Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

LORazepam 1 mg Tab [VDMC]

Facility

$3.15

Service Code	HCPCS A9270
Hospital Charge Code	10401577
Hospital Revenue Code	259
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$2.84
Rate for Payer: Aetna of IA Commercial	$2.84
Rate for Payer: Aetna of IA Medical Rental Products	$2.84
Rate for Payer: Aetna of IA Medicare	$1.80
Rate for Payer: Amerigroup Medicaid	$1.82
Rate for Payer: Amerigroup Medicare	$1.43
Rate for Payer: Cash Price	$2.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.36
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.42
Rate for Payer: Iowa Total Care Managed Medicaid	$1.80
Rate for Payer: Medical Associates Commercial	$2.36
Rate for Payer: Medical Associates Managed Medicare	$1.42
Rate for Payer: Midlands Choice Commercial	$2.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1.83
Rate for Payer: Partners Health Alliance Commercial	$1.63
Rate for Payer: United Healthcare Commercial	$2.84
Rate for Payer: United Healthcare Managed Medicare	$1.86

LORazepam 1 mg Tab [VDMC]

Facility

$3.15

Service Code	HCPCS A9270
Hospital Charge Code	10401577
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$2.84
Rate for Payer: Aetna of IA Commercial	$2.84
Rate for Payer: Aetna of IA Medical Rental Products	$2.84
Rate for Payer: Cash Price	$2.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.36
Rate for Payer: Medical Associates Commercial	$2.36
Rate for Payer: Midlands Choice Commercial	$2.20
Rate for Payer: United Healthcare Commercial	$2.84

LORazepam 2 mg/mL 1ml MDV [VDMC]

Facility

$44.26

Service Code	HCPCS J2060
Hospital Charge Code	10401707
Hospital Revenue Code	259
Min. Negotiated Rate	$30.98
Max. Negotiated Rate	$39.84
Rate for Payer: Aetna of IA Commercial	$39.84
Rate for Payer: Aetna of IA Medical Rental Products	$39.84
Rate for Payer: Cash Price	$35.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.20
Rate for Payer: Medical Associates Commercial	$33.20
Rate for Payer: Midlands Choice Commercial	$30.98
Rate for Payer: United Healthcare Commercial	$39.84

LORazepam 2 mg/mL 1ml MDV [VDMC]

Facility

$44.26

Service Code	HCPCS J2060
Hospital Charge Code	10401707
Hospital Revenue Code	259
Min. Negotiated Rate	$19.92
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$39.84
Rate for Payer: Aetna of IA Medical Rental Products	$39.84
Rate for Payer: Aetna of IA Medicare	$25.23
Rate for Payer: Amerigroup Medicaid	$25.53
Rate for Payer: Amerigroup Medicare	$20.12
Rate for Payer: Cash Price	$35.41
Rate for Payer: Cash Price	$35.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.20
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$19.92
Rate for Payer: Iowa Total Care Managed Medicaid	$25.28
Rate for Payer: Medical Associates Commercial	$33.20
Rate for Payer: Medical Associates Managed Medicare	$19.92
Rate for Payer: Midlands Choice Commercial	$30.98
Rate for Payer: Molina Healthcare Managed Medicaid	$25.65
Rate for Payer: Partners Health Alliance Commercial	$22.91
Rate for Payer: United Healthcare Commercial	$39.84
Rate for Payer: United Healthcare Managed Medicare	$26.11
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

LORazepam 2 mg/mL 1ml Syringe [VDMC]

Facility

$52.92

Service Code	HCPCS J2060
Hospital Charge Code	11729055
Hospital Revenue Code	259
Min. Negotiated Rate	$37.04
Max. Negotiated Rate	$47.62
Rate for Payer: Aetna of IA Commercial	$47.62
Rate for Payer: Aetna of IA Medical Rental Products	$47.62
Rate for Payer: Cash Price	$42.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.69
Rate for Payer: Medical Associates Commercial	$39.69
Rate for Payer: Midlands Choice Commercial	$37.04
Rate for Payer: United Healthcare Commercial	$47.62

LORazepam 2 mg/mL 1ml Syringe [VDMC]

Facility

$52.92

Service Code	HCPCS J2060
Hospital Charge Code	11729055
Hospital Revenue Code	259
Min. Negotiated Rate	$23.81
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$47.62
Rate for Payer: Aetna of IA Medical Rental Products	$47.62
Rate for Payer: Aetna of IA Medicare	$30.16
Rate for Payer: Amerigroup Medicaid	$30.52
Rate for Payer: Amerigroup Medicare	$24.05
Rate for Payer: Cash Price	$42.33
Rate for Payer: Cash Price	$42.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.69
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.81
Rate for Payer: Iowa Total Care Managed Medicaid	$30.23
Rate for Payer: Medical Associates Commercial	$39.69
Rate for Payer: Medical Associates Managed Medicare	$23.81
Rate for Payer: Midlands Choice Commercial	$37.04
Rate for Payer: Molina Healthcare Managed Medicaid	$30.67
Rate for Payer: Partners Health Alliance Commercial	$27.38
Rate for Payer: United Healthcare Commercial	$47.62
Rate for Payer: United Healthcare Managed Medicare	$31.22
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

LORazepam 2 mg/mL 30 ml Oral Conc [VDMC]

Facility

$35.32

Service Code	HCPCS A9270
Hospital Charge Code	10401791
Hospital Revenue Code	259
Min. Negotiated Rate	$24.72
Max. Negotiated Rate	$31.79
Rate for Payer: Aetna of IA Commercial	$31.79
Rate for Payer: Aetna of IA Medical Rental Products	$31.79
Rate for Payer: Cash Price	$28.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.49
Rate for Payer: Medical Associates Commercial	$26.49
Rate for Payer: Midlands Choice Commercial	$24.72
Rate for Payer: United Healthcare Commercial	$31.79

LORazepam 2 mg/mL 30 ml Oral Conc [VDMC]

Facility

$35.32

Service Code	HCPCS A9270
Hospital Charge Code	10401791
Hospital Revenue Code	259
Min. Negotiated Rate	$15.89
Max. Negotiated Rate	$31.79
Rate for Payer: Aetna of IA Commercial	$31.79
Rate for Payer: Aetna of IA Medical Rental Products	$31.79
Rate for Payer: Aetna of IA Medicare	$20.13
Rate for Payer: Amerigroup Medicaid	$20.37
Rate for Payer: Amerigroup Medicare	$16.05
Rate for Payer: Cash Price	$28.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.49
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.89
Rate for Payer: Iowa Total Care Managed Medicaid	$20.17
Rate for Payer: Medical Associates Commercial	$26.49
Rate for Payer: Medical Associates Managed Medicare	$15.89
Rate for Payer: Midlands Choice Commercial	$24.72
Rate for Payer: Molina Healthcare Managed Medicaid	$20.47
Rate for Payer: Partners Health Alliance Commercial	$18.28
Rate for Payer: United Healthcare Commercial	$31.79
Rate for Payer: United Healthcare Managed Medicare	$20.84

losartan 50 mg Tab [VDMC]

Facility

$1.86

Service Code	HCPCS A9270
Hospital Charge Code	10401856
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.67
Rate for Payer: Aetna of IA Commercial	$1.67
Rate for Payer: Aetna of IA Medical Rental Products	$1.67
Rate for Payer: Cash Price	$1.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.39
Rate for Payer: Medical Associates Commercial	$1.39
Rate for Payer: Midlands Choice Commercial	$1.30
Rate for Payer: United Healthcare Commercial	$1.67

losartan 50 mg Tab [VDMC]

Facility

$1.86

Service Code	HCPCS A9270
Hospital Charge Code	10401856
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.67
Rate for Payer: Aetna of IA Commercial	$1.67
Rate for Payer: Aetna of IA Medical Rental Products	$1.67
Rate for Payer: Aetna of IA Medicare	$1.06
Rate for Payer: Amerigroup Medicaid	$1.07
Rate for Payer: Amerigroup Medicare	$0.84
Rate for Payer: Cash Price	$1.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.39
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.84
Rate for Payer: Iowa Total Care Managed Medicaid	$1.06
Rate for Payer: Medical Associates Commercial	$1.39
Rate for Payer: Medical Associates Managed Medicare	$0.84
Rate for Payer: Midlands Choice Commercial	$1.30
Rate for Payer: Molina Healthcare Managed Medicaid	$1.08
Rate for Payer: Partners Health Alliance Commercial	$0.96
Rate for Payer: United Healthcare Commercial	$1.67
Rate for Payer: United Healthcare Managed Medicare	$1.09

losartan-hydrochlorothiazide 50 mg- 12.5 mg-Tab [VDMC]

Facility

$1.23

Service Code	HCPCS A9270
Hospital Charge Code	10394043
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
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	$0.86
Rate for Payer: United Healthcare Commercial	$1.10

losartan-hydrochlorothiazide 50 mg- 12.5 mg-Tab [VDMC]

Facility

$1.23

Service Code	HCPCS A9270
Hospital Charge Code	10394043
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	$0.71
Rate for Payer: Amerigroup Medicare	$0.56
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	$0.86
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

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC

Facility

$24,281.69

Service Code	MSDRG 493
Min. Negotiated Rate	$23,929.77
Max. Negotiated Rate	$24,281.69
Rate for Payer: Amerigroup Medicaid	$24,164.38
Rate for Payer: Iowa Total Care Managed Medicaid	$23,929.77
Rate for Payer: Molina Healthcare Managed Medicaid	$24,281.69

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC

Facility

$40,753.61

Service Code	MSDRG 492
Min. Negotiated Rate	$40,162.96
Max. Negotiated Rate	$40,753.61
Rate for Payer: Amerigroup Medicaid	$40,556.72
Rate for Payer: Iowa Total Care Managed Medicaid	$40,162.96
Rate for Payer: Molina Healthcare Managed Medicaid	$40,753.61

LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC

Facility

$16,751.16

Service Code	MSDRG 494
Min. Negotiated Rate	$16,508.38
Max. Negotiated Rate	$16,751.16
Rate for Payer: Amerigroup Medicaid	$16,670.23
Rate for Payer: Iowa Total Care Managed Medicaid	$16,508.38
Rate for Payer: Molina Healthcare Managed Medicaid	$16,751.16

lubiprostone 24 mcg oral capsule [VDMC]

Facility

$4.68

Service Code	HCPCS A9270
Hospital Charge Code	10401925
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$4.21
Rate for Payer: Aetna of IA Commercial	$4.21
Rate for Payer: Aetna of IA Medical Rental Products	$4.21
Rate for Payer: Aetna of IA Medicare	$2.67
Rate for Payer: Amerigroup Medicaid	$2.70
Rate for Payer: Amerigroup Medicare	$2.13
Rate for Payer: Cash Price	$3.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.51
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.11
Rate for Payer: Iowa Total Care Managed Medicaid	$2.67
Rate for Payer: Medical Associates Commercial	$3.51
Rate for Payer: Medical Associates Managed Medicare	$2.11
Rate for Payer: Midlands Choice Commercial	$3.28
Rate for Payer: Molina Healthcare Managed Medicaid	$2.71
Rate for Payer: Partners Health Alliance Commercial	$2.42
Rate for Payer: United Healthcare Commercial	$4.21
Rate for Payer: United Healthcare Managed Medicare	$2.76

lubiprostone 24 mcg oral capsule [VDMC]

Facility

$4.68

Service Code	HCPCS A9270
Hospital Charge Code	10401925
Hospital Revenue Code	259
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$4.21
Rate for Payer: Aetna of IA Commercial	$4.21
Rate for Payer: Aetna of IA Medical Rental Products	$4.21
Rate for Payer: Cash Price	$3.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.51
Rate for Payer: Medical Associates Commercial	$3.51
Rate for Payer: Midlands Choice Commercial	$3.28
Rate for Payer: United Healthcare Commercial	$4.21

LUNG TRANSPLANT

Facility

$173,433.11

Service Code	MSDRG 007
Min. Negotiated Rate	$170,919.51
Max. Negotiated Rate	$173,433.11
Rate for Payer: Amerigroup Medicaid	$172,595.19
Rate for Payer: Iowa Total Care Managed Medicaid	$170,919.51
Rate for Payer: Molina Healthcare Managed Medicaid	$173,433.11

Lupus Anticoagulant DMCL

Facility

$64.00

Service Code	CPT 85730
Hospital Charge Code	8037728
Hospital Revenue Code	305
Min. Negotiated Rate	$28.80
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: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
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	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76
Rate for Payer: Wellmark IA HMO WHPI	$29.07
Rate for Payer: Wellmark IA PPO	$32.02

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	$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

Luteinizing Hormone DMCL

Facility

$135.00

Service Code	CPT 83002
Hospital Charge Code	8037729
Hospital Revenue Code	301
Min. Negotiated Rate	$49.63
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	$77.87
Rate for Payer: Amerigroup Medicare	$61.36
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	$60.75
Rate for Payer: Iowa Total Care Managed Medicaid	$77.11
Rate for Payer: Medical Associates Commercial	$101.25
Rate for Payer: Medical Associates Managed Medicare	$60.75
Rate for Payer: Midlands Choice Commercial	$94.50
Rate for Payer: Molina Healthcare Managed Medicaid	$78.25
Rate for Payer: Partners Health Alliance Commercial	$69.86
Rate for Payer: United Healthcare Commercial	$121.50
Rate for Payer: United Healthcare Managed Medicare	$79.65
Rate for Payer: Wellmark IA HMO WHPI	$49.63
Rate for Payer: Wellmark IA PPO	$54.67

Lyme Antibody Screen DMCL

Facility

$139.00

Service Code	CPT 86618
Hospital Charge Code	8037730
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
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	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

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	$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

Know your out-of-pocket cost for care.

All Charges