Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

lisinopril-HCTZ 20mg-25mg tab [VDMC]

Facility

$1.14

Service Code	HCPCS A9270
Hospital Charge Code	23268711
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of IA Commercial	$1.03
Rate for Payer: Aetna of IA Medical Rental Products	$1.03
Rate for Payer: Aetna of IA Medicare	$0.65
Rate for Payer: Amerigroup Medicaid	$0.58
Rate for Payer: Amerigroup Medicare	$0.58
Rate for Payer: Cash Price	$0.92
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.86
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	$0.57
Rate for Payer: Medical Associates Commercial	$0.86
Rate for Payer: Medical Associates Managed Medicare	$0.57
Rate for Payer: Midlands Choice Commercial	$0.80
Rate for Payer: Molina Healthcare Managed Medicaid	$0.58
Rate for Payer: Molina Healthcare Managed Medicare	$0.58
Rate for Payer: Oscar Health of IA Commercial	$0.86
Rate for Payer: Partners Health Alliance Commercial	$0.86
Rate for Payer: United Healthcare Commercial	$1.03
Rate for Payer: United Healthcare Managed Medicare	$0.67

lisinopril-HCTZ 20mg-25mg tab [VDMC]

Facility

$1.14

Service Code	HCPCS A9270
Hospital Charge Code	23268711
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of IA Commercial	$1.03
Rate for Payer: Aetna of IA Medical Rental Products	$1.03
Rate for Payer: Cash Price	$0.92
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.86
Rate for Payer: Medical Associates Commercial	$0.86
Rate for Payer: Midlands Choice Commercial	$0.80
Rate for Payer: United Healthcare Commercial	$1.03

lithium 150 mg Cap [VDMC]

Facility

$1.30

Service Code	HCPCS A9270
Hospital Charge Code	18866238
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of IA Commercial	$1.17
Rate for Payer: Aetna of IA Medical Rental Products	$1.17
Rate for Payer: Aetna of IA Medicare	$0.74
Rate for Payer: Amerigroup Medicaid	$0.66
Rate for Payer: Amerigroup Medicare	$0.66
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.98
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.65
Rate for Payer: Iowa Total Care Managed Medicaid	$0.65
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Medical Associates Managed Medicare	$0.65
Rate for Payer: Midlands Choice Commercial	$0.91
Rate for Payer: Molina Healthcare Managed Medicaid	$0.66
Rate for Payer: Molina Healthcare Managed Medicare	$0.66
Rate for Payer: Oscar Health of IA Commercial	$0.98
Rate for Payer: Partners Health Alliance Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.17
Rate for Payer: United Healthcare Managed Medicare	$0.77

lithium 150 mg Cap [VDMC]

Facility

$1.30

Service Code	HCPCS A9270
Hospital Charge Code	18866238
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of IA Commercial	$1.17
Rate for Payer: Aetna of IA Medical Rental Products	$1.17
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.98
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Midlands Choice Commercial	$0.91
Rate for Payer: United Healthcare Commercial	$1.17

lithium 300 mg Cap [VDMC]

Facility

$1.72

Service Code	HCPCS A9270
Hospital Charge Code	10401297
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.55
Rate for Payer: Aetna of IA Commercial	$1.55
Rate for Payer: Aetna of IA Medical Rental Products	$1.55
Rate for Payer: Cash Price	$1.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.29
Rate for Payer: Medical Associates Commercial	$1.29
Rate for Payer: Midlands Choice Commercial	$1.20
Rate for Payer: United Healthcare Commercial	$1.55

lithium 300 mg Cap [VDMC]

Facility

$1.72

Service Code	HCPCS A9270
Hospital Charge Code	10401297
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.55
Rate for Payer: Aetna of IA Commercial	$1.55
Rate for Payer: Aetna of IA Medical Rental Products	$1.55
Rate for Payer: Aetna of IA Medicare	$0.98
Rate for Payer: Amerigroup Medicaid	$0.87
Rate for Payer: Amerigroup Medicare	$0.87
Rate for Payer: Cash Price	$1.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.29
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	$0.86
Rate for Payer: Medical Associates Commercial	$1.29
Rate for Payer: Medical Associates Managed Medicare	$0.86
Rate for Payer: Midlands Choice Commercial	$1.20
Rate for Payer: Molina Healthcare Managed Medicaid	$0.87
Rate for Payer: Molina Healthcare Managed Medicare	$0.87
Rate for Payer: Oscar Health of IA Commercial	$1.29
Rate for Payer: Partners Health Alliance Commercial	$1.29
Rate for Payer: United Healthcare Commercial	$1.55
Rate for Payer: United Healthcare Managed Medicare	$1.01

Lithium Level DMCL

Facility

$63.00

Service Code	CPT 80178
Hospital Charge Code	8037727
Hospital Revenue Code	301
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of IA Commercial	$56.70
Rate for Payer: Aetna of IA Medical Rental Products	$56.70
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.25
Rate for Payer: Medical Associates Commercial	$47.25
Rate for Payer: Midlands Choice Commercial	$44.10
Rate for Payer: United Healthcare Commercial	$56.70

Lithium Level DMCL

Facility

$63.00

Service Code	CPT 80178
Hospital Charge Code	8037727
Hospital Revenue Code	301
Min. Negotiated Rate	$31.49
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of IA Commercial	$56.70
Rate for Payer: Aetna of IA Medical Rental Products	$56.70
Rate for Payer: Aetna of IA Medicare	$35.91
Rate for Payer: Amerigroup Medicaid	$31.80
Rate for Payer: Amerigroup Medicare	$31.82
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.50
Rate for Payer: Iowa Total Care Managed Medicaid	$31.49
Rate for Payer: Medical Associates Commercial	$47.25
Rate for Payer: Medical Associates Managed Medicare	$31.50
Rate for Payer: Midlands Choice Commercial	$44.10
Rate for Payer: Molina Healthcare Managed Medicaid	$31.97
Rate for Payer: Molina Healthcare Managed Medicare	$31.95
Rate for Payer: Oscar Health of IA Commercial	$47.25
Rate for Payer: Partners Health Alliance Commercial	$47.25
Rate for Payer: United Healthcare Commercial	$56.70
Rate for Payer: United Healthcare Managed Medicare	$37.17
Rate for Payer: Wellmark IA HMO	$49.60
Rate for Payer: Wellmark IA PPO	$54.56

LITHOTRIPSY CHARGE

Facility

$4,114.00

Hospital Charge Code	8069084
Hospital Revenue Code	360
Min. Negotiated Rate	$2,879.80
Max. Negotiated Rate	$3,702.60
Rate for Payer: Aetna of IA Commercial	$3,702.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,702.60
Rate for Payer: Cash Price	$3,291.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,085.50
Rate for Payer: Medical Associates Commercial	$3,085.50
Rate for Payer: Midlands Choice Commercial	$2,879.80
Rate for Payer: United Healthcare Commercial	$3,702.60

LITHOTRIPSY CHARGE

Facility

$4,114.00

Hospital Charge Code	8069084
Hospital Revenue Code	360
Min. Negotiated Rate	$2,056.18
Max. Negotiated Rate	$3,702.60
Rate for Payer: Aetna of IA Commercial	$3,702.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,702.60
Rate for Payer: Aetna of IA Medicare	$2,344.98
Rate for Payer: Amerigroup Medicaid	$2,076.34
Rate for Payer: Amerigroup Medicare	$2,077.57
Rate for Payer: Cash Price	$3,291.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,085.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,057.00
Rate for Payer: Iowa Total Care Managed Medicaid	$2,056.18
Rate for Payer: Medical Associates Commercial	$3,085.50
Rate for Payer: Medical Associates Managed Medicare	$2,057.00
Rate for Payer: Midlands Choice Commercial	$2,879.80
Rate for Payer: Molina Healthcare Managed Medicaid	$2,087.86
Rate for Payer: Molina Healthcare Managed Medicare	$2,086.62
Rate for Payer: Oscar Health of IA Commercial	$3,085.50
Rate for Payer: Partners Health Alliance Commercial	$3,085.50
Rate for Payer: United Healthcare Commercial	$3,702.60
Rate for Payer: United Healthcare Managed Medicare	$2,427.26

LIVER PROFILE

Facility

$111.00

Service Code	CPT 80076
Hospital Charge Code	633744
Hospital Revenue Code	301
Min. Negotiated Rate	$52.08
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of IA Commercial	$99.90
Rate for Payer: Aetna of IA Medical Rental Products	$99.90
Rate for Payer: Aetna of IA Medicare	$63.27
Rate for Payer: Amerigroup Medicaid	$56.02
Rate for Payer: Amerigroup Medicare	$56.06
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$55.50
Rate for Payer: Iowa Total Care Managed Medicaid	$55.48
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Medical Associates Managed Medicare	$55.50
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: Molina Healthcare Managed Medicaid	$56.33
Rate for Payer: Molina Healthcare Managed Medicare	$56.30
Rate for Payer: Oscar Health of IA Commercial	$83.25
Rate for Payer: Partners Health Alliance Commercial	$83.25
Rate for Payer: United Healthcare Commercial	$99.90
Rate for Payer: United Healthcare Managed Medicare	$65.49
Rate for Payer: Wellmark IA HMO	$52.08
Rate for Payer: Wellmark IA PPO	$57.29

LIVER PROFILE

Facility

$111.00

Service Code	CPT 80076
Hospital Charge Code	633744
Hospital Revenue Code	301
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of IA Commercial	$99.90
Rate for Payer: Aetna of IA Medical Rental Products	$99.90
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.25
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: United Healthcare Commercial	$99.90

Liver Transplant With MCC or Intestinal Transplant

Facility

$158,834.93

Service Code	MS-DRG 005
Hospital Charge Code	696
Min. Negotiated Rate	$156,532.97
Max. Negotiated Rate	$158,834.93
Rate for Payer: Amerigroup Medicaid	$158,067.61
Rate for Payer: Iowa Total Care Managed Medicaid	$156,532.97
Rate for Payer: Molina Healthcare Managed Medicaid	$158,834.93

Liver Transplant Without MCC

Facility

$89,346.49

Service Code	MS-DRG 006
Hospital Charge Code	697
Min. Negotiated Rate	$88,051.61
Max. Negotiated Rate	$89,346.49
Rate for Payer: Amerigroup Medicaid	$88,914.86
Rate for Payer: Iowa Total Care Managed Medicaid	$88,051.61
Rate for Payer: Molina Healthcare Managed Medicaid	$89,346.49

Local Excision and Removal of Internal Fixation Devices Except Hip and Femur With CC

Facility

$17,486.04

Service Code	MS-DRG 496
Hospital Charge Code	313
Min. Negotiated Rate	$17,232.61
Max. Negotiated Rate	$17,486.04
Rate for Payer: Amerigroup Medicaid	$17,401.56
Rate for Payer: Iowa Total Care Managed Medicaid	$17,232.61
Rate for Payer: Molina Healthcare Managed Medicaid	$17,486.04

Local Excision and Removal of Internal Fixation Devices Except Hip and Femur With MCC

Facility

$35,778.16

Service Code	MS-DRG 495
Hospital Charge Code	312
Min. Negotiated Rate	$35,259.64
Max. Negotiated Rate	$35,778.16
Rate for Payer: Amerigroup Medicaid	$35,605.32
Rate for Payer: Iowa Total Care Managed Medicaid	$35,259.64
Rate for Payer: Molina Healthcare Managed Medicaid	$35,778.16

Local Excision and Removal of Internal Fixation Devices Except Hip and Femur Without CC/MCC

Facility

$11,221.34

Service Code	MS-DRG 497
Hospital Charge Code	314
Min. Negotiated Rate	$11,058.71
Max. Negotiated Rate	$11,221.34
Rate for Payer: Amerigroup Medicaid	$11,167.13
Rate for Payer: Iowa Total Care Managed Medicaid	$11,058.71
Rate for Payer: Molina Healthcare Managed Medicaid	$11,221.34

Local Excision and Removal of Internal Fixation Devices of Hip and Femur With CC/MCC

Facility

$25,442.64

Service Code	MS-DRG 498
Hospital Charge Code	315
Min. Negotiated Rate	$25,073.91
Max. Negotiated Rate	$25,442.64
Rate for Payer: Amerigroup Medicaid	$25,319.73
Rate for Payer: Iowa Total Care Managed Medicaid	$25,073.91
Rate for Payer: Molina Healthcare Managed Medicaid	$25,442.64

Local Excision and Removal of Internal Fixation Devices of Hip and Femur Without CC/MCC

Facility

$10,628.83

Service Code	MS-DRG 499
Hospital Charge Code	316
Min. Negotiated Rate	$10,474.79
Max. Negotiated Rate	$10,628.83
Rate for Payer: Amerigroup Medicaid	$10,577.48
Rate for Payer: Iowa Total Care Managed Medicaid	$10,474.79
Rate for Payer: Molina Healthcare Managed Medicaid	$10,628.83

LOCKING COMPR BROAD 10 HOLE / L 191MM

Facility

$251.00

Service Code	CPT C1713
Hospital Charge Code	8046758
Hospital Revenue Code	278
Min. Negotiated Rate	$125.45
Max. Negotiated Rate	$225.90
Rate for Payer: Aetna of IA Commercial	$225.90
Rate for Payer: Aetna of IA Medical Rental Products	$225.90
Rate for Payer: Aetna of IA Medicare	$143.07
Rate for Payer: Amerigroup Medicaid	$126.68
Rate for Payer: Amerigroup Medicare	$126.76
Rate for Payer: Cash Price	$200.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$188.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$125.50
Rate for Payer: Iowa Total Care Managed Medicaid	$125.45
Rate for Payer: Medical Associates Commercial	$188.25
Rate for Payer: Medical Associates Managed Medicare	$125.50
Rate for Payer: Midlands Choice Commercial	$175.70
Rate for Payer: Molina Healthcare Managed Medicaid	$127.38
Rate for Payer: Molina Healthcare Managed Medicare	$127.31
Rate for Payer: Oscar Health of IA Commercial	$188.25
Rate for Payer: Partners Health Alliance Commercial	$188.25
Rate for Payer: United Healthcare Commercial	$225.90
Rate for Payer: United Healthcare Managed Medicare	$148.09

LOCKING COMPR BROAD 10 HOLE / L 191MM

Facility

$251.00

Service Code	CPT C1713
Hospital Charge Code	8046758
Hospital Revenue Code	278
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$225.90
Rate for Payer: Aetna of IA Commercial	$225.90
Rate for Payer: Aetna of IA Medical Rental Products	$225.90
Rate for Payer: Cash Price	$200.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$188.25
Rate for Payer: Medical Associates Commercial	$188.25
Rate for Payer: Midlands Choice Commercial	$175.70
Rate for Payer: United Healthcare Commercial	$225.90

LOCKING COMPR BROAD 11 HOLE / L 209MM

Facility

$279.00

Service Code	CPT C1713
Hospital Charge Code	8046759
Hospital Revenue Code	278
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: United Healthcare Commercial	$251.10

LOCKING COMPR BROAD 11 HOLE / L 209MM

Facility

$279.00

Service Code	CPT C1713
Hospital Charge Code	8046759
Hospital Revenue Code	278
Min. Negotiated Rate	$139.44
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Aetna of IA Medicare	$159.03
Rate for Payer: Amerigroup Medicaid	$140.81
Rate for Payer: Amerigroup Medicare	$140.90
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$139.50
Rate for Payer: Iowa Total Care Managed Medicaid	$139.44
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Medical Associates Managed Medicare	$139.50
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: Molina Healthcare Managed Medicaid	$141.59
Rate for Payer: Molina Healthcare Managed Medicare	$141.51
Rate for Payer: Oscar Health of IA Commercial	$209.25
Rate for Payer: Partners Health Alliance Commercial	$209.25
Rate for Payer: United Healthcare Commercial	$251.10
Rate for Payer: United Healthcare Managed Medicare	$164.61

LOCKING COMPR BROAD 12 HOLE / L 227MM

Facility

$279.00

Service Code	CPT C1713
Hospital Charge Code	8046760
Hospital Revenue Code	278
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: United Healthcare Commercial	$251.10

LOCKING COMPR BROAD 12 HOLE / L 227MM

Facility

$279.00

Service Code	CPT C1713
Hospital Charge Code	8046760
Hospital Revenue Code	278
Min. Negotiated Rate	$139.44
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Aetna of IA Medicare	$159.03
Rate for Payer: Amerigroup Medicaid	$140.81
Rate for Payer: Amerigroup Medicare	$140.90
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$139.50
Rate for Payer: Iowa Total Care Managed Medicaid	$139.44
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Medical Associates Managed Medicare	$139.50
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: Molina Healthcare Managed Medicaid	$141.59
Rate for Payer: Molina Healthcare Managed Medicare	$141.51
Rate for Payer: Oscar Health of IA Commercial	$209.25
Rate for Payer: Partners Health Alliance Commercial	$209.25
Rate for Payer: United Healthcare Commercial	$251.10
Rate for Payer: United Healthcare Managed Medicare	$164.61

Know your out-of-pocket cost for care.

All Charges