Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

LENS 20.0 SN6AT6+20.0D

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8914430
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 20.0 TFNT00+20.0D

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8912061
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 20.0 TFNT00+20.0D

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8912061
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 20.5

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047325
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 20.5

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047325
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 20.5 CNA0T0+20.5D

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8925115
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 20.5 CNA0T0+20.5D

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8925115
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 20.5 CNW0T3.205

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8963779
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 20.5 CNW0T3.205

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8963779
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 20.5 CNW0T4.205

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8976636
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 20.5 CNW0T4.205

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8976636
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 20.5D CNWTT020.5D

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8948119
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 20.5D CNWTT020.5D

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8948119
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 20.5 SN60WF205

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8896445
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 20.5 SN60WF205

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8896445
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 21.0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047326
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 21.0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047326
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 21.0-0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047361
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 21.0-0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8047361
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 21.0 CNA0T021.0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8900229
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 21.0 CNA0T021.0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8900229
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 21.0 CNW0T4.210

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8981516
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 21.0 CNW0T4.210

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8981516
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 21.0 CNWET3.210

Facility

$1,827.00

Service Code	HCPCS V2632
Hospital Charge Code	9000490
Hospital Revenue Code	276
Min. Negotiated Rate	$822.15
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	$1,053.81
Rate for Payer: Amerigroup Medicare	$830.37
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	$822.15
Rate for Payer: Iowa Total Care Managed Medicaid	$1,043.58
Rate for Payer: Medical Associates Commercial	$1,370.25
Rate for Payer: Medical Associates Managed Medicare	$822.15
Rate for Payer: Midlands Choice Commercial	$1,278.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,058.93
Rate for Payer: Partners Health Alliance Commercial	$945.47
Rate for Payer: United Healthcare Commercial	$1,644.30
Rate for Payer: United Healthcare Managed Medicare	$1,077.93

LENS 21.0 CNWET3.210

Facility

$1,827.00

Service Code	HCPCS V2632
Hospital Charge Code	9000490
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

Know your out-of-pocket cost for care.

All Charges