Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ACRYSOF IQ 20.0 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8885197
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

ACRYSOF IQ 20.0 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8885197
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

ACRYSOF IQ 20.5 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8891552
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

ACRYSOF IQ 20.5 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8891552
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

ACRYSOF IQ 21.0 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8891554
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

ACRYSOF IQ 21.0 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8891554
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

ACRYSOF IQ 21.5 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8885199
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

ACRYSOF IQ 21.5 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8885199
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

ACRYSOF IQ 22.5 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8885201
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

ACRYSOF IQ 22.5 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8885201
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

ACRYSOF IQ 23.5 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8895998
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

ACRYSOF IQ 23.5 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8895998
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

ACRYSOF IQ 24.0 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8885205
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

ACRYSOF IQ 24.0 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8885205
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

ACRYSOF IQ 24.5 LENS AU00T0245

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8897429
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

ACRYSOF IQ 24.5 LENS AU00T0245

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8897429
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

ACRYSOF IQ 29.5 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8896000
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

ACRYSOF IQ 29.5 LENS

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8896000
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

ACRYSOF IQ LENS 23.0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8885203
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

ACRYSOF IQ LENS 23.0

Facility

$270.00

Service Code	HCPCS V2632
Hospital Charge Code	8885203
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

ACRYSOF IQ PAN OPTIX TORIC 14.0

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8891558
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

ACRYSOF IQ PAN OPTIX TORIC 14.0

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8891558
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

ACRYSOF IQ TORIC IOL 14.5D

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8891556
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

ACRYSOF IQ TORIC IOL 14.5D

Facility

$375.00

Service Code	HCPCS V2787
Hospital Charge Code	8891556
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

ACRYSOF IQ VIVITY TORIC 22.5 LENS

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8885211
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

Know your out-of-pocket cost for care.

All Charges