Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Prolactin DMCL

Facility

$158.00

Service Code	CPT 84146
Hospital Charge Code	8037783
Hospital Revenue Code	301
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of IA Commercial	$142.20
Rate for Payer: Aetna of IA Medical Rental Products	$142.20
Rate for Payer: Aetna of IA Medicare	$90.06
Rate for Payer: Amerigroup Medicaid	$79.74
Rate for Payer: Amerigroup Medicare	$79.79
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$126.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.00
Rate for Payer: Iowa Total Care Managed Medicaid	$78.97
Rate for Payer: Medical Associates Commercial	$118.50
Rate for Payer: Medical Associates Managed Medicare	$79.00
Rate for Payer: Midlands Choice Commercial	$110.60
Rate for Payer: Molina Healthcare Managed Medicaid	$80.18
Rate for Payer: Molina Healthcare Managed Medicare	$80.14
Rate for Payer: Oscar Health of IA Commercial	$118.50
Rate for Payer: Partners Health Alliance Commercial	$118.50
Rate for Payer: United Healthcare Commercial	$142.20
Rate for Payer: United Healthcare Managed Medicare	$93.22
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

promethazine 25 mg/mL 1ml SDV [VDMC]

Facility

$24.48

Service Code	HCPCS J2550
Hospital Charge Code	11554245
Hospital Revenue Code	259
Min. Negotiated Rate	$17.14
Max. Negotiated Rate	$22.03
Rate for Payer: Aetna of IA Commercial	$22.03
Rate for Payer: Aetna of IA Medical Rental Products	$22.03
Rate for Payer: Cash Price	$19.58
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.36
Rate for Payer: Medical Associates Commercial	$18.36
Rate for Payer: Midlands Choice Commercial	$17.14
Rate for Payer: United Healthcare Commercial	$22.03

promethazine 25 mg/mL 1ml SDV [VDMC]

Facility

$24.48

Service Code	HCPCS J2550
Hospital Charge Code	11554245
Hospital Revenue Code	259
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$22.03
Rate for Payer: Aetna of IA Commercial	$22.03
Rate for Payer: Aetna of IA Medical Rental Products	$22.03
Rate for Payer: Aetna of IA Medicare	$13.95
Rate for Payer: Amerigroup Medicaid	$12.36
Rate for Payer: Amerigroup Medicare	$12.36
Rate for Payer: Cash Price	$19.58
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.36
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.24
Rate for Payer: Iowa Total Care Managed Medicaid	$12.24
Rate for Payer: Medical Associates Commercial	$18.36
Rate for Payer: Medical Associates Managed Medicare	$12.24
Rate for Payer: Midlands Choice Commercial	$17.14
Rate for Payer: Molina Healthcare Managed Medicaid	$12.42
Rate for Payer: Molina Healthcare Managed Medicare	$12.42
Rate for Payer: Oscar Health of IA Commercial	$18.36
Rate for Payer: Partners Health Alliance Commercial	$18.36
Rate for Payer: United Healthcare Commercial	$22.03
Rate for Payer: United Healthcare Managed Medicare	$14.44

promethazine 25 mg Supp [VDMC]

Facility

$21.51

Service Code	NDC 00713-0526-12
Hospital Charge Code	10416664
Hospital Revenue Code	259
Min. Negotiated Rate	$15.06
Max. Negotiated Rate	$19.36
Rate for Payer: Aetna of IA Commercial	$19.36
Rate for Payer: Aetna of IA Medical Rental Products	$19.36
Rate for Payer: Cash Price	$17.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.13
Rate for Payer: Medical Associates Commercial	$16.13
Rate for Payer: Midlands Choice Commercial	$15.06
Rate for Payer: United Healthcare Commercial	$19.36

promethazine 25 mg Supp [VDMC]

Facility

$21.51

Service Code	NDC 00713-0526-12
Hospital Charge Code	10416664
Hospital Revenue Code	259
Min. Negotiated Rate	$10.75
Max. Negotiated Rate	$19.36
Rate for Payer: Aetna of IA Commercial	$19.36
Rate for Payer: Aetna of IA Medical Rental Products	$19.36
Rate for Payer: Aetna of IA Medicare	$12.26
Rate for Payer: Amerigroup Medicaid	$10.86
Rate for Payer: Amerigroup Medicare	$10.86
Rate for Payer: Cash Price	$17.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.13
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.76
Rate for Payer: Iowa Total Care Managed Medicaid	$10.75
Rate for Payer: Medical Associates Commercial	$16.13
Rate for Payer: Medical Associates Managed Medicare	$10.76
Rate for Payer: Midlands Choice Commercial	$15.06
Rate for Payer: Molina Healthcare Managed Medicaid	$10.92
Rate for Payer: Molina Healthcare Managed Medicare	$10.91
Rate for Payer: Oscar Health of IA Commercial	$16.13
Rate for Payer: Partners Health Alliance Commercial	$16.13
Rate for Payer: United Healthcare Commercial	$19.36
Rate for Payer: United Healthcare Managed Medicare	$12.69

promethazine 25 mg Tab [VDMC]

Facility

$1.63

Service Code	HCPCS A9270
Hospital Charge Code	10416729
Hospital Revenue Code	259
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.47
Rate for Payer: Aetna of IA Commercial	$1.47
Rate for Payer: Aetna of IA Medical Rental Products	$1.47
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.22
Rate for Payer: Medical Associates Commercial	$1.22
Rate for Payer: Midlands Choice Commercial	$1.14
Rate for Payer: United Healthcare Commercial	$1.47

promethazine 25 mg Tab [VDMC]

Facility

$1.63

Service Code	HCPCS A9270
Hospital Charge Code	10416729
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.47
Rate for Payer: Aetna of IA Commercial	$1.47
Rate for Payer: Aetna of IA Medical Rental Products	$1.47
Rate for Payer: Aetna of IA Medicare	$0.93
Rate for Payer: Amerigroup Medicaid	$0.82
Rate for Payer: Amerigroup Medicare	$0.82
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.22
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.82
Rate for Payer: Iowa Total Care Managed Medicaid	$0.81
Rate for Payer: Medical Associates Commercial	$1.22
Rate for Payer: Medical Associates Managed Medicare	$0.82
Rate for Payer: Midlands Choice Commercial	$1.14
Rate for Payer: Molina Healthcare Managed Medicaid	$0.83
Rate for Payer: Molina Healthcare Managed Medicare	$0.83
Rate for Payer: Oscar Health of IA Commercial	$1.22
Rate for Payer: Partners Health Alliance Commercial	$1.22
Rate for Payer: United Healthcare Commercial	$1.47
Rate for Payer: United Healthcare Managed Medicare	$0.96

promethazine 6.25 mg/5 mL Oral Syrup [VDMC]

Facility

$4.00

Service Code	HCPCS Q0169
Hospital Charge Code	10416800
Hospital Revenue Code	259
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of IA Commercial	$3.60
Rate for Payer: Aetna of IA Medical Rental Products	$3.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.00
Rate for Payer: Medical Associates Commercial	$3.00
Rate for Payer: Midlands Choice Commercial	$2.80
Rate for Payer: United Healthcare Commercial	$3.60

promethazine 6.25 mg/5 mL Oral Syrup [VDMC]

Facility

$4.00

Service Code	HCPCS Q0169
Hospital Charge Code	10416800
Hospital Revenue Code	259
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of IA Commercial	$3.60
Rate for Payer: Aetna of IA Medical Rental Products	$3.60
Rate for Payer: Aetna of IA Medicare	$2.28
Rate for Payer: Amerigroup Medicaid	$2.02
Rate for Payer: Amerigroup Medicare	$2.02
Rate for Payer: Cash Price	$3.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.00
Rate for Payer: Iowa Total Care Managed Medicaid	$2.00
Rate for Payer: Medical Associates Commercial	$3.00
Rate for Payer: Medical Associates Managed Medicare	$2.00
Rate for Payer: Midlands Choice Commercial	$2.80
Rate for Payer: Molina Healthcare Managed Medicaid	$2.03
Rate for Payer: Molina Healthcare Managed Medicare	$2.03
Rate for Payer: Oscar Health of IA Commercial	$3.00
Rate for Payer: Partners Health Alliance Commercial	$3.00
Rate for Payer: United Healthcare Commercial	$3.60
Rate for Payer: United Healthcare Managed Medicare	$2.36

promethazine-codein 6.25 mg-10mg/5 mL 5ml Oral Syrup [VDMC]

Facility

$3.55

Service Code	HCPCS A9270
Hospital Charge Code	10379233
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$3.20
Rate for Payer: Aetna of IA Commercial	$3.20
Rate for Payer: Aetna of IA Medical Rental Products	$3.20
Rate for Payer: Aetna of IA Medicare	$2.02
Rate for Payer: Amerigroup Medicaid	$1.79
Rate for Payer: Amerigroup Medicare	$1.79
Rate for Payer: Cash Price	$2.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.66
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.78
Rate for Payer: Iowa Total Care Managed Medicaid	$1.77
Rate for Payer: Medical Associates Commercial	$2.66
Rate for Payer: Medical Associates Managed Medicare	$1.78
Rate for Payer: Midlands Choice Commercial	$2.48
Rate for Payer: Molina Healthcare Managed Medicaid	$1.80
Rate for Payer: Molina Healthcare Managed Medicare	$1.80
Rate for Payer: Oscar Health of IA Commercial	$2.66
Rate for Payer: Partners Health Alliance Commercial	$2.66
Rate for Payer: United Healthcare Commercial	$3.20
Rate for Payer: United Healthcare Managed Medicare	$2.09

promethazine-codein 6.25 mg-10mg/5 mL 5ml Oral Syrup [VDMC]

Facility

$3.55

Service Code	HCPCS A9270
Hospital Charge Code	10379233
Hospital Revenue Code	259
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$3.20
Rate for Payer: Aetna of IA Commercial	$3.20
Rate for Payer: Aetna of IA Medical Rental Products	$3.20
Rate for Payer: Cash Price	$2.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.66
Rate for Payer: Medical Associates Commercial	$2.66
Rate for Payer: Midlands Choice Commercial	$2.48
Rate for Payer: United Healthcare Commercial	$3.20

promethazine-dextromethorphan 6.25mg-15 mg/5 mL Oral Syrup 10mL [VDMC]

Facility

$5.25

Service Code	HCPCS A9270
Hospital Charge Code	10382102
Hospital Revenue Code	259
Min. Negotiated Rate	$3.68
Max. Negotiated Rate	$4.72
Rate for Payer: Aetna of IA Commercial	$4.72
Rate for Payer: Aetna of IA Medical Rental Products	$4.72
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.94
Rate for Payer: Medical Associates Commercial	$3.94
Rate for Payer: Midlands Choice Commercial	$3.68
Rate for Payer: United Healthcare Commercial	$4.72

promethazine-dextromethorphan 6.25mg-15 mg/5 mL Oral Syrup 10mL [VDMC]

Facility

$5.25

Service Code	HCPCS A9270
Hospital Charge Code	10382102
Hospital Revenue Code	259
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$4.72
Rate for Payer: Aetna of IA Commercial	$4.72
Rate for Payer: Aetna of IA Medical Rental Products	$4.72
Rate for Payer: Aetna of IA Medicare	$2.99
Rate for Payer: Amerigroup Medicaid	$2.65
Rate for Payer: Amerigroup Medicare	$2.65
Rate for Payer: Cash Price	$4.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.62
Rate for Payer: Iowa Total Care Managed Medicaid	$2.62
Rate for Payer: Medical Associates Commercial	$3.94
Rate for Payer: Medical Associates Managed Medicare	$2.62
Rate for Payer: Midlands Choice Commercial	$3.68
Rate for Payer: Molina Healthcare Managed Medicaid	$2.66
Rate for Payer: Molina Healthcare Managed Medicare	$2.66
Rate for Payer: Oscar Health of IA Commercial	$3.94
Rate for Payer: Partners Health Alliance Commercial	$3.94
Rate for Payer: United Healthcare Commercial	$4.72
Rate for Payer: United Healthcare Managed Medicare	$3.10

propafenone 150 mg Tab [VDMC]

Facility

$1.46

Service Code	HCPCS A9270
Hospital Charge Code	10416869
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of IA Commercial	$1.31
Rate for Payer: Aetna of IA Medical Rental Products	$1.31
Rate for Payer: Aetna of IA Medicare	$0.83
Rate for Payer: Amerigroup Medicaid	$0.74
Rate for Payer: Amerigroup Medicare	$0.74
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.10
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.73
Rate for Payer: Iowa Total Care Managed Medicaid	$0.73
Rate for Payer: Medical Associates Commercial	$1.10
Rate for Payer: Medical Associates Managed Medicare	$0.73
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: Molina Healthcare Managed Medicaid	$0.74
Rate for Payer: Molina Healthcare Managed Medicare	$0.74
Rate for Payer: Oscar Health of IA Commercial	$1.10
Rate for Payer: Partners Health Alliance Commercial	$1.10
Rate for Payer: United Healthcare Commercial	$1.31
Rate for Payer: United Healthcare Managed Medicare	$0.86

propafenone 150 mg Tab [VDMC]

Facility

$1.46

Service Code	HCPCS A9270
Hospital Charge Code	10416869
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of IA Commercial	$1.31
Rate for Payer: Aetna of IA Medical Rental Products	$1.31
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.10
Rate for Payer: Medical Associates Commercial	$1.10
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: United Healthcare Commercial	$1.31

propafenone 225 mg Tab [VDMC]

Facility

$1.71

Service Code	HCPCS A9270
Hospital Charge Code	10416930
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of IA Commercial	$1.54
Rate for Payer: Aetna of IA Medical Rental Products	$1.54
Rate for Payer: Aetna of IA Medicare	$0.97
Rate for Payer: Amerigroup Medicaid	$0.86
Rate for Payer: Amerigroup Medicare	$0.86
Rate for Payer: Cash Price	$1.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.28
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.86
Rate for Payer: Iowa Total Care Managed Medicaid	$0.85
Rate for Payer: Medical Associates Commercial	$1.28
Rate for Payer: Medical Associates Managed Medicare	$0.86
Rate for Payer: Midlands Choice Commercial	$1.20
Rate for Payer: Molina Healthcare Managed Medicaid	$0.87
Rate for Payer: Molina Healthcare Managed Medicare	$0.87
Rate for Payer: Oscar Health of IA Commercial	$1.28
Rate for Payer: Partners Health Alliance Commercial	$1.28
Rate for Payer: United Healthcare Commercial	$1.54
Rate for Payer: United Healthcare Managed Medicare	$1.01

propafenone 225 mg Tab [VDMC]

Facility

$1.71

Service Code	HCPCS A9270
Hospital Charge Code	10416930
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of IA Commercial	$1.54
Rate for Payer: Aetna of IA Medical Rental Products	$1.54
Rate for Payer: Cash Price	$1.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.28
Rate for Payer: Medical Associates Commercial	$1.28
Rate for Payer: Midlands Choice Commercial	$1.20
Rate for Payer: United Healthcare Commercial	$1.54

proparacaine ophthalmic 0.5% Sol[VDMC]

Facility

$144.80

Service Code	HCPCS A9270
Hospital Charge Code	12444571
Hospital Revenue Code	259
Min. Negotiated Rate	$72.37
Max. Negotiated Rate	$130.32
Rate for Payer: Aetna of IA Commercial	$130.32
Rate for Payer: Aetna of IA Medical Rental Products	$130.32
Rate for Payer: Aetna of IA Medicare	$82.54
Rate for Payer: Amerigroup Medicaid	$73.08
Rate for Payer: Amerigroup Medicare	$73.12
Rate for Payer: Cash Price	$115.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.60
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$72.40
Rate for Payer: Iowa Total Care Managed Medicaid	$72.37
Rate for Payer: Medical Associates Commercial	$108.60
Rate for Payer: Medical Associates Managed Medicare	$72.40
Rate for Payer: Midlands Choice Commercial	$101.36
Rate for Payer: Molina Healthcare Managed Medicaid	$73.49
Rate for Payer: Molina Healthcare Managed Medicare	$73.44
Rate for Payer: Oscar Health of IA Commercial	$108.60
Rate for Payer: Partners Health Alliance Commercial	$108.60
Rate for Payer: United Healthcare Commercial	$130.32
Rate for Payer: United Healthcare Managed Medicare	$85.43

proparacaine ophthalmic 0.5% Sol[VDMC]

Facility

$144.80

Service Code	HCPCS A9270
Hospital Charge Code	12444571
Hospital Revenue Code	259
Min. Negotiated Rate	$101.36
Max. Negotiated Rate	$130.32
Rate for Payer: Aetna of IA Commercial	$130.32
Rate for Payer: Aetna of IA Medical Rental Products	$130.32
Rate for Payer: Cash Price	$115.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.60
Rate for Payer: Medical Associates Commercial	$108.60
Rate for Payer: Midlands Choice Commercial	$101.36
Rate for Payer: United Healthcare Commercial	$130.32

propofol 10 mg/mL 100ml SDV IV Emul [VDMC]

Facility

$60.80

Service Code	HCPCS J2704
Hospital Charge Code	17564591
Hospital Revenue Code	259
Min. Negotiated Rate	$42.56
Max. Negotiated Rate	$54.72
Rate for Payer: Aetna of IA Commercial	$54.72
Rate for Payer: Aetna of IA Medical Rental Products	$54.72
Rate for Payer: Cash Price	$48.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.60
Rate for Payer: Medical Associates Commercial	$45.60
Rate for Payer: Midlands Choice Commercial	$42.56
Rate for Payer: United Healthcare Commercial	$54.72

propofol 10 mg/mL 100ml SDV IV Emul [VDMC]

Facility

$60.80

Service Code	HCPCS J2704
Hospital Charge Code	17564591
Hospital Revenue Code	259
Min. Negotiated Rate	$30.39
Max. Negotiated Rate	$54.72
Rate for Payer: Aetna of IA Commercial	$54.72
Rate for Payer: Aetna of IA Medical Rental Products	$54.72
Rate for Payer: Aetna of IA Medicare	$34.66
Rate for Payer: Amerigroup Medicaid	$30.69
Rate for Payer: Amerigroup Medicare	$30.70
Rate for Payer: Cash Price	$48.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.60
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$30.40
Rate for Payer: Iowa Total Care Managed Medicaid	$30.39
Rate for Payer: Medical Associates Commercial	$45.60
Rate for Payer: Medical Associates Managed Medicare	$30.40
Rate for Payer: Midlands Choice Commercial	$42.56
Rate for Payer: Molina Healthcare Managed Medicaid	$30.86
Rate for Payer: Molina Healthcare Managed Medicare	$30.84
Rate for Payer: Oscar Health of IA Commercial	$45.60
Rate for Payer: Partners Health Alliance Commercial	$45.60
Rate for Payer: United Healthcare Commercial	$54.72
Rate for Payer: United Healthcare Managed Medicare	$35.87

propofol 10 mg/mL 20 ml SDV IV Emul [VDMC]

Facility

$28.17

Service Code	HCPCS J2704
Hospital Charge Code	10417070
Hospital Revenue Code	259
Min. Negotiated Rate	$14.08
Max. Negotiated Rate	$25.35
Rate for Payer: Aetna of IA Commercial	$25.35
Rate for Payer: Aetna of IA Medical Rental Products	$25.35
Rate for Payer: Aetna of IA Medicare	$16.06
Rate for Payer: Amerigroup Medicaid	$14.22
Rate for Payer: Amerigroup Medicare	$14.23
Rate for Payer: Cash Price	$22.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.13
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.08
Rate for Payer: Iowa Total Care Managed Medicaid	$14.08
Rate for Payer: Medical Associates Commercial	$21.13
Rate for Payer: Medical Associates Managed Medicare	$14.08
Rate for Payer: Midlands Choice Commercial	$19.72
Rate for Payer: Molina Healthcare Managed Medicaid	$14.30
Rate for Payer: Molina Healthcare Managed Medicare	$14.29
Rate for Payer: Oscar Health of IA Commercial	$21.13
Rate for Payer: Partners Health Alliance Commercial	$21.13
Rate for Payer: United Healthcare Commercial	$25.35
Rate for Payer: United Healthcare Managed Medicare	$16.62

propofol 10 mg/mL 20 ml SDV IV Emul [VDMC]

Facility

$28.17

Service Code	HCPCS J2704
Hospital Charge Code	10417070
Hospital Revenue Code	259
Min. Negotiated Rate	$19.72
Max. Negotiated Rate	$25.35
Rate for Payer: Aetna of IA Commercial	$25.35
Rate for Payer: Aetna of IA Medical Rental Products	$25.35
Rate for Payer: Cash Price	$22.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.13
Rate for Payer: Medical Associates Commercial	$21.13
Rate for Payer: Midlands Choice Commercial	$19.72
Rate for Payer: United Healthcare Commercial	$25.35

propofol 10 mg/mL 50 ml SDV IV Emul [VDMC]

Facility

$41.05

Service Code	HCPCS J2704
Hospital Charge Code	10416999
Hospital Revenue Code	259
Min. Negotiated Rate	$28.74
Max. Negotiated Rate	$36.94
Rate for Payer: Aetna of IA Commercial	$36.94
Rate for Payer: Aetna of IA Medical Rental Products	$36.94
Rate for Payer: Cash Price	$32.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.79
Rate for Payer: Medical Associates Commercial	$30.79
Rate for Payer: Midlands Choice Commercial	$28.74
Rate for Payer: United Healthcare Commercial	$36.94

propofol 10 mg/mL 50 ml SDV IV Emul [VDMC]

Facility

$41.05

Service Code	HCPCS J2704
Hospital Charge Code	10416999
Hospital Revenue Code	259
Min. Negotiated Rate	$20.52
Max. Negotiated Rate	$36.94
Rate for Payer: Aetna of IA Commercial	$36.94
Rate for Payer: Aetna of IA Medical Rental Products	$36.94
Rate for Payer: Aetna of IA Medicare	$23.40
Rate for Payer: Amerigroup Medicaid	$20.72
Rate for Payer: Amerigroup Medicare	$20.73
Rate for Payer: Cash Price	$32.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.79
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$20.52
Rate for Payer: Iowa Total Care Managed Medicaid	$20.52
Rate for Payer: Medical Associates Commercial	$30.79
Rate for Payer: Medical Associates Managed Medicare	$20.52
Rate for Payer: Midlands Choice Commercial	$28.74
Rate for Payer: Molina Healthcare Managed Medicaid	$20.83
Rate for Payer: Molina Healthcare Managed Medicare	$20.82
Rate for Payer: Oscar Health of IA Commercial	$30.79
Rate for Payer: Partners Health Alliance Commercial	$30.79
Rate for Payer: United Healthcare Commercial	$36.94
Rate for Payer: United Healthcare Managed Medicare	$24.22

Know your out-of-pocket cost for care.

All Charges