Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Lyme by PCR DMCL

Facility

$290.00

Service Code	CPT 87476
Hospital Charge Code	8037731
Hospital Revenue Code	306
Min. Negotiated Rate	$86.50
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	$167.27
Rate for Payer: Amerigroup Medicare	$131.80
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	$130.50
Rate for Payer: Iowa Total Care Managed Medicaid	$165.65
Rate for Payer: Medical Associates Commercial	$217.50
Rate for Payer: Medical Associates Managed Medicare	$130.50
Rate for Payer: Midlands Choice Commercial	$203.00
Rate for Payer: Molina Healthcare Managed Medicaid	$168.08
Rate for Payer: Partners Health Alliance Commercial	$150.08
Rate for Payer: United Healthcare Commercial	$261.00
Rate for Payer: United Healthcare Managed Medicare	$171.10
Rate for Payer: Wellmark IA HMO WHPI	$86.50
Rate for Payer: Wellmark IA PPO	$95.28

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 IgG Antibody DMCL

Facility

$139.00

Service Code	CPT 86618
Hospital Charge Code	8505651
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 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

Lyme IgM Antibody DMCL

Facility

$139.00

Service Code	CPT 86618
Hospital Charge Code	8505652
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 Western Blot DMCL

Facility

$139.00

Service Code	CPT 86617
Hospital Charge Code	8632480
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 Western Blot DMCL

Facility

$139.00

Service Code	CPT 86617
Hospital Charge Code	8632480
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

$20,994.97

Service Code	MSDRG 821
Min. Negotiated Rate	$20,690.68
Max. Negotiated Rate	$20,994.97
Rate for Payer: Amerigroup Medicaid	$20,893.53
Rate for Payer: Iowa Total Care Managed Medicaid	$20,690.68
Rate for Payer: Molina Healthcare Managed Medicaid	$20,994.97

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$64,054.58

Service Code	MSDRG 820
Min. Negotiated Rate	$63,126.22
Max. Negotiated Rate	$64,054.58
Rate for Payer: Amerigroup Medicaid	$63,745.11
Rate for Payer: Iowa Total Care Managed Medicaid	$63,126.22
Rate for Payer: Molina Healthcare Managed Medicaid	$64,054.58

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$11,266.53

Service Code	MSDRG 822
Min. Negotiated Rate	$11,103.24
Max. Negotiated Rate	$11,266.53
Rate for Payer: Amerigroup Medicaid	$11,212.09
Rate for Payer: Iowa Total Care Managed Medicaid	$11,103.24
Rate for Payer: Molina Healthcare Managed Medicaid	$11,266.53

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC

Facility

$16,429.13

Service Code	MSDRG 841
Min. Negotiated Rate	$16,191.02
Max. Negotiated Rate	$16,429.13
Rate for Payer: Amerigroup Medicaid	$16,349.76
Rate for Payer: Iowa Total Care Managed Medicaid	$16,191.02
Rate for Payer: Molina Healthcare Managed Medicaid	$16,429.13

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC

Facility

$25,378.40

Service Code	MSDRG 840
Min. Negotiated Rate	$25,010.58
Max. Negotiated Rate	$25,378.40
Rate for Payer: Amerigroup Medicaid	$25,255.78
Rate for Payer: Iowa Total Care Managed Medicaid	$25,010.58
Rate for Payer: Molina Healthcare Managed Medicaid	$25,378.40

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC

Facility

$22,931.65

Service Code	MSDRG 824
Min. Negotiated Rate	$22,599.29
Max. Negotiated Rate	$22,931.65
Rate for Payer: Amerigroup Medicaid	$22,820.86
Rate for Payer: Iowa Total Care Managed Medicaid	$22,599.29
Rate for Payer: Molina Healthcare Managed Medicaid	$22,931.65

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC

Facility

$46,913.83

Service Code	MSDRG 823
Min. Negotiated Rate	$46,233.90
Max. Negotiated Rate	$46,913.83
Rate for Payer: Amerigroup Medicaid	$46,687.17
Rate for Payer: Iowa Total Care Managed Medicaid	$46,233.90
Rate for Payer: Molina Healthcare Managed Medicaid	$46,913.83

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$14,008.28

Service Code	MSDRG 825
Min. Negotiated Rate	$13,805.26
Max. Negotiated Rate	$14,008.28
Rate for Payer: Amerigroup Medicaid	$13,940.60
Rate for Payer: Iowa Total Care Managed Medicaid	$13,805.26
Rate for Payer: Molina Healthcare Managed Medicaid	$14,008.28

LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$10,615.71

Service Code	MSDRG 842
Min. Negotiated Rate	$10,461.86
Max. Negotiated Rate	$10,615.71
Rate for Payer: Amerigroup Medicaid	$10,564.42
Rate for Payer: Iowa Total Care Managed Medicaid	$10,461.86
Rate for Payer: Molina Healthcare Managed Medicaid	$10,615.71

LYSE CHEST FIBRIN INIT DAY

Facility

$541.00

Service Code	CPT 32561
Hospital Charge Code	7982931
Hospital Revenue Code	450
Min. Negotiated Rate	$378.70
Max. Negotiated Rate	$486.90
Rate for Payer: Aetna of IA Commercial	$486.90
Rate for Payer: Aetna of IA Medical Rental Products	$486.90
Rate for Payer: Cash Price	$432.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$405.75
Rate for Payer: Medical Associates Commercial	$405.75
Rate for Payer: Midlands Choice Commercial	$378.70
Rate for Payer: United Healthcare Commercial	$486.90

LYSE CHEST FIBRIN INIT DAY

Facility

$541.00

Service Code	CPT 32561
Hospital Charge Code	7982931
Hospital Revenue Code	450
Min. Negotiated Rate	$243.45
Max. Negotiated Rate	$1,640.88
Rate for Payer: Aetna of IA Commercial	$486.90
Rate for Payer: Aetna of IA Medical Rental Products	$486.90
Rate for Payer: Aetna of IA Medicare	$308.37
Rate for Payer: Amerigroup Medicaid	$312.05
Rate for Payer: Amerigroup Medicare	$245.88
Rate for Payer: Cash Price	$432.80
Rate for Payer: Cash Price	$432.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$405.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$243.45
Rate for Payer: Iowa Total Care Managed Medicaid	$309.02
Rate for Payer: Medical Associates Commercial	$405.75
Rate for Payer: Medical Associates Managed Medicare	$243.45
Rate for Payer: Midlands Choice Commercial	$378.70
Rate for Payer: Molina Healthcare Managed Medicaid	$313.56
Rate for Payer: Partners Health Alliance Commercial	$279.97
Rate for Payer: United Healthcare Commercial	$486.90
Rate for Payer: United Healthcare Managed Medicare	$319.19
Rate for Payer: Wellmark IA HMO WHPI	$1,489.61
Rate for Payer: Wellmark IA PPO	$1,640.88

LYSIS OF LABIAL ADHESIONS

Professional

Both

$477.00

Service Code	CPT 56441
Hospital Charge Code	8068969
Hospital Revenue Code	975
Min. Negotiated Rate	$141.42
Max. Negotiated Rate	$411.40
Rate for Payer: Amerigroup Medicaid	$142.81
Rate for Payer: Cash Price	$381.60
Rate for Payer: Cash Price	$381.60
Rate for Payer: Iowa Total Care Managed Medicaid	$141.42
Rate for Payer: Medical Associates Commercial	$357.75
Rate for Payer: Midlands Choice Commercial	$333.90
Rate for Payer: Molina Healthcare Managed Medicaid	$142.12
Rate for Payer: Partners Health Alliance Commercial	$357.75
Rate for Payer: United Healthcare Commercial	$250.24
Rate for Payer: Wellmark IA HMO WHPI	$349.70
Rate for Payer: Wellmark IA PPO	$411.40

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

MAC ENDO CHARGE

Facility

$134.00

Hospital Charge Code	8059073
Hospital Revenue Code	370
Min. Negotiated Rate	$60.30
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	$77.29
Rate for Payer: Amerigroup Medicare	$60.90
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	$60.30
Rate for Payer: Iowa Total Care Managed Medicaid	$76.54
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Medical Associates Managed Medicare	$60.30
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: Molina Healthcare Managed Medicaid	$77.67
Rate for Payer: Partners Health Alliance Commercial	$69.34
Rate for Payer: United Healthcare Commercial	$120.60
Rate for Payer: United Healthcare Managed Medicare	$79.06

Magic Mouthwash [VDMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Charge Code	28639935
Hospital Revenue Code	259
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$2.70
Rate for Payer: Aetna of IA Commercial	$2.70
Rate for Payer: Aetna of IA Medical Rental Products	$2.70
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.25
Rate for Payer: Medical Associates Commercial	$2.25
Rate for Payer: Midlands Choice Commercial	$2.10
Rate for Payer: United Healthcare Commercial	$2.70

Magic Mouthwash [VDMC]

Facility

$3.00

Service Code	HCPCS A9270
Hospital Charge Code	28639935
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$2.70
Rate for Payer: Aetna of IA Commercial	$2.70
Rate for Payer: Aetna of IA Medical Rental Products	$2.70
Rate for Payer: Aetna of IA Medicare	$1.71
Rate for Payer: Amerigroup Medicaid	$1.73
Rate for Payer: Amerigroup Medicare	$1.36
Rate for Payer: Cash Price	$2.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.35
Rate for Payer: Iowa Total Care Managed Medicaid	$1.71
Rate for Payer: Medical Associates Commercial	$2.25
Rate for Payer: Medical Associates Managed Medicare	$1.35
Rate for Payer: Midlands Choice Commercial	$2.10
Rate for Payer: Molina Healthcare Managed Medicaid	$1.74
Rate for Payer: Partners Health Alliance Commercial	$1.55
Rate for Payer: United Healthcare Commercial	$2.70
Rate for Payer: United Healthcare Managed Medicare	$1.77

Magic Mouthwash [VDMC]

Facility

$167.52

Service Code	HCPCS A9270
Hospital Charge Code	20213408
Hospital Revenue Code	259
Min. Negotiated Rate	$75.38
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: Aetna of IA Medicare	$95.49
Rate for Payer: Amerigroup Medicaid	$96.63
Rate for Payer: Amerigroup Medicare	$76.14
Rate for Payer: Cash Price	$134.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$125.64
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$75.38
Rate for Payer: Iowa Total Care Managed Medicaid	$95.69
Rate for Payer: Medical Associates Commercial	$125.64
Rate for Payer: Medical Associates Managed Medicare	$75.38
Rate for Payer: Midlands Choice Commercial	$117.26
Rate for Payer: Molina Healthcare Managed Medicaid	$97.09
Rate for Payer: Partners Health Alliance Commercial	$86.69
Rate for Payer: United Healthcare Commercial	$150.77
Rate for Payer: United Healthcare Managed Medicare	$98.84

Magic Mouthwash [VDMC]

Facility

$167.52

Service Code	HCPCS A9270
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