Hilo Benioff Medical Center

All Charges

Charge

Type

Setting

Price

IOLENS DIOP 9.5 SN6AT5 9.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS DIOP 9.5 SN6AT5 9.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS TORICE 27.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$970.48
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IOLENS TORICE 27.5

Facility

$1,733.00

Service Code	HCPCS V2787
Hospital Revenue Code	276
Min. Negotiated Rate	$883.83
Max. Negotiated Rate	$1,681.01
Rate for Payer: Cash Price	$1,039.80
Rate for Payer: Hawaii Western Management Group Commercial	$1,213.10
Rate for Payer: Health Management Network Commercial	$1,473.05
Rate for Payer: Kaiser Permanente Commercial	$1,091.79
Rate for Payer: Kaiser Permanente Medicaid	$883.83
Rate for Payer: MDX Hawaii PPO	$1,681.01
Rate for Payer: University Health Alliance Commercial	$970.48

IPERIA PROMRI 7DR-T 392409

Facility

$41,580.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$21,205.80
Max. Negotiated Rate	$40,332.60
Rate for Payer: Cash Price	$24,948.00
Rate for Payer: Hawaii Western Management Group Commercial	$29,106.00
Rate for Payer: Health Management Network Commercial	$35,343.00
Rate for Payer: Kaiser Permanente Commercial	$26,195.40
Rate for Payer: Kaiser Permanente Medicaid	$21,205.80
Rate for Payer: MDX Hawaii PPO	$40,332.60
Rate for Payer: University Health Alliance Commercial	$23,284.80

IPERIA PROMRI 7DR-T 392409

Facility

$41,580.00

Service Code	HCPCS C1721
Hospital Revenue Code	275
Min. Negotiated Rate	$23,284.80
Max. Negotiated Rate	$40,332.60
Rate for Payer: Cash Price	$24,948.00
Rate for Payer: Hawaii Western Management Group Commercial	$29,106.00
Rate for Payer: Health Management Network Commercial	$35,343.00
Rate for Payer: MDX Hawaii PPO	$40,332.60
Rate for Payer: University Health Alliance Commercial	$23,284.80

IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION [108956]

Facility

$28,534.00

Service Code	HCPCS J9228
Hospital Revenue Code	250
Min. Negotiated Rate	$24,253.90
Max. Negotiated Rate	$27,677.98
Rate for Payer: Cash Price	$17,120.40
Rate for Payer: Cash Price	$26,377.80
Rate for Payer: Health Management Network Commercial	$24,253.90
Rate for Payer: Health Management Network Commercial	$37,368.55
Rate for Payer: MDX Hawaii PPO	$27,677.98
Rate for Payer: MDX Hawaii PPO	$42,644.11

IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION [108956]

Facility

$43,963.00

Service Code	HCPCS J9228
Hospital Revenue Code	636
Min. Negotiated Rate	$183.41
Max. Negotiated Rate	$42,644.11
Rate for Payer: AlohaCare Medicaid	$187.17
Rate for Payer: AlohaCare Medicaid	$187.17
Rate for Payer: AlohaCare Medicare	$187.17
Rate for Payer: AlohaCare Medicare	$187.17
Rate for Payer: Cash Price	$26,377.80
Rate for Payer: Cash Price	$26,377.80
Rate for Payer: Cash Price	$17,120.40
Rate for Payer: Cash Price	$17,120.40
Rate for Payer: Devoted Health Medicare	$205.89
Rate for Payer: Devoted Health Medicare	$205.89
Rate for Payer: Hawaii Medical Service Association ABD	$183.41
Rate for Payer: Hawaii Medical Service Association ABD	$183.41
Rate for Payer: Hawaii Medical Service Association Commercial	$233.96
Rate for Payer: Hawaii Medical Service Association Commercial	$233.96
Rate for Payer: Hawaii Medical Service Association Medicare	$187.17
Rate for Payer: Hawaii Medical Service Association Medicare	$187.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$183.41
Rate for Payer: Hawaii Medical Service Association Non-ABD	$183.41
Rate for Payer: Hawaii Western Management Group Commercial	$27,107.30
Rate for Payer: Hawaii Western Management Group Commercial	$41,764.85
Rate for Payer: Health Management Network Commercial	$24,253.90
Rate for Payer: Health Management Network Commercial	$37,368.55
Rate for Payer: Humana Medicare	$187.17
Rate for Payer: Humana Medicare	$187.17
Rate for Payer: Kaiser Permanente Commercial	$17,976.42
Rate for Payer: Kaiser Permanente Commercial	$27,696.69
Rate for Payer: Kaiser Permanente Medicaid	$22,421.13
Rate for Payer: Kaiser Permanente Medicaid	$14,552.34
Rate for Payer: Kaiser Permanente Medicare	$187.17
Rate for Payer: Kaiser Permanente Medicare	$187.17
Rate for Payer: MDX Hawaii PPO	$42,644.11
Rate for Payer: MDX Hawaii PPO	$27,677.98
Rate for Payer: Ohana Health Plan Medicaid	$205.89
Rate for Payer: Ohana Health Plan Medicaid	$205.89
Rate for Payer: Ohana Health Plan Medicare	$187.17
Rate for Payer: Ohana Health Plan Medicare	$187.17
Rate for Payer: UnitedHealthcare Medicaid	$26,377.80
Rate for Payer: UnitedHealthcare Medicaid	$17,120.40
Rate for Payer: UnitedHealthcare Medicare	$187.17
Rate for Payer: UnitedHealthcare Medicare	$187.17
Rate for Payer: University Health Alliance Commercial	$32,044.63
Rate for Payer: University Health Alliance Commercial	$20,798.43

IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [108955]

Facility

$11,366.00

Service Code	HCPCS J9228
Hospital Revenue Code	636
Min. Negotiated Rate	$183.41
Max. Negotiated Rate	$11,025.02
Rate for Payer: AlohaCare Medicaid	$187.17
Rate for Payer: AlohaCare Medicare	$187.17
Rate for Payer: Cash Price	$6,819.60
Rate for Payer: Cash Price	$6,819.60
Rate for Payer: Devoted Health Medicare	$205.89
Rate for Payer: Hawaii Medical Service Association ABD	$183.41
Rate for Payer: Hawaii Medical Service Association Commercial	$233.96
Rate for Payer: Hawaii Medical Service Association Medicare	$187.17
Rate for Payer: Hawaii Medical Service Association Non-ABD	$183.41
Rate for Payer: Hawaii Western Management Group Commercial	$10,797.70
Rate for Payer: Health Management Network Commercial	$9,661.10
Rate for Payer: Humana Medicare	$187.17
Rate for Payer: Kaiser Permanente Commercial	$7,160.58
Rate for Payer: Kaiser Permanente Medicaid	$5,796.66
Rate for Payer: Kaiser Permanente Medicare	$187.17
Rate for Payer: MDX Hawaii PPO	$11,025.02
Rate for Payer: Ohana Health Plan Medicaid	$205.89
Rate for Payer: Ohana Health Plan Medicare	$187.17
Rate for Payer: UnitedHealthcare Medicaid	$6,819.60
Rate for Payer: UnitedHealthcare Medicare	$187.17
Rate for Payer: University Health Alliance Commercial	$8,284.68

IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION [108955]

Facility

$11,366.00

Service Code	HCPCS J9228
Hospital Revenue Code	250
Min. Negotiated Rate	$9,661.10
Max. Negotiated Rate	$11,025.02
Rate for Payer: Cash Price	$6,819.60
Rate for Payer: Health Management Network Commercial	$9,661.10
Rate for Payer: MDX Hawaii PPO	$11,025.02

IPRATROPIUM-ALBUTEROL 0.5-3 MG/3ML IN SOLN [93931]

Facility

$9.00

Service Code	HCPCS J7620
Hospital Revenue Code	250
Min. Negotiated Rate	$7.65
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: MDX Hawaii PPO	$8.73

IPRATROPIUM-ALBUTEROL 0.5-3 MG/3ML IN SOLN [93931]

Facility

$8.00

Service Code	HCPCS J7620
Hospital Revenue Code	636
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$7.76
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$4.80
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$5.40
Rate for Payer: Hawaii Medical Service Association ABD	$0.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.20
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.20
Rate for Payer: Hawaii Western Management Group Commercial	$7.60
Rate for Payer: Hawaii Western Management Group Commercial	$8.55
Rate for Payer: Health Management Network Commercial	$7.65
Rate for Payer: Health Management Network Commercial	$6.80
Rate for Payer: Kaiser Permanente Commercial	$5.67
Rate for Payer: Kaiser Permanente Commercial	$5.04
Rate for Payer: Kaiser Permanente Medicaid	$4.08
Rate for Payer: Kaiser Permanente Medicaid	$4.59
Rate for Payer: MDX Hawaii PPO	$8.73
Rate for Payer: MDX Hawaii PPO	$7.76
Rate for Payer: UnitedHealthcare Medicaid	$4.80
Rate for Payer: UnitedHealthcare Medicaid	$5.40
Rate for Payer: University Health Alliance Commercial	$6.56
Rate for Payer: University Health Alliance Commercial	$5.83

IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]

Facility

$2.00

Service Code	HCPCS J7644
Hospital Revenue Code	250
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: MDX Hawaii PPO	$1.94

IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION [12580]

Facility

$2.00

Service Code	HCPCS J7644
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.20
Rate for Payer: Cash Price	$1.20
Rate for Payer: Hawaii Medical Service Association ABD	$0.39
Rate for Payer: Hawaii Medical Service Association Non-ABD	$0.39
Rate for Payer: Hawaii Western Management Group Commercial	$1.90
Rate for Payer: Health Management Network Commercial	$1.70
Rate for Payer: Kaiser Permanente Commercial	$1.26
Rate for Payer: Kaiser Permanente Medicaid	$1.02
Rate for Payer: MDX Hawaii PPO	$1.94
Rate for Payer: UnitedHealthcare Medicaid	$1.20
Rate for Payer: University Health Alliance Commercial	$1.46

IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER [41142]

Facility

$921.00

Service Code	NDC 00597008717
Hospital Revenue Code	250
Min. Negotiated Rate	$782.85
Max. Negotiated Rate	$893.37
Rate for Payer: Cash Price	$552.60
Rate for Payer: Health Management Network Commercial	$782.85
Rate for Payer: MDX Hawaii PPO	$893.37

IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER [41142]

Facility

$921.00

Service Code	NDC 00597008717
Hospital Revenue Code	637
Min. Negotiated Rate	$469.71
Max. Negotiated Rate	$893.37
Rate for Payer: Cash Price	$552.60
Rate for Payer: Hawaii Western Management Group Commercial	$874.95
Rate for Payer: Health Management Network Commercial	$782.85
Rate for Payer: Kaiser Permanente Commercial	$580.23
Rate for Payer: Kaiser Permanente Medicaid	$469.71
Rate for Payer: MDX Hawaii PPO	$893.37
Rate for Payer: University Health Alliance Commercial	$671.32

IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION [91054]

Facility

$330.00

Service Code	HCPCS J9206
Hospital Revenue Code	250
Min. Negotiated Rate	$280.50
Max. Negotiated Rate	$320.10
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cash Price	$89.40
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Health Management Network Commercial	$280.50
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: MDX Hawaii PPO	$320.10

IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION [91054]

Facility

$149.00

Service Code	HCPCS J9206
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$144.53
Rate for Payer: Cash Price	$89.40
Rate for Payer: Cash Price	$89.40
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Hawaii Medical Service Association ABD	$1.40
Rate for Payer: Hawaii Medical Service Association ABD	$1.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.40
Rate for Payer: Hawaii Western Management Group Commercial	$141.55
Rate for Payer: Hawaii Western Management Group Commercial	$313.50
Rate for Payer: Health Management Network Commercial	$280.50
Rate for Payer: Health Management Network Commercial	$126.65
Rate for Payer: Kaiser Permanente Commercial	$207.90
Rate for Payer: Kaiser Permanente Commercial	$93.87
Rate for Payer: Kaiser Permanente Medicaid	$75.99
Rate for Payer: Kaiser Permanente Medicaid	$168.30
Rate for Payer: MDX Hawaii PPO	$320.10
Rate for Payer: MDX Hawaii PPO	$144.53
Rate for Payer: UnitedHealthcare Medicaid	$89.40
Rate for Payer: UnitedHealthcare Medicaid	$198.00
Rate for Payer: University Health Alliance Commercial	$240.54
Rate for Payer: University Health Alliance Commercial	$108.61

IRINOTECAN 300 MG/15 ML INTRAVENOUS SOLUTION [108138]

Facility

$410.00

Service Code	HCPCS J9206
Hospital Revenue Code	250
Min. Negotiated Rate	$348.50
Max. Negotiated Rate	$397.70
Rate for Payer: Cash Price	$246.00
Rate for Payer: Health Management Network Commercial	$348.50
Rate for Payer: MDX Hawaii PPO	$397.70

IRINOTECAN 300 MG/15 ML INTRAVENOUS SOLUTION [108138]

Facility

$410.00

Service Code	HCPCS J9206
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$397.70
Rate for Payer: Cash Price	$246.00
Rate for Payer: Cash Price	$246.00
Rate for Payer: Hawaii Medical Service Association ABD	$1.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.40
Rate for Payer: Hawaii Western Management Group Commercial	$389.50
Rate for Payer: Health Management Network Commercial	$348.50
Rate for Payer: Kaiser Permanente Commercial	$258.30
Rate for Payer: Kaiser Permanente Medicaid	$209.10
Rate for Payer: MDX Hawaii PPO	$397.70
Rate for Payer: UnitedHealthcare Medicaid	$246.00
Rate for Payer: University Health Alliance Commercial	$298.85

IRINOTECAN 40 MG/2 ML INTRAVENOUS SOLUTION [91055]

Facility

$32.00

Service Code	HCPCS J9206
Hospital Revenue Code	636
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.80
Rate for Payer: Cash Price	$31.80
Rate for Payer: Cash Price	$49.80
Rate for Payer: Cash Price	$49.80
Rate for Payer: Hawaii Medical Service Association ABD	$1.40
Rate for Payer: Hawaii Medical Service Association ABD	$1.40
Rate for Payer: Hawaii Medical Service Association ABD	$1.40
Rate for Payer: Hawaii Medical Service Association ABD	$1.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.40
Rate for Payer: Hawaii Medical Service Association Non-ABD	$1.40
Rate for Payer: Hawaii Western Management Group Commercial	$30.40
Rate for Payer: Hawaii Western Management Group Commercial	$49.40
Rate for Payer: Hawaii Western Management Group Commercial	$50.35
Rate for Payer: Hawaii Western Management Group Commercial	$78.85
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Kaiser Permanente Commercial	$33.39
Rate for Payer: Kaiser Permanente Commercial	$32.76
Rate for Payer: Kaiser Permanente Commercial	$20.16
Rate for Payer: Kaiser Permanente Commercial	$52.29
Rate for Payer: Kaiser Permanente Medicaid	$26.52
Rate for Payer: Kaiser Permanente Medicaid	$16.32
Rate for Payer: Kaiser Permanente Medicaid	$27.03
Rate for Payer: Kaiser Permanente Medicaid	$42.33
Rate for Payer: MDX Hawaii PPO	$51.41
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: MDX Hawaii PPO	$50.44
Rate for Payer: MDX Hawaii PPO	$31.04
Rate for Payer: UnitedHealthcare Medicaid	$19.20
Rate for Payer: UnitedHealthcare Medicaid	$31.20
Rate for Payer: UnitedHealthcare Medicaid	$31.80
Rate for Payer: UnitedHealthcare Medicaid	$49.80
Rate for Payer: University Health Alliance Commercial	$23.32
Rate for Payer: University Health Alliance Commercial	$37.90
Rate for Payer: University Health Alliance Commercial	$60.50
Rate for Payer: University Health Alliance Commercial	$38.63

IRINOTECAN 40 MG/2 ML INTRAVENOUS SOLUTION [91055]

Facility

$32.00

Service Code	HCPCS J9206
Hospital Revenue Code	250
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.80
Rate for Payer: Cash Price	$49.80
Rate for Payer: Health Management Network Commercial	$70.55
Rate for Payer: Health Management Network Commercial	$27.20
Rate for Payer: Health Management Network Commercial	$45.05
Rate for Payer: Health Management Network Commercial	$44.20
Rate for Payer: MDX Hawaii PPO	$80.51
Rate for Payer: MDX Hawaii PPO	$50.44
Rate for Payer: MDX Hawaii PPO	$51.41
Rate for Payer: MDX Hawaii PPO	$31.04

IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS [130463]

Facility

$5,496.00

Service Code	HCPCS J9205
Hospital Revenue Code	636
Min. Negotiated Rate	$65.26
Max. Negotiated Rate	$5,331.12
Rate for Payer: AlohaCare Medicaid	$66.37
Rate for Payer: AlohaCare Medicaid	$66.37
Rate for Payer: AlohaCare Medicare	$66.37
Rate for Payer: AlohaCare Medicare	$66.37
Rate for Payer: Cash Price	$3,297.60
Rate for Payer: Cash Price	$3,297.60
Rate for Payer: Cash Price	$7,944.60
Rate for Payer: Cash Price	$7,944.60
Rate for Payer: Devoted Health Medicare	$73.01
Rate for Payer: Devoted Health Medicare	$73.01
Rate for Payer: Hawaii Medical Service Association ABD	$65.26
Rate for Payer: Hawaii Medical Service Association ABD	$65.26
Rate for Payer: Hawaii Medical Service Association Commercial	$82.96
Rate for Payer: Hawaii Medical Service Association Commercial	$82.96
Rate for Payer: Hawaii Medical Service Association Medicare	$66.37
Rate for Payer: Hawaii Medical Service Association Medicare	$66.37
Rate for Payer: Hawaii Medical Service Association Non-ABD	$65.26
Rate for Payer: Hawaii Medical Service Association Non-ABD	$65.26
Rate for Payer: Hawaii Western Management Group Commercial	$12,578.95
Rate for Payer: Hawaii Western Management Group Commercial	$5,221.20
Rate for Payer: Health Management Network Commercial	$11,254.85
Rate for Payer: Health Management Network Commercial	$4,671.60
Rate for Payer: Humana Medicare	$66.37
Rate for Payer: Humana Medicare	$66.37
Rate for Payer: Kaiser Permanente Commercial	$8,341.83
Rate for Payer: Kaiser Permanente Commercial	$3,462.48
Rate for Payer: Kaiser Permanente Medicaid	$2,802.96
Rate for Payer: Kaiser Permanente Medicaid	$6,752.91
Rate for Payer: Kaiser Permanente Medicare	$66.37
Rate for Payer: Kaiser Permanente Medicare	$66.37
Rate for Payer: MDX Hawaii PPO	$5,331.12
Rate for Payer: MDX Hawaii PPO	$12,843.77
Rate for Payer: Ohana Health Plan Medicaid	$73.01
Rate for Payer: Ohana Health Plan Medicaid	$73.01
Rate for Payer: Ohana Health Plan Medicare	$66.37
Rate for Payer: Ohana Health Plan Medicare	$66.37
Rate for Payer: UnitedHealthcare Medicaid	$3,297.60
Rate for Payer: UnitedHealthcare Medicaid	$7,944.60
Rate for Payer: UnitedHealthcare Medicare	$66.37
Rate for Payer: UnitedHealthcare Medicare	$66.37
Rate for Payer: University Health Alliance Commercial	$4,006.03
Rate for Payer: University Health Alliance Commercial	$9,651.36

IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS [130463]

Facility

$13,241.00

Service Code	HCPCS J9205
Hospital Revenue Code	250
Min. Negotiated Rate	$11,254.85
Max. Negotiated Rate	$12,843.77
Rate for Payer: Cash Price	$7,944.60
Rate for Payer: Cash Price	$3,297.60
Rate for Payer: Health Management Network Commercial	$11,254.85
Rate for Payer: Health Management Network Commercial	$4,671.60
Rate for Payer: MDX Hawaii PPO	$12,843.77
Rate for Payer: MDX Hawaii PPO	$5,331.12

IRON DEXTRAN 50 MG/ML INJECTION SOLUTION [3990]

Facility

$112.00

Service Code	HCPCS J1750
Hospital Revenue Code	250
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$108.64
Rate for Payer: Cash Price	$67.20
Rate for Payer: Health Management Network Commercial	$95.20
Rate for Payer: MDX Hawaii PPO	$108.64

Know your out-of-pocket cost for care.

All Charges