Van Diest Medical Center

All Charges

Charge

Type

Price

LAC COMPLEX <2.5 CM CHOLE CHARGE

Professional

$828.00

Hospital Charge Code	8069097
Hospital Revenue Code	981
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$579.60
Rate for Payer: Cash Price	$662.40
Rate for Payer: Cash Price	$662.40
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$579.60

LAC COMPLEX 2.6-7.5 CM CHARGE

Professional

$1,152.00

Hospital Charge Code	8069062
Hospital Revenue Code	981
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$806.40
Rate for Payer: Cash Price	$921.60
Rate for Payer: Cash Price	$921.60
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$806.40

LAC COMPLEX EACH ADDT'L >7.6CM CHARGE

Professional

$472.00

Hospital Charge Code	8069182
Hospital Revenue Code	981
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$330.40
Rate for Payer: Cash Price	$377.60
Rate for Payer: Cash Price	$377.60
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$330.40

LAC INTERMEDIATE 12.6-20 CM CHARGE

Professional

$1,006.00

Hospital Charge Code	8069136
Hospital Revenue Code	981
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$704.20
Rate for Payer: Cash Price	$804.80
Rate for Payer: Cash Price	$804.80
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$704.20

LAC INTERMEDIATE 20.1-30 CM CHARGE

Professional

$930.00

Hospital Charge Code	8069157
Hospital Revenue Code	981
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$651.00
Rate for Payer: Cash Price	$744.00
Rate for Payer: Cash Price	$744.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$651.00

LAC INTERMEDIATE <2.5 CM CHARGE

Professional

$565.00

Hospital Charge Code	8068966
Hospital Revenue Code	981
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$395.50
Rate for Payer: Cash Price	$452.00
Rate for Payer: Cash Price	$452.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$395.50

LAC INTERMEDIATE 2.6-7.5 CM CHARGE

Professional

$639.00

Hospital Charge Code	8068984
Hospital Revenue Code	981
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$447.30
Rate for Payer: Cash Price	$511.20
Rate for Payer: Cash Price	$511.20
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$447.30

LAC INTERMEDIATE >30.1 CM CHARGE

Professional

$1,260.00

Hospital Charge Code	8069044
Hospital Revenue Code	981
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$882.00
Rate for Payer: Cash Price	$1,008.00
Rate for Payer: Cash Price	$1,008.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$882.00

LAC INTERMEDIATE 7.6-12.5 CM CHARGE

Professional

$757.00

Hospital Charge Code	8069058
Hospital Revenue Code	981
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$529.90
Rate for Payer: Cash Price	$605.60
Rate for Payer: Cash Price	$605.60
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$529.90

LAC SIMPLE 7.6-12.5 CM CHARGE

Professional

$331.00

Hospital Charge Code	8069026
Hospital Revenue Code	981
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$231.70
Rate for Payer: Cash Price	$264.80
Rate for Payer: Cash Price	$264.80
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$231.70

lactase 3000 units Tab

Facility IP

$1.39

Service Code	CPT A9270
Hospital Charge Code	43735488
Hospital Revenue Code	637
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$1.25
Rate for Payer: Aetna of IA Commercial	$1.25
Rate for Payer: Aetna of IA Medical Rental Products	$1.25
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.04
Rate for Payer: Medical Associates Commercial	$1.04
Rate for Payer: Midlands Choice Commercial	$0.97
Rate for Payer: United Healthcare Commercial	$1.25

lactase 3000 units Tab

Facility OP

$1.39

Service Code	CPT A9270
Hospital Charge Code	43735488
Hospital Revenue Code	637
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.25
Rate for Payer: Aetna of IA Commercial	$1.25
Rate for Payer: Aetna of IA Medical Rental Products	$1.25
Rate for Payer: Aetna of IA Medicare	$0.79
Rate for Payer: Amerigroup Medicaid	$0.70
Rate for Payer: Amerigroup Medicare	$0.70
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.04
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.70
Rate for Payer: Iowa Total Care Managed Medicaid	$0.69
Rate for Payer: Medical Associates Commercial	$1.04
Rate for Payer: Medical Associates Managed Medicare	$0.70
Rate for Payer: Midlands Choice Commercial	$0.97
Rate for Payer: Molina Healthcare Managed Medicaid	$0.71
Rate for Payer: Partners Health Alliance Commercial	$1.04
Rate for Payer: United Healthcare Commercial	$1.25
Rate for Payer: United Healthcare Managed Medicare	$0.82

Lactated Ringers Injection intravenous solution

Facility OP

$66.80

Service Code	CPT J7120
Hospital Charge Code	43700080
Hospital Revenue Code	636
Min. Negotiated Rate	$33.39
Max. Negotiated Rate	$60.12
Rate for Payer: Aetna of IA Commercial	$60.12
Rate for Payer: Aetna of IA Medical Rental Products	$60.12
Rate for Payer: Aetna of IA Medicare	$38.08
Rate for Payer: Amerigroup Medicaid	$33.71
Rate for Payer: Amerigroup Medicare	$33.73
Rate for Payer: Cash Price	$53.44
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$50.10
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$33.40
Rate for Payer: Iowa Total Care Managed Medicaid	$33.39
Rate for Payer: Medical Associates Commercial	$50.10
Rate for Payer: Medical Associates Managed Medicare	$33.40
Rate for Payer: Midlands Choice Commercial	$46.76
Rate for Payer: Molina Healthcare Managed Medicaid	$33.90
Rate for Payer: Partners Health Alliance Commercial	$50.10
Rate for Payer: United Healthcare Commercial	$60.12
Rate for Payer: United Healthcare Managed Medicare	$39.41

Lactated Ringers Injection intravenous solution

Facility IP

$74.52

Service Code	CPT J7120
Hospital Charge Code	43700079
Hospital Revenue Code	636
Min. Negotiated Rate	$52.16
Max. Negotiated Rate	$67.07
Rate for Payer: Aetna of IA Commercial	$67.07
Rate for Payer: Aetna of IA Medical Rental Products	$67.07
Rate for Payer: Cash Price	$59.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.89
Rate for Payer: Medical Associates Commercial	$55.89
Rate for Payer: Midlands Choice Commercial	$52.16
Rate for Payer: United Healthcare Commercial	$67.07

Lactated Ringers Injection intravenous solution

Facility OP

$74.52

Service Code	CPT J7120
Hospital Charge Code	43700079
Hospital Revenue Code	636
Min. Negotiated Rate	$37.25
Max. Negotiated Rate	$67.07
Rate for Payer: Aetna of IA Commercial	$67.07
Rate for Payer: Aetna of IA Medical Rental Products	$67.07
Rate for Payer: Aetna of IA Medicare	$42.48
Rate for Payer: Amerigroup Medicaid	$37.61
Rate for Payer: Amerigroup Medicare	$37.63
Rate for Payer: Cash Price	$59.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.89
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$37.26
Rate for Payer: Iowa Total Care Managed Medicaid	$37.25
Rate for Payer: Medical Associates Commercial	$55.89
Rate for Payer: Medical Associates Managed Medicare	$37.26
Rate for Payer: Midlands Choice Commercial	$52.16
Rate for Payer: Molina Healthcare Managed Medicaid	$37.82
Rate for Payer: Partners Health Alliance Commercial	$55.89
Rate for Payer: United Healthcare Commercial	$67.07
Rate for Payer: United Healthcare Managed Medicare	$43.97

Lactated Ringers Injection intravenous solution

Facility IP

$66.80

Service Code	CPT J7120
Hospital Charge Code	43700080
Hospital Revenue Code	636
Min. Negotiated Rate	$46.76
Max. Negotiated Rate	$60.12
Rate for Payer: Aetna of IA Commercial	$60.12
Rate for Payer: Aetna of IA Medical Rental Products	$60.12
Rate for Payer: Cash Price	$53.44
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$50.10
Rate for Payer: Medical Associates Commercial	$50.10
Rate for Payer: Midlands Choice Commercial	$46.76
Rate for Payer: United Healthcare Commercial	$60.12

LACTIC ACID

Facility OP

$139.00

Service Code	CPT 83605
Hospital Charge Code	1503766
Hospital Revenue Code	301
Min. Negotiated Rate	$45.88
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Aetna of IA Medicare	$79.23
Rate for Payer: Amerigroup Medicaid	$70.15
Rate for Payer: Amerigroup Medicare	$70.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$69.50
Rate for Payer: Iowa Total Care Managed Medicaid	$69.47
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$69.50
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$70.54
Rate for Payer: Partners Health Alliance Commercial	$104.25
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

LACTIC ACID

Facility IP

$139.00

Service Code	CPT 83605
Hospital Charge Code	1503766
Hospital Revenue Code	301
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: United Healthcare Commercial	$125.10

lactobacillus acidophilus and bulgaricus Chew Tab

Facility OP

$1.66

Service Code	CPT A9270
Hospital Charge Code	43766548
Hospital Revenue Code	637
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.49
Rate for Payer: Aetna of IA Commercial	$1.49
Rate for Payer: Aetna of IA Medical Rental Products	$1.49
Rate for Payer: Aetna of IA Medicare	$0.95
Rate for Payer: Amerigroup Medicaid	$0.84
Rate for Payer: Amerigroup Medicare	$0.84
Rate for Payer: Cash Price	$1.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.24
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.83
Rate for Payer: Iowa Total Care Managed Medicaid	$0.83
Rate for Payer: Medical Associates Commercial	$1.24
Rate for Payer: Medical Associates Managed Medicare	$0.83
Rate for Payer: Midlands Choice Commercial	$1.16
Rate for Payer: Molina Healthcare Managed Medicaid	$0.84
Rate for Payer: Partners Health Alliance Commercial	$1.24
Rate for Payer: United Healthcare Commercial	$1.49
Rate for Payer: United Healthcare Managed Medicare	$0.98

lactobacillus acidophilus and bulgaricus Chew Tab

Facility IP

$1.66

Service Code	CPT A9270
Hospital Charge Code	43766548
Hospital Revenue Code	637
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.49
Rate for Payer: Aetna of IA Commercial	$1.49
Rate for Payer: Aetna of IA Medical Rental Products	$1.49
Rate for Payer: Cash Price	$1.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.24
Rate for Payer: Medical Associates Commercial	$1.24
Rate for Payer: Midlands Choice Commercial	$1.16
Rate for Payer: United Healthcare Commercial	$1.49

lactulose 20 g/30 mL Syr UD

Facility OP

$7.93

Service Code	CPT A9270
Hospital Charge Code	43700419
Hospital Revenue Code	637
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$7.14
Rate for Payer: Aetna of IA Commercial	$7.14
Rate for Payer: Aetna of IA Medical Rental Products	$7.14
Rate for Payer: Aetna of IA Medicare	$4.52
Rate for Payer: Amerigroup Medicaid	$4.00
Rate for Payer: Amerigroup Medicare	$4.00
Rate for Payer: Cash Price	$6.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.96
Rate for Payer: Iowa Total Care Managed Medicaid	$3.96
Rate for Payer: Medical Associates Commercial	$5.95
Rate for Payer: Medical Associates Managed Medicare	$3.96
Rate for Payer: Midlands Choice Commercial	$5.55
Rate for Payer: Molina Healthcare Managed Medicaid	$4.02
Rate for Payer: Partners Health Alliance Commercial	$5.95
Rate for Payer: United Healthcare Commercial	$7.14
Rate for Payer: United Healthcare Managed Medicare	$4.68

lactulose 20 g/30 mL Syr UD

Facility IP

$7.93

Service Code	CPT A9270
Hospital Charge Code	43700419
Hospital Revenue Code	637
Min. Negotiated Rate	$5.55
Max. Negotiated Rate	$7.14
Rate for Payer: Aetna of IA Commercial	$7.14
Rate for Payer: Aetna of IA Medical Rental Products	$7.14
Rate for Payer: Cash Price	$6.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.95
Rate for Payer: Medical Associates Commercial	$5.95
Rate for Payer: Midlands Choice Commercial	$5.55
Rate for Payer: United Healthcare Commercial	$7.14

LAMINECT IMPL NS ELECTRODES EPIDURAL

Professional

$2,810.00

Service Code	CPT 63655
Hospital Charge Code	8015897
Hospital Revenue Code	975
Min. Negotiated Rate	$739.39
Max. Negotiated Rate	$1,967.00
Rate for Payer: Aetna of IA Medicare	$739.39
Rate for Payer: Amerigroup Medicaid	$764.53
Rate for Payer: Cash Price	$2,248.00
Rate for Payer: Cash Price	$2,248.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$887.27
Rate for Payer: Iowa Total Care Managed Medicaid	$754.18
Rate for Payer: Medical Associates Commercial	$1,404.84
Rate for Payer: Medical Associates Managed Medicare	$739.39
Rate for Payer: Midlands Choice Commercial	$1,967.00
Rate for Payer: Partners Health Alliance Commercial	$1,109.08
Rate for Payer: Wellmark IA HMO	$1,613.00
Rate for Payer: Wellmark IA PPO	$1,893.00

lamoTRIgine 100 mg Tab

Facility OP

$1.13

Service Code	CPT A9270
Hospital Charge Code	43754567
Hospital Revenue Code	637
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$1.02
Rate for Payer: Aetna of IA Commercial	$1.02
Rate for Payer: Aetna of IA Medical Rental Products	$1.02
Rate for Payer: Aetna of IA Medicare	$0.64
Rate for Payer: Amerigroup Medicaid	$0.57
Rate for Payer: Amerigroup Medicare	$0.57
Rate for Payer: Cash Price	$0.90
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.85
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.57
Rate for Payer: Iowa Total Care Managed Medicaid	$0.56
Rate for Payer: Medical Associates Commercial	$0.85
Rate for Payer: Medical Associates Managed Medicare	$0.57
Rate for Payer: Midlands Choice Commercial	$0.79
Rate for Payer: Molina Healthcare Managed Medicaid	$0.57
Rate for Payer: Partners Health Alliance Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$1.02
Rate for Payer: United Healthcare Managed Medicare	$0.67

lamoTRIgine 100 mg Tab

Facility IP

$1.13

Service Code	CPT A9270
Hospital Charge Code	43754567
Hospital Revenue Code	637
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.02
Rate for Payer: Aetna of IA Commercial	$1.02
Rate for Payer: Aetna of IA Medical Rental Products	$1.02
Rate for Payer: Cash Price	$0.90
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.85
Rate for Payer: Medical Associates Commercial	$0.85
Rate for Payer: Midlands Choice Commercial	$0.79
Rate for Payer: United Healthcare Commercial	$1.02

Price Transparency.

All Charges