Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION

Facility

$27,021.78

Service Code	APR-DRG 6253
Min. Negotiated Rate	$27,021.78
Max. Negotiated Rate	$27,021.78
Rate for Payer: AlohaCare Medicaid	$27,021.78
Rate for Payer: Hawaii Medical Service Association ABD	$27,021.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$27,021.78
Rate for Payer: Kaiser Permanente Medicaid	$27,021.78
Rate for Payer: Ohana Health Plan Medicaid	$27,021.78
Rate for Payer: UnitedHealthcare Medicaid	$27,021.78

NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION

Facility

$29,831.43

Service Code	APR-DRG 6254
Min. Negotiated Rate	$29,831.43
Max. Negotiated Rate	$29,831.43
Rate for Payer: AlohaCare Medicaid	$29,831.43
Rate for Payer: Hawaii Medical Service Association ABD	$29,831.43
Rate for Payer: Hawaii Medical Service Association Non-ABD	$29,831.43
Rate for Payer: Kaiser Permanente Medicaid	$29,831.43
Rate for Payer: Ohana Health Plan Medicaid	$29,831.43
Rate for Payer: UnitedHealthcare Medicaid	$29,831.43

NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION

Facility

$12,096.97

Service Code	APR-DRG 6251
Min. Negotiated Rate	$12,096.97
Max. Negotiated Rate	$12,096.97
Rate for Payer: AlohaCare Medicaid	$12,096.97
Rate for Payer: Hawaii Medical Service Association ABD	$12,096.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$12,096.97
Rate for Payer: Kaiser Permanente Medicaid	$12,096.97
Rate for Payer: Ohana Health Plan Medicaid	$12,096.97
Rate for Payer: UnitedHealthcare Medicaid	$12,096.97

NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION

Facility

$18,486.67

Service Code	APR-DRG 6252
Min. Negotiated Rate	$18,486.67
Max. Negotiated Rate	$18,486.67
Rate for Payer: AlohaCare Medicaid	$18,486.67
Rate for Payer: Hawaii Medical Service Association ABD	$18,486.67
Rate for Payer: Hawaii Medical Service Association Non-ABD	$18,486.67
Rate for Payer: Kaiser Permanente Medicaid	$18,486.67
Rate for Payer: Ohana Health Plan Medicaid	$18,486.67
Rate for Payer: UnitedHealthcare Medicaid	$18,486.67

NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND

Facility

$16,725.46

Service Code	APR-DRG 6221
Min. Negotiated Rate	$16,725.46
Max. Negotiated Rate	$16,725.46
Rate for Payer: AlohaCare Medicaid	$16,725.46
Rate for Payer: Hawaii Medical Service Association ABD	$16,725.46
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16,725.46
Rate for Payer: Kaiser Permanente Medicaid	$16,725.46
Rate for Payer: Ohana Health Plan Medicaid	$16,725.46
Rate for Payer: UnitedHealthcare Medicaid	$16,725.46

NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND

Facility

$22,562.13

Service Code	APR-DRG 6222
Min. Negotiated Rate	$22,562.13
Max. Negotiated Rate	$22,562.13
Rate for Payer: AlohaCare Medicaid	$22,562.13
Rate for Payer: Hawaii Medical Service Association ABD	$22,562.13
Rate for Payer: Hawaii Medical Service Association Non-ABD	$22,562.13
Rate for Payer: Kaiser Permanente Medicaid	$22,562.13
Rate for Payer: Ohana Health Plan Medicaid	$22,562.13
Rate for Payer: UnitedHealthcare Medicaid	$22,562.13

NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND

Facility

$28,607.08

Service Code	APR-DRG 6223
Min. Negotiated Rate	$28,607.08
Max. Negotiated Rate	$28,607.08
Rate for Payer: AlohaCare Medicaid	$28,607.08
Rate for Payer: Hawaii Medical Service Association ABD	$28,607.08
Rate for Payer: Hawaii Medical Service Association Non-ABD	$28,607.08
Rate for Payer: Kaiser Permanente Medicaid	$28,607.08
Rate for Payer: Ohana Health Plan Medicaid	$28,607.08
Rate for Payer: UnitedHealthcare Medicaid	$28,607.08

NEONATE BWT 2000-2499G W RESP DIST SYND/OTH MAJ RESP COND

Facility

$48,966.17

Service Code	APR-DRG 6224
Min. Negotiated Rate	$48,966.17
Max. Negotiated Rate	$48,966.17
Rate for Payer: AlohaCare Medicaid	$48,966.17
Rate for Payer: Hawaii Medical Service Association ABD	$48,966.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$48,966.17
Rate for Payer: Kaiser Permanente Medicaid	$48,966.17
Rate for Payer: Ohana Health Plan Medicaid	$48,966.17
Rate for Payer: UnitedHealthcare Medicaid	$48,966.17

NEONATE BWT < 500G, OR BWT 500-999G & GESTATIONAL AGE <24 WKS, OR BWT 500-749G W MAJOR ANOMALY OR W/O LIFE SUSTAINING IN

Facility

$2,294.03

Service Code	APR-DRG 5894
Min. Negotiated Rate	$2,294.03
Max. Negotiated Rate	$2,294.03
Rate for Payer: AlohaCare Medicaid	$2,294.03
Rate for Payer: Hawaii Medical Service Association ABD	$2,294.03
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,294.03
Rate for Payer: Kaiser Permanente Medicaid	$2,294.03
Rate for Payer: Ohana Health Plan Medicaid	$2,294.03
Rate for Payer: UnitedHealthcare Medicaid	$2,294.03

NEONATE BWT < 500G, OR BWT 500-999G & GESTATIONAL AGE <24 WKS, OR BWT 500-749G W MAJOR ANOMALY OR W/O LIFE SUSTAINING IN

Facility

$117,484.64

Service Code	APR-DRG 5893
Min. Negotiated Rate	$117,484.64
Max. Negotiated Rate	$117,484.64
Rate for Payer: AlohaCare Medicaid	$117,484.64
Rate for Payer: Hawaii Medical Service Association ABD	$117,484.64
Rate for Payer: Hawaii Medical Service Association Non-ABD	$117,484.64
Rate for Payer: Kaiser Permanente Medicaid	$117,484.64
Rate for Payer: Ohana Health Plan Medicaid	$117,484.64
Rate for Payer: UnitedHealthcare Medicaid	$117,484.64

NEONATE BWT < 500G, OR BWT 500-999G & GESTATIONAL AGE <24 WKS, OR BWT 500-749G W MAJOR ANOMALY OR W/O LIFE SUSTAINING IN

Facility

$129,527.01

Service Code	APR-DRG 5891
Min. Negotiated Rate	$129,527.01
Max. Negotiated Rate	$129,527.01
Rate for Payer: AlohaCare Medicaid	$129,527.01
Rate for Payer: Hawaii Medical Service Association ABD	$129,527.01
Rate for Payer: Hawaii Medical Service Association Non-ABD	$129,527.01
Rate for Payer: Kaiser Permanente Medicaid	$129,527.01
Rate for Payer: Ohana Health Plan Medicaid	$129,527.01
Rate for Payer: UnitedHealthcare Medicaid	$129,527.01

NEONATE BWT < 500G, OR BWT 500-999G & GESTATIONAL AGE <24 WKS, OR BWT 500-749G W MAJOR ANOMALY OR W/O LIFE SUSTAINING IN

Facility

$123,358.72

Service Code	APR-DRG 5892
Min. Negotiated Rate	$123,358.72
Max. Negotiated Rate	$123,358.72
Rate for Payer: AlohaCare Medicaid	$123,358.72
Rate for Payer: Hawaii Medical Service Association ABD	$123,358.72
Rate for Payer: Hawaii Medical Service Association Non-ABD	$123,358.72
Rate for Payer: Kaiser Permanente Medicaid	$123,358.72
Rate for Payer: Ohana Health Plan Medicaid	$123,358.72
Rate for Payer: UnitedHealthcare Medicaid	$123,358.72

NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY

Facility

$65,954.99

Service Code	MSDRG 789
Min. Negotiated Rate	$20,498.68
Max. Negotiated Rate	$65,954.99
Rate for Payer: AlohaCare Medicare	$20,498.68
Rate for Payer: Devoted Health Medicare	$22,548.55
Rate for Payer: Hawaii Medical Service Association Commercial	$65,954.99
Rate for Payer: Hawaii Medical Service Association Medicare	$20,498.68
Rate for Payer: Humana Medicare	$20,498.68
Rate for Payer: Kaiser Permanente Commercial	$31,087.95
Rate for Payer: Kaiser Permanente Medicare	$20,498.68
Rate for Payer: Ohana Health Plan Medicare	$20,498.68
Rate for Payer: UnitedHealthcare Medicare	$20,498.68

NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE

Facility

$1,769.30

Service Code	APR-DRG 5812
Min. Negotiated Rate	$1,769.30
Max. Negotiated Rate	$1,769.30
Rate for Payer: AlohaCare Medicaid	$1,769.30
Rate for Payer: Hawaii Medical Service Association ABD	$1,769.30
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,769.30
Rate for Payer: Kaiser Permanente Medicaid	$1,769.30
Rate for Payer: Ohana Health Plan Medicaid	$1,769.30
Rate for Payer: UnitedHealthcare Medicaid	$1,769.30

NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE

Facility

$1,480.15

Service Code	APR-DRG 5811
Min. Negotiated Rate	$1,480.15
Max. Negotiated Rate	$1,480.15
Rate for Payer: AlohaCare Medicaid	$1,480.15
Rate for Payer: Hawaii Medical Service Association ABD	$1,480.15
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1,480.15
Rate for Payer: Kaiser Permanente Medicaid	$1,480.15
Rate for Payer: Ohana Health Plan Medicaid	$1,480.15
Rate for Payer: UnitedHealthcare Medicaid	$1,480.15

NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE

Facility

$2,916.82

Service Code	APR-DRG 5813
Min. Negotiated Rate	$2,916.82
Max. Negotiated Rate	$2,916.82
Rate for Payer: AlohaCare Medicaid	$2,916.82
Rate for Payer: Hawaii Medical Service Association ABD	$2,916.82
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,916.82
Rate for Payer: Kaiser Permanente Medicaid	$2,916.82
Rate for Payer: Ohana Health Plan Medicaid	$2,916.82
Rate for Payer: UnitedHealthcare Medicaid	$2,916.82

NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE

Facility

$4,503.12

Service Code	APR-DRG 5814
Min. Negotiated Rate	$4,503.12
Max. Negotiated Rate	$4,503.12
Rate for Payer: AlohaCare Medicaid	$4,503.12
Rate for Payer: Hawaii Medical Service Association ABD	$4,503.12
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,503.12
Rate for Payer: Kaiser Permanente Medicaid	$4,503.12
Rate for Payer: Ohana Health Plan Medicaid	$4,503.12
Rate for Payer: UnitedHealthcare Medicaid	$4,503.12

NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE

Facility

$10,021.32

Service Code	APR-DRG 5804
Min. Negotiated Rate	$10,021.32
Max. Negotiated Rate	$10,021.32
Rate for Payer: AlohaCare Medicaid	$10,021.32
Rate for Payer: Hawaii Medical Service Association ABD	$10,021.32
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,021.32
Rate for Payer: Kaiser Permanente Medicaid	$10,021.32
Rate for Payer: Ohana Health Plan Medicaid	$10,021.32
Rate for Payer: UnitedHealthcare Medicaid	$10,021.32

NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE

Facility

$2,545.77

Service Code	APR-DRG 5801
Min. Negotiated Rate	$2,545.77
Max. Negotiated Rate	$2,545.77
Rate for Payer: AlohaCare Medicaid	$2,545.77
Rate for Payer: Hawaii Medical Service Association ABD	$2,545.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,545.77
Rate for Payer: Kaiser Permanente Medicaid	$2,545.77
Rate for Payer: Ohana Health Plan Medicaid	$2,545.77
Rate for Payer: UnitedHealthcare Medicaid	$2,545.77

NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE

Facility

$3,645.77

Service Code	APR-DRG 5802
Min. Negotiated Rate	$3,645.77
Max. Negotiated Rate	$3,645.77
Rate for Payer: AlohaCare Medicaid	$3,645.77
Rate for Payer: Hawaii Medical Service Association ABD	$3,645.77
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,645.77
Rate for Payer: Kaiser Permanente Medicaid	$3,645.77
Rate for Payer: Ohana Health Plan Medicaid	$3,645.77
Rate for Payer: UnitedHealthcare Medicaid	$3,645.77

NEONATE, TRANSFERRED <5 DAYS OLD, NOT BORN HERE

Facility

$5,750.73

Service Code	APR-DRG 5803
Min. Negotiated Rate	$5,750.73
Max. Negotiated Rate	$5,750.73
Rate for Payer: AlohaCare Medicaid	$5,750.73
Rate for Payer: Hawaii Medical Service Association ABD	$5,750.73
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,750.73
Rate for Payer: Kaiser Permanente Medicaid	$5,750.73
Rate for Payer: Ohana Health Plan Medicaid	$5,750.73
Rate for Payer: UnitedHealthcare Medicaid	$5,750.73

NEONATE W ECMO

Facility

$143,311.39

Service Code	APR-DRG 5833
Min. Negotiated Rate	$143,311.39
Max. Negotiated Rate	$143,311.39
Rate for Payer: AlohaCare Medicaid	$143,311.39
Rate for Payer: Hawaii Medical Service Association ABD	$143,311.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$143,311.39
Rate for Payer: Kaiser Permanente Medicaid	$143,311.39
Rate for Payer: Ohana Health Plan Medicaid	$143,311.39
Rate for Payer: UnitedHealthcare Medicaid	$143,311.39

NEONATE W ECMO

Facility

$235,228.11

Service Code	APR-DRG 5834
Min. Negotiated Rate	$235,228.11
Max. Negotiated Rate	$235,228.11
Rate for Payer: AlohaCare Medicaid	$235,228.11
Rate for Payer: Hawaii Medical Service Association ABD	$235,228.11
Rate for Payer: Hawaii Medical Service Association Non-ABD	$235,228.11
Rate for Payer: Kaiser Permanente Medicaid	$235,228.11
Rate for Payer: Ohana Health Plan Medicaid	$235,228.11
Rate for Payer: UnitedHealthcare Medicaid	$235,228.11

NEONATE W ECMO

Facility

$86,204.41

Service Code	APR-DRG 5831
Min. Negotiated Rate	$86,204.41
Max. Negotiated Rate	$86,204.41
Rate for Payer: AlohaCare Medicaid	$86,204.41
Rate for Payer: Hawaii Medical Service Association ABD	$86,204.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$86,204.41
Rate for Payer: Kaiser Permanente Medicaid	$86,204.41
Rate for Payer: Ohana Health Plan Medicaid	$86,204.41
Rate for Payer: UnitedHealthcare Medicaid	$86,204.41

NEONATE W ECMO

Facility

$136,122.97

Service Code	APR-DRG 5832
Min. Negotiated Rate	$136,122.97
Max. Negotiated Rate	$136,122.97
Rate for Payer: AlohaCare Medicaid	$136,122.97
Rate for Payer: Hawaii Medical Service Association ABD	$136,122.97
Rate for Payer: Hawaii Medical Service Association Non-ABD	$136,122.97
Rate for Payer: Kaiser Permanente Medicaid	$136,122.97
Rate for Payer: Ohana Health Plan Medicaid	$136,122.97
Rate for Payer: UnitedHealthcare Medicaid	$136,122.97

Know your out-of-pocket cost for care.

All Charges