Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

levothyroxine 88 mcg (0.088 mg) Tab [VDMC]

Facility

$1.40

Service Code	HCPCS A9270
Hospital Charge Code	10400603
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of IA Commercial	$1.26
Rate for Payer: Aetna of IA Medical Rental Products	$1.26
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.26

lidocaine 0.5% 50 ml PF SDV [VDMC]

Facility

$27.93

Service Code	HCPCS J2003
Hospital Charge Code	10430842
Hospital Revenue Code	259
Min. Negotiated Rate	$12.57
Max. Negotiated Rate	$25.14
Rate for Payer: Aetna of IA Commercial	$25.14
Rate for Payer: Aetna of IA Medical Rental Products	$25.14
Rate for Payer: Aetna of IA Medicare	$15.92
Rate for Payer: Amerigroup Medicaid	$16.11
Rate for Payer: Amerigroup Medicare	$12.70
Rate for Payer: Cash Price	$22.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.57
Rate for Payer: Iowa Total Care Managed Medicaid	$15.95
Rate for Payer: Medical Associates Commercial	$20.95
Rate for Payer: Medical Associates Managed Medicare	$12.57
Rate for Payer: Midlands Choice Commercial	$19.55
Rate for Payer: Molina Healthcare Managed Medicaid	$16.19
Rate for Payer: Partners Health Alliance Commercial	$14.45
Rate for Payer: United Healthcare Commercial	$25.14
Rate for Payer: United Healthcare Managed Medicare	$16.48

lidocaine 0.5% 50 ml PF SDV [VDMC]

Facility

$27.93

Service Code	HCPCS J2003
Hospital Charge Code	10430842
Hospital Revenue Code	259
Min. Negotiated Rate	$19.55
Max. Negotiated Rate	$25.14
Rate for Payer: Aetna of IA Commercial	$25.14
Rate for Payer: Aetna of IA Medical Rental Products	$25.14
Rate for Payer: Cash Price	$22.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.95
Rate for Payer: Medical Associates Commercial	$20.95
Rate for Payer: Midlands Choice Commercial	$19.55
Rate for Payer: United Healthcare Commercial	$25.14

lidocaine 1% 10 ml MDV [VDMC]

Facility

$29.79

Service Code	HCPCS J2003
Hospital Charge Code	13648301
Hospital Revenue Code	259
Min. Negotiated Rate	$13.40
Max. Negotiated Rate	$26.81
Rate for Payer: Aetna of IA Commercial	$26.81
Rate for Payer: Aetna of IA Medical Rental Products	$26.81
Rate for Payer: Aetna of IA Medicare	$16.98
Rate for Payer: Amerigroup Medicaid	$17.18
Rate for Payer: Amerigroup Medicare	$13.54
Rate for Payer: Cash Price	$23.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.34
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.40
Rate for Payer: Iowa Total Care Managed Medicaid	$17.01
Rate for Payer: Medical Associates Commercial	$22.34
Rate for Payer: Medical Associates Managed Medicare	$13.40
Rate for Payer: Midlands Choice Commercial	$20.85
Rate for Payer: Molina Healthcare Managed Medicaid	$17.26
Rate for Payer: Partners Health Alliance Commercial	$15.41
Rate for Payer: United Healthcare Commercial	$26.81
Rate for Payer: United Healthcare Managed Medicare	$17.57

lidocaine 1% 10 ml MDV [VDMC]

Facility

$29.79

Service Code	HCPCS J2003
Hospital Charge Code	13648301
Hospital Revenue Code	259
Min. Negotiated Rate	$20.85
Max. Negotiated Rate	$26.81
Rate for Payer: Aetna of IA Commercial	$26.81
Rate for Payer: Aetna of IA Medical Rental Products	$26.81
Rate for Payer: Cash Price	$23.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.34
Rate for Payer: Medical Associates Commercial	$22.34
Rate for Payer: Midlands Choice Commercial	$20.85
Rate for Payer: United Healthcare Commercial	$26.81

lidocaine 1% 200mg/20ml MDV 20ml [VDMC]

Facility

$25.84

Service Code	HCPCS J2003
Hospital Charge Code	10441819
Hospital Revenue Code	259
Min. Negotiated Rate	$11.63
Max. Negotiated Rate	$23.25
Rate for Payer: Aetna of IA Commercial	$23.25
Rate for Payer: Aetna of IA Medical Rental Products	$23.25
Rate for Payer: Aetna of IA Medicare	$14.73
Rate for Payer: Amerigroup Medicaid	$14.90
Rate for Payer: Amerigroup Medicare	$11.74
Rate for Payer: Cash Price	$20.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.38
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.63
Rate for Payer: Iowa Total Care Managed Medicaid	$14.76
Rate for Payer: Medical Associates Commercial	$19.38
Rate for Payer: Medical Associates Managed Medicare	$11.63
Rate for Payer: Midlands Choice Commercial	$18.08
Rate for Payer: Molina Healthcare Managed Medicaid	$14.97
Rate for Payer: Partners Health Alliance Commercial	$13.37
Rate for Payer: United Healthcare Commercial	$23.25
Rate for Payer: United Healthcare Managed Medicare	$15.24

lidocaine 1% 200mg/20ml MDV 20ml [VDMC]

Facility

$25.84

Service Code	HCPCS J2003
Hospital Charge Code	10441819
Hospital Revenue Code	259
Min. Negotiated Rate	$18.08
Max. Negotiated Rate	$23.25
Rate for Payer: Aetna of IA Commercial	$23.25
Rate for Payer: Aetna of IA Medical Rental Products	$23.25
Rate for Payer: Cash Price	$20.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.38
Rate for Payer: Medical Associates Commercial	$19.38
Rate for Payer: Midlands Choice Commercial	$18.08
Rate for Payer: United Healthcare Commercial	$23.25

lidocaine 1% 20mg/2 mL PF SDV [VDMC]

Facility

$28.68

Service Code	HCPCS J2003
Hospital Charge Code	10430909
Hospital Revenue Code	259
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$25.81
Rate for Payer: Aetna of IA Commercial	$25.81
Rate for Payer: Aetna of IA Medical Rental Products	$25.81
Rate for Payer: Aetna of IA Medicare	$16.35
Rate for Payer: Amerigroup Medicaid	$16.54
Rate for Payer: Amerigroup Medicare	$13.04
Rate for Payer: Cash Price	$22.95
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.51
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.91
Rate for Payer: Iowa Total Care Managed Medicaid	$16.38
Rate for Payer: Medical Associates Commercial	$21.51
Rate for Payer: Medical Associates Managed Medicare	$12.91
Rate for Payer: Midlands Choice Commercial	$20.08
Rate for Payer: Molina Healthcare Managed Medicaid	$16.62
Rate for Payer: Partners Health Alliance Commercial	$14.84
Rate for Payer: United Healthcare Commercial	$25.81
Rate for Payer: United Healthcare Managed Medicare	$16.92

lidocaine 1% 20mg/2 mL PF SDV [VDMC]

Facility

$28.68

Service Code	HCPCS J2003
Hospital Charge Code	10430909
Hospital Revenue Code	259
Min. Negotiated Rate	$20.08
Max. Negotiated Rate	$25.81
Rate for Payer: Aetna of IA Commercial	$25.81
Rate for Payer: Aetna of IA Medical Rental Products	$25.81
Rate for Payer: Cash Price	$22.95
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.51
Rate for Payer: Medical Associates Commercial	$21.51
Rate for Payer: Midlands Choice Commercial	$20.08
Rate for Payer: United Healthcare Commercial	$25.81

lidocaine 1% 30 mL PF SDV [VDMC]

Facility

$32.05

Service Code	HCPCS J2003
Hospital Charge Code	10430976
Hospital Revenue Code	259
Min. Negotiated Rate	$22.43
Max. Negotiated Rate	$28.84
Rate for Payer: Aetna of IA Commercial	$28.84
Rate for Payer: Aetna of IA Medical Rental Products	$28.84
Rate for Payer: Cash Price	$25.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.04
Rate for Payer: Medical Associates Commercial	$24.04
Rate for Payer: Midlands Choice Commercial	$22.43
Rate for Payer: United Healthcare Commercial	$28.84

lidocaine 1% 30 mL PF SDV [VDMC]

Facility

$32.05

Service Code	HCPCS J2003
Hospital Charge Code	10430976
Hospital Revenue Code	259
Min. Negotiated Rate	$14.42
Max. Negotiated Rate	$28.84
Rate for Payer: Aetna of IA Commercial	$28.84
Rate for Payer: Aetna of IA Medical Rental Products	$28.84
Rate for Payer: Aetna of IA Medicare	$18.27
Rate for Payer: Amerigroup Medicaid	$18.49
Rate for Payer: Amerigroup Medicare	$14.57
Rate for Payer: Cash Price	$25.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.04
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.42
Rate for Payer: Iowa Total Care Managed Medicaid	$18.31
Rate for Payer: Medical Associates Commercial	$24.04
Rate for Payer: Medical Associates Managed Medicare	$14.42
Rate for Payer: Midlands Choice Commercial	$22.43
Rate for Payer: Molina Healthcare Managed Medicaid	$18.58
Rate for Payer: Partners Health Alliance Commercial	$16.58
Rate for Payer: United Healthcare Commercial	$28.84
Rate for Payer: United Healthcare Managed Medicare	$18.91

lidocaine 1% 5 ml PF SDV [VDMC]

Facility

$23.83

Service Code	HCPCS J2003
Hospital Charge Code	13647996
Hospital Revenue Code	259
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$21.44
Rate for Payer: Aetna of IA Commercial	$21.44
Rate for Payer: Aetna of IA Medical Rental Products	$21.44
Rate for Payer: Aetna of IA Medicare	$13.58
Rate for Payer: Amerigroup Medicaid	$13.74
Rate for Payer: Amerigroup Medicare	$10.83
Rate for Payer: Cash Price	$19.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.87
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.72
Rate for Payer: Iowa Total Care Managed Medicaid	$13.61
Rate for Payer: Medical Associates Commercial	$17.87
Rate for Payer: Medical Associates Managed Medicare	$10.72
Rate for Payer: Midlands Choice Commercial	$16.68
Rate for Payer: Molina Healthcare Managed Medicaid	$13.81
Rate for Payer: Partners Health Alliance Commercial	$12.33
Rate for Payer: United Healthcare Commercial	$21.44
Rate for Payer: United Healthcare Managed Medicare	$14.06

lidocaine 1% 5 ml PF SDV [VDMC]

Facility

$23.83

Service Code	HCPCS J2003
Hospital Charge Code	13647996
Hospital Revenue Code	259
Min. Negotiated Rate	$16.68
Max. Negotiated Rate	$21.44
Rate for Payer: Aetna of IA Commercial	$21.44
Rate for Payer: Aetna of IA Medical Rental Products	$21.44
Rate for Payer: Cash Price	$19.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.87
Rate for Payer: Medical Associates Commercial	$17.87
Rate for Payer: Midlands Choice Commercial	$16.68
Rate for Payer: United Healthcare Commercial	$21.44

Lidocaine 1% Phenylephrine 1.5% Opht PF Syringe [VDMC]

Facility

$83.00

Service Code	HCPCS A9270
Hospital Charge Code	23138084
Hospital Revenue Code	259
Min. Negotiated Rate	$37.35
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of IA Commercial	$74.70
Rate for Payer: Aetna of IA Medical Rental Products	$74.70
Rate for Payer: Aetna of IA Medicare	$47.31
Rate for Payer: Amerigroup Medicaid	$47.87
Rate for Payer: Amerigroup Medicare	$37.72
Rate for Payer: Cash Price	$66.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$62.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$37.35
Rate for Payer: Iowa Total Care Managed Medicaid	$47.41
Rate for Payer: Medical Associates Commercial	$62.25
Rate for Payer: Medical Associates Managed Medicare	$37.35
Rate for Payer: Midlands Choice Commercial	$58.10
Rate for Payer: Molina Healthcare Managed Medicaid	$48.11
Rate for Payer: Partners Health Alliance Commercial	$42.95
Rate for Payer: United Healthcare Commercial	$74.70
Rate for Payer: United Healthcare Managed Medicare	$48.97

Lidocaine 1% Phenylephrine 1.5% Opht PF Syringe [VDMC]

Facility

$83.00

Service Code	HCPCS A9270
Hospital Charge Code	23138084
Hospital Revenue Code	259
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of IA Commercial	$74.70
Rate for Payer: Aetna of IA Medical Rental Products	$74.70
Rate for Payer: Cash Price	$66.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$62.25
Rate for Payer: Medical Associates Commercial	$62.25
Rate for Payer: Midlands Choice Commercial	$58.10
Rate for Payer: United Healthcare Commercial	$74.70

lidocaine 2% 200mg/10 mL MDV [VDMC]

Facility

$23.57

Service Code	HCPCS J2003
Hospital Charge Code	24290303
Hospital Revenue Code	259
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$21.21
Rate for Payer: Aetna of IA Commercial	$21.21
Rate for Payer: Aetna of IA Medical Rental Products	$21.21
Rate for Payer: Cash Price	$18.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.68
Rate for Payer: Medical Associates Commercial	$17.68
Rate for Payer: Midlands Choice Commercial	$16.50
Rate for Payer: United Healthcare Commercial	$21.21

lidocaine 2% 200mg/10 mL MDV [VDMC]

Facility

$23.57

Service Code	HCPCS J2003
Hospital Charge Code	24290303
Hospital Revenue Code	259
Min. Negotiated Rate	$10.61
Max. Negotiated Rate	$21.21
Rate for Payer: Aetna of IA Commercial	$21.21
Rate for Payer: Aetna of IA Medical Rental Products	$21.21
Rate for Payer: Aetna of IA Medicare	$13.43
Rate for Payer: Amerigroup Medicaid	$13.59
Rate for Payer: Amerigroup Medicare	$10.71
Rate for Payer: Cash Price	$18.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.68
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.61
Rate for Payer: Iowa Total Care Managed Medicaid	$13.46
Rate for Payer: Medical Associates Commercial	$17.68
Rate for Payer: Medical Associates Managed Medicare	$10.61
Rate for Payer: Midlands Choice Commercial	$16.50
Rate for Payer: Molina Healthcare Managed Medicaid	$13.66
Rate for Payer: Partners Health Alliance Commercial	$12.20
Rate for Payer: United Healthcare Commercial	$21.21
Rate for Payer: United Healthcare Managed Medicare	$13.91

lidocaine 2% 400mg/20 mL MDV [VDMC]

Facility

$25.49

Service Code	HCPCS J2003
Hospital Charge Code	10440174
Hospital Revenue Code	259
Min. Negotiated Rate	$17.84
Max. Negotiated Rate	$22.94
Rate for Payer: Aetna of IA Commercial	$22.94
Rate for Payer: Aetna of IA Medical Rental Products	$22.94
Rate for Payer: Cash Price	$20.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.12
Rate for Payer: Medical Associates Commercial	$19.12
Rate for Payer: Midlands Choice Commercial	$17.84
Rate for Payer: United Healthcare Commercial	$22.94

lidocaine 2% 400mg/20 mL MDV [VDMC]

Facility

$25.49

Service Code	HCPCS J2003
Hospital Charge Code	10440174
Hospital Revenue Code	259
Min. Negotiated Rate	$11.47
Max. Negotiated Rate	$22.94
Rate for Payer: Aetna of IA Commercial	$22.94
Rate for Payer: Aetna of IA Medical Rental Products	$22.94
Rate for Payer: Aetna of IA Medicare	$14.53
Rate for Payer: Amerigroup Medicaid	$14.70
Rate for Payer: Amerigroup Medicare	$11.59
Rate for Payer: Cash Price	$20.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.47
Rate for Payer: Iowa Total Care Managed Medicaid	$14.56
Rate for Payer: Medical Associates Commercial	$19.12
Rate for Payer: Medical Associates Managed Medicare	$11.47
Rate for Payer: Midlands Choice Commercial	$17.84
Rate for Payer: Molina Healthcare Managed Medicaid	$14.77
Rate for Payer: Partners Health Alliance Commercial	$13.19
Rate for Payer: United Healthcare Commercial	$22.94
Rate for Payer: United Healthcare Managed Medicare	$15.04

lidocaine 2% 5 mL PF SDV [VDMC]

Facility

$23.31

Service Code	HCPCS J2003
Hospital Charge Code	29084093
Hospital Revenue Code	259
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$20.98
Rate for Payer: Aetna of IA Commercial	$20.98
Rate for Payer: Aetna of IA Medical Rental Products	$20.98
Rate for Payer: Cash Price	$18.65
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.48
Rate for Payer: Medical Associates Commercial	$17.48
Rate for Payer: Midlands Choice Commercial	$16.32
Rate for Payer: United Healthcare Commercial	$20.98

lidocaine 2% 5 mL PF SDV [VDMC]

Facility

$23.31

Service Code	HCPCS J2003
Hospital Charge Code	29084093
Hospital Revenue Code	259
Min. Negotiated Rate	$10.49
Max. Negotiated Rate	$20.98
Rate for Payer: Aetna of IA Commercial	$20.98
Rate for Payer: Aetna of IA Medical Rental Products	$20.98
Rate for Payer: Aetna of IA Medicare	$13.29
Rate for Payer: Amerigroup Medicaid	$13.45
Rate for Payer: Amerigroup Medicare	$10.60
Rate for Payer: Cash Price	$18.65
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.49
Rate for Payer: Iowa Total Care Managed Medicaid	$13.32
Rate for Payer: Medical Associates Commercial	$17.48
Rate for Payer: Medical Associates Managed Medicare	$10.49
Rate for Payer: Midlands Choice Commercial	$16.32
Rate for Payer: Molina Healthcare Managed Medicaid	$13.51
Rate for Payer: Partners Health Alliance Commercial	$12.06
Rate for Payer: United Healthcare Commercial	$20.98
Rate for Payer: United Healthcare Managed Medicare	$13.75

lidocaine 4% PF 5 ML SDV [VDMC]

Facility

$28.41

Service Code	HCPCS J2003
Hospital Charge Code	10431043
Hospital Revenue Code	259
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$25.57
Rate for Payer: Aetna of IA Commercial	$25.57
Rate for Payer: Aetna of IA Medical Rental Products	$25.57
Rate for Payer: Aetna of IA Medicare	$16.19
Rate for Payer: Amerigroup Medicaid	$16.39
Rate for Payer: Amerigroup Medicare	$12.91
Rate for Payer: Cash Price	$22.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.31
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.79
Rate for Payer: Iowa Total Care Managed Medicaid	$16.23
Rate for Payer: Medical Associates Commercial	$21.31
Rate for Payer: Medical Associates Managed Medicare	$12.79
Rate for Payer: Midlands Choice Commercial	$19.89
Rate for Payer: Molina Healthcare Managed Medicaid	$16.47
Rate for Payer: Partners Health Alliance Commercial	$14.70
Rate for Payer: United Healthcare Commercial	$25.57
Rate for Payer: United Healthcare Managed Medicare	$16.76

lidocaine 4% PF 5 ML SDV [VDMC]

Facility

$28.41

Service Code	HCPCS J2003
Hospital Charge Code	10431043
Hospital Revenue Code	259
Min. Negotiated Rate	$19.89
Max. Negotiated Rate	$25.57
Rate for Payer: Aetna of IA Commercial	$25.57
Rate for Payer: Aetna of IA Medical Rental Products	$25.57
Rate for Payer: Cash Price	$22.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.31
Rate for Payer: Medical Associates Commercial	$21.31
Rate for Payer: Midlands Choice Commercial	$19.89
Rate for Payer: United Healthcare Commercial	$25.57

lidocaine emergency syringe 100mg/5ml [VDMC]

Facility

$42.19

Service Code	HCPCS J2003
Hospital Charge Code	10433017
Hospital Revenue Code	259
Min. Negotiated Rate	$18.98
Max. Negotiated Rate	$37.97
Rate for Payer: Aetna of IA Commercial	$37.97
Rate for Payer: Aetna of IA Medical Rental Products	$37.97
Rate for Payer: Aetna of IA Medicare	$24.05
Rate for Payer: Amerigroup Medicaid	$24.33
Rate for Payer: Amerigroup Medicare	$19.17
Rate for Payer: Cash Price	$33.75
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$31.64
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$18.98
Rate for Payer: Iowa Total Care Managed Medicaid	$24.10
Rate for Payer: Medical Associates Commercial	$31.64
Rate for Payer: Medical Associates Managed Medicare	$18.98
Rate for Payer: Midlands Choice Commercial	$29.53
Rate for Payer: Molina Healthcare Managed Medicaid	$24.45
Rate for Payer: Partners Health Alliance Commercial	$21.83
Rate for Payer: United Healthcare Commercial	$37.97
Rate for Payer: United Healthcare Managed Medicare	$24.89

lidocaine emergency syringe 100mg/5ml [VDMC]

Facility

$42.19

Service Code	HCPCS J2003
Hospital Charge Code	10433017
Hospital Revenue Code	259
Min. Negotiated Rate	$29.53
Max. Negotiated Rate	$37.97
Rate for Payer: Aetna of IA Commercial	$37.97
Rate for Payer: Aetna of IA Medical Rental Products	$37.97
Rate for Payer: Cash Price	$33.75
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$31.64
Rate for Payer: Medical Associates Commercial	$31.64
Rate for Payer: Midlands Choice Commercial	$29.53
Rate for Payer: United Healthcare Commercial	$37.97

Know your out-of-pocket cost for care.

All Charges