|
VIRAL MENINGITIS
|
Facility
|
IP
|
$19,290.28
|
|
|
Service Code
|
APR-DRG 0514
|
| Min. Negotiated Rate |
$17,134.83 |
| Max. Negotiated Rate |
$19,290.28 |
| Rate for Payer: Anthem Medicaid |
$18,471.51
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$18,471.51
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$18,471.51
|
| Rate for Payer: Dean Health Medicaid |
$18,471.51
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$17,134.83
|
| Rate for Payer: Managed Health Services Medicaid |
$19,290.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,471.51
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$18,471.51
|
| Rate for Payer: United Healthcare Medicaid |
$18,471.51
|
|
|
VIRAL MENINGITIS
|
Facility
|
IP
|
$12,100.27
|
|
|
Service Code
|
APR-DRG 0513
|
| Min. Negotiated Rate |
$10,748.21 |
| Max. Negotiated Rate |
$12,100.27 |
| Rate for Payer: Anthem Medicaid |
$11,586.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$11,586.67
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$11,586.67
|
| Rate for Payer: Dean Health Medicaid |
$11,586.67
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$10,748.21
|
| Rate for Payer: Managed Health Services Medicaid |
$12,100.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,586.67
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$11,586.67
|
| Rate for Payer: United Healthcare Medicaid |
$11,586.67
|
|
|
VIRAL MENINGITIS
|
Facility
|
IP
|
$5,699.40
|
|
|
Service Code
|
APR-DRG 0511
|
| Min. Negotiated Rate |
$5,062.56 |
| Max. Negotiated Rate |
$5,699.40 |
| Rate for Payer: Anthem Medicaid |
$5,457.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$5,457.49
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$5,457.49
|
| Rate for Payer: Dean Health Medicaid |
$5,457.49
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$5,062.56
|
| Rate for Payer: Managed Health Services Medicaid |
$5,699.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,457.49
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$5,457.49
|
| Rate for Payer: United Healthcare Medicaid |
$5,457.49
|
|
|
VIRAL MENINGITIS
|
Facility
|
IP
|
$7,716.11
|
|
|
Service Code
|
APR-DRG 0512
|
| Min. Negotiated Rate |
$6,853.93 |
| Max. Negotiated Rate |
$7,716.11 |
| Rate for Payer: Anthem Medicaid |
$7,388.60
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$7,388.60
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$7,388.60
|
| Rate for Payer: Dean Health Medicaid |
$7,388.60
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$6,853.93
|
| Rate for Payer: Managed Health Services Medicaid |
$7,716.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,388.60
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$7,388.60
|
| Rate for Payer: United Healthcare Medicaid |
$7,388.60
|
|
|
VIRAL MENINGITIS WITH CC/MCC
|
Facility
|
IP
|
$53,249.04
|
|
|
Service Code
|
MSDRG 075
|
| Min. Negotiated Rate |
$15,191.37 |
| Max. Negotiated Rate |
$53,249.04 |
| Rate for Payer: Aetna Managed Medicare |
$15,191.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$41,838.32
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32,068.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30,467.39
|
| Rate for Payer: Anthem Medicare Advantage |
$15,191.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,191.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,191.37
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,191.37
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$33,821.59
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,191.37
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$38,811.86
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,191.37
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,191.37
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,191.37
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,191.37
|
| Rate for Payer: NAPHCARE Commercial |
$22,787.06
|
| Rate for Payer: Quartz Medicare Advantage |
$15,191.37
|
| Rate for Payer: The Alliance Commercial |
$53,249.04
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,191.37
|
| Rate for Payer: United Healthcare PPO |
$30,215.54
|
| Rate for Payer: Wellcare Medicare |
$15,191.37
|
|
|
VIRAL MENINGITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$25,839.84
|
|
|
Service Code
|
MSDRG 076
|
| Min. Negotiated Rate |
$6,826.32 |
| Max. Negotiated Rate |
$25,839.84 |
| Rate for Payer: Aetna Managed Medicare |
$6,826.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$16,338.22
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$12,523.11
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$11,897.77
|
| Rate for Payer: Anthem Medicare Advantage |
$6,826.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$6,826.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$6,826.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$6,826.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$13,207.62
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$6,826.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$18,708.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,826.32
|
| Rate for Payer: Independent Care Health Plan Medicare |
$6,826.32
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$6,826.32
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$6,826.32
|
| Rate for Payer: NAPHCARE Commercial |
$10,239.48
|
| Rate for Payer: Quartz Medicare Advantage |
$6,826.32
|
| Rate for Payer: The Alliance Commercial |
$25,839.84
|
| Rate for Payer: United Healthcare Medicare Advantage |
$6,826.32
|
| Rate for Payer: United Healthcare PPO |
$14,564.65
|
| Rate for Payer: Wellcare Medicare |
$6,826.32
|
|
|
Viral Respiratory, Rapid Culture w/ Reflex
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
3899563
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$183.46 |
| Max. Negotiated Rate |
$344.45 |
| Rate for Payer: Aetna Commercial |
$336.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.43
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: Health EOS Commercial |
$333.22
|
| Rate for Payer: HFN Commercial |
$344.45
|
| Rate for Payer: Multiplan Commercial |
$299.52
|
| Rate for Payer: Preferred Network Access Commercial |
$344.45
|
| Rate for Payer: Quartz Beloit One Network |
$183.46
|
| Rate for Payer: Quartz Commercial |
$224.64
|
| Rate for Payer: WEA Trust Commercial |
$205.92
|
| Rate for Payer: WPS Commercial |
$277.31
|
|
|
Viral Respiratory, Rapid Culture w/ Reflex
|
Professional
|
Both
|
$360.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
3899563
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.34 |
| Max. Negotiated Rate |
$355.68 |
| Rate for Payer: Aetna Commercial |
$355.68
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.98
|
| Rate for Payer: Aetna Managed Medicare |
$20.34
|
| Rate for Payer: Anthem Medicare Advantage |
$20.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.34
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$355.68
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$187.20
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$20.34
|
| Rate for Payer: Health EOS Commercial |
$340.70
|
| Rate for Payer: HFN Commercial |
$355.68
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.81
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$71.81
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.34
|
| Rate for Payer: Multiplan Commercial |
$299.52
|
| Rate for Payer: NAPHCARE Commercial |
$30.51
|
| Rate for Payer: Preferred Network Access Commercial |
$355.68
|
| Rate for Payer: Quartz Beloit One Network |
$164.74
|
| Rate for Payer: Quartz Commercial |
$213.41
|
| Rate for Payer: Quartz Medicare Advantage |
$20.34
|
| Rate for Payer: The Alliance Commercial |
$80.35
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.34
|
| Rate for Payer: WEA Trust Commercial |
$205.92
|
| Rate for Payer: WPS Commercial |
$89.51
|
|
|
Viral Respiratory, Rapid Culture w/ Reflex
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
3899563
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.34 |
| Max. Negotiated Rate |
$344.45 |
| Rate for Payer: Aetna Commercial |
$336.96
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$321.98
|
| Rate for Payer: Aetna Managed Medicare |
$20.34
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$76.28
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$33.77
|
| Rate for Payer: Anthem Medicare Advantage |
$20.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$198.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$20.34
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$20.34
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$344.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$20.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$209.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$20.34
|
| Rate for Payer: Health EOS Commercial |
$333.22
|
| Rate for Payer: HFN Commercial |
$344.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$75.67
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$20.34
|
| Rate for Payer: Independent Care Health Plan Medicare |
$20.34
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$20.34
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$20.34
|
| Rate for Payer: Multiplan Commercial |
$299.52
|
| Rate for Payer: NAPHCARE Commercial |
$30.51
|
| Rate for Payer: Preferred Network Access Commercial |
$344.45
|
| Rate for Payer: Quartz Beloit One Network |
$183.46
|
| Rate for Payer: Quartz Commercial |
$243.36
|
| Rate for Payer: Quartz Medicare Advantage |
$20.34
|
| Rate for Payer: The Alliance Commercial |
$81.37
|
| Rate for Payer: United Healthcare Medicare Advantage |
$20.34
|
| Rate for Payer: United Healthcare PPO |
$280.80
|
| Rate for Payer: WEA Trust Commercial |
$205.92
|
| Rate for Payer: Wellcare Medicare |
$20.34
|
| Rate for Payer: WPS Commercial |
$277.31
|
|
|
VIRTUOSAPH PLUS EVH SYSTEM VSP550EX
|
Facility
|
OP
|
$9,974.00
|
|
| Hospital Charge Code |
2967354
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,904.43 |
| Max. Negotiated Rate |
$9,543.12 |
| Rate for Payer: Aetna Commercial |
$9,335.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,920.75
|
| Rate for Payer: Aetna Managed Medicare |
$2,904.43
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$6,742.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$5,186.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$4,979.02
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,497.67
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cigna Commercial |
$9,543.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$5,804.87
|
| Rate for Payer: Health EOS Commercial |
$9,231.93
|
| Rate for Payer: HFN Commercial |
$9,543.12
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,779.72
|
| Rate for Payer: Multiplan Commercial |
$8,298.37
|
| Rate for Payer: NAPHCARE Commercial |
$6,223.78
|
| Rate for Payer: Preferred Network Access Commercial |
$9,543.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,082.75
|
| Rate for Payer: Quartz Commercial |
$6,742.42
|
| Rate for Payer: Quartz Medicare Advantage |
$6,223.78
|
| Rate for Payer: The Alliance Commercial |
$5,186.48
|
| Rate for Payer: WEA Trust Commercial |
$5,705.13
|
| Rate for Payer: WPS Commercial |
$7,682.97
|
|
|
VIRTUOSAPH PLUS EVH SYSTEM VSP550EX
|
Facility
|
IP
|
$9,974.00
|
|
| Hospital Charge Code |
2967354
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,082.75 |
| Max. Negotiated Rate |
$9,543.12 |
| Rate for Payer: Aetna Commercial |
$9,335.66
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$8,920.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$5,497.67
|
| Rate for Payer: Cash Price |
$2,992.20
|
| Rate for Payer: Cigna Commercial |
$9,543.12
|
| Rate for Payer: Health EOS Commercial |
$9,231.93
|
| Rate for Payer: HFN Commercial |
$9,543.12
|
| Rate for Payer: Multiplan Commercial |
$8,298.37
|
| Rate for Payer: Preferred Network Access Commercial |
$9,543.12
|
| Rate for Payer: Quartz Beloit One Network |
$5,082.75
|
| Rate for Payer: Quartz Commercial |
$6,223.78
|
| Rate for Payer: WEA Trust Commercial |
$5,705.13
|
| Rate for Payer: WPS Commercial |
$7,682.97
|
|
|
Viscosity Serum Level
|
Facility
|
OP
|
$302.00
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
1043317
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.14 |
| Max. Negotiated Rate |
$288.95 |
| Rate for Payer: Aetna Commercial |
$282.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$270.11
|
| Rate for Payer: Aetna Managed Medicare |
$12.14
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$45.51
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$21.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$20.15
|
| Rate for Payer: Anthem Medicare Advantage |
$12.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$166.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.14
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cigna Commercial |
$288.95
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$12.14
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$175.76
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$12.14
|
| Rate for Payer: Health EOS Commercial |
$279.53
|
| Rate for Payer: HFN Commercial |
$288.95
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$45.15
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$12.14
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.14
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$12.14
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$12.14
|
| Rate for Payer: Multiplan Commercial |
$251.26
|
| Rate for Payer: NAPHCARE Commercial |
$18.21
|
| Rate for Payer: Preferred Network Access Commercial |
$288.95
|
| Rate for Payer: Quartz Beloit One Network |
$153.90
|
| Rate for Payer: Quartz Commercial |
$204.15
|
| Rate for Payer: Quartz Medicare Advantage |
$12.14
|
| Rate for Payer: The Alliance Commercial |
$48.55
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.14
|
| Rate for Payer: United Healthcare PPO |
$235.56
|
| Rate for Payer: WEA Trust Commercial |
$172.74
|
| Rate for Payer: Wellcare Medicare |
$12.14
|
| Rate for Payer: WPS Commercial |
$232.63
|
|
|
Viscosity Serum Level
|
Facility
|
IP
|
$302.00
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
1043317
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$153.90 |
| Max. Negotiated Rate |
$288.95 |
| Rate for Payer: Aetna Commercial |
$282.67
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$270.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$166.46
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cigna Commercial |
$288.95
|
| Rate for Payer: Health EOS Commercial |
$279.53
|
| Rate for Payer: HFN Commercial |
$288.95
|
| Rate for Payer: Multiplan Commercial |
$251.26
|
| Rate for Payer: Preferred Network Access Commercial |
$288.95
|
| Rate for Payer: Quartz Beloit One Network |
$153.90
|
| Rate for Payer: Quartz Commercial |
$188.45
|
| Rate for Payer: WEA Trust Commercial |
$172.74
|
| Rate for Payer: WPS Commercial |
$232.63
|
|
|
Viscosity Serum Level
|
Professional
|
Both
|
$302.00
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
1043317
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.14 |
| Max. Negotiated Rate |
$298.38 |
| Rate for Payer: Aetna Commercial |
$298.38
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$270.11
|
| Rate for Payer: Aetna Managed Medicare |
$12.14
|
| Rate for Payer: Anthem Medicare Advantage |
$12.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$12.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$12.14
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cash Price |
$90.60
|
| Rate for Payer: Cigna Commercial |
$298.38
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$157.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$12.14
|
| Rate for Payer: Health EOS Commercial |
$285.81
|
| Rate for Payer: HFN Commercial |
$298.38
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$42.85
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$42.85
|
| Rate for Payer: Independent Care Health Plan Medicare |
$12.14
|
| Rate for Payer: Multiplan Commercial |
$251.26
|
| Rate for Payer: NAPHCARE Commercial |
$18.21
|
| Rate for Payer: Preferred Network Access Commercial |
$298.38
|
| Rate for Payer: Quartz Beloit One Network |
$138.20
|
| Rate for Payer: Quartz Commercial |
$179.03
|
| Rate for Payer: Quartz Medicare Advantage |
$12.14
|
| Rate for Payer: The Alliance Commercial |
$47.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$12.14
|
| Rate for Payer: WEA Trust Commercial |
$172.74
|
| Rate for Payer: WPS Commercial |
$53.40
|
|
|
Vision 2.5mm x 23mm
|
Facility
|
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159058
|
|
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 2.5mm x 23mm
|
Facility
|
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159058
|
|
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 2.5mm x 23mm
|
Professional
|
Both
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159058
|
|
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 3.0mm x 12mm
|
Facility
|
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159060
|
|
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 3.0mm x 12mm
|
Facility
|
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159060
|
|
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 3.0mm x 12mm
|
Professional
|
Both
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159060
|
|
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 3.0mm x 18mm
|
Facility
|
IP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159062
|
|
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 3.0mm x 18mm
|
Professional
|
Both
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159062
|
|
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 3.0mm x 18mm
|
Facility
|
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159062
|
|
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 3.0mm x 23mm
|
Facility
|
OP
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159064
|
|
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 3.0mm x 23mm
|
Professional
|
Both
|
$17,408.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
1159064
|
|
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
|
|
