Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

MERSILENE 5 CTX 12" DBL RS22

Facility

$247.00

Hospital Revenue Code	272
Min. Negotiated Rate	$209.95
Max. Negotiated Rate	$239.59
Rate for Payer: Cash Price	$148.20
Rate for Payer: Health Management Network Commercial	$209.95
Rate for Payer: MDX Hawaii PPO	$239.59

MERSILENE 5 CTX 12" DBL RS22

Facility

$247.00

Hospital Revenue Code	272
Min. Negotiated Rate	$125.97
Max. Negotiated Rate	$239.59
Rate for Payer: Cash Price	$148.20
Rate for Payer: Hawaii Western Management Group Commercial	$234.65
Rate for Payer: Health Management Network Commercial	$209.95
Rate for Payer: Kaiser Permanente Commercial	$155.61
Rate for Payer: Kaiser Permanente Medicaid	$125.97
Rate for Payer: MDX Hawaii PPO	$239.59
Rate for Payer: University Health Alliance Commercial	$180.04

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]

Facility

$31.00

Service Code	NDC 63304017513
Hospital Revenue Code	637
Min. Negotiated Rate	$15.81
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Hawaii Western Management Group Commercial	$29.45
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: Kaiser Permanente Commercial	$19.53
Rate for Payer: Kaiser Permanente Medicaid	$15.81
Rate for Payer: MDX Hawaii PPO	$30.07
Rate for Payer: University Health Alliance Commercial	$22.60

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]

Facility

$33.00

Service Code	NDC 00591224522
Hospital Revenue Code	250
Min. Negotiated Rate	$28.05
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: MDX Hawaii PPO	$32.01

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]

Facility

$31.00

Service Code	NDC 63304017513
Hospital Revenue Code	250
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$30.07
Rate for Payer: Cash Price	$18.60
Rate for Payer: Health Management Network Commercial	$26.35
Rate for Payer: MDX Hawaii PPO	$30.07

MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE [78310]

Facility

$33.00

Service Code	NDC 00591224522
Hospital Revenue Code	637
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$32.01
Rate for Payer: Cash Price	$19.80
Rate for Payer: Hawaii Western Management Group Commercial	$31.35
Rate for Payer: Health Management Network Commercial	$28.05
Rate for Payer: Kaiser Permanente Commercial	$20.79
Rate for Payer: Kaiser Permanente Medicaid	$16.83
Rate for Payer: MDX Hawaii PPO	$32.01
Rate for Payer: University Health Alliance Commercial	$24.05

MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [119913]

Facility

$16.00

Service Code	NDC 00093590786
Hospital Revenue Code	250
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: MDX Hawaii PPO	$15.52

MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE) [119913]

Facility

$16.00

Service Code	NDC 00093590786
Hospital Revenue Code	637
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$15.52
Rate for Payer: Cash Price	$9.60
Rate for Payer: Hawaii Western Management Group Commercial	$15.20
Rate for Payer: Health Management Network Commercial	$13.60
Rate for Payer: Kaiser Permanente Commercial	$10.08
Rate for Payer: Kaiser Permanente Medicaid	$8.16
Rate for Payer: MDX Hawaii PPO	$15.52
Rate for Payer: University Health Alliance Commercial	$11.66

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$62.00

Service Code	NDC 62559042007
Hospital Revenue Code	250
Min. Negotiated Rate	$52.70
Max. Negotiated Rate	$60.14
Rate for Payer: Cash Price	$37.20
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: MDX Hawaii PPO	$60.14

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$61.00

Service Code	NDC 45802009851
Hospital Revenue Code	637
Min. Negotiated Rate	$31.11
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$36.60
Rate for Payer: Hawaii Western Management Group Commercial	$57.95
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: Kaiser Permanente Commercial	$38.43
Rate for Payer: Kaiser Permanente Medicaid	$31.11
Rate for Payer: MDX Hawaii PPO	$59.17
Rate for Payer: University Health Alliance Commercial	$44.46

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$62.00

Service Code	NDC 62559042007
Hospital Revenue Code	637
Min. Negotiated Rate	$31.62
Max. Negotiated Rate	$60.14
Rate for Payer: Cash Price	$37.20
Rate for Payer: Hawaii Western Management Group Commercial	$58.90
Rate for Payer: Health Management Network Commercial	$52.70
Rate for Payer: Kaiser Permanente Commercial	$39.06
Rate for Payer: Kaiser Permanente Medicaid	$31.62
Rate for Payer: MDX Hawaii PPO	$60.14
Rate for Payer: University Health Alliance Commercial	$45.19

MESALAMINE 4 GRAM/60 ML ENEMA [10535]

Facility

$61.00

Service Code	NDC 45802009851
Hospital Revenue Code	250
Min. Negotiated Rate	$51.85
Max. Negotiated Rate	$59.17
Rate for Payer: Cash Price	$36.60
Rate for Payer: Health Management Network Commercial	$51.85
Rate for Payer: MDX Hawaii PPO	$59.17

MESH 10X15CM PROLENE GPSL

Facility

$2,528.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,415.68
Max. Negotiated Rate	$2,452.16
Rate for Payer: Cash Price	$1,516.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,769.60
Rate for Payer: Health Management Network Commercial	$2,148.80
Rate for Payer: MDX Hawaii PPO	$2,452.16
Rate for Payer: University Health Alliance Commercial	$1,415.68

MESH 10X15CM PROLENE GPSL

Facility

$2,528.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,289.28
Max. Negotiated Rate	$2,452.16
Rate for Payer: Cash Price	$1,516.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,769.60
Rate for Payer: Health Management Network Commercial	$2,148.80
Rate for Payer: Kaiser Permanente Commercial	$1,592.64
Rate for Payer: Kaiser Permanente Medicaid	$1,289.28
Rate for Payer: MDX Hawaii PPO	$2,452.16
Rate for Payer: University Health Alliance Commercial	$1,415.68

MESH 15X10CM

Facility

$1,509.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$769.59
Max. Negotiated Rate	$1,463.73
Rate for Payer: Cash Price	$905.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,056.30
Rate for Payer: Health Management Network Commercial	$1,282.65
Rate for Payer: Kaiser Permanente Commercial	$950.67
Rate for Payer: Kaiser Permanente Medicaid	$769.59
Rate for Payer: MDX Hawaii PPO	$1,463.73
Rate for Payer: University Health Alliance Commercial	$845.04

MESH 15X10CM

Facility

$1,509.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$845.04
Max. Negotiated Rate	$1,463.73
Rate for Payer: Cash Price	$905.40
Rate for Payer: Hawaii Western Management Group Commercial	$1,056.30
Rate for Payer: Health Management Network Commercial	$1,282.65
Rate for Payer: MDX Hawaii PPO	$1,463.73
Rate for Payer: University Health Alliance Commercial	$845.04

MESH 25X20CM

Facility

$2,102.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,072.02
Max. Negotiated Rate	$2,038.94
Rate for Payer: Cash Price	$1,261.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,471.40
Rate for Payer: Health Management Network Commercial	$1,786.70
Rate for Payer: Kaiser Permanente Commercial	$1,324.26
Rate for Payer: Kaiser Permanente Medicaid	$1,072.02
Rate for Payer: MDX Hawaii PPO	$2,038.94
Rate for Payer: University Health Alliance Commercial	$1,177.12

MESH 25X20CM

Facility

$2,102.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,177.12
Max. Negotiated Rate	$2,038.94
Rate for Payer: Cash Price	$1,261.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,471.40
Rate for Payer: Health Management Network Commercial	$1,786.70
Rate for Payer: MDX Hawaii PPO	$2,038.94
Rate for Payer: University Health Alliance Commercial	$1,177.12

MESH 3.2X3.2 CIRCLE 5950009

Facility

$2,520.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,411.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: University Health Alliance Commercial	$1,411.20

MESH 3.2X3.2 CIRCLE 5950009

Facility

$2,520.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,285.20
Max. Negotiated Rate	$2,444.40
Rate for Payer: Cash Price	$1,512.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,764.00
Rate for Payer: Health Management Network Commercial	$2,142.00
Rate for Payer: Kaiser Permanente Commercial	$1,587.60
Rate for Payer: Kaiser Permanente Medicaid	$1,285.20
Rate for Payer: MDX Hawaii PPO	$2,444.40
Rate for Payer: University Health Alliance Commercial	$1,411.20

MESH 3D EXTRA LARGE #0117322

Facility

$1,389.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$777.84
Max. Negotiated Rate	$1,347.33
Rate for Payer: Cash Price	$833.40
Rate for Payer: Hawaii Western Management Group Commercial	$972.30
Rate for Payer: Health Management Network Commercial	$1,180.65
Rate for Payer: MDX Hawaii PPO	$1,347.33
Rate for Payer: University Health Alliance Commercial	$777.84

MESH 3D EXTRA LARGE #0117322

Facility

$1,389.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$708.39
Max. Negotiated Rate	$1,347.33
Rate for Payer: Cash Price	$833.40
Rate for Payer: Hawaii Western Management Group Commercial	$972.30
Rate for Payer: Health Management Network Commercial	$1,180.65
Rate for Payer: Kaiser Permanente Commercial	$875.07
Rate for Payer: Kaiser Permanente Medicaid	$708.39
Rate for Payer: MDX Hawaii PPO	$1,347.33
Rate for Payer: University Health Alliance Commercial	$777.84

MESH 3D MAX LARGE LT 0117311

Facility

$1,302.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$729.12
Max. Negotiated Rate	$1,262.94
Rate for Payer: Cash Price	$781.20
Rate for Payer: Hawaii Western Management Group Commercial	$911.40
Rate for Payer: Health Management Network Commercial	$1,106.70
Rate for Payer: MDX Hawaii PPO	$1,262.94
Rate for Payer: University Health Alliance Commercial	$729.12

MESH 3D MAX LARGE LT 0117311

Facility

$1,302.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$664.02
Max. Negotiated Rate	$1,262.94
Rate for Payer: Cash Price	$781.20
Rate for Payer: Hawaii Western Management Group Commercial	$911.40
Rate for Payer: Health Management Network Commercial	$1,106.70
Rate for Payer: Kaiser Permanente Commercial	$820.26
Rate for Payer: Kaiser Permanente Medicaid	$664.02
Rate for Payer: MDX Hawaii PPO	$1,262.94
Rate for Payer: University Health Alliance Commercial	$729.12

MESH 3D MAX LARGE RT 0117321

Facility

$1,314.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$735.84
Max. Negotiated Rate	$1,274.58
Rate for Payer: Cash Price	$788.40
Rate for Payer: Hawaii Western Management Group Commercial	$919.80
Rate for Payer: Health Management Network Commercial	$1,116.90
Rate for Payer: MDX Hawaii PPO	$1,274.58
Rate for Payer: University Health Alliance Commercial	$735.84

Know your out-of-pocket cost for care.

All Charges