|
XR Optic Foramina Left
|
Facility
OP
|
$489.00
|
|
|
Service Code
|
CPT 70190
|
| Hospital Charge Code |
630305
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$449.88 |
| Rate for Payer: Aetna Commercial |
$440.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.54
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$317.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$244.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$234.72
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$449.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$435.21
|
| Rate for Payer: HFN Commercial |
$449.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$391.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$449.88
|
| Rate for Payer: Quartz Beloit One Network |
$239.61
|
| Rate for Payer: Quartz Commercial |
$317.85
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$148.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$268.95
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$362.20
|
|
|
XR Optic Foramina Left
|
Facility
OP
|
$509.00
|
|
|
Service Code
|
CPT 70190 LT,TC
|
| Hospital Charge Code |
1537210
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$142.52 |
| Max. Negotiated Rate |
$2,036.00 |
| Rate for Payer: Aetna Commercial |
$458.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$437.74
|
| Rate for Payer: Aetna Managed Medicare |
$142.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$330.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$254.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$244.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$269.77
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cigna Commercial |
$468.28
|
| Rate for Payer: Health EOS Commercial |
$453.01
|
| Rate for Payer: HFN Commercial |
$468.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$381.75
|
| Rate for Payer: Multiplan Commercial |
$407.20
|
| Rate for Payer: NAPHCARE Commercial |
$305.40
|
| Rate for Payer: Preferred Network Access Commercial |
$468.28
|
| Rate for Payer: Quartz Beloit One Network |
$249.41
|
| Rate for Payer: Quartz Commercial |
$330.85
|
| Rate for Payer: Quartz Medicare Advantage |
$305.40
|
| Rate for Payer: The Alliance Commercial |
$2,036.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$279.95
|
| Rate for Payer: WPS Commercial |
$377.02
|
|
|
XR Optic Foramina Left
|
Facility
IP
|
$489.00
|
|
|
Service Code
|
CPT 70190
|
| Hospital Charge Code |
630305
|
| Min. Negotiated Rate |
$239.61 |
| Max. Negotiated Rate |
$449.88 |
| Rate for Payer: Aetna Commercial |
$440.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.17
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$449.88
|
| Rate for Payer: Health EOS Commercial |
$435.21
|
| Rate for Payer: HFN Commercial |
$449.88
|
| Rate for Payer: Multiplan Commercial |
$391.20
|
| Rate for Payer: NAPHCARE Commercial |
$293.40
|
| Rate for Payer: Preferred Network Access Commercial |
$449.88
|
| Rate for Payer: Quartz Beloit One Network |
$239.61
|
| Rate for Payer: Quartz Commercial |
$293.40
|
| Rate for Payer: WEA Trust Commercial |
$268.95
|
| Rate for Payer: WPS Commercial |
$362.20
|
|
|
XR Optic Foramina Left
|
Professional
|
$489.00
|
|
|
Service Code
|
CPT 70190
|
| Hospital Charge Code |
630305
|
| Min. Negotiated Rate |
$36.30 |
| Max. Negotiated Rate |
$464.55 |
| Rate for Payer: Aetna Commercial |
$464.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.54
|
| Rate for Payer: Aetna Managed Medicare |
$36.30
|
| Rate for Payer: Anthem Medicare Advantage |
$36.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.30
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$464.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$244.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.30
|
| Rate for Payer: Health EOS Commercial |
$444.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$131.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.30
|
| Rate for Payer: Multiplan Commercial |
$391.20
|
| Rate for Payer: Preferred Network Access Commercial |
$464.55
|
| Rate for Payer: Quartz Beloit One Network |
$215.16
|
| Rate for Payer: Quartz Commercial |
$278.73
|
| Rate for Payer: Quartz Medicare Advantage |
$36.30
|
| Rate for Payer: The Alliance Commercial |
$137.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.30
|
| Rate for Payer: WEA Trust Commercial |
$268.95
|
| Rate for Payer: WPS Commercial |
$181.50
|
|
|
XR Optic Foramina Right
|
Facility
OP
|
$489.00
|
|
|
Service Code
|
CPT 70190
|
| Hospital Charge Code |
630303
|
| Min. Negotiated Rate |
$89.82 |
| Max. Negotiated Rate |
$449.88 |
| Rate for Payer: Aetna Commercial |
$440.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.54
|
| Rate for Payer: Aetna Managed Medicare |
$89.82
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$317.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$244.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$234.72
|
| Rate for Payer: Anthem Medicare Advantage |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.17
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$89.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$89.82
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$449.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$89.82
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$89.82
|
| Rate for Payer: Health EOS Commercial |
$435.21
|
| Rate for Payer: HFN Commercial |
$449.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$334.13
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$89.82
|
| Rate for Payer: Independent Care Health Plan Medicare |
$89.82
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$89.82
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$89.82
|
| Rate for Payer: Multiplan Commercial |
$391.20
|
| Rate for Payer: NAPHCARE Commercial |
$134.73
|
| Rate for Payer: Preferred Network Access Commercial |
$449.88
|
| Rate for Payer: Quartz Beloit One Network |
$239.61
|
| Rate for Payer: Quartz Commercial |
$317.85
|
| Rate for Payer: Quartz Medicare Advantage |
$89.82
|
| Rate for Payer: The Alliance Commercial |
$148.96
|
| Rate for Payer: United Healthcare Medicare Advantage |
$89.82
|
| Rate for Payer: WEA Trust Commercial |
$268.95
|
| Rate for Payer: Wellcare Medicare |
$89.82
|
| Rate for Payer: WPS Commercial |
$362.20
|
|
|
XR Optic Foramina Right
|
Facility
IP
|
$509.00
|
|
|
Service Code
|
CPT 70190 RT,TC
|
| Hospital Charge Code |
1537212
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$249.41 |
| Max. Negotiated Rate |
$468.28 |
| Rate for Payer: Aetna Commercial |
$458.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$269.77
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cigna Commercial |
$468.28
|
| Rate for Payer: Health EOS Commercial |
$453.01
|
| Rate for Payer: HFN Commercial |
$468.28
|
| Rate for Payer: Multiplan Commercial |
$407.20
|
| Rate for Payer: NAPHCARE Commercial |
$305.40
|
| Rate for Payer: Preferred Network Access Commercial |
$468.28
|
| Rate for Payer: Quartz Beloit One Network |
$249.41
|
| Rate for Payer: Quartz Commercial |
$305.40
|
| Rate for Payer: WEA Trust Commercial |
$279.95
|
| Rate for Payer: WPS Commercial |
$377.02
|
|
|
XR Optic Foramina Right
|
Facility
IP
|
$489.00
|
|
|
Service Code
|
CPT 70190
|
| Hospital Charge Code |
630303
|
| Min. Negotiated Rate |
$239.61 |
| Max. Negotiated Rate |
$449.88 |
| Rate for Payer: Aetna Commercial |
$440.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$259.17
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$449.88
|
| Rate for Payer: Health EOS Commercial |
$435.21
|
| Rate for Payer: HFN Commercial |
$449.88
|
| Rate for Payer: Multiplan Commercial |
$391.20
|
| Rate for Payer: NAPHCARE Commercial |
$293.40
|
| Rate for Payer: Preferred Network Access Commercial |
$449.88
|
| Rate for Payer: Quartz Beloit One Network |
$239.61
|
| Rate for Payer: Quartz Commercial |
$293.40
|
| Rate for Payer: WEA Trust Commercial |
$268.95
|
| Rate for Payer: WPS Commercial |
$362.20
|
|
|
XR Optic Foramina Right
|
Professional
|
$509.00
|
|
|
Service Code
|
CPT 70190 RT,TC
|
| Hospital Charge Code |
1537212
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$223.96 |
| Max. Negotiated Rate |
$483.55 |
| Rate for Payer: Aetna Commercial |
$483.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$437.74
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cigna Commercial |
$483.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$254.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$305.40
|
| Rate for Payer: Health EOS Commercial |
$463.19
|
| Rate for Payer: Multiplan Commercial |
$407.20
|
| Rate for Payer: Preferred Network Access Commercial |
$483.55
|
| Rate for Payer: Quartz Beloit One Network |
$223.96
|
| Rate for Payer: Quartz Commercial |
$290.13
|
| Rate for Payer: The Alliance Commercial |
$254.50
|
| Rate for Payer: WEA Trust Commercial |
$279.95
|
| Rate for Payer: WPS Commercial |
$377.02
|
|
|
XR Optic Foramina Right
|
Facility
OP
|
$509.00
|
|
|
Service Code
|
CPT 70190 RT,TC
|
| Hospital Charge Code |
1537212
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$142.52 |
| Max. Negotiated Rate |
$2,036.00 |
| Rate for Payer: Aetna Commercial |
$458.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$437.74
|
| Rate for Payer: Aetna Managed Medicare |
$142.52
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$330.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$254.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$244.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$269.77
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cash Price |
$152.70
|
| Rate for Payer: Cigna Commercial |
$468.28
|
| Rate for Payer: Health EOS Commercial |
$453.01
|
| Rate for Payer: HFN Commercial |
$468.28
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$381.75
|
| Rate for Payer: Multiplan Commercial |
$407.20
|
| Rate for Payer: NAPHCARE Commercial |
$305.40
|
| Rate for Payer: Preferred Network Access Commercial |
$468.28
|
| Rate for Payer: Quartz Beloit One Network |
$249.41
|
| Rate for Payer: Quartz Commercial |
$330.85
|
| Rate for Payer: Quartz Medicare Advantage |
$305.40
|
| Rate for Payer: The Alliance Commercial |
$2,036.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$279.95
|
| Rate for Payer: WPS Commercial |
$377.02
|
|
|
XR Optic Foramina Right
|
Professional
|
$489.00
|
|
|
Service Code
|
CPT 70190
|
| Hospital Charge Code |
630303
|
| Min. Negotiated Rate |
$36.30 |
| Max. Negotiated Rate |
$464.55 |
| Rate for Payer: Aetna Commercial |
$464.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$420.54
|
| Rate for Payer: Aetna Managed Medicare |
$36.30
|
| Rate for Payer: Anthem Medicare Advantage |
$36.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$36.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$36.30
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cash Price |
$146.70
|
| Rate for Payer: Cigna Commercial |
$464.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$244.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$36.30
|
| Rate for Payer: Health EOS Commercial |
$444.99
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$131.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$131.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$36.30
|
| Rate for Payer: Multiplan Commercial |
$391.20
|
| Rate for Payer: Preferred Network Access Commercial |
$464.55
|
| Rate for Payer: Quartz Beloit One Network |
$215.16
|
| Rate for Payer: Quartz Commercial |
$278.73
|
| Rate for Payer: Quartz Medicare Advantage |
$36.30
|
| Rate for Payer: The Alliance Commercial |
$137.94
|
| Rate for Payer: United Healthcare Medicare Advantage |
$36.30
|
| Rate for Payer: WEA Trust Commercial |
$268.95
|
| Rate for Payer: WPS Commercial |
$181.50
|
|
|
XR OR Ankle
|
Facility
OP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724184
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$975.20 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Aetna Managed Medicare |
$242.20
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$908.25
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$726.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$690.27
|
| Rate for Payer: Anthem Medicare Advantage |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$561.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$242.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$242.20
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$242.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$242.20
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$900.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$242.20
|
| Rate for Payer: Independent Care Health Plan Medicare |
$242.20
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$242.20
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$242.20
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$363.30
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$689.00
|
| Rate for Payer: Quartz Medicare Advantage |
$242.20
|
| Rate for Payer: The Alliance Commercial |
$7.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$242.20
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: Wellcare Medicare |
$242.20
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR OR Ankle
|
Professional
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724184
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$41.28 |
| Max. Negotiated Rate |
$1,007.00 |
| Rate for Payer: Aetna Commercial |
$1,007.00
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$911.60
|
| Rate for Payer: Aetna Managed Medicare |
$41.28
|
| Rate for Payer: Anthem Medicare Advantage |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$41.28
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$41.28
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$1,007.00
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$530.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$41.28
|
| Rate for Payer: Health EOS Commercial |
$964.60
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$143.21
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$143.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$41.28
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,007.00
|
| Rate for Payer: Quartz Beloit One Network |
$466.40
|
| Rate for Payer: Quartz Commercial |
$604.20
|
| Rate for Payer: Quartz Medicare Advantage |
$41.28
|
| Rate for Payer: The Alliance Commercial |
$156.86
|
| Rate for Payer: United Healthcare Medicare Advantage |
$41.28
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$206.40
|
|
|
XR OR Ankle
|
Facility
IP
|
$1,060.00
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
5724184
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$519.40 |
| Max. Negotiated Rate |
$975.20 |
| Rate for Payer: Aetna Commercial |
$954.00
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$561.80
|
| Rate for Payer: Cash Price |
$318.00
|
| Rate for Payer: Cigna Commercial |
$975.20
|
| Rate for Payer: Health EOS Commercial |
$943.40
|
| Rate for Payer: HFN Commercial |
$975.20
|
| Rate for Payer: Multiplan Commercial |
$848.00
|
| Rate for Payer: NAPHCARE Commercial |
$636.00
|
| Rate for Payer: Preferred Network Access Commercial |
$975.20
|
| Rate for Payer: Quartz Beloit One Network |
$519.40
|
| Rate for Payer: Quartz Commercial |
$636.00
|
| Rate for Payer: WEA Trust Commercial |
$583.00
|
| Rate for Payer: WPS Commercial |
$785.14
|
|
|
XR Orbits Complete Bilateral
|
Facility
OP
|
$669.00
|
|
|
Service Code
|
CPT 70200 LT,TC
|
| Hospital Charge Code |
1537214
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$187.32 |
| Max. Negotiated Rate |
$2,676.00 |
| Rate for Payer: Aetna Commercial |
$602.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.34
|
| Rate for Payer: Aetna Managed Medicare |
$187.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$434.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$334.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$321.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.57
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$615.48
|
| Rate for Payer: Health EOS Commercial |
$595.41
|
| Rate for Payer: HFN Commercial |
$615.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$501.75
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: NAPHCARE Commercial |
$401.40
|
| Rate for Payer: Preferred Network Access Commercial |
$615.48
|
| Rate for Payer: Quartz Beloit One Network |
$327.81
|
| Rate for Payer: Quartz Commercial |
$434.85
|
| Rate for Payer: Quartz Medicare Advantage |
$401.40
|
| Rate for Payer: The Alliance Commercial |
$2,676.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR Orbits Complete Bilateral
|
Facility
IP
|
$1,238.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
630301
|
| Min. Negotiated Rate |
$606.62 |
| Max. Negotiated Rate |
$1,138.96 |
| Rate for Payer: Aetna Commercial |
$1,114.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$656.14
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Cigna Commercial |
$1,138.96
|
| Rate for Payer: Health EOS Commercial |
$1,101.82
|
| Rate for Payer: HFN Commercial |
$1,138.96
|
| Rate for Payer: Multiplan Commercial |
$990.40
|
| Rate for Payer: NAPHCARE Commercial |
$742.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,138.96
|
| Rate for Payer: Quartz Beloit One Network |
$606.62
|
| Rate for Payer: Quartz Commercial |
$742.80
|
| Rate for Payer: WEA Trust Commercial |
$680.90
|
| Rate for Payer: WPS Commercial |
$916.99
|
|
|
XR Orbits Complete Bilateral
|
Professional
|
$1,238.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
630301
|
| Min. Negotiated Rate |
$46.40 |
| Max. Negotiated Rate |
$1,176.10 |
| Rate for Payer: Aetna Commercial |
$1,176.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,064.68
|
| Rate for Payer: Aetna Managed Medicare |
$46.40
|
| Rate for Payer: Anthem Medicare Advantage |
$46.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.40
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Cigna Commercial |
$1,176.10
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$619.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.40
|
| Rate for Payer: Health EOS Commercial |
$1,126.58
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$164.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$164.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.40
|
| Rate for Payer: Multiplan Commercial |
$990.40
|
| Rate for Payer: Preferred Network Access Commercial |
$1,176.10
|
| Rate for Payer: Quartz Beloit One Network |
$544.72
|
| Rate for Payer: Quartz Commercial |
$705.66
|
| Rate for Payer: Quartz Medicare Advantage |
$46.40
|
| Rate for Payer: The Alliance Commercial |
$176.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.40
|
| Rate for Payer: WEA Trust Commercial |
$680.90
|
| Rate for Payer: WPS Commercial |
$232.00
|
|
|
XR Orbits Complete Bilateral
|
Facility
IP
|
$669.00
|
|
|
Service Code
|
CPT 70200 LT,TC
|
| Hospital Charge Code |
1537214
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$327.81 |
| Max. Negotiated Rate |
$615.48 |
| Rate for Payer: Aetna Commercial |
$602.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.57
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$615.48
|
| Rate for Payer: Health EOS Commercial |
$595.41
|
| Rate for Payer: HFN Commercial |
$615.48
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: NAPHCARE Commercial |
$401.40
|
| Rate for Payer: Preferred Network Access Commercial |
$615.48
|
| Rate for Payer: Quartz Beloit One Network |
$327.81
|
| Rate for Payer: Quartz Commercial |
$401.40
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR Orbits Complete Bilateral
|
Professional
|
$669.00
|
|
|
Service Code
|
CPT 70200 LT,TC
|
| Hospital Charge Code |
1537214
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$294.36 |
| Max. Negotiated Rate |
$635.55 |
| Rate for Payer: Aetna Commercial |
$635.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.34
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$635.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$334.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$401.40
|
| Rate for Payer: Health EOS Commercial |
$608.79
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: Preferred Network Access Commercial |
$635.55
|
| Rate for Payer: Quartz Beloit One Network |
$294.36
|
| Rate for Payer: Quartz Commercial |
$381.33
|
| Rate for Payer: The Alliance Commercial |
$334.50
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR Orbits Complete Bilateral
|
Facility
OP
|
$1,238.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
630301
|
| Min. Negotiated Rate |
$17.88 |
| Max. Negotiated Rate |
$1,138.96 |
| Rate for Payer: Aetna Commercial |
$1,114.20
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,064.68
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$804.70
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$619.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$594.24
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$656.14
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Cash Price |
$371.40
|
| Rate for Payer: Cigna Commercial |
$1,138.96
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$1,101.82
|
| Rate for Payer: HFN Commercial |
$1,138.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$990.40
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$1,138.96
|
| Rate for Payer: Quartz Beloit One Network |
$606.62
|
| Rate for Payer: Quartz Commercial |
$804.70
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$17.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$680.90
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$916.99
|
|
|
XR Orbits Complete Left
|
Facility
OP
|
$619.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
630299
|
| Min. Negotiated Rate |
$17.88 |
| Max. Negotiated Rate |
$569.48 |
| Rate for Payer: Aetna Commercial |
$557.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$532.34
|
| Rate for Payer: Aetna Managed Medicare |
$108.67
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$402.35
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$309.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$297.12
|
| Rate for Payer: Anthem Medicare Advantage |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$328.07
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$108.67
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$108.67
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cigna Commercial |
$569.48
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$108.67
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$108.67
|
| Rate for Payer: Health EOS Commercial |
$550.91
|
| Rate for Payer: HFN Commercial |
$569.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$404.25
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$108.67
|
| Rate for Payer: Independent Care Health Plan Medicare |
$108.67
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$108.67
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$108.67
|
| Rate for Payer: Multiplan Commercial |
$495.20
|
| Rate for Payer: NAPHCARE Commercial |
$163.00
|
| Rate for Payer: Preferred Network Access Commercial |
$569.48
|
| Rate for Payer: Quartz Beloit One Network |
$303.31
|
| Rate for Payer: Quartz Commercial |
$402.35
|
| Rate for Payer: Quartz Medicare Advantage |
$108.67
|
| Rate for Payer: The Alliance Commercial |
$17.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$108.67
|
| Rate for Payer: WEA Trust Commercial |
$340.45
|
| Rate for Payer: Wellcare Medicare |
$108.67
|
| Rate for Payer: WPS Commercial |
$458.49
|
|
|
XR Orbits Complete Left
|
Professional
|
$619.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
630299
|
| Min. Negotiated Rate |
$46.40 |
| Max. Negotiated Rate |
$588.05 |
| Rate for Payer: Aetna Commercial |
$588.05
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$532.34
|
| Rate for Payer: Aetna Managed Medicare |
$46.40
|
| Rate for Payer: Anthem Medicare Advantage |
$46.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$46.40
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$46.40
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cigna Commercial |
$588.05
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$309.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$46.40
|
| Rate for Payer: Health EOS Commercial |
$563.29
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$164.00
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$164.00
|
| Rate for Payer: Independent Care Health Plan Medicare |
$46.40
|
| Rate for Payer: Multiplan Commercial |
$495.20
|
| Rate for Payer: Preferred Network Access Commercial |
$588.05
|
| Rate for Payer: Quartz Beloit One Network |
$272.36
|
| Rate for Payer: Quartz Commercial |
$352.83
|
| Rate for Payer: Quartz Medicare Advantage |
$46.40
|
| Rate for Payer: The Alliance Commercial |
$176.32
|
| Rate for Payer: United Healthcare Medicare Advantage |
$46.40
|
| Rate for Payer: WEA Trust Commercial |
$340.45
|
| Rate for Payer: WPS Commercial |
$232.00
|
|
|
XR Orbits Complete Left
|
Facility
OP
|
$669.00
|
|
|
Service Code
|
CPT 70200 LT,TC
|
| Hospital Charge Code |
1537216
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$187.32 |
| Max. Negotiated Rate |
$2,676.00 |
| Rate for Payer: Aetna Commercial |
$602.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.34
|
| Rate for Payer: Aetna Managed Medicare |
$187.32
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$434.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$334.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$321.12
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.57
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$615.48
|
| Rate for Payer: Health EOS Commercial |
$595.41
|
| Rate for Payer: HFN Commercial |
$615.48
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$501.75
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: NAPHCARE Commercial |
$401.40
|
| Rate for Payer: Preferred Network Access Commercial |
$615.48
|
| Rate for Payer: Quartz Beloit One Network |
$327.81
|
| Rate for Payer: Quartz Commercial |
$434.85
|
| Rate for Payer: Quartz Medicare Advantage |
$401.40
|
| Rate for Payer: The Alliance Commercial |
$2,676.00
|
| Rate for Payer: United Healthcare PPO |
$301.00
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR Orbits Complete Left
|
Facility
IP
|
$619.00
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
630299
|
| Min. Negotiated Rate |
$303.31 |
| Max. Negotiated Rate |
$569.48 |
| Rate for Payer: Aetna Commercial |
$557.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$328.07
|
| Rate for Payer: Cash Price |
$185.70
|
| Rate for Payer: Cigna Commercial |
$569.48
|
| Rate for Payer: Health EOS Commercial |
$550.91
|
| Rate for Payer: HFN Commercial |
$569.48
|
| Rate for Payer: Multiplan Commercial |
$495.20
|
| Rate for Payer: NAPHCARE Commercial |
$371.40
|
| Rate for Payer: Preferred Network Access Commercial |
$569.48
|
| Rate for Payer: Quartz Beloit One Network |
$303.31
|
| Rate for Payer: Quartz Commercial |
$371.40
|
| Rate for Payer: WEA Trust Commercial |
$340.45
|
| Rate for Payer: WPS Commercial |
$458.49
|
|
|
XR Orbits Complete Left
|
Professional
|
$669.00
|
|
|
Service Code
|
CPT 70200 LT,TC
|
| Hospital Charge Code |
1537216
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$294.36 |
| Max. Negotiated Rate |
$635.55 |
| Rate for Payer: Aetna Commercial |
$635.55
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$575.34
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$635.55
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$334.50
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$401.40
|
| Rate for Payer: Health EOS Commercial |
$608.79
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: Preferred Network Access Commercial |
$635.55
|
| Rate for Payer: Quartz Beloit One Network |
$294.36
|
| Rate for Payer: Quartz Commercial |
$381.33
|
| Rate for Payer: The Alliance Commercial |
$334.50
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
|
XR Orbits Complete Left
|
Facility
IP
|
$669.00
|
|
|
Service Code
|
CPT 70200 LT,TC
|
| Hospital Charge Code |
1537216
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$327.81 |
| Max. Negotiated Rate |
$615.48 |
| Rate for Payer: Aetna Commercial |
$602.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$354.57
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: Cigna Commercial |
$615.48
|
| Rate for Payer: Health EOS Commercial |
$595.41
|
| Rate for Payer: HFN Commercial |
$615.48
|
| Rate for Payer: Multiplan Commercial |
$535.20
|
| Rate for Payer: NAPHCARE Commercial |
$401.40
|
| Rate for Payer: Preferred Network Access Commercial |
$615.48
|
| Rate for Payer: Quartz Beloit One Network |
$327.81
|
| Rate for Payer: Quartz Commercial |
$401.40
|
| Rate for Payer: WEA Trust Commercial |
$367.95
|
| Rate for Payer: WPS Commercial |
$495.53
|
|
