Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

lactobacillus acidophilus and bulgaricus Chew Tab [VDMC]

Facility

$1.91

Service Code	HCPCS A9270
Hospital Charge Code	10398885
Hospital Revenue Code	259
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$1.72
Rate for Payer: Aetna of IA Commercial	$1.72
Rate for Payer: Aetna of IA Medical Rental Products	$1.72
Rate for Payer: Cash Price	$1.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.43
Rate for Payer: Medical Associates Commercial	$1.43
Rate for Payer: Midlands Choice Commercial	$1.34
Rate for Payer: United Healthcare Commercial	$1.72

lactobacillus acidophilus and bulgaricus Chew Tab [VDMC]

Facility

$1.91

Service Code	HCPCS A9270
Hospital Charge Code	10398885
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.72
Rate for Payer: Aetna of IA Commercial	$1.72
Rate for Payer: Aetna of IA Medical Rental Products	$1.72
Rate for Payer: Aetna of IA Medicare	$1.09
Rate for Payer: Amerigroup Medicaid	$1.10
Rate for Payer: Amerigroup Medicare	$0.87
Rate for Payer: Cash Price	$1.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.43
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	$1.09
Rate for Payer: Medical Associates Commercial	$1.43
Rate for Payer: Medical Associates Managed Medicare	$0.86
Rate for Payer: Midlands Choice Commercial	$1.34
Rate for Payer: Molina Healthcare Managed Medicaid	$1.11
Rate for Payer: Partners Health Alliance Commercial	$0.99
Rate for Payer: United Healthcare Commercial	$1.72
Rate for Payer: United Healthcare Managed Medicare	$1.13

lactulose 20 g/30 mL Syr UD [VDMC]

Facility

$7.55

Service Code	HCPCS A9270
Hospital Charge Code	11222102
Hospital Revenue Code	259
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$6.79
Rate for Payer: Aetna of IA Commercial	$6.79
Rate for Payer: Aetna of IA Medical Rental Products	$6.79
Rate for Payer: Cash Price	$6.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.66
Rate for Payer: Medical Associates Commercial	$5.66
Rate for Payer: Midlands Choice Commercial	$5.28
Rate for Payer: United Healthcare Commercial	$6.79

lactulose 20 g/30 mL Syr UD [VDMC]

Facility

$7.55

Service Code	HCPCS A9270
Hospital Charge Code	11222102
Hospital Revenue Code	259
Min. Negotiated Rate	$3.40
Max. Negotiated Rate	$6.79
Rate for Payer: Aetna of IA Commercial	$6.79
Rate for Payer: Aetna of IA Medical Rental Products	$6.79
Rate for Payer: Aetna of IA Medicare	$4.30
Rate for Payer: Amerigroup Medicaid	$4.35
Rate for Payer: Amerigroup Medicare	$3.43
Rate for Payer: Cash Price	$6.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.66
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.40
Rate for Payer: Iowa Total Care Managed Medicaid	$4.31
Rate for Payer: Medical Associates Commercial	$5.66
Rate for Payer: Medical Associates Managed Medicare	$3.40
Rate for Payer: Midlands Choice Commercial	$5.28
Rate for Payer: Molina Healthcare Managed Medicaid	$4.37
Rate for Payer: Partners Health Alliance Commercial	$3.91
Rate for Payer: United Healthcare Commercial	$6.79
Rate for Payer: United Healthcare Managed Medicare	$4.45

LAMINECT IMPL NS ELECTRODES EPIDURAL

Professional

Both

$2,810.00

Service Code	CPT 63655
Hospital Charge Code	8015897
Hospital Revenue Code	975
Min. Negotiated Rate	$1,219.90
Max. Negotiated Rate	$2,107.50
Rate for Payer: Cash Price	$2,248.00
Rate for Payer: Cash Price	$2,248.00
Rate for Payer: Medical Associates Commercial	$2,107.50
Rate for Payer: Midlands Choice Commercial	$1,967.00
Rate for Payer: Partners Health Alliance Commercial	$2,107.50
Rate for Payer: United Healthcare Commercial	$1,219.90

lamoTRIgine 100 mg Tab [VDMC]

Facility

$1.13

Service Code	HCPCS A9270
Hospital Charge Code	10398954
Hospital Revenue Code	259
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

lamoTRIgine 100 mg Tab [VDMC]

Facility

$1.13

Service Code	HCPCS A9270
Hospital Charge Code	10398954
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
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	$0.65
Rate for Payer: Amerigroup Medicare	$0.51
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	$0.51
Rate for Payer: Iowa Total Care Managed Medicaid	$0.65
Rate for Payer: Medical Associates Commercial	$0.85
Rate for Payer: Medical Associates Managed Medicare	$0.51
Rate for Payer: Midlands Choice Commercial	$0.79
Rate for Payer: Molina Healthcare Managed Medicaid	$0.65
Rate for Payer: Partners Health Alliance Commercial	$0.58
Rate for Payer: United Healthcare Commercial	$1.02
Rate for Payer: United Healthcare Managed Medicare	$0.67

lamoTRIgine 25 mg Tab [VDMC]

Facility

$1.22

Service Code	HCPCS A9270
Hospital Charge Code	10399025
Hospital Revenue Code	259
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 [VDMC]

Facility

$1.22

Service Code	HCPCS A9270
Hospital Charge Code	10399025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
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	$0.70
Rate for Payer: Amerigroup Medicare	$0.55
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	$0.55
Rate for Payer: Iowa Total Care Managed Medicaid	$0.70
Rate for Payer: Medical Associates Commercial	$0.92
Rate for Payer: Medical Associates Managed Medicare	$0.55
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: Molina Healthcare Managed Medicaid	$0.71
Rate for Payer: Partners Health Alliance Commercial	$0.63
Rate for Payer: United Healthcare Commercial	$1.10
Rate for Payer: United Healthcare Managed Medicare	$0.72

Lamotrigine Level DMCL

Facility

$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

Lamotrigine Level DMCL

Facility

$121.00

Service Code	CPT 80175
Hospital Charge Code	8037722
Hospital Revenue Code	301
Min. Negotiated Rate	$54.45
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	$69.79
Rate for Payer: Amerigroup Medicare	$54.99
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	$54.45
Rate for Payer: Iowa Total Care Managed Medicaid	$69.12
Rate for Payer: Medical Associates Commercial	$90.75
Rate for Payer: Medical Associates Managed Medicare	$54.45
Rate for Payer: Midlands Choice Commercial	$84.70
Rate for Payer: Molina Healthcare Managed Medicaid	$70.13
Rate for Payer: Partners Health Alliance Commercial	$62.62
Rate for Payer: United Healthcare Commercial	$108.90
Rate for Payer: United Healthcare Managed Medicare	$71.39

lansoprazole 30 mg Oral EC Cap [VDMC]

Facility

$1.33

Service Code	HCPCS A9270
Hospital Charge Code	10399094
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
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	$0.77
Rate for Payer: Amerigroup Medicare	$0.61
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	$0.60
Rate for Payer: Iowa Total Care Managed Medicaid	$0.76
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Medical Associates Managed Medicare	$0.60
Rate for Payer: Midlands Choice Commercial	$0.93
Rate for Payer: Molina Healthcare Managed Medicaid	$0.77
Rate for Payer: Partners Health Alliance Commercial	$0.69
Rate for Payer: United Healthcare Commercial	$1.20
Rate for Payer: United Healthcare Managed Medicare	$0.79

lansoprazole 30 mg Oral EC Cap [VDMC]

Facility

$1.33

Service Code	HCPCS A9270
Hospital Charge Code	10399094
Hospital Revenue Code	259
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

LAP; ABD PERIT OMENTUM W ASP CYST

Professional

Both

$1,245.00

Service Code	CPT 49322
Hospital Charge Code	8069087
Hospital Revenue Code	975
Min. Negotiated Rate	$564.54
Max. Negotiated Rate	$933.75
Rate for Payer: Cash Price	$996.00
Rate for Payer: Cash Price	$996.00
Rate for Payer: Medical Associates Commercial	$933.75
Rate for Payer: Midlands Choice Commercial	$871.50
Rate for Payer: Partners Health Alliance Commercial	$933.75
Rate for Payer: United Healthcare Commercial	$564.54

Laparoscopic colectomy partial with anastomosis

Professional

Both

$5,204.00

Service Code	CPT 44204
Hospital Charge Code	8068987
Hospital Revenue Code	975
Min. Negotiated Rate	$2,328.74
Max. Negotiated Rate	$3,903.00
Rate for Payer: Cash Price	$4,163.20
Rate for Payer: Cash Price	$4,163.20
Rate for Payer: Medical Associates Commercial	$3,903.00
Rate for Payer: Midlands Choice Commercial	$3,642.80
Rate for Payer: Partners Health Alliance Commercial	$3,903.00
Rate for Payer: United Healthcare Commercial	$2,328.74

Laparoscopic urethral sling for stress incontinence

Professional

Both

$2,826.00

Service Code	CPT 51992
Hospital Charge Code	8069155
Hospital Revenue Code	975
Min. Negotiated Rate	$1,293.39
Max. Negotiated Rate	$2,119.50
Rate for Payer: Cash Price	$2,260.80
Rate for Payer: Cash Price	$2,260.80
Rate for Payer: Medical Associates Commercial	$2,119.50
Rate for Payer: Midlands Choice Commercial	$1,978.20
Rate for Payer: Partners Health Alliance Commercial	$2,119.50
Rate for Payer: United Healthcare Commercial	$1,293.39

Laparoscopy; surgical; enterolysis (separate procedure)

Professional

Both

$3,106.00

Service Code	CPT 44180
Hospital Charge Code	8069049
Hospital Revenue Code	975
Min. Negotiated Rate	$1,386.91
Max. Negotiated Rate	$2,329.50
Rate for Payer: Cash Price	$2,484.80
Rate for Payer: Cash Price	$2,484.80
Rate for Payer: Medical Associates Commercial	$2,329.50
Rate for Payer: Midlands Choice Commercial	$2,174.20
Rate for Payer: Partners Health Alliance Commercial	$2,329.50
Rate for Payer: United Healthcare Commercial	$1,386.91

Laparoscopy; surgical; with aspiration of cavity or cyst (single or multiple)

Professional

Both

$1,245.00

Service Code	CPT 49322
Hospital Charge Code	8378860
Hospital Revenue Code	975
Min. Negotiated Rate	$564.54
Max. Negotiated Rate	$933.75
Rate for Payer: Cash Price	$996.00
Rate for Payer: Cash Price	$996.00
Rate for Payer: Medical Associates Commercial	$933.75
Rate for Payer: Midlands Choice Commercial	$871.50
Rate for Payer: Partners Health Alliance Commercial	$933.75
Rate for Payer: United Healthcare Commercial	$564.54

LAPIDUS VLC GRIDLOCK PLATE NEUTRAL

Facility

$2,592.00

Service Code	HCPCS 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

$2,592.00

Service Code	HCPCS C1713
Hospital Charge Code	8463688
Hospital Revenue Code	278
Min. Negotiated Rate	$1,166.40
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: Aetna of IA Medicare	$1,477.44
Rate for Payer: Amerigroup Medicaid	$1,495.07
Rate for Payer: Amerigroup Medicare	$1,178.06
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	$1,166.40
Rate for Payer: Iowa Total Care Managed Medicaid	$1,480.55
Rate for Payer: Medical Associates Commercial	$1,944.00
Rate for Payer: Medical Associates Managed Medicare	$1,166.40
Rate for Payer: Midlands Choice Commercial	$1,814.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1,502.32
Rate for Payer: Partners Health Alliance Commercial	$1,341.36
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 [VDMC]

Facility

$29.24

Service Code	HCPCS A9270
Hospital Charge Code	10435379
Hospital Revenue Code	259
Min. Negotiated Rate	$20.47
Max. Negotiated Rate	$26.32
Rate for Payer: Aetna of IA Commercial	$26.32
Rate for Payer: Aetna of IA Medical Rental Products	$26.32
Rate for Payer: Cash Price	$23.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.93
Rate for Payer: Medical Associates Commercial	$21.93
Rate for Payer: Midlands Choice Commercial	$20.47
Rate for Payer: United Healthcare Commercial	$26.32

latanoprost Ophth 0.005% 2.5 ml Sol [VDMC]

Facility

$29.24

Service Code	HCPCS A9270
Hospital Charge Code	10435379
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$26.32
Rate for Payer: Aetna of IA Commercial	$26.32
Rate for Payer: Aetna of IA Medical Rental Products	$26.32
Rate for Payer: Aetna of IA Medicare	$16.67
Rate for Payer: Amerigroup Medicaid	$16.87
Rate for Payer: Amerigroup Medicare	$13.29
Rate for Payer: Cash Price	$23.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.93
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.16
Rate for Payer: Iowa Total Care Managed Medicaid	$16.70
Rate for Payer: Medical Associates Commercial	$21.93
Rate for Payer: Medical Associates Managed Medicare	$13.16
Rate for Payer: Midlands Choice Commercial	$20.47
Rate for Payer: Molina Healthcare Managed Medicaid	$16.95
Rate for Payer: Partners Health Alliance Commercial	$15.13
Rate for Payer: United Healthcare Commercial	$26.32
Rate for Payer: United Healthcare Managed Medicare	$17.25

L-carnitine 500mg Tab [VDMC]

Facility

$2.22

Service Code	HCPCS A9270
Hospital Charge Code	11521770
Hospital Revenue Code	259
Min. Negotiated Rate	$1.00
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	$1.28
Rate for Payer: Amerigroup Medicare	$1.01
Rate for Payer: Cash Price	$1.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.67
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1.27
Rate for Payer: Medical Associates Commercial	$1.67
Rate for Payer: Medical Associates Managed Medicare	$1.00
Rate for Payer: Midlands Choice Commercial	$1.55
Rate for Payer: Molina Healthcare Managed Medicaid	$1.29
Rate for Payer: Partners Health Alliance Commercial	$1.15
Rate for Payer: United Healthcare Commercial	$2.00
Rate for Payer: United Healthcare Managed Medicare	$1.31

L-carnitine 500mg Tab [VDMC]

Facility

$2.22

Service Code	HCPCS A9270
Hospital Charge Code	11521770
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
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: Cash Price	$1.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.67
Rate for Payer: Medical Associates Commercial	$1.67
Rate for Payer: Midlands Choice Commercial	$1.55
Rate for Payer: United Healthcare Commercial	$2.00

L-Carnitine 500mg [VDMC]

Facility

$2.62

Service Code	HCPCS A9720
Hospital Charge Code	23410802
Hospital Revenue Code	259
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.36
Rate for Payer: Aetna of IA Commercial	$2.36
Rate for Payer: Aetna of IA Medical Rental Products	$2.36
Rate for Payer: Cash Price	$2.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.97
Rate for Payer: Medical Associates Commercial	$1.97
Rate for Payer: Midlands Choice Commercial	$1.84
Rate for Payer: United Healthcare Commercial	$2.36

Know your out-of-pocket cost for care.

All Charges