Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

LENS 16.5

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047317
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 16.5

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047317
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 16.5 CNA0T016.5D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8900227
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 16.5 CNA0T016.5D

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8900227
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 16.5 CNWTT6.165D

Facility

$1,827.00

Service Code	CPT V2788
Hospital Charge Code	8960507
Hospital Revenue Code	276
Min. Negotiated Rate	$913.13
Max. Negotiated Rate	$1,644.30
Rate for Payer: Aetna of IA Commercial	$1,644.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,644.30
Rate for Payer: Aetna of IA Medicare	$1,041.39
Rate for Payer: Amerigroup Medicaid	$922.09
Rate for Payer: Amerigroup Medicare	$922.64
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,370.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$913.50
Rate for Payer: Iowa Total Care Managed Medicaid	$913.13
Rate for Payer: Medical Associates Commercial	$1,370.25
Rate for Payer: Medical Associates Managed Medicare	$913.50
Rate for Payer: Midlands Choice Commercial	$1,278.90
Rate for Payer: Molina Healthcare Managed Medicaid	$927.20
Rate for Payer: Molina Healthcare Managed Medicare	$926.65
Rate for Payer: Oscar Health of IA Commercial	$1,370.25
Rate for Payer: Partners Health Alliance Commercial	$1,370.25
Rate for Payer: United Healthcare Commercial	$1,644.30
Rate for Payer: United Healthcare Managed Medicare	$1,077.93

LENS 16.5 CNWTT6.165D

Facility

$1,827.00

Service Code	CPT V2788
Hospital Charge Code	8960507
Hospital Revenue Code	276
Min. Negotiated Rate	$1,278.90
Max. Negotiated Rate	$1,644.30
Rate for Payer: Aetna of IA Commercial	$1,644.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,644.30
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,370.25
Rate for Payer: Medical Associates Commercial	$1,370.25
Rate for Payer: Midlands Choice Commercial	$1,278.90
Rate for Payer: United Healthcare Commercial	$1,644.30

LENS 16.5 SN60WF165

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8896439
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 16.5 SN60WF165

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8896439
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 16.5 SN6AT616.5

Facility

$845.00

Service Code	CPT V2632
Hospital Charge Code	8904645
Hospital Revenue Code	276
Min. Negotiated Rate	$591.50
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: Cash Price	$676.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$633.75
Rate for Payer: Medical Associates Commercial	$633.75
Rate for Payer: Midlands Choice Commercial	$591.50
Rate for Payer: United Healthcare Commercial	$760.50

LENS 16.5 SN6AT616.5

Facility

$845.00

Service Code	CPT V2632
Hospital Charge Code	8904645
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 17.0

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047318
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 17.0

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047318
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 17.0-0

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047356
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 17.0-0

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047356
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 17.0 CNA0T017

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8896892
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 17.0 CNA0T017

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8896892
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 17.0 CNWTT4.170

Facility

$1,827.00

Service Code	CPT V2788
Hospital Charge Code	8963781
Hospital Revenue Code	276
Min. Negotiated Rate	$913.13
Max. Negotiated Rate	$1,644.30
Rate for Payer: Aetna of IA Commercial	$1,644.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,644.30
Rate for Payer: Aetna of IA Medicare	$1,041.39
Rate for Payer: Amerigroup Medicaid	$922.09
Rate for Payer: Amerigroup Medicare	$922.64
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,370.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$913.50
Rate for Payer: Iowa Total Care Managed Medicaid	$913.13
Rate for Payer: Medical Associates Commercial	$1,370.25
Rate for Payer: Medical Associates Managed Medicare	$913.50
Rate for Payer: Midlands Choice Commercial	$1,278.90
Rate for Payer: Molina Healthcare Managed Medicaid	$927.20
Rate for Payer: Molina Healthcare Managed Medicare	$926.65
Rate for Payer: Oscar Health of IA Commercial	$1,370.25
Rate for Payer: Partners Health Alliance Commercial	$1,370.25
Rate for Payer: United Healthcare Commercial	$1,644.30
Rate for Payer: United Healthcare Managed Medicare	$1,077.93

LENS 17.0 CNWTT4.170

Facility

$1,827.00

Service Code	CPT V2788
Hospital Charge Code	8963781
Hospital Revenue Code	276
Min. Negotiated Rate	$1,278.90
Max. Negotiated Rate	$1,644.30
Rate for Payer: Aetna of IA Commercial	$1,644.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,644.30
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,370.25
Rate for Payer: Medical Associates Commercial	$1,370.25
Rate for Payer: Midlands Choice Commercial	$1,278.90
Rate for Payer: United Healthcare Commercial	$1,644.30

LENS 17.0 TFNT0017.0D

Facility

$845.00

Service Code	CPT V2787
Hospital Charge Code	8904643
Hospital Revenue Code	276
Min. Negotiated Rate	$591.50
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: Cash Price	$676.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$633.75
Rate for Payer: Medical Associates Commercial	$633.75
Rate for Payer: Midlands Choice Commercial	$591.50
Rate for Payer: United Healthcare Commercial	$760.50

LENS 17.0 TFNT0017.0D

Facility

$845.00

Service Code	CPT V2787
Hospital Charge Code	8904643
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 17.5

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047319
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 17.5

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8047319
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 17.5 (OLD STYLE)

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8046909
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 17.5 (OLD STYLE)

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8046909
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 17.5 SN6AT417.5D

Facility

$891.00

Service Code	CPT V2787
Hospital Charge Code	8933162
Hospital Revenue Code	276
Min. Negotiated Rate	$623.70
Max. Negotiated Rate	$801.90
Rate for Payer: Aetna of IA Commercial	$801.90
Rate for Payer: Aetna of IA Medical Rental Products	$801.90
Rate for Payer: Cash Price	$712.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$668.25
Rate for Payer: Medical Associates Commercial	$668.25
Rate for Payer: Midlands Choice Commercial	$623.70
Rate for Payer: United Healthcare Commercial	$801.90

Know your out-of-pocket cost for care.

All Charges