Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Partners Health Alliance Commercial	$423.75

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
Rate for Payer: Partners Health Alliance Commercial	$479.25

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
Rate for Payer: Partners Health Alliance Commercial	$945.00

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
Rate for Payer: Partners Health Alliance Commercial	$567.75

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
Rate for Payer: Partners Health Alliance Commercial	$248.25

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	$30.06
Max. Negotiated Rate	$221.80
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	$38.53
Rate for Payer: Amerigroup Medicare	$30.36
Rate for Payer: Cash Price	$53.44
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	$30.06
Rate for Payer: Iowa Total Care Managed Medicaid	$38.16
Rate for Payer: Medical Associates Commercial	$50.10
Rate for Payer: Medical Associates Managed Medicare	$30.06
Rate for Payer: Midlands Choice Commercial	$46.76
Rate for Payer: Molina Healthcare Managed Medicaid	$38.72
Rate for Payer: Partners Health Alliance Commercial	$34.57
Rate for Payer: United Healthcare Commercial	$60.12
Rate for Payer: United Healthcare Managed Medicare	$39.41
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

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	$33.53
Max. Negotiated Rate	$221.80
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	$42.98
Rate for Payer: Amerigroup Medicare	$33.87
Rate for Payer: Cash Price	$59.62
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	$33.53
Rate for Payer: Iowa Total Care Managed Medicaid	$42.57
Rate for Payer: Medical Associates Commercial	$55.89
Rate for Payer: Medical Associates Managed Medicare	$33.53
Rate for Payer: Midlands Choice Commercial	$52.16
Rate for Payer: Molina Healthcare Managed Medicaid	$43.19
Rate for Payer: Partners Health Alliance Commercial	$38.56
Rate for Payer: United Healthcare Commercial	$67.07
Rate for Payer: United Healthcare Managed Medicare	$43.97
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

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

LACTIC ACID

Facility

$139.00

Service Code	CPT 83605
Hospital Charge Code	1503766
Hospital Revenue Code	301
Min. Negotiated Rate	$61.68
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	$80.18
Rate for Payer: Amerigroup Medicare	$63.18
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	$62.55
Rate for Payer: Iowa Total Care Managed Medicaid	$79.40
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$62.55
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$80.56
Rate for Payer: Partners Health Alliance Commercial	$71.93
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO WHPI	$61.68
Rate for Payer: Wellmark IA PPO	$67.95

LACTIC ACID

Facility

$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 [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

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

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

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

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	$727.04
Max. Negotiated Rate	$2,107.50
Rate for Payer: Amerigroup Medicaid	$734.16
Rate for Payer: Cash Price	$2,248.00
Rate for Payer: Cash Price	$2,248.00
Rate for Payer: Iowa Total Care Managed Medicaid	$727.04
Rate for Payer: Medical Associates Commercial	$2,107.50
Rate for Payer: Midlands Choice Commercial	$1,967.00
Rate for Payer: Molina Healthcare Managed Medicaid	$730.60
Rate for Payer: Partners Health Alliance Commercial	$2,107.50
Rate for Payer: United Healthcare Commercial	$1,219.90
Rate for Payer: Wellmark IA HMO WHPI	$1,603.70
Rate for Payer: Wellmark IA PPO	$1,886.70

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 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 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 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 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: 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
Rate for Payer: Wellmark IA HMO WHPI	$65.23
Rate for Payer: Wellmark IA PPO	$71.85

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

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

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

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	$340.15
Max. Negotiated Rate	$933.75
Rate for Payer: Amerigroup Medicaid	$343.48
Rate for Payer: Cash Price	$996.00
Rate for Payer: Cash Price	$996.00
Rate for Payer: Iowa Total Care Managed Medicaid	$340.15
Rate for Payer: Medical Associates Commercial	$933.75
Rate for Payer: Midlands Choice Commercial	$871.50
Rate for Payer: Molina Healthcare Managed Medicaid	$341.82
Rate for Payer: Partners Health Alliance Commercial	$933.75
Rate for Payer: United Healthcare Commercial	$564.54
Rate for Payer: Wellmark IA HMO WHPI	$724.20
Rate for Payer: Wellmark IA PPO	$852.00

Know your out-of-pocket cost for care.

All Charges