|
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 |
$8,871.12 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$10,862.59
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
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 |
$8,871.12 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$10,862.59
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
Vision 3.5mm x 28mm
|
Professional
|
Both
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,965.90 |
| Max. Negotiated Rate |
$17,199.10 |
| Rate for Payer: Aetna Commercial |
$17,199.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$17,199.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,052.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,862.59
|
| Rate for Payer: Health EOS Commercial |
$16,474.93
|
| Rate for Payer: HFN Commercial |
$17,199.10
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$17,199.10
|
| Rate for Payer: Quartz Beloit One Network |
$7,965.90
|
| Rate for Payer: Quartz Commercial |
$10,319.46
|
| Rate for Payer: The Alliance Commercial |
$9,052.16
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
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 |
$5,069.21 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Aetna Managed Medicare |
$5,069.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,767.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,052.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,690.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,131.46
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,578.24
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: NAPHCARE Commercial |
$10,862.59
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$11,767.81
|
| Rate for Payer: Quartz Medicare Advantage |
$10,862.59
|
| Rate for Payer: The Alliance Commercial |
$9,052.16
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
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 |
$5,069.21 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Aetna Managed Medicare |
$5,069.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,767.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,052.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,690.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,131.46
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,578.24
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: NAPHCARE Commercial |
$10,862.59
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$11,767.81
|
| Rate for Payer: Quartz Medicare Advantage |
$10,862.59
|
| Rate for Payer: The Alliance Commercial |
$9,052.16
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
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 |
$8,871.12 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$10,862.59
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
Vision 4.0mm x 12mm
|
Professional
|
Both
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159076
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,965.90 |
| Max. Negotiated Rate |
$17,199.10 |
| Rate for Payer: Aetna Commercial |
$17,199.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$17,199.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,052.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,862.59
|
| Rate for Payer: Health EOS Commercial |
$16,474.93
|
| Rate for Payer: HFN Commercial |
$17,199.10
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$17,199.10
|
| Rate for Payer: Quartz Beloit One Network |
$7,965.90
|
| Rate for Payer: Quartz Commercial |
$10,319.46
|
| Rate for Payer: The Alliance Commercial |
$9,052.16
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
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 |
$8,871.12 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$10,862.59
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
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 |
$5,069.21 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Aetna Managed Medicare |
$5,069.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,767.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,052.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,690.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,131.46
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,578.24
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: NAPHCARE Commercial |
$10,862.59
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$11,767.81
|
| Rate for Payer: Quartz Medicare Advantage |
$10,862.59
|
| Rate for Payer: The Alliance Commercial |
$9,052.16
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
Vision 4.0mm x 18mm
|
Professional
|
Both
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159078
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,965.90 |
| Max. Negotiated Rate |
$17,199.10 |
| Rate for Payer: Aetna Commercial |
$17,199.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$17,199.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,052.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,862.59
|
| Rate for Payer: Health EOS Commercial |
$16,474.93
|
| Rate for Payer: HFN Commercial |
$17,199.10
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$17,199.10
|
| Rate for Payer: Quartz Beloit One Network |
$7,965.90
|
| Rate for Payer: Quartz Commercial |
$10,319.46
|
| Rate for Payer: The Alliance Commercial |
$9,052.16
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
Vision 4.0mm x 23mm
|
Professional
|
Both
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159080
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,965.90 |
| Max. Negotiated Rate |
$17,199.10 |
| Rate for Payer: Aetna Commercial |
$17,199.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$17,199.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,052.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,862.59
|
| Rate for Payer: Health EOS Commercial |
$16,474.93
|
| Rate for Payer: HFN Commercial |
$17,199.10
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$17,199.10
|
| Rate for Payer: Quartz Beloit One Network |
$7,965.90
|
| Rate for Payer: Quartz Commercial |
$10,319.46
|
| Rate for Payer: The Alliance Commercial |
$9,052.16
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
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 |
$5,069.21 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Aetna Managed Medicare |
$5,069.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,767.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,052.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,690.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,131.46
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,578.24
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: NAPHCARE Commercial |
$10,862.59
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$11,767.81
|
| Rate for Payer: Quartz Medicare Advantage |
$10,862.59
|
| Rate for Payer: The Alliance Commercial |
$9,052.16
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
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 |
$8,871.12 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$10,862.59
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
Vision 4.0mm x 28mm
|
Facility
|
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,069.21 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Aetna Managed Medicare |
$5,069.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$11,767.81
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$9,052.16
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$8,690.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,131.46
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$13,578.24
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: NAPHCARE Commercial |
$10,862.59
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$11,767.81
|
| Rate for Payer: Quartz Medicare Advantage |
$10,862.59
|
| Rate for Payer: The Alliance Commercial |
$9,052.16
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
Vision 4.0mm x 28mm
|
Facility
|
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,871.12 |
| Max. Negotiated Rate |
$16,655.97 |
| Rate for Payer: Aetna Commercial |
$16,293.89
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$9,595.29
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$16,655.97
|
| Rate for Payer: Health EOS Commercial |
$16,112.84
|
| Rate for Payer: HFN Commercial |
$16,655.97
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$16,655.97
|
| Rate for Payer: Quartz Beloit One Network |
$8,871.12
|
| Rate for Payer: Quartz Commercial |
$10,862.59
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
Vision 4.0mm x 28mm
|
Professional
|
Both
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159082
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,965.90 |
| Max. Negotiated Rate |
$17,199.10 |
| Rate for Payer: Aetna Commercial |
$17,199.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$15,569.72
|
| Rate for Payer: Cash Price |
$5,222.40
|
| Rate for Payer: Cigna Commercial |
$17,199.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$9,052.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$10,862.59
|
| Rate for Payer: Health EOS Commercial |
$16,474.93
|
| Rate for Payer: HFN Commercial |
$17,199.10
|
| Rate for Payer: Multiplan Commercial |
$14,483.46
|
| Rate for Payer: Preferred Network Access Commercial |
$17,199.10
|
| Rate for Payer: Quartz Beloit One Network |
$7,965.90
|
| Rate for Payer: Quartz Commercial |
$10,319.46
|
| Rate for Payer: The Alliance Commercial |
$9,052.16
|
| Rate for Payer: WEA Trust Commercial |
$9,957.38
|
| Rate for Payer: WPS Commercial |
$13,409.38
|
|
|
Visipaque 100cc
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444867
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Aetna Managed Medicare |
$69.31
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$160.89
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$123.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$118.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$185.64
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: NAPHCARE Commercial |
$148.51
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$160.89
|
| Rate for Payer: Quartz Medicare Advantage |
$148.51
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Visipaque 100cc
|
Professional
|
Both
|
$243.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$240.08 |
| Rate for Payer: Aetna Commercial |
$240.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Aetna Managed Medicare |
$0.16
|
| Rate for Payer: Anthem Medicare Advantage |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.16
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.16
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$240.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.16
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.14
|
| Rate for Payer: Health EOS Commercial |
$229.98
|
| Rate for Payer: HFN Commercial |
$240.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.17
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.17
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: NAPHCARE Commercial |
$0.23
|
| Rate for Payer: Preferred Network Access Commercial |
$240.08
|
| Rate for Payer: Quartz Beloit One Network |
$111.20
|
| Rate for Payer: Quartz Commercial |
$144.05
|
| Rate for Payer: Quartz Medicare Advantage |
$0.16
|
| Rate for Payer: The Alliance Commercial |
$0.43
|
| Rate for Payer: United Healthcare Medicaid |
$0.16
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.16
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Visipaque 100cc
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
3444867
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$121.28 |
| Max. Negotiated Rate |
$227.72 |
| Rate for Payer: Aetna Commercial |
$222.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$212.87
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$131.19
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cigna Commercial |
$227.72
|
| Rate for Payer: Health EOS Commercial |
$220.29
|
| Rate for Payer: HFN Commercial |
$227.72
|
| Rate for Payer: Multiplan Commercial |
$198.02
|
| Rate for Payer: Preferred Network Access Commercial |
$227.72
|
| Rate for Payer: Quartz Beloit One Network |
$121.28
|
| Rate for Payer: Quartz Commercial |
$148.51
|
| Rate for Payer: WEA Trust Commercial |
$136.14
|
| Rate for Payer: WPS Commercial |
$183.33
|
|
|
Visipaque 100cc
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$123.83 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$151.63
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$187.18
|
|
|
Visipaque 100cc
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
2550870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$232.50 |
| Rate for Payer: Aetna Commercial |
$227.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$217.34
|
| Rate for Payer: Aetna Managed Medicare |
$70.76
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$164.27
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$126.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$121.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$133.94
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cash Price |
$72.90
|
| Rate for Payer: Cigna Commercial |
$232.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.19
|
| Rate for Payer: Health EOS Commercial |
$224.92
|
| Rate for Payer: HFN Commercial |
$232.50
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$189.54
|
| Rate for Payer: Multiplan Commercial |
$202.18
|
| Rate for Payer: NAPHCARE Commercial |
$151.63
|
| Rate for Payer: Preferred Network Access Commercial |
$232.50
|
| Rate for Payer: Quartz Beloit One Network |
$123.83
|
| Rate for Payer: Quartz Commercial |
$164.27
|
| Rate for Payer: Quartz Medicare Advantage |
$151.63
|
| Rate for Payer: The Alliance Commercial |
$0.62
|
| Rate for Payer: WEA Trust Commercial |
$139.00
|
| Rate for Payer: WPS Commercial |
$0.36
|
|
|
Visipaque 270 100ml
|
Facility
|
OP
|
$354.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
1158858
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$103.08
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$239.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$184.08
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$176.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.53
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$276.12
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$220.90
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$239.30
|
| Rate for Payer: Quartz Medicare Advantage |
$220.90
|
| Rate for Payer: The Alliance Commercial |
$1.66
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
Visipaque 270 100ml
|
Professional
|
Both
|
$354.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
1158858
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$349.75 |
| Rate for Payer: Aetna Commercial |
$349.75
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Aetna Managed Medicare |
$0.42
|
| Rate for Payer: Anthem Medicare Advantage |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$0.42
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$349.75
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$0.42
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$0.40
|
| Rate for Payer: Health EOS Commercial |
$335.03
|
| Rate for Payer: HFN Commercial |
$349.75
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$0.49
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$0.49
|
| Rate for Payer: Independent Care Health Plan Medicare |
$0.42
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: NAPHCARE Commercial |
$0.62
|
| Rate for Payer: Preferred Network Access Commercial |
$349.75
|
| Rate for Payer: Quartz Beloit One Network |
$161.99
|
| Rate for Payer: Quartz Commercial |
$209.85
|
| Rate for Payer: Quartz Medicare Advantage |
$0.42
|
| Rate for Payer: The Alliance Commercial |
$1.14
|
| Rate for Payer: United Healthcare Medicaid |
$0.42
|
| Rate for Payer: United Healthcare Medicare Advantage |
$0.42
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$1.01
|
|
|
Visipaque 270 100ml
|
Facility
|
IP
|
$354.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
1158858
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$180.40 |
| Max. Negotiated Rate |
$338.71 |
| Rate for Payer: Aetna Commercial |
$331.34
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$316.62
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$195.12
|
| Rate for Payer: Cash Price |
$106.20
|
| Rate for Payer: Cigna Commercial |
$338.71
|
| Rate for Payer: Health EOS Commercial |
$327.66
|
| Rate for Payer: HFN Commercial |
$338.71
|
| Rate for Payer: Multiplan Commercial |
$294.53
|
| Rate for Payer: Preferred Network Access Commercial |
$338.71
|
| Rate for Payer: Quartz Beloit One Network |
$180.40
|
| Rate for Payer: Quartz Commercial |
$220.90
|
| Rate for Payer: WEA Trust Commercial |
$202.49
|
| Rate for Payer: WPS Commercial |
$272.69
|
|
|
Visipaque 270 150ml
|
Facility
|
IP
|
$529.00
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
2944291
|
|
Hospital Revenue Code
|
255
|
| Min. Negotiated Rate |
$269.58 |
| Max. Negotiated Rate |
$506.15 |
| Rate for Payer: Aetna Commercial |
$495.14
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$473.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$291.58
|
| Rate for Payer: Cash Price |
$158.70
|
| Rate for Payer: Cigna Commercial |
$506.15
|
| Rate for Payer: Health EOS Commercial |
$489.64
|
| Rate for Payer: HFN Commercial |
$506.15
|
| Rate for Payer: Multiplan Commercial |
$440.13
|
| Rate for Payer: Preferred Network Access Commercial |
$506.15
|
| Rate for Payer: Quartz Beloit One Network |
$269.58
|
| Rate for Payer: Quartz Commercial |
$330.10
|
| Rate for Payer: WEA Trust Commercial |
$302.59
|
| Rate for Payer: WPS Commercial |
$407.49
|
|
