Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

LENS 15.0-0

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047354
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

LENS 15.0 CNA0T0+15.0D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8912057
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

LENS 15.0 CNA0T0+15.0D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8912057
Hospital Revenue Code	276
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 15.0 CNW0T615.0

Facility

$927.00

Service Code	CPT V2787
Hospital Charge Code	8960505
Hospital Revenue Code	276
Min. Negotiated Rate	$463.31
Max. Negotiated Rate	$834.30
Rate for Payer: Aetna of IA Commercial	$834.30
Rate for Payer: Aetna of IA Medical Rental Products	$834.30
Rate for Payer: Aetna of IA Medicare	$528.39
Rate for Payer: Amerigroup Medicaid	$467.86
Rate for Payer: Amerigroup Medicare	$468.14
Rate for Payer: Cash Price	$741.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$695.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$463.50
Rate for Payer: Iowa Total Care Managed Medicaid	$463.31
Rate for Payer: Medical Associates Commercial	$695.25
Rate for Payer: Medical Associates Managed Medicare	$463.50
Rate for Payer: Midlands Choice Commercial	$648.90
Rate for Payer: Molina Healthcare Managed Medicaid	$470.45
Rate for Payer: Molina Healthcare Managed Medicare	$470.17
Rate for Payer: Oscar Health of IA Commercial	$695.25
Rate for Payer: Partners Health Alliance Commercial	$695.25
Rate for Payer: United Healthcare Commercial	$834.30
Rate for Payer: United Healthcare Managed Medicare	$546.93

LENS 15.0 CNW0T615.0

Facility

$927.00

Service Code	CPT V2787
Hospital Charge Code	8960505
Hospital Revenue Code	276
Min. Negotiated Rate	$648.90
Max. Negotiated Rate	$834.30
Rate for Payer: Aetna of IA Commercial	$834.30
Rate for Payer: Aetna of IA Medical Rental Products	$834.30
Rate for Payer: Cash Price	$741.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$695.25
Rate for Payer: Medical Associates Commercial	$695.25
Rate for Payer: Midlands Choice Commercial	$648.90
Rate for Payer: United Healthcare Commercial	$834.30

LENS 15.0D CNW0T3.150D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8952398
Hospital Revenue Code	276
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 15.0D CNW0T3.150D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8952398
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

LENS 15.5

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047315
Hospital Revenue Code	276
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 15.5

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047315
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

LENS 15.5 CNA0T015.5D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8914424
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

LENS 15.5 CNA0T015.5D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8914424
Hospital Revenue Code	276
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 16.0

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047316
Hospital Revenue Code	276
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 16.0

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047316
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

LENS 16.0-0

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047355
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

LENS 16.0-0

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047355
Hospital Revenue Code	276
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 16.0 AU00T016.0D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8900223
Hospital Revenue Code	276
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 16.0 AU00T016.0D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8900223
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

LENS 16.0 CNA0T016.0D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8909070
Hospital Revenue Code	276
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 16.0 CNA0T016.0D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8909070
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

LENS 16.0 (OLD STYLE)

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8046908
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

LENS 16.0 (OLD STYLE)

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8046908
Hospital Revenue Code	276
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 16.0 PANOPTICS

Facility

$845.00

Service Code	CPT V2788
Hospital Charge Code	8895772
Hospital Revenue Code	276
Min. Negotiated Rate	$591.50
Max. Negotiated Rate	$760.50
Rate for Payer: Medical Associates Commercial	$633.75
Rate for Payer: Aetna of IA Commercial	$760.50
Rate for Payer: Aetna of IA Medical Rental Products	$760.50
Rate for Payer: Cash Price	$676.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$633.75
Rate for Payer: Midlands Choice Commercial	$591.50
Rate for Payer: United Healthcare Commercial	$760.50

LENS 16.0 PANOPTICS

Facility

$845.00

Service Code	CPT V2788
Hospital Charge Code	8895772
Hospital Revenue Code	276
Min. Negotiated Rate	$422.33
Max. Negotiated Rate	$760.50
Rate for Payer: Aetna of IA Commercial	$760.50
Rate for Payer: Aetna of IA Medical Rental Products	$760.50
Rate for Payer: Aetna of IA Medicare	$481.65
Rate for Payer: Amerigroup Medicaid	$426.47
Rate for Payer: Amerigroup Medicare	$426.72
Rate for Payer: Cash Price	$676.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$633.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$422.50
Rate for Payer: Iowa Total Care Managed Medicaid	$422.33
Rate for Payer: Medical Associates Commercial	$633.75
Rate for Payer: Medical Associates Managed Medicare	$422.50
Rate for Payer: Midlands Choice Commercial	$591.50
Rate for Payer: Molina Healthcare Managed Medicaid	$428.84
Rate for Payer: Molina Healthcare Managed Medicare	$428.58
Rate for Payer: Oscar Health of IA Commercial	$633.75
Rate for Payer: Partners Health Alliance Commercial	$633.75
Rate for Payer: United Healthcare Commercial	$760.50
Rate for Payer: United Healthcare Managed Medicare	$498.55

LENS 16.0 TORIC

Facility

$375.00

Service Code	CPT V2787
Hospital Charge Code	8895768
Hospital Revenue Code	276
Min. Negotiated Rate	$187.42
Max. Negotiated Rate	$337.50
Rate for Payer: Aetna of IA Commercial	$337.50
Rate for Payer: Aetna of IA Medical Rental Products	$337.50
Rate for Payer: Aetna of IA Medicare	$213.75
Rate for Payer: Amerigroup Medicaid	$189.26
Rate for Payer: Amerigroup Medicare	$189.38
Rate for Payer: Cash Price	$300.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$281.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$187.50
Rate for Payer: Iowa Total Care Managed Medicaid	$187.42
Rate for Payer: Medical Associates Commercial	$281.25
Rate for Payer: Medical Associates Managed Medicare	$187.50
Rate for Payer: Midlands Choice Commercial	$262.50
Rate for Payer: Molina Healthcare Managed Medicaid	$190.31
Rate for Payer: Molina Healthcare Managed Medicare	$190.20
Rate for Payer: Oscar Health of IA Commercial	$281.25
Rate for Payer: Partners Health Alliance Commercial	$281.25
Rate for Payer: United Healthcare Commercial	$337.50
Rate for Payer: United Healthcare Managed Medicare	$221.25

LENS 16.0 TORIC

Facility

$375.00

Service Code	CPT V2787
Hospital Charge Code	8895768
Hospital Revenue Code	276
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$337.50
Rate for Payer: Aetna of IA Commercial	$337.50
Rate for Payer: Aetna of IA Medical Rental Products	$337.50
Rate for Payer: Cash Price	$300.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$281.25
Rate for Payer: Medical Associates Commercial	$281.25
Rate for Payer: Midlands Choice Commercial	$262.50
Rate for Payer: United Healthcare Commercial	$337.50

Know your out-of-pocket cost for care.

All Charges