEREOF, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT 15005
Hospital Revenue Code	360
Min. Negotiated Rate	$59.52
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$59.52

SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN

Facility

$5,509.00

Service Code	CPT 15004
Hospital Revenue Code	360
Min. Negotiated Rate	$180.95
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$480.23
Rate for Payer: AlohaCare Medicare	$480.23
Rate for Payer: Devoted Health Medicare	$528.25
Rate for Payer: Hawaii Medical Service Association ABD	$695.00
Rate for Payer: Hawaii Medical Service Association Commercial	$5,509.00
Rate for Payer: Hawaii Medical Service Association Medicare	$480.23
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$480.23
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$480.23
Rate for Payer: Ohana Health Plan Medicaid	$528.25
Rate for Payer: Ohana Health Plan Medicare	$480.23
Rate for Payer: UnitedHealthcare Medicaid	$180.95
Rate for Payer: UnitedHealthcare Medicare	$480.23

Know your out-of-pocket cost for care.

All Charges