Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$3,988.02

Service Code	APR-DRG 6942
Min. Negotiated Rate	$3,988.02
Max. Negotiated Rate	$3,988.02
Rate for Payer: AlohaCare Medicaid	$3,988.02
Rate for Payer: Hawaii Medical Service Association ABD	$3,988.02
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,988.02
Rate for Payer: Kaiser Permanente Medicaid	$3,988.02
Rate for Payer: Ohana Health Plan Medicaid	$3,988.02
Rate for Payer: UnitedHealthcare Medicaid	$3,988.02

LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$3,297.26

Service Code	APR-DRG 6941
Min. Negotiated Rate	$3,297.26
Max. Negotiated Rate	$3,297.26
Rate for Payer: AlohaCare Medicaid	$3,297.26
Rate for Payer: Hawaii Medical Service Association ABD	$3,297.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,297.26
Rate for Payer: Kaiser Permanente Medicaid	$3,297.26
Rate for Payer: Ohana Health Plan Medicaid	$3,297.26
Rate for Payer: UnitedHealthcare Medicaid	$3,297.26

LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$10,110.29

Service Code	APR-DRG 6944
Min. Negotiated Rate	$10,110.29
Max. Negotiated Rate	$10,110.29
Rate for Payer: AlohaCare Medicaid	$10,110.29
Rate for Payer: Hawaii Medical Service Association ABD	$10,110.29
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,110.29
Rate for Payer: Kaiser Permanente Medicaid	$10,110.29
Rate for Payer: Ohana Health Plan Medicaid	$10,110.29
Rate for Payer: UnitedHealthcare Medicaid	$10,110.29

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$78,330.65

Service Code	MSDRG 821
Min. Negotiated Rate	$25,462.40
Max. Negotiated Rate	$78,330.65
Rate for Payer: AlohaCare Medicare	$25,462.40
Rate for Payer: Devoted Health Medicare	$28,008.64
Rate for Payer: Hawaii Medical Service Association Commercial	$78,330.65
Rate for Payer: Hawaii Medical Service Association Medicare	$25,462.40
Rate for Payer: Humana Medicare	$25,462.40
Rate for Payer: Kaiser Permanente Commercial	$38,615.85
Rate for Payer: Kaiser Permanente Medicare	$25,462.40
Rate for Payer: Ohana Health Plan Medicare	$25,462.40
Rate for Payer: UnitedHealthcare Medicare	$25,462.40

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$101,167.80

Service Code	MSDRG 820
Min. Negotiated Rate	$66,707.73
Max. Negotiated Rate	$101,167.80
Rate for Payer: AlohaCare Medicare	$66,707.73
Rate for Payer: Devoted Health Medicare	$73,378.50
Rate for Payer: Hawaii Medical Service Association Commercial	$78,330.65
Rate for Payer: Hawaii Medical Service Association Medicare	$66,707.73
Rate for Payer: Humana Medicare	$66,707.73
Rate for Payer: Kaiser Permanente Commercial	$101,167.80
Rate for Payer: Kaiser Permanente Medicare	$66,707.73
Rate for Payer: Ohana Health Plan Medicare	$66,707.73
Rate for Payer: UnitedHealthcare Medicare	$66,707.73

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$31,375.94

Service Code	MSDRG 822
Min. Negotiated Rate	$13,694.59
Max. Negotiated Rate	$31,375.94
Rate for Payer: AlohaCare Medicare	$13,694.59
Rate for Payer: Devoted Health Medicare	$15,064.05
Rate for Payer: Hawaii Medical Service Association Commercial	$31,375.94
Rate for Payer: Hawaii Medical Service Association Medicare	$13,694.59
Rate for Payer: Humana Medicare	$13,694.59
Rate for Payer: Kaiser Permanente Commercial	$20,769.00
Rate for Payer: Kaiser Permanente Medicare	$13,694.59
Rate for Payer: Ohana Health Plan Medicare	$13,694.59
Rate for Payer: UnitedHealthcare Medicare	$13,694.59

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC

Facility

$79,568.21

Service Code	MSDRG 841
Min. Negotiated Rate	$18,555.97
Max. Negotiated Rate	$79,568.21
Rate for Payer: AlohaCare Medicare	$18,555.97
Rate for Payer: Devoted Health Medicare	$20,411.57
Rate for Payer: Hawaii Medical Service Association Commercial	$79,568.21
Rate for Payer: Hawaii Medical Service Association Medicare	$18,555.97
Rate for Payer: Humana Medicare	$18,555.97
Rate for Payer: Kaiser Permanente Commercial	$28,141.65
Rate for Payer: Kaiser Permanente Medicare	$18,555.97
Rate for Payer: Ohana Health Plan Medicare	$18,555.97
Rate for Payer: UnitedHealthcare Medicare	$18,555.97

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC

Facility

$84,251.55

Service Code	MSDRG 840
Min. Negotiated Rate	$36,794.59
Max. Negotiated Rate	$84,251.55
Rate for Payer: AlohaCare Medicare	$36,794.59
Rate for Payer: Devoted Health Medicare	$40,474.05
Rate for Payer: Hawaii Medical Service Association Commercial	$84,251.55
Rate for Payer: Hawaii Medical Service Association Medicare	$36,794.59
Rate for Payer: Humana Medicare	$36,794.59
Rate for Payer: Kaiser Permanente Commercial	$55,802.03
Rate for Payer: Kaiser Permanente Medicare	$36,794.59
Rate for Payer: Ohana Health Plan Medicare	$36,794.59
Rate for Payer: UnitedHealthcare Medicare	$36,794.59

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC

Facility

$94,734.46

Service Code	MSDRG 824
Min. Negotiated Rate	$25,769.51
Max. Negotiated Rate	$94,734.46
Rate for Payer: AlohaCare Medicare	$25,769.51
Rate for Payer: Devoted Health Medicare	$28,346.46
Rate for Payer: Hawaii Medical Service Association Commercial	$94,734.46
Rate for Payer: Hawaii Medical Service Association Medicare	$25,769.51
Rate for Payer: Humana Medicare	$25,769.51
Rate for Payer: Kaiser Permanente Commercial	$39,081.60
Rate for Payer: Kaiser Permanente Medicare	$25,769.51
Rate for Payer: Ohana Health Plan Medicare	$25,769.51
Rate for Payer: UnitedHealthcare Medicare	$25,769.51

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC

Facility

$94,734.46

Service Code	MSDRG 823
Min. Negotiated Rate	$52,148.68
Max. Negotiated Rate	$94,734.46
Rate for Payer: AlohaCare Medicare	$52,148.68
Rate for Payer: Devoted Health Medicare	$57,363.55
Rate for Payer: Hawaii Medical Service Association Commercial	$94,734.46
Rate for Payer: Hawaii Medical Service Association Medicare	$52,148.68
Rate for Payer: Humana Medicare	$52,148.68
Rate for Payer: Kaiser Permanente Commercial	$79,087.80
Rate for Payer: Kaiser Permanente Medicare	$52,148.68
Rate for Payer: Ohana Health Plan Medicare	$52,148.68
Rate for Payer: UnitedHealthcare Medicare	$52,148.68

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$25,649.16

Service Code	MSDRG 825
Min. Negotiated Rate	$15,348.43
Max. Negotiated Rate	$25,649.16
Rate for Payer: AlohaCare Medicare	$15,348.43
Rate for Payer: Devoted Health Medicare	$16,883.27
Rate for Payer: Hawaii Medical Service Association Commercial	$25,649.16
Rate for Payer: Hawaii Medical Service Association Medicare	$15,348.43
Rate for Payer: Humana Medicare	$15,348.43
Rate for Payer: Kaiser Permanente Commercial	$23,277.15
Rate for Payer: Kaiser Permanente Medicare	$15,348.43
Rate for Payer: Ohana Health Plan Medicare	$15,348.43
Rate for Payer: UnitedHealthcare Medicare	$15,348.43

LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$52,244.70

Service Code	MSDRG 842
Min. Negotiated Rate	$11,492.56
Max. Negotiated Rate	$52,244.70
Rate for Payer: AlohaCare Medicare	$11,492.56
Rate for Payer: Devoted Health Medicare	$12,641.82
Rate for Payer: Hawaii Medical Service Association Commercial	$52,244.70
Rate for Payer: Hawaii Medical Service Association Medicare	$11,492.56
Rate for Payer: Humana Medicare	$11,492.56
Rate for Payer: Kaiser Permanente Commercial	$17,429.40
Rate for Payer: Kaiser Permanente Medicare	$11,492.56
Rate for Payer: Ohana Health Plan Medicare	$11,492.56
Rate for Payer: UnitedHealthcare Medicare	$11,492.56

LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA

Facility

$16,391.72

Service Code	APR-DRG 6914
Min. Negotiated Rate	$16,391.72
Max. Negotiated Rate	$16,391.72
Rate for Payer: AlohaCare Medicaid	$16,391.72
Rate for Payer: Hawaii Medical Service Association ABD	$16,391.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16,391.72
Rate for Payer: Kaiser Permanente Medicaid	$16,391.72
Rate for Payer: Ohana Health Plan Medicaid	$16,391.72
Rate for Payer: UnitedHealthcare Medicaid	$16,391.72

LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA

Facility

$4,858.81

Service Code	APR-DRG 6911
Min. Negotiated Rate	$4,858.81
Max. Negotiated Rate	$4,858.81
Rate for Payer: AlohaCare Medicaid	$4,858.81
Rate for Payer: Hawaii Medical Service Association ABD	$4,858.81
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,858.81
Rate for Payer: Kaiser Permanente Medicaid	$4,858.81
Rate for Payer: Ohana Health Plan Medicaid	$4,858.81
Rate for Payer: UnitedHealthcare Medicaid	$4,858.81

LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA

Facility

$8,706.59

Service Code	APR-DRG 6913
Min. Negotiated Rate	$8,706.59
Max. Negotiated Rate	$8,706.59
Rate for Payer: AlohaCare Medicaid	$8,706.59
Rate for Payer: Hawaii Medical Service Association ABD	$8,706.59
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,706.59
Rate for Payer: Kaiser Permanente Medicaid	$8,706.59
Rate for Payer: Ohana Health Plan Medicaid	$8,706.59
Rate for Payer: UnitedHealthcare Medicaid	$8,706.59

LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA

Facility

$5,578.93

Service Code	APR-DRG 6912
Min. Negotiated Rate	$5,578.93
Max. Negotiated Rate	$5,578.93
Rate for Payer: AlohaCare Medicaid	$5,578.93
Rate for Payer: Hawaii Medical Service Association ABD	$5,578.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,578.93
Rate for Payer: Kaiser Permanente Medicaid	$5,578.93
Rate for Payer: Ohana Health Plan Medicaid	$5,578.93
Rate for Payer: UnitedHealthcare Medicaid	$5,578.93

LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS

Facility

$5,509.00

Service Code	CPT 54162
Hospital Revenue Code	360
Min. Negotiated Rate	$456.03
Max. Negotiated Rate	$5,509.00
Rate for Payer: AlohaCare Medicaid	$2,469.46
Rate for Payer: AlohaCare Medicare	$2,469.46
Rate for Payer: Devoted Health Medicare	$2,716.41
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	$2,469.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,028.67
Rate for Payer: Humana Medicare	$2,469.46
Rate for Payer: Kaiser Permanente Medicaid	$2,837.00
Rate for Payer: Kaiser Permanente Medicare	$2,469.46
Rate for Payer: Ohana Health Plan Medicaid	$2,716.41
Rate for Payer: Ohana Health Plan Medicare	$2,469.46
Rate for Payer: UnitedHealthcare Medicaid	$456.03
Rate for Payer: UnitedHealthcare Medicare	$2,469.46
Rate for Payer: University Health Alliance Commercial	$5,160.40

MAG HYDROX/AL HYDROX/SIMETH/LIDO SUSPENSION (GI COCKTAIL) (35E [4080001]

Facility

$23.00

Service Code	NDC 00004080001
Hospital Revenue Code	637
Min. Negotiated Rate	$11.73
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Hawaii Western Management Group Commercial	$21.85
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: Kaiser Permanente Commercial	$14.49
Rate for Payer: Kaiser Permanente Medicaid	$11.73
Rate for Payer: MDX Hawaii PPO	$22.31
Rate for Payer: University Health Alliance Commercial	$16.76

MAG HYDROX/AL HYDROX/SIMETH/LIDO SUSPENSION (GI COCKTAIL) (35E [4080001]

Facility

$23.00

Service Code	NDC 00004080001
Hospital Revenue Code	250
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$22.31
Rate for Payer: Cash Price	$13.80
Rate for Payer: Health Management Network Commercial	$19.55
Rate for Payer: MDX Hawaii PPO	$22.31

MAGNESIUM CITRATE ORAL SOLUTION [1701]

Facility

$13.00

Service Code	NDC 71399005101
Hospital Revenue Code	637
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Hawaii Western Management Group Commercial	$12.35
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: Kaiser Permanente Commercial	$8.19
Rate for Payer: Kaiser Permanente Medicaid	$6.63
Rate for Payer: MDX Hawaii PPO	$12.61
Rate for Payer: University Health Alliance Commercial	$9.48

MAGNESIUM CITRATE ORAL SOLUTION [1701]

Facility

$13.00

Service Code	NDC 71399005101
Hospital Revenue Code	250
Min. Negotiated Rate	$11.05
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$7.80
Rate for Payer: Health Management Network Commercial	$11.05
Rate for Payer: MDX Hawaii PPO	$12.61

MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [28836]

Facility

$9.00

Service Code	NDC 00121043130
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [28836]

Facility

$9.00

Service Code	NDC 60687042976
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [28836]

Facility

$9.00

Service Code	NDC 00121043130
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$8.73

MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION [28836]

Facility

$9.00

Service Code	NDC 60687042976
Hospital Revenue Code	637
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: University Health Alliance Commercial	$6.56

Know your out-of-pocket cost for care.

All Charges