Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

labetalol 100 mg Tab [VDMC]

Facility

$1.80

Service Code	HCPCS A9270
Hospital Charge Code	10398611
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.62
Rate for Payer: Aetna of IA Commercial	$1.62
Rate for Payer: Aetna of IA Medical Rental Products	$1.62
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.35
Rate for Payer: Medical Associates Commercial	$1.35
Rate for Payer: Midlands Choice Commercial	$1.26
Rate for Payer: United Healthcare Commercial	$1.62

labetalol 100 mg Tab [VDMC]

Facility

$1.80

Service Code	HCPCS A9270
Hospital Charge Code	10398611
Hospital Revenue Code	259
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.62
Rate for Payer: Aetna of IA Commercial	$1.62
Rate for Payer: Aetna of IA Medical Rental Products	$1.62
Rate for Payer: Aetna of IA Medicare	$1.03
Rate for Payer: Amerigroup Medicaid	$0.91
Rate for Payer: Amerigroup Medicare	$0.91
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.35
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.90
Rate for Payer: Iowa Total Care Managed Medicaid	$0.90
Rate for Payer: Medical Associates Commercial	$1.35
Rate for Payer: Medical Associates Managed Medicare	$0.90
Rate for Payer: Midlands Choice Commercial	$1.26
Rate for Payer: Molina Healthcare Managed Medicaid	$0.91
Rate for Payer: Molina Healthcare Managed Medicare	$0.91
Rate for Payer: Oscar Health of IA Commercial	$1.35
Rate for Payer: Partners Health Alliance Commercial	$1.35
Rate for Payer: United Healthcare Commercial	$1.62
Rate for Payer: United Healthcare Managed Medicare	$1.06

labetalol 5 mg/mL 20 ml IV MDV [VDMC]

Facility

$27.64

Service Code	HCPCS J3490
Hospital Charge Code	10398680
Hospital Revenue Code	259
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$24.88
Rate for Payer: Aetna of IA Commercial	$24.88
Rate for Payer: Aetna of IA Medical Rental Products	$24.88
Rate for Payer: Cash Price	$22.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.73
Rate for Payer: Medical Associates Commercial	$20.73
Rate for Payer: Midlands Choice Commercial	$19.35
Rate for Payer: United Healthcare Commercial	$24.88

labetalol 5 mg/mL 20 ml IV MDV [VDMC]

Facility

$27.64

Service Code	HCPCS J3490
Hospital Charge Code	10398680
Hospital Revenue Code	259
Min. Negotiated Rate	$13.81
Max. Negotiated Rate	$24.88
Rate for Payer: Aetna of IA Commercial	$24.88
Rate for Payer: Aetna of IA Medical Rental Products	$24.88
Rate for Payer: Aetna of IA Medicare	$15.75
Rate for Payer: Amerigroup Medicaid	$13.95
Rate for Payer: Amerigroup Medicare	$13.96
Rate for Payer: Cash Price	$22.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.73
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.82
Rate for Payer: Iowa Total Care Managed Medicaid	$13.81
Rate for Payer: Medical Associates Commercial	$20.73
Rate for Payer: Medical Associates Managed Medicare	$13.82
Rate for Payer: Midlands Choice Commercial	$19.35
Rate for Payer: Molina Healthcare Managed Medicaid	$14.03
Rate for Payer: Molina Healthcare Managed Medicare	$14.02
Rate for Payer: Oscar Health of IA Commercial	$20.73
Rate for Payer: Partners Health Alliance Commercial	$20.73
Rate for Payer: United Healthcare Commercial	$24.88
Rate for Payer: United Healthcare Managed Medicare	$16.31

labetalol 5 mg/mL 4ml syringe [VDMC]

Facility

$43.41

Service Code	HCPCS J3490
Hospital Charge Code	18871942
Hospital Revenue Code	259
Min. Negotiated Rate	$30.39
Max. Negotiated Rate	$39.07
Rate for Payer: Aetna of IA Commercial	$39.07
Rate for Payer: Aetna of IA Medical Rental Products	$39.07
Rate for Payer: Cash Price	$34.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.56
Rate for Payer: Medical Associates Commercial	$32.56
Rate for Payer: Midlands Choice Commercial	$30.39
Rate for Payer: United Healthcare Commercial	$39.07

labetalol 5 mg/mL 4ml syringe [VDMC]

Facility

$43.41

Service Code	HCPCS J3490
Hospital Charge Code	18871942
Hospital Revenue Code	259
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$39.07
Rate for Payer: Aetna of IA Commercial	$39.07
Rate for Payer: Aetna of IA Medical Rental Products	$39.07
Rate for Payer: Aetna of IA Medicare	$24.74
Rate for Payer: Amerigroup Medicaid	$21.91
Rate for Payer: Amerigroup Medicare	$21.92
Rate for Payer: Cash Price	$34.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.56
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$21.70
Rate for Payer: Iowa Total Care Managed Medicaid	$21.70
Rate for Payer: Medical Associates Commercial	$32.56
Rate for Payer: Medical Associates Managed Medicare	$21.70
Rate for Payer: Midlands Choice Commercial	$30.39
Rate for Payer: Molina Healthcare Managed Medicaid	$22.03
Rate for Payer: Molina Healthcare Managed Medicare	$22.02
Rate for Payer: Oscar Health of IA Commercial	$32.56
Rate for Payer: Partners Health Alliance Commercial	$32.56
Rate for Payer: United Healthcare Commercial	$39.07
Rate for Payer: United Healthcare Managed Medicare	$25.61

LABOR DIRECT ADMIT

Facility

$460.00

Service Code	CPT G0379
Hospital Charge Code	7984750
Hospital Revenue Code	721
Min. Negotiated Rate	$322.00
Max. Negotiated Rate	$414.00
Rate for Payer: Aetna of IA Commercial	$414.00
Rate for Payer: Aetna of IA Medical Rental Products	$414.00
Rate for Payer: Cash Price	$368.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$345.00
Rate for Payer: Medical Associates Commercial	$345.00
Rate for Payer: Midlands Choice Commercial	$322.00
Rate for Payer: United Healthcare Commercial	$414.00

LABOR DIRECT ADMIT

Facility

$460.00

Service Code	CPT G0379
Hospital Charge Code	7984750
Hospital Revenue Code	721
Min. Negotiated Rate	$229.91
Max. Negotiated Rate	$414.00
Rate for Payer: Aetna of IA Commercial	$414.00
Rate for Payer: Aetna of IA Medical Rental Products	$414.00
Rate for Payer: Aetna of IA Medicare	$262.20
Rate for Payer: Amerigroup Medicaid	$232.16
Rate for Payer: Amerigroup Medicare	$232.30
Rate for Payer: Cash Price	$368.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$345.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$230.00
Rate for Payer: Iowa Total Care Managed Medicaid	$229.91
Rate for Payer: Medical Associates Commercial	$345.00
Rate for Payer: Medical Associates Managed Medicare	$230.00
Rate for Payer: Midlands Choice Commercial	$322.00
Rate for Payer: Molina Healthcare Managed Medicaid	$233.45
Rate for Payer: Molina Healthcare Managed Medicare	$233.31
Rate for Payer: Oscar Health of IA Commercial	$345.00
Rate for Payer: Partners Health Alliance Commercial	$345.00
Rate for Payer: United Healthcare Commercial	$414.00
Rate for Payer: United Healthcare Managed Medicare	$271.40

LABOR PER HOUR

Facility

$62.00

Service Code	CPT G0378
Hospital Charge Code	7984749
Hospital Revenue Code	721
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of IA Commercial	$55.80
Rate for Payer: Aetna of IA Medical Rental Products	$55.80
Rate for Payer: Cash Price	$49.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$46.50
Rate for Payer: Medical Associates Commercial	$46.50
Rate for Payer: Midlands Choice Commercial	$43.40
Rate for Payer: United Healthcare Commercial	$55.80

LABOR PER HOUR

Facility

$62.00

Service Code	CPT G0378
Hospital Charge Code	7984749
Hospital Revenue Code	721
Min. Negotiated Rate	$30.99
Max. Negotiated Rate	$2,238.32
Rate for Payer: Aetna of IA Commercial	$55.80
Rate for Payer: Aetna of IA Medical Rental Products	$55.80
Rate for Payer: Aetna of IA Medicare	$35.34
Rate for Payer: Amerigroup Medicaid	$31.29
Rate for Payer: Amerigroup Medicare	$31.31
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cash Price	$49.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$46.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.00
Rate for Payer: Iowa Total Care Managed Medicaid	$30.99
Rate for Payer: Medical Associates Commercial	$46.50
Rate for Payer: Medical Associates Managed Medicare	$31.00
Rate for Payer: Midlands Choice Commercial	$43.40
Rate for Payer: Molina Healthcare Managed Medicaid	$31.46
Rate for Payer: Molina Healthcare Managed Medicare	$31.45
Rate for Payer: Oscar Health of IA Commercial	$46.50
Rate for Payer: Partners Health Alliance Commercial	$46.50
Rate for Payer: United Healthcare Commercial	$55.80
Rate for Payer: United Healthcare Managed Medicare	$36.58
Rate for Payer: Wellmark IA HMO	$2,034.84
Rate for Payer: Wellmark IA PPO	$2,238.32

LAC COMPLEX <2.5 CM CHOLE CHARGE

Professional

Both

$828.00

Hospital Charge Code	8069097
Hospital Revenue Code	981
Min. Negotiated Rate	$579.60
Max. Negotiated Rate	$621.00
Rate for Payer: Cash Price	$662.40
Rate for Payer: Medical Associates Commercial	$621.00
Rate for Payer: Midlands Choice Commercial	$579.60

LAC COMPLEX 2.6-7.5 CM CHARGE

Professional

Both

$1,152.00

Hospital Charge Code	8069062
Hospital Revenue Code	981
Min. Negotiated Rate	$806.40
Max. Negotiated Rate	$864.00
Rate for Payer: Cash Price	$921.60
Rate for Payer: Medical Associates Commercial	$864.00
Rate for Payer: Midlands Choice Commercial	$806.40

LAC COMPLEX EACH ADDT'L >7.6CM CHARGE

Professional

Both

$472.00

Hospital Charge Code	8069182
Hospital Revenue Code	981
Min. Negotiated Rate	$330.40
Max. Negotiated Rate	$354.00
Rate for Payer: Cash Price	$377.60
Rate for Payer: Medical Associates Commercial	$354.00
Rate for Payer: Midlands Choice Commercial	$330.40

LAC INTERMEDIATE 12.6-20 CM CHARGE

Professional

Both

$1,006.00

Hospital Charge Code	8069136
Hospital Revenue Code	981
Min. Negotiated Rate	$704.20
Max. Negotiated Rate	$754.50
Rate for Payer: Cash Price	$804.80
Rate for Payer: Medical Associates Commercial	$754.50
Rate for Payer: Midlands Choice Commercial	$704.20

LAC INTERMEDIATE 20.1-30 CM CHARGE

Professional

Both

$930.00

Hospital Charge Code	8069157
Hospital Revenue Code	981
Min. Negotiated Rate	$651.00
Max. Negotiated Rate	$697.50
Rate for Payer: Cash Price	$744.00
Rate for Payer: Medical Associates Commercial	$697.50
Rate for Payer: Midlands Choice Commercial	$651.00

LAC INTERMEDIATE <2.5 CM CHARGE

Professional

Both

$565.00

Hospital Charge Code	8068966
Hospital Revenue Code	981
Min. Negotiated Rate	$395.50
Max. Negotiated Rate	$423.75
Rate for Payer: Cash Price	$452.00
Rate for Payer: Medical Associates Commercial	$423.75
Rate for Payer: Midlands Choice Commercial	$395.50

LAC INTERMEDIATE 2.6-7.5 CM CHARGE

Professional

Both

$639.00

Hospital Charge Code	8068984
Hospital Revenue Code	981
Min. Negotiated Rate	$447.30
Max. Negotiated Rate	$479.25
Rate for Payer: Cash Price	$511.20
Rate for Payer: Medical Associates Commercial	$479.25
Rate for Payer: Midlands Choice Commercial	$447.30

LAC INTERMEDIATE >30.1 CM CHARGE

Professional

Both

$1,260.00

Hospital Charge Code	8069044
Hospital Revenue Code	981
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$945.00
Rate for Payer: Cash Price	$1,008.00
Rate for Payer: Medical Associates Commercial	$945.00
Rate for Payer: Midlands Choice Commercial	$882.00

LAC INTERMEDIATE 7.6-12.5 CM CHARGE

Professional

Both

$757.00

Hospital Charge Code	8069058
Hospital Revenue Code	981
Min. Negotiated Rate	$529.90
Max. Negotiated Rate	$567.75
Rate for Payer: Cash Price	$605.60
Rate for Payer: Medical Associates Commercial	$567.75
Rate for Payer: Midlands Choice Commercial	$529.90

LAC SIMPLE 7.6-12.5 CM CHARGE

Professional

Both

$331.00

Hospital Charge Code	8069026
Hospital Revenue Code	981
Min. Negotiated Rate	$231.70
Max. Negotiated Rate	$248.25
Rate for Payer: Cash Price	$264.80
Rate for Payer: Medical Associates Commercial	$248.25
Rate for Payer: Midlands Choice Commercial	$231.70

lactase 3000 units Tab [VDMC]

Facility

$1.39

Service Code	HCPCS A9270
Hospital Charge Code	10398749
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$0.71
Rate for Payer: Oscar Health of IA Commercial	$1.04
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

lactase 3000 units Tab [VDMC]

Facility

$1.39

Service Code	HCPCS A9270
Hospital Charge Code	10398749
Hospital Revenue Code	259
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

Lactated Ringers IV Sol 1000 mL [VDMC]

Facility

$66.80

Service Code	HCPCS J7120
Hospital Charge Code	10431110
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$33.88
Rate for Payer: Oscar Health of IA Commercial	$50.10
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 IV Sol 1000 mL [VDMC]

Facility

$66.80

Service Code	HCPCS J7120
Hospital Charge Code	10431110
Hospital Revenue Code	259
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

Lactated Ringers IV Sol 500 mL [VDMC]

Facility

$74.52

Service Code	HCPCS J7120
Hospital Charge Code	10431177
Hospital Revenue Code	259
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

Know your out-of-pocket cost for care.

All Charges