Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Lupus Anticoagulant DMCL

Facility

$64.00

Service Code	CPT 85730
Hospital Charge Code	8037728
Hospital Revenue Code	305
Min. Negotiated Rate	$24.18
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$32.30
Rate for Payer: Amerigroup Medicare	$32.32
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$32.00
Rate for Payer: Iowa Total Care Managed Medicaid	$31.99
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$32.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$32.48
Rate for Payer: Molina Healthcare Managed Medicare	$32.46
Rate for Payer: Oscar Health of IA Commercial	$48.00
Rate for Payer: Partners Health Alliance Commercial	$48.00
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76
Rate for Payer: Wellmark IA HMO	$24.18
Rate for Payer: Wellmark IA PPO	$26.60

Lupus Anticoagulant DMCL

Facility

$64.00

Service Code	CPT 85730
Hospital Charge Code	8037728
Hospital Revenue Code	305
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

Luteinizing Hormone DMCL

Facility

$135.00

Service Code	CPT 83002
Hospital Charge Code	8037729
Hospital Revenue Code	301
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of IA Commercial	$121.50
Rate for Payer: Aetna of IA Medical Rental Products	$121.50
Rate for Payer: Aetna of IA Medicare	$76.95
Rate for Payer: Amerigroup Medicaid	$68.13
Rate for Payer: Amerigroup Medicare	$68.18
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$101.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.50
Rate for Payer: Iowa Total Care Managed Medicaid	$67.47
Rate for Payer: Medical Associates Commercial	$101.25
Rate for Payer: Medical Associates Managed Medicare	$67.50
Rate for Payer: Midlands Choice Commercial	$94.50
Rate for Payer: Molina Healthcare Managed Medicaid	$68.51
Rate for Payer: Molina Healthcare Managed Medicare	$68.47
Rate for Payer: Oscar Health of IA Commercial	$101.25
Rate for Payer: Partners Health Alliance Commercial	$101.25
Rate for Payer: United Healthcare Commercial	$121.50
Rate for Payer: United Healthcare Managed Medicare	$79.65
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Luteinizing Hormone DMCL

Facility

$135.00

Service Code	CPT 83002
Hospital Charge Code	8037729
Hospital Revenue Code	301
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of IA Commercial	$121.50
Rate for Payer: Aetna of IA Medical Rental Products	$121.50
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$101.25
Rate for Payer: Medical Associates Commercial	$101.25
Rate for Payer: Midlands Choice Commercial	$94.50
Rate for Payer: United Healthcare Commercial	$121.50

Lyme Antibody Screen DMCL

Facility

$139.00

Service Code	CPT 86618
Hospital Charge Code	8037730
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
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	$70.15
Rate for Payer: Amerigroup Medicare	$70.20
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	$69.50
Rate for Payer: Iowa Total Care Managed Medicaid	$69.47
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$69.50
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$70.54
Rate for Payer: Molina Healthcare Managed Medicare	$70.50
Rate for Payer: Oscar Health of IA Commercial	$104.25
Rate for Payer: Partners Health Alliance Commercial	$104.25
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Lyme Antibody Screen DMCL

Facility

$139.00

Service Code	CPT 86618
Hospital Charge Code	8037730
Hospital Revenue Code	302
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

Lyme by PCR DMCL

Facility

$290.00

Service Code	CPT 87476
Hospital Charge Code	8037731
Hospital Revenue Code	306
Min. Negotiated Rate	$68.82
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of IA Commercial	$261.00
Rate for Payer: Aetna of IA Medical Rental Products	$261.00
Rate for Payer: Aetna of IA Medicare	$165.30
Rate for Payer: Amerigroup Medicaid	$146.36
Rate for Payer: Amerigroup Medicare	$146.45
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cash Price	$232.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$217.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$145.00
Rate for Payer: Iowa Total Care Managed Medicaid	$144.94
Rate for Payer: Medical Associates Commercial	$217.50
Rate for Payer: Medical Associates Managed Medicare	$145.00
Rate for Payer: Midlands Choice Commercial	$203.00
Rate for Payer: Molina Healthcare Managed Medicaid	$147.18
Rate for Payer: Molina Healthcare Managed Medicare	$147.09
Rate for Payer: Oscar Health of IA Commercial	$217.50
Rate for Payer: Partners Health Alliance Commercial	$217.50
Rate for Payer: United Healthcare Commercial	$261.00
Rate for Payer: United Healthcare Managed Medicare	$171.10
Rate for Payer: Wellmark IA HMO	$68.82
Rate for Payer: Wellmark IA PPO	$75.70

Lyme by PCR DMCL

Facility

$290.00

Service Code	CPT 87476
Hospital Charge Code	8037731
Hospital Revenue Code	306
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of IA Commercial	$261.00
Rate for Payer: Aetna of IA Medical Rental Products	$261.00
Rate for Payer: Cash Price	$232.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$217.50
Rate for Payer: Medical Associates Commercial	$217.50
Rate for Payer: Midlands Choice Commercial	$203.00
Rate for Payer: United Healthcare Commercial	$261.00

Lyme IgG Antibody DMCL

Facility

$139.00

Service Code	CPT 86618
Hospital Charge Code	8505651
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
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	$70.15
Rate for Payer: Amerigroup Medicare	$70.20
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	$69.50
Rate for Payer: Iowa Total Care Managed Medicaid	$69.47
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$69.50
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$70.54
Rate for Payer: Molina Healthcare Managed Medicare	$70.50
Rate for Payer: Oscar Health of IA Commercial	$104.25
Rate for Payer: Partners Health Alliance Commercial	$104.25
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Lyme IgG Antibody DMCL

Facility

$139.00

Service Code	CPT 86618
Hospital Charge Code	8505651
Hospital Revenue Code	302
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

Lyme IgM Antibody DMCL

Facility

$139.00

Service Code	CPT 86618
Hospital Charge Code	8505652
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
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	$70.15
Rate for Payer: Amerigroup Medicare	$70.20
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	$69.50
Rate for Payer: Iowa Total Care Managed Medicaid	$69.47
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$69.50
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$70.54
Rate for Payer: Molina Healthcare Managed Medicare	$70.50
Rate for Payer: Oscar Health of IA Commercial	$104.25
Rate for Payer: Partners Health Alliance Commercial	$104.25
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Lyme IgM Antibody DMCL

Facility

$139.00

Service Code	CPT 86618
Hospital Charge Code	8505652
Hospital Revenue Code	302
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

Lymphoma and Leukemia With Major O.R. Procedures With CC

Facility

$18,352.16

Service Code	MS-DRG 821
Hospital Charge Code	563
Min. Negotiated Rate	$18,086.19
Max. Negotiated Rate	$18,352.16
Rate for Payer: Amerigroup Medicaid	$18,263.51
Rate for Payer: Iowa Total Care Managed Medicaid	$18,086.19
Rate for Payer: Molina Healthcare Managed Medicaid	$18,352.16

Lymphoma and Leukemia With Major O.R. Procedures With MCC

Facility

$55,991.53

Service Code	MS-DRG 820
Hospital Charge Code	562
Min. Negotiated Rate	$55,180.06
Max. Negotiated Rate	$55,991.53
Rate for Payer: Amerigroup Medicaid	$55,721.04
Rate for Payer: Iowa Total Care Managed Medicaid	$55,180.06
Rate for Payer: Molina Healthcare Managed Medicaid	$55,991.53

Lymphoma and Leukemia With Major O.R. Procedures Without CC/MCC

Facility

$9,848.33

Service Code	MS-DRG 822
Hospital Charge Code	564
Min. Negotiated Rate	$9,705.60
Max. Negotiated Rate	$9,848.33
Rate for Payer: Amerigroup Medicaid	$9,800.75
Rate for Payer: Iowa Total Care Managed Medicaid	$9,705.60
Rate for Payer: Molina Healthcare Managed Medicaid	$9,848.33

Lymphoma and Non-acute Leukemia With CC

Facility

$14,361.07

Service Code	MS-DRG 841
Hospital Charge Code	583
Min. Negotiated Rate	$14,152.94
Max. Negotiated Rate	$14,361.07
Rate for Payer: Amerigroup Medicaid	$14,291.69
Rate for Payer: Iowa Total Care Managed Medicaid	$14,152.94
Rate for Payer: Molina Healthcare Managed Medicaid	$14,361.07

Lymphoma and Non-acute Leukemia With MCC

Facility

$22,183.82

Service Code	MS-DRG 840
Hospital Charge Code	582
Min. Negotiated Rate	$21,862.31
Max. Negotiated Rate	$22,183.82
Rate for Payer: Amerigroup Medicaid	$22,076.65
Rate for Payer: Iowa Total Care Managed Medicaid	$21,862.31
Rate for Payer: Molina Healthcare Managed Medicaid	$22,183.82

Lymphoma and Non-acute Leukemia With Other Procedures With CC

Facility

$20,045.06

Service Code	MS-DRG 824
Hospital Charge Code	566
Min. Negotiated Rate	$19,754.55
Max. Negotiated Rate	$20,045.06
Rate for Payer: Amerigroup Medicaid	$19,948.23
Rate for Payer: Iowa Total Care Managed Medicaid	$19,754.55
Rate for Payer: Molina Healthcare Managed Medicaid	$20,045.06

Lymphoma and Non-acute Leukemia With Other Procedures With MCC

Facility

$41,008.43

Service Code	MS-DRG 823
Hospital Charge Code	565
Min. Negotiated Rate	$40,414.10
Max. Negotiated Rate	$41,008.43
Rate for Payer: Amerigroup Medicaid	$40,810.32
Rate for Payer: Iowa Total Care Managed Medicaid	$40,414.10
Rate for Payer: Molina Healthcare Managed Medicaid	$41,008.43

Lymphoma and Non-acute Leukemia With Other Procedures Without CC/MCC

Facility

$12,244.95

Service Code	MS-DRG 825
Hospital Charge Code	567
Min. Negotiated Rate	$12,067.49
Max. Negotiated Rate	$12,244.95
Rate for Payer: Amerigroup Medicaid	$12,185.80
Rate for Payer: Iowa Total Care Managed Medicaid	$12,067.49
Rate for Payer: Molina Healthcare Managed Medicaid	$12,244.95

Lymphoma and Non-acute Leukemia Without CC/MCC

Facility

$9,279.43

Service Code	MS-DRG 842
Hospital Charge Code	584
Min. Negotiated Rate	$9,144.94
Max. Negotiated Rate	$9,279.43
Rate for Payer: Amerigroup Medicaid	$9,234.60
Rate for Payer: Iowa Total Care Managed Medicaid	$9,144.94
Rate for Payer: Molina Healthcare Managed Medicaid	$9,279.43

LYSIS OF LABIAL ADHESIONS

Professional

Both

$477.00

Service Code	CPT 56441
Hospital Charge Code	8068969
Hospital Revenue Code	975
Min. Negotiated Rate	$141.78
Max. Negotiated Rate	$333.90
Rate for Payer: Aetna of IA Medicare	$141.78
Rate for Payer: Amerigroup Medicaid	$146.60
Rate for Payer: Cash Price	$381.60
Rate for Payer: Cash Price	$381.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.14
Rate for Payer: Iowa Total Care Managed Medicaid	$144.62
Rate for Payer: Medical Associates Commercial	$269.38
Rate for Payer: Medical Associates Managed Medicare	$141.78
Rate for Payer: Midlands Choice Commercial	$333.90
Rate for Payer: Oscar Health of IA Commercial	$245.28
Rate for Payer: Partners Health Alliance Commercial	$212.67

MAC ENDO CHARGE

Facility

$134.00

Hospital Charge Code	8059073
Hospital Revenue Code	370
Min. Negotiated Rate	$66.97
Max. Negotiated Rate	$120.60
Rate for Payer: Aetna of IA Commercial	$120.60
Rate for Payer: Aetna of IA Medical Rental Products	$120.60
Rate for Payer: Aetna of IA Medicare	$76.38
Rate for Payer: Amerigroup Medicaid	$67.63
Rate for Payer: Amerigroup Medicare	$67.67
Rate for Payer: Cash Price	$107.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.00
Rate for Payer: Iowa Total Care Managed Medicaid	$66.97
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Medical Associates Managed Medicare	$67.00
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: Molina Healthcare Managed Medicaid	$68.00
Rate for Payer: Molina Healthcare Managed Medicare	$67.96
Rate for Payer: Oscar Health of IA Commercial	$100.50
Rate for Payer: Partners Health Alliance Commercial	$100.50
Rate for Payer: United Healthcare Commercial	$120.60
Rate for Payer: United Healthcare Managed Medicare	$79.06

MAC ENDO CHARGE

Facility

$134.00

Hospital Charge Code	8059073
Hospital Revenue Code	370
Min. Negotiated Rate	$93.80
Max. Negotiated Rate	$120.60
Rate for Payer: Aetna of IA Commercial	$120.60
Rate for Payer: Aetna of IA Medical Rental Products	$120.60
Rate for Payer: Cash Price	$107.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.50
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: United Healthcare Commercial	$120.60

Magic Mouthwash [VDMC]

Facility

$167.52

Service Code	HCPCS A9270GY
Hospital Charge Code	20213408
Hospital Revenue Code	259
Min. Negotiated Rate	$117.26
Max. Negotiated Rate	$150.77
Rate for Payer: Aetna of IA Commercial	$150.77
Rate for Payer: Aetna of IA Medical Rental Products	$150.77
Rate for Payer: Cash Price	$134.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$125.64
Rate for Payer: Medical Associates Commercial	$125.64
Rate for Payer: Midlands Choice Commercial	$117.26
Rate for Payer: United Healthcare Commercial	$150.77

Know your out-of-pocket cost for care.

All Charges