Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION [127843]

Facility

$2,383.00

Service Code	HCPCS J9299
Hospital Revenue Code	636
Min. Negotiated Rate	$33.00
Max. Negotiated Rate	$2,311.51
Rate for Payer: AlohaCare Medicaid	$33.62
Rate for Payer: AlohaCare Medicare	$33.62
Rate for Payer: Cash Price	$1,429.80
Rate for Payer: Cash Price	$1,429.80
Rate for Payer: Devoted Health Medicare	$36.98
Rate for Payer: Hawaii Medical Service Association ABD	$33.00
Rate for Payer: Hawaii Medical Service Association Commercial	$42.02
Rate for Payer: Hawaii Medical Service Association Medicare	$33.62
Rate for Payer: Hawaii Medical Service Association Non-ABD	$33.00
Rate for Payer: Hawaii Western Management Group Commercial	$2,263.85
Rate for Payer: Health Management Network Commercial	$2,025.55
Rate for Payer: Humana Medicare	$33.62
Rate for Payer: Kaiser Permanente Commercial	$1,501.29
Rate for Payer: Kaiser Permanente Medicaid	$1,215.33
Rate for Payer: Kaiser Permanente Medicare	$33.62
Rate for Payer: MDX Hawaii PPO	$2,311.51
Rate for Payer: Ohana Health Plan Medicaid	$36.98
Rate for Payer: Ohana Health Plan Medicare	$33.62
Rate for Payer: UnitedHealthcare Medicaid	$1,429.80
Rate for Payer: UnitedHealthcare Medicare	$33.62
Rate for Payer: University Health Alliance Commercial	$1,736.97

NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC

Facility

$39,587.03

Service Code	MSDRG 098
Min. Negotiated Rate	$26,102.77
Max. Negotiated Rate	$39,587.03
Rate for Payer: AlohaCare Medicare	$26,102.77
Rate for Payer: Devoted Health Medicare	$28,713.05
Rate for Payer: Hawaii Medical Service Association Commercial	$38,437.34
Rate for Payer: Hawaii Medical Service Association Medicare	$26,102.77
Rate for Payer: Humana Medicare	$26,102.77
Rate for Payer: Kaiser Permanente Commercial	$39,587.03
Rate for Payer: Kaiser Permanente Medicare	$26,102.77
Rate for Payer: Ohana Health Plan Medicare	$26,102.77
Rate for Payer: UnitedHealthcare Medicare	$26,102.77

NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC

Facility

$62,303.55

Service Code	MSDRG 097
Min. Negotiated Rate	$38,437.34
Max. Negotiated Rate	$62,303.55
Rate for Payer: AlohaCare Medicare	$41,081.52
Rate for Payer: Devoted Health Medicare	$45,189.67
Rate for Payer: Hawaii Medical Service Association Commercial	$38,437.34
Rate for Payer: Hawaii Medical Service Association Medicare	$41,081.52
Rate for Payer: Humana Medicare	$41,081.52
Rate for Payer: Kaiser Permanente Commercial	$62,303.55
Rate for Payer: Kaiser Permanente Medicare	$41,081.52
Rate for Payer: Ohana Health Plan Medicare	$41,081.52
Rate for Payer: UnitedHealthcare Medicare	$41,081.52

NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC

Facility

$38,437.34

Service Code	MSDRG 099
Min. Negotiated Rate	$15,496.28
Max. Negotiated Rate	$38,437.34
Rate for Payer: AlohaCare Medicare	$15,496.28
Rate for Payer: Devoted Health Medicare	$17,045.91
Rate for Payer: Hawaii Medical Service Association Commercial	$38,437.34
Rate for Payer: Hawaii Medical Service Association Medicare	$15,496.28
Rate for Payer: Humana Medicare	$15,496.28
Rate for Payer: Kaiser Permanente Commercial	$23,501.40
Rate for Payer: Kaiser Permanente Medicare	$15,496.28
Rate for Payer: Ohana Health Plan Medicare	$15,496.28
Rate for Payer: UnitedHealthcare Medicare	$15,496.28

NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS

Facility

$3,432.93

Service Code	APR-DRG 0501
Min. Negotiated Rate	$3,432.93
Max. Negotiated Rate	$3,432.93
Rate for Payer: AlohaCare Medicaid	$3,432.93
Rate for Payer: Hawaii Medical Service Association ABD	$3,432.93
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,432.93
Rate for Payer: Kaiser Permanente Medicaid	$3,432.93
Rate for Payer: Ohana Health Plan Medicaid	$3,432.93
Rate for Payer: UnitedHealthcare Medicaid	$3,432.93

NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS

Facility

$6,199.89

Service Code	APR-DRG 0502
Min. Negotiated Rate	$6,199.89
Max. Negotiated Rate	$6,199.89
Rate for Payer: AlohaCare Medicaid	$6,199.89
Rate for Payer: Hawaii Medical Service Association ABD	$6,199.89
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,199.89
Rate for Payer: Kaiser Permanente Medicaid	$6,199.89
Rate for Payer: Ohana Health Plan Medicaid	$6,199.89
Rate for Payer: UnitedHealthcare Medicaid	$6,199.89

NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS

Facility

$9,887.87

Service Code	APR-DRG 0503
Min. Negotiated Rate	$9,887.87
Max. Negotiated Rate	$9,887.87
Rate for Payer: AlohaCare Medicaid	$9,887.87
Rate for Payer: Hawaii Medical Service Association ABD	$9,887.87
Rate for Payer: Hawaii Medical Service Association Non-ABD	$9,887.87
Rate for Payer: Kaiser Permanente Medicaid	$9,887.87
Rate for Payer: Ohana Health Plan Medicaid	$9,887.87
Rate for Payer: UnitedHealthcare Medicaid	$9,887.87

NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS

Facility

$20,014.47

Service Code	APR-DRG 0504
Min. Negotiated Rate	$20,014.47
Max. Negotiated Rate	$20,014.47
Rate for Payer: AlohaCare Medicaid	$20,014.47
Rate for Payer: Hawaii Medical Service Association ABD	$20,014.47
Rate for Payer: Hawaii Medical Service Association Non-ABD	$20,014.47
Rate for Payer: Kaiser Permanente Medicaid	$20,014.47
Rate for Payer: Ohana Health Plan Medicaid	$20,014.47
Rate for Payer: UnitedHealthcare Medicaid	$20,014.47

NON-EXTENSIVE BURNS

Facility

$35,535.00

Service Code	MSDRG 935
Min. Negotiated Rate	$23,430.97
Max. Negotiated Rate	$35,535.00
Rate for Payer: AlohaCare Medicare	$23,430.97
Rate for Payer: Devoted Health Medicare	$25,774.07
Rate for Payer: Hawaii Medical Service Association Medicare	$23,430.97
Rate for Payer: Humana Medicare	$23,430.97
Rate for Payer: Kaiser Permanente Commercial	$35,535.00
Rate for Payer: Kaiser Permanente Medicare	$23,430.97
Rate for Payer: Ohana Health Plan Medicare	$23,430.97
Rate for Payer: UnitedHealthcare Medicare	$23,430.97

NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$16,266.48

Service Code	APR-DRG 7944
Min. Negotiated Rate	$16,266.48
Max. Negotiated Rate	$16,266.48
Rate for Payer: AlohaCare Medicaid	$16,266.48
Rate for Payer: Hawaii Medical Service Association ABD	$16,266.48
Rate for Payer: Hawaii Medical Service Association Non-ABD	$16,266.48
Rate for Payer: Kaiser Permanente Medicaid	$16,266.48
Rate for Payer: Ohana Health Plan Medicaid	$16,266.48
Rate for Payer: UnitedHealthcare Medicaid	$16,266.48

NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$8,484.17

Service Code	APR-DRG 7943
Min. Negotiated Rate	$8,484.17
Max. Negotiated Rate	$8,484.17
Rate for Payer: AlohaCare Medicaid	$8,484.17
Rate for Payer: Hawaii Medical Service Association ABD	$8,484.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,484.17
Rate for Payer: Kaiser Permanente Medicaid	$8,484.17
Rate for Payer: Ohana Health Plan Medicaid	$8,484.17
Rate for Payer: UnitedHealthcare Medicaid	$8,484.17

NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$5,647.41

Service Code	APR-DRG 7942
Min. Negotiated Rate	$5,647.41
Max. Negotiated Rate	$5,647.41
Rate for Payer: AlohaCare Medicaid	$5,647.41
Rate for Payer: Hawaii Medical Service Association ABD	$5,647.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$5,647.41
Rate for Payer: Kaiser Permanente Medicaid	$5,647.41
Rate for Payer: Ohana Health Plan Medicaid	$5,647.41
Rate for Payer: UnitedHealthcare Medicaid	$5,647.41

NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$4,277.63

Service Code	APR-DRG 7941
Min. Negotiated Rate	$4,277.63
Max. Negotiated Rate	$4,277.63
Rate for Payer: AlohaCare Medicaid	$4,277.63
Rate for Payer: Hawaii Medical Service Association ABD	$4,277.63
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,277.63
Rate for Payer: Kaiser Permanente Medicaid	$4,277.63
Rate for Payer: Ohana Health Plan Medicaid	$4,277.63
Rate for Payer: UnitedHealthcare Medicaid	$4,277.63

NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC

Facility

$38,922.66

Service Code	MSDRG 988
Min. Negotiated Rate	$18,694.72
Max. Negotiated Rate	$38,922.66
Rate for Payer: AlohaCare Medicare	$18,694.72
Rate for Payer: Devoted Health Medicare	$20,564.19
Rate for Payer: Hawaii Medical Service Association Commercial	$38,922.66
Rate for Payer: Hawaii Medical Service Association Medicare	$18,694.72
Rate for Payer: Humana Medicare	$18,694.72
Rate for Payer: Kaiser Permanente Commercial	$28,352.10
Rate for Payer: Kaiser Permanente Medicare	$18,694.72
Rate for Payer: Ohana Health Plan Medicare	$18,694.72
Rate for Payer: UnitedHealthcare Medicare	$18,694.72

NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$59,139.90

Service Code	MSDRG 987
Min. Negotiated Rate	$38,922.66
Max. Negotiated Rate	$59,139.90
Rate for Payer: AlohaCare Medicare	$38,995.50
Rate for Payer: Devoted Health Medicare	$42,895.05
Rate for Payer: Hawaii Medical Service Association Commercial	$38,922.66
Rate for Payer: Hawaii Medical Service Association Medicare	$38,995.50
Rate for Payer: Humana Medicare	$38,995.50
Rate for Payer: Kaiser Permanente Commercial	$59,139.90
Rate for Payer: Kaiser Permanente Medicare	$38,995.50
Rate for Payer: Ohana Health Plan Medicare	$38,995.50
Rate for Payer: UnitedHealthcare Medicare	$38,995.50

NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$38,922.66

Service Code	MSDRG 989
Min. Negotiated Rate	$13,640.00
Max. Negotiated Rate	$38,922.66
Rate for Payer: AlohaCare Medicare	$13,640.00
Rate for Payer: Devoted Health Medicare	$15,004.00
Rate for Payer: Hawaii Medical Service Association Commercial	$38,922.66
Rate for Payer: Hawaii Medical Service Association Medicare	$13,640.00
Rate for Payer: Humana Medicare	$13,640.00
Rate for Payer: Kaiser Permanente Commercial	$20,686.20
Rate for Payer: Kaiser Permanente Medicare	$13,640.00
Rate for Payer: Ohana Health Plan Medicare	$13,640.00
Rate for Payer: UnitedHealthcare Medicare	$13,640.00

NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$6,649.96

Service Code	APR-DRG 9522
Min. Negotiated Rate	$6,649.96
Max. Negotiated Rate	$6,649.96
Rate for Payer: AlohaCare Medicaid	$6,649.96
Rate for Payer: Hawaii Medical Service Association ABD	$6,649.96
Rate for Payer: Hawaii Medical Service Association Non-ABD	$6,649.96
Rate for Payer: Kaiser Permanente Medicaid	$6,649.96
Rate for Payer: Ohana Health Plan Medicaid	$6,649.96
Rate for Payer: UnitedHealthcare Medicaid	$6,649.96

NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$10,437.74

Service Code	APR-DRG 9523
Min. Negotiated Rate	$10,437.74
Max. Negotiated Rate	$10,437.74
Rate for Payer: AlohaCare Medicaid	$10,437.74
Rate for Payer: Hawaii Medical Service Association ABD	$10,437.74
Rate for Payer: Hawaii Medical Service Association Non-ABD	$10,437.74
Rate for Payer: Kaiser Permanente Medicaid	$10,437.74
Rate for Payer: Ohana Health Plan Medicaid	$10,437.74
Rate for Payer: UnitedHealthcare Medicaid	$10,437.74

NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$19,781.60

Service Code	APR-DRG 9524
Min. Negotiated Rate	$19,781.60
Max. Negotiated Rate	$19,781.60
Rate for Payer: AlohaCare Medicaid	$19,781.60
Rate for Payer: Hawaii Medical Service Association ABD	$19,781.60
Rate for Payer: Hawaii Medical Service Association Non-ABD	$19,781.60
Rate for Payer: Kaiser Permanente Medicaid	$19,781.60
Rate for Payer: Ohana Health Plan Medicaid	$19,781.60
Rate for Payer: UnitedHealthcare Medicaid	$19,781.60

NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$4,815.76

Service Code	APR-DRG 9521
Min. Negotiated Rate	$4,815.76
Max. Negotiated Rate	$4,815.76
Rate for Payer: AlohaCare Medicaid	$4,815.76
Rate for Payer: Hawaii Medical Service Association ABD	$4,815.76
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,815.76
Rate for Payer: Kaiser Permanente Medicaid	$4,815.76
Rate for Payer: Ohana Health Plan Medicaid	$4,815.76
Rate for Payer: UnitedHealthcare Medicaid	$4,815.76

NON-HYPOVOLEMIC SODIUM DISORDERS

Facility

$2,472.78

Service Code	APR-DRG 4261
Min. Negotiated Rate	$2,472.78
Max. Negotiated Rate	$2,472.78
Rate for Payer: AlohaCare Medicaid	$2,472.78
Rate for Payer: Hawaii Medical Service Association ABD	$2,472.78
Rate for Payer: Hawaii Medical Service Association Non-ABD	$2,472.78
Rate for Payer: Kaiser Permanente Medicaid	$2,472.78
Rate for Payer: Ohana Health Plan Medicaid	$2,472.78
Rate for Payer: UnitedHealthcare Medicaid	$2,472.78

NON-HYPOVOLEMIC SODIUM DISORDERS

Facility

$4,613.56

Service Code	APR-DRG 4263
Min. Negotiated Rate	$4,613.56
Max. Negotiated Rate	$4,613.56
Rate for Payer: AlohaCare Medicaid	$4,613.56
Rate for Payer: Hawaii Medical Service Association ABD	$4,613.56
Rate for Payer: Hawaii Medical Service Association Non-ABD	$4,613.56
Rate for Payer: Kaiser Permanente Medicaid	$4,613.56
Rate for Payer: Ohana Health Plan Medicaid	$4,613.56
Rate for Payer: UnitedHealthcare Medicaid	$4,613.56

NON-HYPOVOLEMIC SODIUM DISORDERS

Facility

$3,200.07

Service Code	APR-DRG 4262
Min. Negotiated Rate	$3,200.07
Max. Negotiated Rate	$3,200.07
Rate for Payer: AlohaCare Medicaid	$3,200.07
Rate for Payer: Hawaii Medical Service Association ABD	$3,200.07
Rate for Payer: Hawaii Medical Service Association Non-ABD	$3,200.07
Rate for Payer: Kaiser Permanente Medicaid	$3,200.07
Rate for Payer: Ohana Health Plan Medicaid	$3,200.07
Rate for Payer: UnitedHealthcare Medicaid	$3,200.07

NON-HYPOVOLEMIC SODIUM DISORDERS

Facility

$8,451.55

Service Code	APR-DRG 4264
Min. Negotiated Rate	$8,451.55
Max. Negotiated Rate	$8,451.55
Rate for Payer: AlohaCare Medicaid	$8,451.55
Rate for Payer: Hawaii Medical Service Association ABD	$8,451.55
Rate for Payer: Hawaii Medical Service Association Non-ABD	$8,451.55
Rate for Payer: Kaiser Permanente Medicaid	$8,451.55
Rate for Payer: Ohana Health Plan Medicaid	$8,451.55
Rate for Payer: UnitedHealthcare Medicaid	$8,451.55

NON-MALIGNANT BREAST DISORDERS WITH CC/MCC

Facility

$17,967.60

Service Code	MSDRG 600
Min. Negotiated Rate	$11,847.42
Max. Negotiated Rate	$17,967.60
Rate for Payer: AlohaCare Medicare	$11,847.42
Rate for Payer: Devoted Health Medicare	$13,032.16
Rate for Payer: Hawaii Medical Service Association Commercial	$16,379.55
Rate for Payer: Hawaii Medical Service Association Medicare	$11,847.42
Rate for Payer: Humana Medicare	$11,847.42
Rate for Payer: Kaiser Permanente Commercial	$17,967.60
Rate for Payer: Kaiser Permanente Medicare	$11,847.42
Rate for Payer: Ohana Health Plan Medicare	$11,847.42
Rate for Payer: UnitedHealthcare Medicare	$11,847.42

Know your out-of-pocket cost for care.

All Charges