Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

LEAD

Facility

$82.00

Service Code	CPT 83655
Hospital Charge Code	8094268
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: United Healthcare Commercial	$73.80

LEAD

Facility

$82.00

Service Code	CPT 83655
Hospital Charge Code	8094268
Hospital Revenue Code	301
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Aetna of IA Medicare	$46.74
Rate for Payer: Amerigroup Medicaid	$47.30
Rate for Payer: Amerigroup Medicare	$37.27
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$36.90
Rate for Payer: Iowa Total Care Managed Medicaid	$46.84
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Medical Associates Managed Medicare	$36.90
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: Molina Healthcare Managed Medicaid	$47.53
Rate for Payer: Partners Health Alliance Commercial	$42.44
Rate for Payer: United Healthcare Commercial	$73.80
Rate for Payer: United Healthcare Managed Medicare	$48.38
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

Lead Level Screen

Facility

$82.00

Service Code	CPT 83655
Hospital Charge Code	8487747
Hospital Revenue Code	301
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Aetna of IA Medicare	$46.74
Rate for Payer: Amerigroup Medicaid	$47.30
Rate for Payer: Amerigroup Medicare	$37.27
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$36.90
Rate for Payer: Iowa Total Care Managed Medicaid	$46.84
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Medical Associates Managed Medicare	$36.90
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: Molina Healthcare Managed Medicaid	$47.53
Rate for Payer: Partners Health Alliance Commercial	$42.44
Rate for Payer: United Healthcare Commercial	$73.80
Rate for Payer: United Healthcare Managed Medicare	$48.38
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

Lead Level Screen

Facility

$82.00

Service Code	CPT 83655
Hospital Charge Code	8487747
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: United Healthcare Commercial	$73.80

Lead Level Screen DMCL

Facility

$82.00

Service Code	CPT 83655
Hospital Charge Code	8037723
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: United Healthcare Commercial	$73.80

Lead Level Screen DMCL

Facility

$82.00

Service Code	CPT 83655
Hospital Charge Code	8037723
Hospital Revenue Code	301
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Aetna of IA Medicare	$46.74
Rate for Payer: Amerigroup Medicaid	$47.30
Rate for Payer: Amerigroup Medicare	$37.27
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$36.90
Rate for Payer: Iowa Total Care Managed Medicaid	$46.84
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Medical Associates Managed Medicare	$36.90
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: Molina Healthcare Managed Medicaid	$47.53
Rate for Payer: Partners Health Alliance Commercial	$42.44
Rate for Payer: United Healthcare Commercial	$73.80
Rate for Payer: United Healthcare Managed Medicare	$48.38
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

leflunomide 20 mg Tab [VDMC]

Facility

$2.92

Service Code	HCPCS A9270
Hospital Charge Code	10399163
Hospital Revenue Code	259
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$2.63
Rate for Payer: Aetna of IA Commercial	$2.63
Rate for Payer: Aetna of IA Medical Rental Products	$2.63
Rate for Payer: Cash Price	$2.34
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.19
Rate for Payer: Medical Associates Commercial	$2.19
Rate for Payer: Midlands Choice Commercial	$2.04
Rate for Payer: United Healthcare Commercial	$2.63

leflunomide 20 mg Tab [VDMC]

Facility

$2.92

Service Code	HCPCS A9270
Hospital Charge Code	10399163
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$2.63
Rate for Payer: Aetna of IA Commercial	$2.63
Rate for Payer: Aetna of IA Medical Rental Products	$2.63
Rate for Payer: Aetna of IA Medicare	$1.67
Rate for Payer: Amerigroup Medicaid	$1.69
Rate for Payer: Amerigroup Medicare	$1.33
Rate for Payer: Cash Price	$2.34
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.19
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.31
Rate for Payer: Iowa Total Care Managed Medicaid	$1.67
Rate for Payer: Medical Associates Commercial	$2.19
Rate for Payer: Medical Associates Managed Medicare	$1.31
Rate for Payer: Midlands Choice Commercial	$2.04
Rate for Payer: Molina Healthcare Managed Medicaid	$1.69
Rate for Payer: Partners Health Alliance Commercial	$1.51
Rate for Payer: United Healthcare Commercial	$2.63
Rate for Payer: United Healthcare Managed Medicare	$1.72

Legionella Antigen DMCL

Facility

$114.00

Service Code	CPT 87449
Hospital Charge Code	8037724
Hospital Revenue Code	302
Min. Negotiated Rate	$34.03
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Aetna of IA Medicare	$64.98
Rate for Payer: Amerigroup Medicaid	$65.76
Rate for Payer: Amerigroup Medicare	$51.81
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$51.30
Rate for Payer: Iowa Total Care Managed Medicaid	$65.12
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$51.30
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$66.07
Rate for Payer: Partners Health Alliance Commercial	$59.00
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26
Rate for Payer: Wellmark IA HMO WHPI	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

Legionella Antigen DMCL

Facility

$114.00

Service Code	CPT 87449
Hospital Charge Code	8037724
Hospital Revenue Code	302
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: United Healthcare Commercial	$102.60

LENS 10.0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047304
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 10.0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047304
Hospital Revenue Code	276
Min. Negotiated Rate	$121.50
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	$155.74
Rate for Payer: Amerigroup Medicare	$122.72
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	$121.50
Rate for Payer: Iowa Total Care Managed Medicaid	$154.22
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$121.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$156.49
Rate for Payer: Partners Health Alliance Commercial	$139.72
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 10.0 CNW0T4.100

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8972634
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

LENS 10.0 CNW0T4.100

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8972634
Hospital Revenue Code	276
Min. Negotiated Rate	$168.75
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	$216.30
Rate for Payer: Amerigroup Medicare	$170.44
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	$168.75
Rate for Payer: Iowa Total Care Managed Medicaid	$214.20
Rate for Payer: Medical Associates Commercial	$281.25
Rate for Payer: Medical Associates Managed Medicare	$168.75
Rate for Payer: Midlands Choice Commercial	$262.50
Rate for Payer: Molina Healthcare Managed Medicaid	$217.35
Rate for Payer: Partners Health Alliance Commercial	$194.06
Rate for Payer: United Healthcare Commercial	$337.50
Rate for Payer: United Healthcare Managed Medicare	$221.25

LENS 10.0 CNWET0.100

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8965705
Hospital Revenue Code	276
Min. Negotiated Rate	$393.75
Max. Negotiated Rate	$787.50
Rate for Payer: Aetna of IA Commercial	$787.50
Rate for Payer: Aetna of IA Medical Rental Products	$787.50
Rate for Payer: Aetna of IA Medicare	$498.75
Rate for Payer: Amerigroup Medicaid	$504.70
Rate for Payer: Amerigroup Medicare	$397.69
Rate for Payer: Cash Price	$700.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$656.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$393.75
Rate for Payer: Iowa Total Care Managed Medicaid	$499.80
Rate for Payer: Medical Associates Commercial	$656.25
Rate for Payer: Medical Associates Managed Medicare	$393.75
Rate for Payer: Midlands Choice Commercial	$612.50
Rate for Payer: Molina Healthcare Managed Medicaid	$507.15
Rate for Payer: Partners Health Alliance Commercial	$452.81
Rate for Payer: United Healthcare Commercial	$787.50
Rate for Payer: United Healthcare Managed Medicare	$516.25

LENS 10.0 CNWET0.100

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8965705
Hospital Revenue Code	276
Min. Negotiated Rate	$612.50
Max. Negotiated Rate	$787.50
Rate for Payer: Aetna of IA Commercial	$787.50
Rate for Payer: Aetna of IA Medical Rental Products	$787.50
Rate for Payer: Cash Price	$700.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$656.25
Rate for Payer: Medical Associates Commercial	$656.25
Rate for Payer: Midlands Choice Commercial	$612.50
Rate for Payer: United Healthcare Commercial	$787.50

LENS 10.5

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047305
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 10.5

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047305
Hospital Revenue Code	276
Min. Negotiated Rate	$121.50
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	$155.74
Rate for Payer: Amerigroup Medicare	$122.72
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	$121.50
Rate for Payer: Iowa Total Care Managed Medicaid	$154.22
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$121.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$156.49
Rate for Payer: Partners Health Alliance Commercial	$139.72
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 10.5D CNA0T0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8944031
Hospital Revenue Code	278
Min. Negotiated Rate	$121.50
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	$155.74
Rate for Payer: Amerigroup Medicare	$122.72
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	$121.50
Rate for Payer: Iowa Total Care Managed Medicaid	$154.22
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$121.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$156.49
Rate for Payer: Partners Health Alliance Commercial	$139.72
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 10.5D CNA0T0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8944031
Hospital Revenue Code	278
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 11.0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047306
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 11.0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047306
Hospital Revenue Code	276
Min. Negotiated Rate	$121.50
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	$155.74
Rate for Payer: Amerigroup Medicare	$122.72
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	$121.50
Rate for Payer: Iowa Total Care Managed Medicaid	$154.22
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$121.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$156.49
Rate for Payer: Partners Health Alliance Commercial	$139.72
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 11.0 CNA0T011.0D

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8904253
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 11.0 CNA0T011.0D

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8904253
Hospital Revenue Code	276
Min. Negotiated Rate	$121.50
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	$155.74
Rate for Payer: Amerigroup Medicare	$122.72
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	$121.50
Rate for Payer: Iowa Total Care Managed Medicaid	$154.22
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$121.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$156.49
Rate for Payer: Partners Health Alliance Commercial	$139.72
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

LENS 11.0 SN6AT9+11.0D

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8914432
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