|
Vision 3.0mm x 23mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 28mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159066
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 28mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159066
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.0mm x 28mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159066
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 12mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 12mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 12mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159068
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 18mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159070
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 18mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159070
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 18mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159070
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 23mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 23mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 23mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159072
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 28mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 28mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 3.5mm x 28mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 4.0mm x 12mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 4.0mm x 12mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 4.0mm x 12mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 4.0mm x 18mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159078
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 4.0mm x 18mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159078
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 4.0mm x 18mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159078
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 4.0mm x 23mm
|
Professional
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,659.52 |
| Max. Negotiated Rate |
$16,537.60 |
| Rate for Payer: Aetna Commercial |
$16,537.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,537.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$8,704.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,444.80
|
| Rate for Payer: Health EOS Commercial |
$15,841.28
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: Preferred Network Access Commercial |
$16,537.60
|
| Rate for Payer: Quartz Beloit One Network |
$7,659.52
|
| Rate for Payer: Quartz Commercial |
$9,922.56
|
| Rate for Payer: The Alliance Commercial |
$8,704.00
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 4.0mm x 23mm
|
Facility
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,874.24 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$14,970.88
|
| Rate for Payer: Aetna Managed Medicare |
$4,874.24
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,315.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$8,704.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,355.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$9,741.52
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,056.00
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$11,315.20
|
| Rate for Payer: Quartz Medicare Advantage |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
|
Vision 4.0mm x 23mm
|
Facility
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,529.92 |
| Max. Negotiated Rate |
$16,015.36 |
| Rate for Payer: Aetna Commercial |
$15,667.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,226.24
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,015.36
|
| Rate for Payer: Health EOS Commercial |
$15,493.12
|
| Rate for Payer: HFN Commercial |
$16,015.36
|
| Rate for Payer: Multiplan Commercial |
$13,926.40
|
| Rate for Payer: NAPHCARE Commercial |
$10,444.80
|
| Rate for Payer: Preferred Network Access Commercial |
$16,015.36
|
| Rate for Payer: Quartz Beloit One Network |
$8,529.92
|
| Rate for Payer: Quartz Commercial |
$10,444.80
|
| Rate for Payer: WEA Trust Commercial |
$9,574.40
|
| Rate for Payer: WPS Commercial |
$12,894.11
|
|
