Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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, TRUNK, ARMS, LEGS; 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 15003
Hospital Revenue Code	360
Min. Negotiated Rate	$29.76
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: UnitedHealthcare Medicaid	$29.76

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, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN

Facility

$5,509.00

Service Code	CPT 15002
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$873.10
Rate for Payer: AlohaCare Medicare	$873.10
Rate for Payer: Devoted Health Medicare	$960.41
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	$873.10
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$873.10
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$873.10
Rate for Payer: Ohana Health Plan Medicaid	$960.41
Rate for Payer: Ohana Health Plan Medicare	$873.10
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$873.10

SURGICAL TECHNIQUES REQUIRING USE OF ROBOTIC SURGICAL SYSTEM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,837.00

Service Code	CPT S2900
Hospital Revenue Code	360
Min. Negotiated Rate	$2,837.00
Max. Negotiated Rate	$2,837.00
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00

SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE

Facility

$5,509.00

Service Code	CPT 46285
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
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	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01

SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS

Facility

$6,743.44

Service Code	CPT 46270
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$6,743.44
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
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	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01
Rate for Payer: University Health Alliance Commercial	$6,743.44

SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED

Facility

$10,679.55

Service Code	CPT 46280
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$10,679.55
Rate for Payer: AlohaCare Medicaid	$3,279.01
Rate for Payer: AlohaCare Medicare	$3,279.01
Rate for Payer: Devoted Health Medicare	$3,606.91
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	$3,279.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$3,279.01
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$3,279.01
Rate for Payer: Ohana Health Plan Medicaid	$3,606.91
Rate for Payer: Ohana Health Plan Medicare	$3,279.01
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$3,279.01
Rate for Payer: University Health Alliance Commercial	$10,679.55

SURGICEL APPLICATOR 3123SPEA

Facility

$133.00

Hospital Revenue Code	272
Min. Negotiated Rate	$67.83
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$79.80
Rate for Payer: Hawaii Western Management Group Commercial	$126.35
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: Kaiser Permanente Commercial	$83.79
Rate for Payer: Kaiser Permanente Medicaid	$67.83
Rate for Payer: MDX Hawaii PPO	$129.01
Rate for Payer: University Health Alliance Commercial	$96.94

SURGICEL APPLICATOR 3123SPEA

Facility

$133.00

Hospital Revenue Code	272
Min. Negotiated Rate	$113.05
Max. Negotiated Rate	$129.01
Rate for Payer: Cash Price	$79.80
Rate for Payer: Health Management Network Commercial	$113.05
Rate for Payer: MDX Hawaii PPO	$129.01

SURGICEL POWDER 3.0GM 3013SP

Facility

$2,248.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,910.80
Max. Negotiated Rate	$2,180.56
Rate for Payer: Cash Price	$1,348.80
Rate for Payer: Health Management Network Commercial	$1,910.80
Rate for Payer: MDX Hawaii PPO	$2,180.56

SURGICEL POWDER 3.0GM 3013SP

Facility

$2,248.00

Hospital Revenue Code	272
Min. Negotiated Rate	$1,146.48
Max. Negotiated Rate	$2,180.56
Rate for Payer: Cash Price	$1,348.80
Rate for Payer: Hawaii Western Management Group Commercial	$2,135.60
Rate for Payer: Health Management Network Commercial	$1,910.80
Rate for Payer: Kaiser Permanente Commercial	$1,416.24
Rate for Payer: Kaiser Permanente Medicaid	$1,146.48
Rate for Payer: MDX Hawaii PPO	$2,180.56
Rate for Payer: University Health Alliance Commercial	$1,638.57

SURGICEL SNOW 2X4IN 2082

Facility

$596.00

Hospital Revenue Code	272
Min. Negotiated Rate	$506.60
Max. Negotiated Rate	$578.12
Rate for Payer: Cash Price	$357.60
Rate for Payer: Health Management Network Commercial	$506.60
Rate for Payer: MDX Hawaii PPO	$578.12

SURGICEL SNOW 2X4IN 2082

Facility

$596.00

Hospital Revenue Code	272
Min. Negotiated Rate	$303.96
Max. Negotiated Rate	$578.12
Rate for Payer: Cash Price	$357.60
Rate for Payer: Hawaii Western Management Group Commercial	$566.20
Rate for Payer: Health Management Network Commercial	$506.60
Rate for Payer: Kaiser Permanente Commercial	$375.48
Rate for Payer: Kaiser Permanente Medicaid	$303.96
Rate for Payer: MDX Hawaii PPO	$578.12
Rate for Payer: University Health Alliance Commercial	$434.42

SURGICLIP PREMIUM

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$109.65
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Hawaii Western Management Group Commercial	$204.25
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: Kaiser Permanente Commercial	$135.45
Rate for Payer: Kaiser Permanente Medicaid	$109.65
Rate for Payer: MDX Hawaii PPO	$208.55
Rate for Payer: University Health Alliance Commercial	$156.71

SURGICLIP PREMIUM

Facility

$215.00

Hospital Revenue Code	272
Min. Negotiated Rate	$182.75
Max. Negotiated Rate	$208.55
Rate for Payer: Cash Price	$129.00
Rate for Payer: Health Management Network Commercial	$182.75
Rate for Payer: MDX Hawaii PPO	$208.55

SURGICLIP PREMIUM LG

Facility

$207.00

Hospital Revenue Code	272
Min. Negotiated Rate	$175.95
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: MDX Hawaii PPO	$200.79

SURGICLIP PREMIUM LG

Facility

$207.00

Hospital Revenue Code	272
Min. Negotiated Rate	$105.57
Max. Negotiated Rate	$200.79
Rate for Payer: Cash Price	$124.20
Rate for Payer: Hawaii Western Management Group Commercial	$196.65
Rate for Payer: Health Management Network Commercial	$175.95
Rate for Payer: Kaiser Permanente Commercial	$130.41
Rate for Payer: Kaiser Permanente Medicaid	$105.57
Rate for Payer: MDX Hawaii PPO	$200.79
Rate for Payer: University Health Alliance Commercial	$150.88

SURGICLIP PREMIUM SM

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$204.00
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: MDX Hawaii PPO	$232.80

SURGICLIP PREMIUM SM

Facility

$240.00

Hospital Revenue Code	272
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$232.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Hawaii Western Management Group Commercial	$228.00
Rate for Payer: Health Management Network Commercial	$204.00
Rate for Payer: Kaiser Permanente Commercial	$151.20
Rate for Payer: Kaiser Permanente Medicaid	$122.40
Rate for Payer: MDX Hawaii PPO	$232.80
Rate for Payer: University Health Alliance Commercial	$174.94

SURGIFOAM SPONGE 8X12.5

Facility

$170.00

Hospital Revenue Code	272
Min. Negotiated Rate	$144.50
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$102.00
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: MDX Hawaii PPO	$164.90

SURGIFOAM SPONGE 8X12.5

Facility

$170.00

Hospital Revenue Code	272
Min. Negotiated Rate	$86.70
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$102.00
Rate for Payer: Hawaii Western Management Group Commercial	$161.50
Rate for Payer: Health Management Network Commercial	$144.50
Rate for Payer: Kaiser Permanente Commercial	$107.10
Rate for Payer: Kaiser Permanente Medicaid	$86.70
Rate for Payer: MDX Hawaii PPO	$164.90
Rate for Payer: University Health Alliance Commercial	$123.91

SURGIMEND PRS 8X16 606-004-108

Facility

$5,888.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$3,002.88
Max. Negotiated Rate	$5,711.36
Rate for Payer: Cash Price	$3,532.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,121.60
Rate for Payer: Health Management Network Commercial	$5,004.80
Rate for Payer: Kaiser Permanente Commercial	$3,709.44
Rate for Payer: Kaiser Permanente Medicaid	$3,002.88
Rate for Payer: MDX Hawaii PPO	$5,711.36
Rate for Payer: University Health Alliance Commercial	$3,297.28

SURGIMEND PRS 8X16 606-004-108

Facility

$5,888.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$3,297.28
Max. Negotiated Rate	$5,711.36
Rate for Payer: Cash Price	$3,532.80
Rate for Payer: Hawaii Western Management Group Commercial	$4,121.60
Rate for Payer: Health Management Network Commercial	$5,004.80
Rate for Payer: MDX Hawaii PPO	$5,711.36
Rate for Payer: University Health Alliance Commercial	$3,297.28

SURGIMEND PRS THIN 606-004-104

Facility

$10,350.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$5,796.00
Max. Negotiated Rate	$10,039.50
Rate for Payer: Cash Price	$6,210.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,245.00
Rate for Payer: Health Management Network Commercial	$8,797.50
Rate for Payer: MDX Hawaii PPO	$10,039.50
Rate for Payer: University Health Alliance Commercial	$5,796.00

SURGIMEND PRS THIN 606-004-104

Facility

$10,350.00

Service Code	HCPCS C9358
Hospital Revenue Code	278
Min. Negotiated Rate	$5,278.50
Max. Negotiated Rate	$10,039.50
Rate for Payer: Cash Price	$6,210.00
Rate for Payer: Hawaii Western Management Group Commercial	$7,245.00
Rate for Payer: Health Management Network Commercial	$8,797.50
Rate for Payer: Kaiser Permanente Commercial	$6,520.50
Rate for Payer: Kaiser Permanente Medicaid	$5,278.50
Rate for Payer: MDX Hawaii PPO	$10,039.50
Rate for Payer: University Health Alliance Commercial	$5,796.00

SUT CHROMIC ENDO LOOP #0

Facility

$91.00

Hospital Revenue Code	272
Min. Negotiated Rate	$77.35
Max. Negotiated Rate	$88.27
Rate for Payer: Cash Price	$54.60
Rate for Payer: Health Management Network Commercial	$77.35
Rate for Payer: MDX Hawaii PPO	$88.27

Know your out-of-pocket cost for care.

All Charges