I just came back from Italy a couple of weeks ago and I paid mostly with VISA and cash withdrawn from ATM's over there.
Quickly looking at my statements, it looks like VISA (Royal Bank) just charged the exchange rate with no fees. (Without knowing the exchange rate at the time it is hard to tell but it is ballpark close to what I checked when I left)
You do have to be careful though because some VISA machines have an option to pay in the currency of the cards origin. In that case there is a fee. Just choose to pay in the local currency and let the bank do the conversion.
As for ATM withdrawls, It looks like the exchange rate was the going rate at the time, but then Royal slapped a 5$ fee on top of that for each transaction, regardless of amount.
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