|
LENS 17.0 SN6AT5 TORIC
|
Facility
|
IP
|
$944.00
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
2964530
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$462.56 |
| Max. Negotiated Rate |
$868.48 |
| Rate for Payer: Aetna Commercial |
$849.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$811.84
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$500.32
|
| Rate for Payer: Cash Price |
$283.20
|
| Rate for Payer: Cigna Commercial |
$868.48
|
| Rate for Payer: Health EOS Commercial |
$840.16
|
| Rate for Payer: HFN Commercial |
$868.48
|
| Rate for Payer: Multiplan Commercial |
$755.20
|
| Rate for Payer: NAPHCARE Commercial |
$566.40
|
| Rate for Payer: Preferred Network Access Commercial |
$868.48
|
| Rate for Payer: Quartz Beloit One Network |
$462.56
|
| Rate for Payer: Quartz Commercial |
$566.40
|
| Rate for Payer: WEA Trust Commercial |
$519.20
|
| Rate for Payer: WPS Commercial |
$699.22
|
|
|
LENS 17.0 TFNT00
|
Facility
|
OP
|
$1,341.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
5547366
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$375.48 |
| Max. Negotiated Rate |
$5,364.00 |
| Rate for Payer: Aetna Commercial |
$1,206.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,153.26
|
| Rate for Payer: Aetna Managed Medicare |
$375.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$871.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$670.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$643.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$710.73
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,233.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$750.42
|
| Rate for Payer: Health EOS Commercial |
$1,193.49
|
| Rate for Payer: HFN Commercial |
$1,233.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,005.75
|
| Rate for Payer: Multiplan Commercial |
$1,072.80
|
| Rate for Payer: NAPHCARE Commercial |
$804.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.72
|
| Rate for Payer: Quartz Beloit One Network |
$657.09
|
| Rate for Payer: Quartz Commercial |
$871.65
|
| Rate for Payer: Quartz Medicare Advantage |
$804.60
|
| Rate for Payer: The Alliance Commercial |
$5,364.00
|
| Rate for Payer: WEA Trust Commercial |
$737.55
|
| Rate for Payer: WPS Commercial |
$993.28
|
|
|
LENS 17.0 TFNT00
|
Facility
|
IP
|
$1,341.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
5547366
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$657.09 |
| Max. Negotiated Rate |
$1,233.72 |
| Rate for Payer: Aetna Commercial |
$1,206.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,153.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$710.73
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,233.72
|
| Rate for Payer: Health EOS Commercial |
$1,193.49
|
| Rate for Payer: HFN Commercial |
$1,233.72
|
| Rate for Payer: Multiplan Commercial |
$1,072.80
|
| Rate for Payer: NAPHCARE Commercial |
$804.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.72
|
| Rate for Payer: Quartz Beloit One Network |
$657.09
|
| Rate for Payer: Quartz Commercial |
$804.60
|
| Rate for Payer: WEA Trust Commercial |
$737.55
|
| Rate for Payer: WPS Commercial |
$993.28
|
|
|
LENS 17.0 TFNT30
|
Facility
|
IP
|
$1,341.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
5563570
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$657.09 |
| Max. Negotiated Rate |
$1,233.72 |
| Rate for Payer: Aetna Commercial |
$1,206.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,153.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$710.73
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,233.72
|
| Rate for Payer: Health EOS Commercial |
$1,193.49
|
| Rate for Payer: HFN Commercial |
$1,233.72
|
| Rate for Payer: Multiplan Commercial |
$1,072.80
|
| Rate for Payer: NAPHCARE Commercial |
$804.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.72
|
| Rate for Payer: Quartz Beloit One Network |
$657.09
|
| Rate for Payer: Quartz Commercial |
$804.60
|
| Rate for Payer: WEA Trust Commercial |
$737.55
|
| Rate for Payer: WPS Commercial |
$993.28
|
|
|
LENS 17.0 TFNT30
|
Facility
|
OP
|
$1,341.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
5563570
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$375.48 |
| Max. Negotiated Rate |
$5,364.00 |
| Rate for Payer: Aetna Commercial |
$1,206.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,153.26
|
| Rate for Payer: Aetna Managed Medicare |
$375.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$871.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$670.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$643.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$710.73
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,233.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$750.42
|
| Rate for Payer: Health EOS Commercial |
$1,193.49
|
| Rate for Payer: HFN Commercial |
$1,233.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,005.75
|
| Rate for Payer: Multiplan Commercial |
$1,072.80
|
| Rate for Payer: NAPHCARE Commercial |
$804.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.72
|
| Rate for Payer: Quartz Beloit One Network |
$657.09
|
| Rate for Payer: Quartz Commercial |
$871.65
|
| Rate for Payer: Quartz Medicare Advantage |
$804.60
|
| Rate for Payer: The Alliance Commercial |
$5,364.00
|
| Rate for Payer: WEA Trust Commercial |
$737.55
|
| Rate for Payer: WPS Commercial |
$993.28
|
|
|
LENS 17.5 AU00T0
|
Facility
|
IP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4595172
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,464.61 |
| Max. Negotiated Rate |
$2,749.88 |
| Rate for Payer: Aetna Commercial |
$2,690.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,570.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.17
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,749.88
|
| Rate for Payer: Health EOS Commercial |
$2,660.21
|
| Rate for Payer: HFN Commercial |
$2,749.88
|
| Rate for Payer: Multiplan Commercial |
$2,391.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,793.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,749.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,464.61
|
| Rate for Payer: Quartz Commercial |
$1,793.40
|
| Rate for Payer: WEA Trust Commercial |
$1,643.95
|
| Rate for Payer: WPS Commercial |
$2,213.95
|
|
|
LENS 17.5 AU00T0
|
Facility
|
OP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4595172
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$11,956.00 |
| Rate for Payer: Aetna Commercial |
$2,690.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,570.54
|
| Rate for Payer: Aetna Managed Medicare |
$836.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,942.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,494.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,434.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.17
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,749.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,672.64
|
| Rate for Payer: Health EOS Commercial |
$2,660.21
|
| Rate for Payer: HFN Commercial |
$2,749.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,241.75
|
| Rate for Payer: Multiplan Commercial |
$2,391.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,793.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,749.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,464.61
|
| Rate for Payer: Quartz Commercial |
$1,942.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,793.40
|
| Rate for Payer: The Alliance Commercial |
$11,956.00
|
| Rate for Payer: WEA Trust Commercial |
$1,643.95
|
| Rate for Payer: WPS Commercial |
$2,213.95
|
|
|
LENS 17.5 CLAREON CNA0T0.175
|
Facility
|
IP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
6172554
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,464.61 |
| Max. Negotiated Rate |
$2,749.88 |
| Rate for Payer: Aetna Commercial |
$2,690.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,570.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.17
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,749.88
|
| Rate for Payer: Health EOS Commercial |
$2,660.21
|
| Rate for Payer: HFN Commercial |
$2,749.88
|
| Rate for Payer: Multiplan Commercial |
$2,391.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,793.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,749.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,464.61
|
| Rate for Payer: Quartz Commercial |
$1,793.40
|
| Rate for Payer: WEA Trust Commercial |
$1,643.95
|
| Rate for Payer: WPS Commercial |
$2,213.95
|
|
|
LENS 17.5 CLAREON CNA0T0.175
|
Facility
|
OP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
6172554
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$11,956.00 |
| Rate for Payer: Aetna Commercial |
$2,690.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,570.54
|
| Rate for Payer: Aetna Managed Medicare |
$836.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,942.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,494.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,434.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.17
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,749.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,672.64
|
| Rate for Payer: Health EOS Commercial |
$2,660.21
|
| Rate for Payer: HFN Commercial |
$2,749.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,241.75
|
| Rate for Payer: Multiplan Commercial |
$2,391.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,793.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,749.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,464.61
|
| Rate for Payer: Quartz Commercial |
$1,942.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,793.40
|
| Rate for Payer: The Alliance Commercial |
$11,956.00
|
| Rate for Payer: WEA Trust Commercial |
$1,643.95
|
| Rate for Payer: WPS Commercial |
$2,213.95
|
|
|
LENS 17.5 MA60AC
|
Facility
|
OP
|
$2,562.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964324
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$717.36 |
| Max. Negotiated Rate |
$10,248.00 |
| Rate for Payer: Aetna Commercial |
$2,305.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,203.32
|
| Rate for Payer: Aetna Managed Medicare |
$717.36
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,665.30
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,281.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,229.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,357.86
|
| Rate for Payer: Cash Price |
$768.60
|
| Rate for Payer: Cigna Commercial |
$2,357.04
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,433.70
|
| Rate for Payer: Health EOS Commercial |
$2,280.18
|
| Rate for Payer: HFN Commercial |
$2,357.04
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,921.50
|
| Rate for Payer: Multiplan Commercial |
$2,049.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,537.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,357.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,255.38
|
| Rate for Payer: Quartz Commercial |
$1,665.30
|
| Rate for Payer: Quartz Medicare Advantage |
$1,537.20
|
| Rate for Payer: The Alliance Commercial |
$10,248.00
|
| Rate for Payer: WEA Trust Commercial |
$1,409.10
|
| Rate for Payer: WPS Commercial |
$1,897.67
|
|
|
LENS 17.5 MA60AC
|
Facility
|
IP
|
$2,562.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964324
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,255.38 |
| Max. Negotiated Rate |
$2,357.04 |
| Rate for Payer: Aetna Commercial |
$2,305.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,203.32
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,357.86
|
| Rate for Payer: Cash Price |
$768.60
|
| Rate for Payer: Cigna Commercial |
$2,357.04
|
| Rate for Payer: Health EOS Commercial |
$2,280.18
|
| Rate for Payer: HFN Commercial |
$2,357.04
|
| Rate for Payer: Multiplan Commercial |
$2,049.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,537.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,357.04
|
| Rate for Payer: Quartz Beloit One Network |
$1,255.38
|
| Rate for Payer: Quartz Commercial |
$1,537.20
|
| Rate for Payer: WEA Trust Commercial |
$1,409.10
|
| Rate for Payer: WPS Commercial |
$1,897.67
|
|
|
LENS 17.5 MTA3UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964362
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$805.07 |
| Max. Negotiated Rate |
$1,511.56 |
| Rate for Payer: Aetna Commercial |
$1,478.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.79
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,511.56
|
| Rate for Payer: Health EOS Commercial |
$1,462.27
|
| Rate for Payer: HFN Commercial |
$1,511.56
|
| Rate for Payer: Multiplan Commercial |
$1,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$985.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,511.56
|
| Rate for Payer: Quartz Beloit One Network |
$805.07
|
| Rate for Payer: Quartz Commercial |
$985.80
|
| Rate for Payer: WEA Trust Commercial |
$903.65
|
| Rate for Payer: WPS Commercial |
$1,216.97
|
|
|
LENS 17.5 MTA3UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964362
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$460.04 |
| Max. Negotiated Rate |
$6,572.00 |
| Rate for Payer: Aetna Commercial |
$1,478.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.98
|
| Rate for Payer: Aetna Managed Medicare |
$460.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,067.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$821.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$788.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.79
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,511.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$919.42
|
| Rate for Payer: Health EOS Commercial |
$1,462.27
|
| Rate for Payer: HFN Commercial |
$1,511.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,232.25
|
| Rate for Payer: Multiplan Commercial |
$1,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$985.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,511.56
|
| Rate for Payer: Quartz Beloit One Network |
$805.07
|
| Rate for Payer: Quartz Commercial |
$1,067.95
|
| Rate for Payer: Quartz Medicare Advantage |
$985.80
|
| Rate for Payer: The Alliance Commercial |
$6,572.00
|
| Rate for Payer: WEA Trust Commercial |
$903.65
|
| Rate for Payer: WPS Commercial |
$1,216.97
|
|
|
LENS 17.5 MTA4UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964391
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$460.04 |
| Max. Negotiated Rate |
$6,572.00 |
| Rate for Payer: Aetna Commercial |
$1,478.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.98
|
| Rate for Payer: Aetna Managed Medicare |
$460.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,067.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$821.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$788.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.79
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,511.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$919.42
|
| Rate for Payer: Health EOS Commercial |
$1,462.27
|
| Rate for Payer: HFN Commercial |
$1,511.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,232.25
|
| Rate for Payer: Multiplan Commercial |
$1,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$985.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,511.56
|
| Rate for Payer: Quartz Beloit One Network |
$805.07
|
| Rate for Payer: Quartz Commercial |
$1,067.95
|
| Rate for Payer: Quartz Medicare Advantage |
$985.80
|
| Rate for Payer: The Alliance Commercial |
$6,572.00
|
| Rate for Payer: WEA Trust Commercial |
$903.65
|
| Rate for Payer: WPS Commercial |
$1,216.97
|
|
|
LENS 17.5 MTA4UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964391
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$805.07 |
| Max. Negotiated Rate |
$1,511.56 |
| Rate for Payer: Aetna Commercial |
$1,478.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.79
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,511.56
|
| Rate for Payer: Health EOS Commercial |
$1,462.27
|
| Rate for Payer: HFN Commercial |
$1,511.56
|
| Rate for Payer: Multiplan Commercial |
$1,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$985.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,511.56
|
| Rate for Payer: Quartz Beloit One Network |
$805.07
|
| Rate for Payer: Quartz Commercial |
$985.80
|
| Rate for Payer: WEA Trust Commercial |
$903.65
|
| Rate for Payer: WPS Commercial |
$1,216.97
|
|
|
LENS 17.5 MTA5UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964420
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$460.04 |
| Max. Negotiated Rate |
$6,572.00 |
| Rate for Payer: Aetna Commercial |
$1,478.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.98
|
| Rate for Payer: Aetna Managed Medicare |
$460.04
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,067.95
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$821.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$788.64
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.79
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,511.56
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$919.42
|
| Rate for Payer: Health EOS Commercial |
$1,462.27
|
| Rate for Payer: HFN Commercial |
$1,511.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,232.25
|
| Rate for Payer: Multiplan Commercial |
$1,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$985.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,511.56
|
| Rate for Payer: Quartz Beloit One Network |
$805.07
|
| Rate for Payer: Quartz Commercial |
$1,067.95
|
| Rate for Payer: Quartz Medicare Advantage |
$985.80
|
| Rate for Payer: The Alliance Commercial |
$6,572.00
|
| Rate for Payer: WEA Trust Commercial |
$903.65
|
| Rate for Payer: WPS Commercial |
$1,216.97
|
|
|
LENS 17.5 MTA5UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964420
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$805.07 |
| Max. Negotiated Rate |
$1,511.56 |
| Rate for Payer: Aetna Commercial |
$1,478.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,412.98
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$870.79
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,511.56
|
| Rate for Payer: Health EOS Commercial |
$1,462.27
|
| Rate for Payer: HFN Commercial |
$1,511.56
|
| Rate for Payer: Multiplan Commercial |
$1,314.40
|
| Rate for Payer: NAPHCARE Commercial |
$985.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,511.56
|
| Rate for Payer: Quartz Beloit One Network |
$805.07
|
| Rate for Payer: Quartz Commercial |
$985.80
|
| Rate for Payer: WEA Trust Commercial |
$903.65
|
| Rate for Payer: WPS Commercial |
$1,216.97
|
|
|
LENS 17.5 SN60WF
|
Facility
|
OP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964233
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$805.56 |
| Max. Negotiated Rate |
$11,508.00 |
| Rate for Payer: Aetna Commercial |
$2,589.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,474.22
|
| Rate for Payer: Aetna Managed Medicare |
$805.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,870.05
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,438.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,380.96
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,524.81
|
| Rate for Payer: Cash Price |
$863.10
|
| Rate for Payer: Cigna Commercial |
$2,646.84
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,609.97
|
| Rate for Payer: Health EOS Commercial |
$2,560.53
|
| Rate for Payer: HFN Commercial |
$2,646.84
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,157.75
|
| Rate for Payer: Multiplan Commercial |
$2,301.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,726.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,646.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,409.73
|
| Rate for Payer: Quartz Commercial |
$1,870.05
|
| Rate for Payer: Quartz Medicare Advantage |
$1,726.20
|
| Rate for Payer: The Alliance Commercial |
$11,508.00
|
| Rate for Payer: WEA Trust Commercial |
$1,582.35
|
| Rate for Payer: WPS Commercial |
$2,130.99
|
|
|
LENS 17.5 SN60WF
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964233
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,409.73 |
| Max. Negotiated Rate |
$2,646.84 |
| Rate for Payer: Aetna Commercial |
$2,589.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,474.22
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,524.81
|
| Rate for Payer: Cash Price |
$863.10
|
| Rate for Payer: Cigna Commercial |
$2,646.84
|
| Rate for Payer: Health EOS Commercial |
$2,560.53
|
| Rate for Payer: HFN Commercial |
$2,646.84
|
| Rate for Payer: Multiplan Commercial |
$2,301.60
|
| Rate for Payer: NAPHCARE Commercial |
$1,726.20
|
| Rate for Payer: Preferred Network Access Commercial |
$2,646.84
|
| Rate for Payer: Quartz Beloit One Network |
$1,409.73
|
| Rate for Payer: Quartz Commercial |
$1,726.20
|
| Rate for Payer: WEA Trust Commercial |
$1,582.35
|
| Rate for Payer: WPS Commercial |
$2,130.99
|
|
|
LENS 17.5 TFNT00
|
Facility
|
IP
|
$1,181.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
5563502
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$578.69 |
| Max. Negotiated Rate |
$1,086.52 |
| Rate for Payer: Aetna Commercial |
$1,062.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,015.66
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.93
|
| Rate for Payer: Cash Price |
$354.30
|
| Rate for Payer: Cigna Commercial |
$1,086.52
|
| Rate for Payer: Health EOS Commercial |
$1,051.09
|
| Rate for Payer: HFN Commercial |
$1,086.52
|
| Rate for Payer: Multiplan Commercial |
$944.80
|
| Rate for Payer: NAPHCARE Commercial |
$708.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.52
|
| Rate for Payer: Quartz Beloit One Network |
$578.69
|
| Rate for Payer: Quartz Commercial |
$708.60
|
| Rate for Payer: WEA Trust Commercial |
$649.55
|
| Rate for Payer: WPS Commercial |
$874.77
|
|
|
LENS 17.5 TFNT00
|
Facility
|
OP
|
$1,181.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
5563502
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$330.68 |
| Max. Negotiated Rate |
$4,724.00 |
| Rate for Payer: Aetna Commercial |
$1,062.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,015.66
|
| Rate for Payer: Aetna Managed Medicare |
$330.68
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$767.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$590.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$566.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$625.93
|
| Rate for Payer: Cash Price |
$354.30
|
| Rate for Payer: Cigna Commercial |
$1,086.52
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$660.89
|
| Rate for Payer: Health EOS Commercial |
$1,051.09
|
| Rate for Payer: HFN Commercial |
$1,086.52
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$885.75
|
| Rate for Payer: Multiplan Commercial |
$944.80
|
| Rate for Payer: NAPHCARE Commercial |
$708.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.52
|
| Rate for Payer: Quartz Beloit One Network |
$578.69
|
| Rate for Payer: Quartz Commercial |
$767.65
|
| Rate for Payer: Quartz Medicare Advantage |
$708.60
|
| Rate for Payer: The Alliance Commercial |
$4,724.00
|
| Rate for Payer: WEA Trust Commercial |
$649.55
|
| Rate for Payer: WPS Commercial |
$874.77
|
|
|
LENS 17.5 TFNT30
|
Facility
|
IP
|
$1,341.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
5547368
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$657.09 |
| Max. Negotiated Rate |
$1,233.72 |
| Rate for Payer: Aetna Commercial |
$1,206.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,153.26
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$710.73
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,233.72
|
| Rate for Payer: Health EOS Commercial |
$1,193.49
|
| Rate for Payer: HFN Commercial |
$1,233.72
|
| Rate for Payer: Multiplan Commercial |
$1,072.80
|
| Rate for Payer: NAPHCARE Commercial |
$804.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.72
|
| Rate for Payer: Quartz Beloit One Network |
$657.09
|
| Rate for Payer: Quartz Commercial |
$804.60
|
| Rate for Payer: WEA Trust Commercial |
$737.55
|
| Rate for Payer: WPS Commercial |
$993.28
|
|
|
LENS 17.5 TFNT30
|
Facility
|
OP
|
$1,341.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
5547368
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$375.48 |
| Max. Negotiated Rate |
$5,364.00 |
| Rate for Payer: Aetna Commercial |
$1,206.90
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,153.26
|
| Rate for Payer: Aetna Managed Medicare |
$375.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$871.65
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$670.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$643.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$710.73
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,233.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$750.42
|
| Rate for Payer: Health EOS Commercial |
$1,193.49
|
| Rate for Payer: HFN Commercial |
$1,233.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,005.75
|
| Rate for Payer: Multiplan Commercial |
$1,072.80
|
| Rate for Payer: NAPHCARE Commercial |
$804.60
|
| Rate for Payer: Preferred Network Access Commercial |
$1,233.72
|
| Rate for Payer: Quartz Beloit One Network |
$657.09
|
| Rate for Payer: Quartz Commercial |
$871.65
|
| Rate for Payer: Quartz Medicare Advantage |
$804.60
|
| Rate for Payer: The Alliance Commercial |
$5,364.00
|
| Rate for Payer: WEA Trust Commercial |
$737.55
|
| Rate for Payer: WPS Commercial |
$993.28
|
|
|
LENS 18.0 AU00T0
|
Facility
|
OP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4595139
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$836.92 |
| Max. Negotiated Rate |
$11,956.00 |
| Rate for Payer: Aetna Commercial |
$2,690.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,570.54
|
| Rate for Payer: Aetna Managed Medicare |
$836.92
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,942.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,494.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,434.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.17
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,749.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,672.64
|
| Rate for Payer: Health EOS Commercial |
$2,660.21
|
| Rate for Payer: HFN Commercial |
$2,749.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,241.75
|
| Rate for Payer: Multiplan Commercial |
$2,391.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,793.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,749.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,464.61
|
| Rate for Payer: Quartz Commercial |
$1,942.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,793.40
|
| Rate for Payer: The Alliance Commercial |
$11,956.00
|
| Rate for Payer: WEA Trust Commercial |
$1,643.95
|
| Rate for Payer: WPS Commercial |
$2,213.95
|
|
|
LENS 18.0 AU00T0
|
Facility
|
IP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4595139
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,464.61 |
| Max. Negotiated Rate |
$2,749.88 |
| Rate for Payer: Aetna Commercial |
$2,690.10
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,570.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,584.17
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,749.88
|
| Rate for Payer: Health EOS Commercial |
$2,660.21
|
| Rate for Payer: HFN Commercial |
$2,749.88
|
| Rate for Payer: Multiplan Commercial |
$2,391.20
|
| Rate for Payer: NAPHCARE Commercial |
$1,793.40
|
| Rate for Payer: Preferred Network Access Commercial |
$2,749.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,464.61
|
| Rate for Payer: Quartz Commercial |
$1,793.40
|
| Rate for Payer: WEA Trust Commercial |
$1,643.95
|
| Rate for Payer: WPS Commercial |
$2,213.95
|
|
