Van Diest Medical Center

All Charges

Charge

Type

Price

lamoTRIgine 25 mg Tab

Facility IP

$1.22

Service Code	CPT A9270
Hospital Charge Code	43726501
Hospital Revenue Code	637
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of IA Commercial	$1.10
Rate for Payer: Aetna of IA Medical Rental Products	$1.10
Rate for Payer: Cash Price	$0.98
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.92
Rate for Payer: Medical Associates Commercial	$0.92
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$1.10

lamoTRIgine 25 mg Tab

Facility OP

$1.22

Service Code	CPT A9270
Hospital Charge Code	43726501
Hospital Revenue Code	637
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of IA Commercial	$1.10
Rate for Payer: Aetna of IA Medical Rental Products	$1.10
Rate for Payer: Aetna of IA Medicare	$0.70
Rate for Payer: Amerigroup Medicaid	$0.62
Rate for Payer: Amerigroup Medicare	$0.62
Rate for Payer: Cash Price	$0.98
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.61
Rate for Payer: Iowa Total Care Managed Medicaid	$0.61
Rate for Payer: Medical Associates Commercial	$0.92
Rate for Payer: Medical Associates Managed Medicare	$0.61
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: Molina Healthcare Managed Medicaid	$0.62
Rate for Payer: Partners Health Alliance Commercial	$0.92
Rate for Payer: United Healthcare Commercial	$1.10
Rate for Payer: United Healthcare Managed Medicare	$0.72

Lamotrigine Level DMCL

Facility OP

$121.00

Service Code	CPT 80175
Hospital Charge Code	8037722
Hospital Revenue Code	301
Min. Negotiated Rate	$49.60
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of IA Commercial	$108.90
Rate for Payer: Aetna of IA Medical Rental Products	$108.90
Rate for Payer: Aetna of IA Medicare	$68.97
Rate for Payer: Amerigroup Medicaid	$61.07
Rate for Payer: Amerigroup Medicare	$61.10
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$90.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$60.50
Rate for Payer: Iowa Total Care Managed Medicaid	$60.48
Rate for Payer: Medical Associates Commercial	$90.75
Rate for Payer: Medical Associates Managed Medicare	$60.50
Rate for Payer: Midlands Choice Commercial	$84.70
Rate for Payer: Molina Healthcare Managed Medicaid	$61.41
Rate for Payer: Partners Health Alliance Commercial	$90.75
Rate for Payer: United Healthcare Commercial	$108.90
Rate for Payer: United Healthcare Managed Medicare	$71.39
Rate for Payer: Wellmark IA HMO	$49.60
Rate for Payer: Wellmark IA PPO	$54.56

Lamotrigine Level DMCL

Facility IP

$121.00

Service Code	CPT 80175
Hospital Charge Code	8037722
Hospital Revenue Code	301
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of IA Commercial	$108.90
Rate for Payer: Aetna of IA Medical Rental Products	$108.90
Rate for Payer: Cash Price	$96.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$90.75
Rate for Payer: Medical Associates Commercial	$90.75
Rate for Payer: Midlands Choice Commercial	$84.70
Rate for Payer: United Healthcare Commercial	$108.90

lansoprazole 30 mg Oral EC Cap

Facility IP

$1.33

Service Code	CPT A9270
Hospital Charge Code	43702741
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of IA Commercial	$1.20
Rate for Payer: Aetna of IA Medical Rental Products	$1.20
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Midlands Choice Commercial	$0.93
Rate for Payer: United Healthcare Commercial	$1.20

lansoprazole 30 mg Oral EC Cap

Facility OP

$1.33

Service Code	CPT A9270
Hospital Charge Code	43702741
Hospital Revenue Code	637
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of IA Commercial	$1.20
Rate for Payer: Aetna of IA Medical Rental Products	$1.20
Rate for Payer: Aetna of IA Medicare	$0.76
Rate for Payer: Amerigroup Medicaid	$0.67
Rate for Payer: Amerigroup Medicare	$0.67
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.67
Rate for Payer: Iowa Total Care Managed Medicaid	$0.66
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Medical Associates Managed Medicare	$0.67
Rate for Payer: Midlands Choice Commercial	$0.93
Rate for Payer: Molina Healthcare Managed Medicaid	$0.67
Rate for Payer: Partners Health Alliance Commercial	$1.00
Rate for Payer: United Healthcare Commercial	$1.20
Rate for Payer: United Healthcare Managed Medicare	$0.78

lansoprazole 3 mg/mL 300ml Suspenion

Facility IP

$394.24

Service Code	CPT A9270
Hospital Charge Code	43700551
Hospital Revenue Code	637
Min. Negotiated Rate	$275.97
Max. Negotiated Rate	$354.82
Rate for Payer: Aetna of IA Commercial	$354.82
Rate for Payer: Aetna of IA Medical Rental Products	$354.82
Rate for Payer: Cash Price	$315.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.68
Rate for Payer: Medical Associates Commercial	$295.68
Rate for Payer: Midlands Choice Commercial	$275.97
Rate for Payer: United Healthcare Commercial	$354.82

lansoprazole 3 mg/mL 300ml Suspenion

Facility OP

$394.24

Service Code	CPT A9270
Hospital Charge Code	43700551
Hospital Revenue Code	637
Min. Negotiated Rate	$197.04
Max. Negotiated Rate	$354.82
Rate for Payer: Aetna of IA Commercial	$354.82
Rate for Payer: Aetna of IA Medical Rental Products	$354.82
Rate for Payer: Aetna of IA Medicare	$224.72
Rate for Payer: Amerigroup Medicaid	$198.97
Rate for Payer: Amerigroup Medicare	$199.09
Rate for Payer: Cash Price	$315.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.68
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$197.12
Rate for Payer: Iowa Total Care Managed Medicaid	$197.04
Rate for Payer: Medical Associates Commercial	$295.68
Rate for Payer: Medical Associates Managed Medicare	$197.12
Rate for Payer: Midlands Choice Commercial	$275.97
Rate for Payer: Molina Healthcare Managed Medicaid	$200.08
Rate for Payer: Partners Health Alliance Commercial	$295.68
Rate for Payer: United Healthcare Commercial	$354.82
Rate for Payer: United Healthcare Managed Medicare	$232.60

LAP; ABD PERIT OMENTUM W ASP CYST

Professional

$1,245.00

Service Code	CPT 49322
Hospital Charge Code	8069087
Hospital Revenue Code	983
Min. Negotiated Rate	$334.19
Max. Negotiated Rate	$871.50
Rate for Payer: Aetna of IA Medicare	$334.19
Rate for Payer: Amerigroup Medicaid	$345.55
Rate for Payer: Cash Price	$996.00
Rate for Payer: Cash Price	$996.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$401.03
Rate for Payer: Iowa Total Care Managed Medicaid	$340.87
Rate for Payer: Medical Associates Commercial	$634.96
Rate for Payer: Medical Associates Managed Medicare	$334.19
Rate for Payer: Midlands Choice Commercial	$871.50
Rate for Payer: Partners Health Alliance Commercial	$501.28
Rate for Payer: Wellmark IA HMO	$715.00
Rate for Payer: Wellmark IA PPO	$840.00

Laparoscopic Cholecystectomy Without C.D.E. With CC

Facility IP

$13,936.86

Service Code	MS-DRG 418
Hospital Charge Code	250
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$13,936.86
Rate for Payer: Amerigroup Medicaid	$13,869.54
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$13,734.88
Rate for Payer: Molina Healthcare Managed Medicaid	$13,936.86

Laparoscopic Cholecystectomy Without C.D.E. With MCC

Facility IP

$16,302.00

Service Code	MS-DRG 417
Hospital Charge Code	249
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$16,302.00
Rate for Payer: Amerigroup Medicaid	$16,223.24
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$16,065.73
Rate for Payer: Molina Healthcare Managed Medicaid	$16,302.00

Laparoscopic Cholecystectomy Without C.D.E. Without CC/MCC

Facility IP

$11,078.62

Service Code	MS-DRG 419
Hospital Charge Code	251
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,078.62
Rate for Payer: Amerigroup Medicaid	$11,025.10
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$10,918.06
Rate for Payer: Molina Healthcare Managed Medicaid	$11,078.62

Laparoscopic colectomy partial with anastomosis

Professional

$5,204.00

Service Code	CPT 44204
Hospital Charge Code	8068987
Hospital Revenue Code	975
Min. Negotiated Rate	$1,358.92
Max. Negotiated Rate	$3,642.80
Rate for Payer: Aetna of IA Medicare	$1,358.92
Rate for Payer: Amerigroup Medicaid	$1,405.12
Rate for Payer: Cash Price	$4,163.20
Rate for Payer: Cash Price	$4,163.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,630.70
Rate for Payer: Iowa Total Care Managed Medicaid	$1,386.10
Rate for Payer: Medical Associates Commercial	$2,581.95
Rate for Payer: Medical Associates Managed Medicare	$1,358.92
Rate for Payer: Midlands Choice Commercial	$3,642.80
Rate for Payer: Partners Health Alliance Commercial	$2,038.38
Rate for Payer: Wellmark IA HMO	$2,906.00
Rate for Payer: Wellmark IA PPO	$3,411.00

Laparoscopic urethral sling for stress incontinence

Professional

$2,826.00

Service Code	CPT 51992
Hospital Charge Code	8069155
Hospital Revenue Code	975
Min. Negotiated Rate	$756.60
Max. Negotiated Rate	$1,978.20
Rate for Payer: Aetna of IA Medicare	$756.60
Rate for Payer: Amerigroup Medicaid	$782.32
Rate for Payer: Cash Price	$2,260.80
Rate for Payer: Cash Price	$2,260.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$907.92
Rate for Payer: Iowa Total Care Managed Medicaid	$771.73
Rate for Payer: Medical Associates Commercial	$1,437.54
Rate for Payer: Medical Associates Managed Medicare	$756.60
Rate for Payer: Midlands Choice Commercial	$1,978.20
Rate for Payer: Partners Health Alliance Commercial	$1,134.90
Rate for Payer: Wellmark IA HMO	$1,579.00
Rate for Payer: Wellmark IA PPO	$1,853.00

Laparoscopy, surgical, appendectomy

Facility OP

$9,126.52

Service Code	CPT 44970
Hospital Revenue Code	360
Min. Negotiated Rate	$8,296.84
Max. Negotiated Rate	$9,126.52
Rate for Payer: Wellmark IA HMO	$8,296.84
Rate for Payer: Wellmark IA PPO	$9,126.52

Laparoscopy, surgical; cholecystectomy

Facility OP

$9,126.52

Service Code	CPT 47562
Hospital Revenue Code	360
Min. Negotiated Rate	$8,296.84
Max. Negotiated Rate	$9,126.52
Rate for Payer: Wellmark IA HMO	$8,296.84
Rate for Payer: Wellmark IA PPO	$9,126.52

Laparoscopy; surgical; enterolysis (separate procedure)

Professional

$3,106.00

Service Code	CPT 44180
Hospital Charge Code	8069049
Hospital Revenue Code	975
Min. Negotiated Rate	$813.37
Max. Negotiated Rate	$2,174.20
Rate for Payer: Aetna of IA Medicare	$813.37
Rate for Payer: Amerigroup Medicaid	$841.02
Rate for Payer: Cash Price	$2,484.80
Rate for Payer: Cash Price	$2,484.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$976.04
Rate for Payer: Iowa Total Care Managed Medicaid	$829.64
Rate for Payer: Medical Associates Commercial	$1,545.40
Rate for Payer: Medical Associates Managed Medicare	$813.37
Rate for Payer: Midlands Choice Commercial	$2,174.20
Rate for Payer: Partners Health Alliance Commercial	$1,220.06
Rate for Payer: Wellmark IA HMO	$1,749.00
Rate for Payer: Wellmark IA PPO	$2,053.00

Laparoscopy, surgical; repair initial inguinal hernia

Facility OP

$9,126.52

Service Code	CPT 49650
Hospital Revenue Code	360
Min. Negotiated Rate	$8,296.84
Max. Negotiated Rate	$9,126.52
Rate for Payer: Wellmark IA HMO	$8,296.84
Rate for Payer: Wellmark IA PPO	$9,126.52

LAPIDUS VLC GRIDLOCK PLATE NEUTRAL

Facility IP

$2,592.00

Service Code	CPT C1713
Hospital Charge Code	8463688
Hospital Revenue Code	278
Min. Negotiated Rate	$1,814.40
Max. Negotiated Rate	$2,332.80
Rate for Payer: Aetna of IA Commercial	$2,332.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,332.80
Rate for Payer: Cash Price	$2,073.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,944.00
Rate for Payer: Medical Associates Commercial	$1,944.00
Rate for Payer: Midlands Choice Commercial	$1,814.40
Rate for Payer: United Healthcare Commercial	$2,332.80

LAPIDUS VLC GRIDLOCK PLATE NEUTRAL

Facility OP

$2,592.00

Service Code	CPT C1713
Hospital Charge Code	8463688
Hospital Revenue Code	278
Min. Negotiated Rate	$1,295.48
Max. Negotiated Rate	$2,332.80
Rate for Payer: Aetna of IA Commercial	$2,332.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,332.80
Rate for Payer: Aetna of IA Medicare	$1,477.44
Rate for Payer: Amerigroup Medicaid	$1,308.18
Rate for Payer: Amerigroup Medicare	$1,308.96
Rate for Payer: Cash Price	$2,073.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,944.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,296.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,295.48
Rate for Payer: Medical Associates Commercial	$1,944.00
Rate for Payer: Medical Associates Managed Medicare	$1,296.00
Rate for Payer: Midlands Choice Commercial	$1,814.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1,315.44
Rate for Payer: Partners Health Alliance Commercial	$1,944.00
Rate for Payer: United Healthcare Commercial	$2,332.80
Rate for Payer: United Healthcare Managed Medicare	$1,529.28

latanoprost Ophth 0.005% 2.5 ml Sol

Facility IP

$53.24

Service Code	CPT A9270
Hospital Charge Code	43705863
Hospital Revenue Code	637
Min. Negotiated Rate	$37.27
Max. Negotiated Rate	$47.92
Rate for Payer: Aetna of IA Commercial	$47.92
Rate for Payer: Aetna of IA Medical Rental Products	$47.92
Rate for Payer: Cash Price	$42.59
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.93
Rate for Payer: Medical Associates Commercial	$39.93
Rate for Payer: Midlands Choice Commercial	$37.27
Rate for Payer: United Healthcare Commercial	$47.92

latanoprost Ophth 0.005% 2.5 ml Sol

Facility OP

$53.24

Service Code	CPT A9270
Hospital Charge Code	43705863
Hospital Revenue Code	637
Min. Negotiated Rate	$26.61
Max. Negotiated Rate	$47.92
Rate for Payer: Aetna of IA Commercial	$47.92
Rate for Payer: Aetna of IA Medical Rental Products	$47.92
Rate for Payer: Aetna of IA Medicare	$30.35
Rate for Payer: Amerigroup Medicaid	$26.87
Rate for Payer: Amerigroup Medicare	$26.89
Rate for Payer: Cash Price	$42.59
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.93
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.62
Rate for Payer: Iowa Total Care Managed Medicaid	$26.61
Rate for Payer: Medical Associates Commercial	$39.93
Rate for Payer: Medical Associates Managed Medicare	$26.62
Rate for Payer: Midlands Choice Commercial	$37.27
Rate for Payer: Molina Healthcare Managed Medicaid	$27.02
Rate for Payer: Partners Health Alliance Commercial	$39.93
Rate for Payer: United Healthcare Commercial	$47.92
Rate for Payer: United Healthcare Managed Medicare	$31.41

L-Carnitine 500mg

Facility OP

$2.36

Service Code	CPT A9720
Hospital Charge Code	43700575
Hospital Revenue Code	637
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$2.12
Rate for Payer: Aetna of IA Commercial	$2.12
Rate for Payer: Aetna of IA Medical Rental Products	$2.12
Rate for Payer: Aetna of IA Medicare	$1.35
Rate for Payer: Amerigroup Medicaid	$1.19
Rate for Payer: Amerigroup Medicare	$1.19
Rate for Payer: Cash Price	$1.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.77
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.18
Rate for Payer: Iowa Total Care Managed Medicaid	$1.18
Rate for Payer: Medical Associates Commercial	$1.77
Rate for Payer: Medical Associates Managed Medicare	$1.18
Rate for Payer: Midlands Choice Commercial	$1.65
Rate for Payer: Molina Healthcare Managed Medicaid	$1.20
Rate for Payer: Partners Health Alliance Commercial	$1.77
Rate for Payer: United Healthcare Commercial	$2.12
Rate for Payer: United Healthcare Managed Medicare	$1.39

L-Carnitine 500mg

Facility IP

$2.36

Service Code	CPT A9720
Hospital Charge Code	43700575
Hospital Revenue Code	637
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$2.12
Rate for Payer: Aetna of IA Commercial	$2.12
Rate for Payer: Aetna of IA Medical Rental Products	$2.12
Rate for Payer: Cash Price	$1.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.77
Rate for Payer: Medical Associates Commercial	$1.77
Rate for Payer: Midlands Choice Commercial	$1.65
Rate for Payer: United Healthcare Commercial	$2.12

L-carnitine 500mg Tab

Facility OP

$2.22

Service Code	CPT A9270
Hospital Charge Code	43700335
Hospital Revenue Code	637
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna of IA Commercial	$2.00
Rate for Payer: Aetna of IA Medical Rental Products	$2.00
Rate for Payer: Aetna of IA Medicare	$1.27
Rate for Payer: Amerigroup Medicaid	$1.12
Rate for Payer: Amerigroup Medicare	$1.12
Rate for Payer: Cash Price	$1.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.66
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.11
Rate for Payer: Iowa Total Care Managed Medicaid	$1.11
Rate for Payer: Medical Associates Commercial	$1.66
Rate for Payer: Medical Associates Managed Medicare	$1.11
Rate for Payer: Midlands Choice Commercial	$1.55
Rate for Payer: Molina Healthcare Managed Medicaid	$1.13
Rate for Payer: Partners Health Alliance Commercial	$1.66
Rate for Payer: United Healthcare Commercial	$2.00
Rate for Payer: United Healthcare Managed Medicare	$1.31

Price Transparency.

All Charges