Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

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

MESH 3D MAX LEFT XL #0117312

Facility

$1,455.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$742.05
Max. Negotiated Rate	$1,411.35
Rate for Payer: Cash Price	$873.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,018.50
Rate for Payer: Health Management Network Commercial	$1,236.75
Rate for Payer: Kaiser Permanente Commercial	$916.65
Rate for Payer: Kaiser Permanente Medicaid	$742.05
Rate for Payer: MDX Hawaii PPO	$1,411.35
Rate for Payer: University Health Alliance Commercial	$814.80

MESH 3D MAX LEFT XL #0117312

Facility

$1,455.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$814.80
Max. Negotiated Rate	$1,411.35
Rate for Payer: Cash Price	$873.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,018.50
Rate for Payer: Health Management Network Commercial	$1,236.75
Rate for Payer: MDX Hawaii PPO	$1,411.35
Rate for Payer: University Health Alliance Commercial	$814.80

MESH 3DMAX LGE LF 0116311

Facility

$1,507.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$768.57
Max. Negotiated Rate	$1,461.79
Rate for Payer: Cash Price	$904.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,054.90
Rate for Payer: Health Management Network Commercial	$1,280.95
Rate for Payer: Kaiser Permanente Commercial	$949.41
Rate for Payer: Kaiser Permanente Medicaid	$768.57
Rate for Payer: MDX Hawaii PPO	$1,461.79
Rate for Payer: University Health Alliance Commercial	$843.92

MESH 3DMAX LGE LF 0116311

Facility

$1,507.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$843.92
Max. Negotiated Rate	$1,461.79
Rate for Payer: Cash Price	$904.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,054.90
Rate for Payer: Health Management Network Commercial	$1,280.95
Rate for Payer: MDX Hawaii PPO	$1,461.79
Rate for Payer: University Health Alliance Commercial	$843.92

MESH 3DMAX LGE RT 0116321

Facility

$1,367.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$697.17
Max. Negotiated Rate	$1,325.99
Rate for Payer: Cash Price	$820.20
Rate for Payer: Hawaii Western Management Group Commercial	$956.90
Rate for Payer: Health Management Network Commercial	$1,161.95
Rate for Payer: Kaiser Permanente Commercial	$861.21
Rate for Payer: Kaiser Permanente Medicaid	$697.17
Rate for Payer: MDX Hawaii PPO	$1,325.99
Rate for Payer: University Health Alliance Commercial	$765.52

MESH 3DMAX LGE RT 0116321

Facility

$1,367.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$765.52
Max. Negotiated Rate	$1,325.99
Rate for Payer: Cash Price	$820.20
Rate for Payer: Hawaii Western Management Group Commercial	$956.90
Rate for Payer: Health Management Network Commercial	$1,161.95
Rate for Payer: MDX Hawaii PPO	$1,325.99
Rate for Payer: University Health Alliance Commercial	$765.52

MESH 3DMAX MED LF 0116310

Facility

$1,316.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$736.96
Max. Negotiated Rate	$1,276.52
Rate for Payer: Cash Price	$789.60
Rate for Payer: Hawaii Western Management Group Commercial	$921.20
Rate for Payer: Health Management Network Commercial	$1,118.60
Rate for Payer: MDX Hawaii PPO	$1,276.52
Rate for Payer: University Health Alliance Commercial	$736.96

MESH 3DMAX MED LF 0116310

Facility

$1,316.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$671.16
Max. Negotiated Rate	$1,276.52
Rate for Payer: Cash Price	$789.60
Rate for Payer: Hawaii Western Management Group Commercial	$921.20
Rate for Payer: Health Management Network Commercial	$1,118.60
Rate for Payer: Kaiser Permanente Commercial	$829.08
Rate for Payer: Kaiser Permanente Medicaid	$671.16
Rate for Payer: MDX Hawaii PPO	$1,276.52
Rate for Payer: University Health Alliance Commercial	$736.96

MESH 3DMAX MED RT 0116320

Facility

$1,382.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$704.82
Max. Negotiated Rate	$1,340.54
Rate for Payer: Cash Price	$829.20
Rate for Payer: Hawaii Western Management Group Commercial	$967.40
Rate for Payer: Health Management Network Commercial	$1,174.70
Rate for Payer: Kaiser Permanente Commercial	$870.66
Rate for Payer: Kaiser Permanente Medicaid	$704.82
Rate for Payer: MDX Hawaii PPO	$1,340.54
Rate for Payer: University Health Alliance Commercial	$773.92

MESH 3DMAX MED RT 0116320

Facility

$1,382.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$773.92
Max. Negotiated Rate	$1,340.54
Rate for Payer: Cash Price	$829.20
Rate for Payer: Hawaii Western Management Group Commercial	$967.40
Rate for Payer: Health Management Network Commercial	$1,174.70
Rate for Payer: MDX Hawaii PPO	$1,340.54
Rate for Payer: University Health Alliance Commercial	$773.92

MESH 3DMAX X-LGE 0116312

Facility

$1,633.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$832.83
Max. Negotiated Rate	$1,584.01
Rate for Payer: Cash Price	$979.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,143.10
Rate for Payer: Health Management Network Commercial	$1,388.05
Rate for Payer: Kaiser Permanente Commercial	$1,028.79
Rate for Payer: Kaiser Permanente Medicaid	$832.83
Rate for Payer: MDX Hawaii PPO	$1,584.01
Rate for Payer: University Health Alliance Commercial	$914.48

MESH 3DMAX X-LGE 0116312

Facility

$1,633.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$914.48
Max. Negotiated Rate	$1,584.01
Rate for Payer: Cash Price	$979.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,143.10
Rate for Payer: Health Management Network Commercial	$1,388.05
Rate for Payer: MDX Hawaii PPO	$1,584.01
Rate for Payer: University Health Alliance Commercial	$914.48

MESH 3DMAX X-LGE RT 0116322

Facility

$1,442.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$807.52
Max. Negotiated Rate	$1,398.74
Rate for Payer: Cash Price	$865.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,009.40
Rate for Payer: Health Management Network Commercial	$1,225.70
Rate for Payer: MDX Hawaii PPO	$1,398.74
Rate for Payer: University Health Alliance Commercial	$807.52

MESH 3DMAX X-LGE RT 0116322

Facility

$1,442.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$735.42
Max. Negotiated Rate	$1,398.74
Rate for Payer: Cash Price	$865.20
Rate for Payer: Hawaii Western Management Group Commercial	$1,009.40
Rate for Payer: Health Management Network Commercial	$1,225.70
Rate for Payer: Kaiser Permanente Commercial	$908.46
Rate for Payer: Kaiser Permanente Medicaid	$735.42
Rate for Payer: MDX Hawaii PPO	$1,398.74
Rate for Payer: University Health Alliance Commercial	$807.52

MESH BIOLOGIC 5X8CM XI0508-S+

Facility

$2,760.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,407.60
Max. Negotiated Rate	$2,677.20
Rate for Payer: Cash Price	$1,656.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,932.00
Rate for Payer: Health Management Network Commercial	$2,346.00
Rate for Payer: Kaiser Permanente Commercial	$1,738.80
Rate for Payer: Kaiser Permanente Medicaid	$1,407.60
Rate for Payer: MDX Hawaii PPO	$2,677.20
Rate for Payer: University Health Alliance Commercial	$1,545.60

MESH BIOLOGIC 5X8CM XI0508-S+

Facility

$2,760.00

Service Code	HCPCS C1781
Hospital Revenue Code	278
Min. Negotiated Rate	$1,545.60
Max. Negotiated Rate	$2,677.20
Rate for Payer: Cash Price	$1,656.00
Rate for Payer: Hawaii Western Management Group Commercial	$1,932.00
Rate for Payer: Health Management Network Commercial	$2,346.00
Rate for Payer: MDX Hawaii PPO	$2,677.20
Rate for Payer: University Health Alliance Commercial	$1,545.60

MESHED BILAYER 2X2 MWM2021

Facility

$5,993.00

Service Code	HCPCS Q4104
Hospital Revenue Code	636
Min. Negotiated Rate	$53.76
Max. Negotiated Rate	$5,813.21
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$3,595.80
Rate for Payer: Cash Price	$3,595.80
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$53.76
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	$53.76
Rate for Payer: Hawaii Western Management Group Commercial	$5,693.35
Rate for Payer: Health Management Network Commercial	$5,094.05
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$3,775.59
Rate for Payer: Kaiser Permanente Medicaid	$3,056.43
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$5,813.21
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$3,595.80
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$4,368.30

MESHED BILAYER 2X2 MWM2021

Facility

$5,993.00

Service Code	HCPCS Q4104
Hospital Revenue Code	636
Min. Negotiated Rate	$5,094.05
Max. Negotiated Rate	$5,813.21
Rate for Payer: Cash Price	$3,595.80
Rate for Payer: Health Management Network Commercial	$5,094.05
Rate for Payer: MDX Hawaii PPO	$5,813.21

MESHED BILAYER 4X5 MWM4051

Facility

$10,451.00

Service Code	HCPCS Q4104
Hospital Revenue Code	636
Min. Negotiated Rate	$8,883.35
Max. Negotiated Rate	$10,137.47
Rate for Payer: Cash Price	$6,270.60
Rate for Payer: Health Management Network Commercial	$8,883.35
Rate for Payer: MDX Hawaii PPO	$10,137.47

MESHED BILAYER 4X5 MWM4051

Facility

$10,451.00

Service Code	HCPCS Q4104
Hospital Revenue Code	636
Min. Negotiated Rate	$53.76
Max. Negotiated Rate	$10,137.47
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$6,270.60
Rate for Payer: Cash Price	$6,270.60
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$53.76
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	$53.76
Rate for Payer: Hawaii Western Management Group Commercial	$9,928.45
Rate for Payer: Health Management Network Commercial	$8,883.35
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$6,584.13
Rate for Payer: Kaiser Permanente Medicaid	$5,330.01
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$10,137.47
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$6,270.60
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$7,617.73

MESHED DERMAL 5CMX5CM MDRT2021

Facility

$7,560.00

Service Code	HCPCS Q4105
Hospital Revenue Code	636
Min. Negotiated Rate	$26.09
Max. Negotiated Rate	$7,333.20
Rate for Payer: AlohaCare Medicaid	$147.01
Rate for Payer: AlohaCare Medicare	$147.01
Rate for Payer: Cash Price	$4,536.00
Rate for Payer: Cash Price	$4,536.00
Rate for Payer: Devoted Health Medicare	$161.71
Rate for Payer: Hawaii Medical Service Association ABD	$26.09
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	$26.09
Rate for Payer: Hawaii Western Management Group Commercial	$7,182.00
Rate for Payer: Health Management Network Commercial	$6,426.00
Rate for Payer: Humana Medicare	$147.01
Rate for Payer: Kaiser Permanente Commercial	$4,762.80
Rate for Payer: Kaiser Permanente Medicaid	$3,855.60
Rate for Payer: Kaiser Permanente Medicare	$147.01
Rate for Payer: MDX Hawaii PPO	$7,333.20
Rate for Payer: Ohana Health Plan Medicaid	$161.71
Rate for Payer: Ohana Health Plan Medicare	$147.01
Rate for Payer: UnitedHealthcare Medicaid	$4,536.00
Rate for Payer: UnitedHealthcare Medicare	$147.01
Rate for Payer: University Health Alliance Commercial	$5,510.48

MESHED DERMAL 5CMX5CM MDRT2021

Facility

$7,560.00

Service Code	HCPCS Q4105
Hospital Revenue Code	636
Min. Negotiated Rate	$6,426.00
Max. Negotiated Rate	$7,333.20
Rate for Payer: Cash Price	$4,536.00
Rate for Payer: Health Management Network Commercial	$6,426.00
Rate for Payer: MDX Hawaii PPO	$7,333.20

MESH FLEX HD 6X16 PF2616

Facility

$8,106.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$4,134.06
Max. Negotiated Rate	$7,862.82
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: Kaiser Permanente Commercial	$5,106.78
Rate for Payer: Kaiser Permanente Medicaid	$4,134.06
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: University Health Alliance Commercial	$4,539.36

MESH FLEX HD 6X16 PF2616

Facility

$8,106.00

Service Code	HCPCS C1763
Hospital Revenue Code	278
Min. Negotiated Rate	$4,539.36
Max. Negotiated Rate	$7,862.82
Rate for Payer: Cash Price	$4,863.60
Rate for Payer: Hawaii Western Management Group Commercial	$5,674.20
Rate for Payer: Health Management Network Commercial	$6,890.10
Rate for Payer: MDX Hawaii PPO	$7,862.82
Rate for Payer: University Health Alliance Commercial	$4,539.36

Know your out-of-pocket cost for care.

All Charges