|
LENS 22.5 MTA3UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964372
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$478.44 |
| Max. Negotiated Rate |
$1,572.02 |
| Rate for Payer: Aetna Commercial |
$1,537.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,469.50
|
| Rate for Payer: Aetna Managed Medicare |
$478.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$820.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.62
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,572.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$956.23
|
| Rate for Payer: Health EOS Commercial |
$1,520.76
|
| Rate for Payer: HFN Commercial |
$1,572.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.54
|
| Rate for Payer: Multiplan Commercial |
$1,366.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,025.23
|
| Rate for Payer: Preferred Network Access Commercial |
$1,572.02
|
| Rate for Payer: Quartz Beloit One Network |
$837.27
|
| Rate for Payer: Quartz Commercial |
$1,110.67
|
| Rate for Payer: Quartz Medicare Advantage |
$1,025.23
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$939.80
|
| Rate for Payer: WPS Commercial |
$1,265.60
|
|
|
LENS 22.5 MTA3UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964372
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$837.27 |
| Max. Negotiated Rate |
$1,572.02 |
| Rate for Payer: Aetna Commercial |
$1,537.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,469.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.62
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,572.02
|
| Rate for Payer: Health EOS Commercial |
$1,520.76
|
| Rate for Payer: HFN Commercial |
$1,572.02
|
| Rate for Payer: Multiplan Commercial |
$1,366.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,572.02
|
| Rate for Payer: Quartz Beloit One Network |
$837.27
|
| Rate for Payer: Quartz Commercial |
$1,025.23
|
| Rate for Payer: WEA Trust Commercial |
$939.80
|
| Rate for Payer: WPS Commercial |
$1,265.60
|
|
|
LENS 22.5 MTA4UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964401
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$837.27 |
| Max. Negotiated Rate |
$1,572.02 |
| Rate for Payer: Aetna Commercial |
$1,537.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,469.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.62
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,572.02
|
| Rate for Payer: Health EOS Commercial |
$1,520.76
|
| Rate for Payer: HFN Commercial |
$1,572.02
|
| Rate for Payer: Multiplan Commercial |
$1,366.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,572.02
|
| Rate for Payer: Quartz Beloit One Network |
$837.27
|
| Rate for Payer: Quartz Commercial |
$1,025.23
|
| Rate for Payer: WEA Trust Commercial |
$939.80
|
| Rate for Payer: WPS Commercial |
$1,265.60
|
|
|
LENS 22.5 MTA4UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964401
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$478.44 |
| Max. Negotiated Rate |
$1,572.02 |
| Rate for Payer: Aetna Commercial |
$1,537.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,469.50
|
| Rate for Payer: Aetna Managed Medicare |
$478.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$820.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.62
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,572.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$956.23
|
| Rate for Payer: Health EOS Commercial |
$1,520.76
|
| Rate for Payer: HFN Commercial |
$1,572.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.54
|
| Rate for Payer: Multiplan Commercial |
$1,366.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,025.23
|
| Rate for Payer: Preferred Network Access Commercial |
$1,572.02
|
| Rate for Payer: Quartz Beloit One Network |
$837.27
|
| Rate for Payer: Quartz Commercial |
$1,110.67
|
| Rate for Payer: Quartz Medicare Advantage |
$1,025.23
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$939.80
|
| Rate for Payer: WPS Commercial |
$1,265.60
|
|
|
LENS 22.5 MTA5UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964430
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$837.27 |
| Max. Negotiated Rate |
$1,572.02 |
| Rate for Payer: Aetna Commercial |
$1,537.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,469.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.62
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,572.02
|
| Rate for Payer: Health EOS Commercial |
$1,520.76
|
| Rate for Payer: HFN Commercial |
$1,572.02
|
| Rate for Payer: Multiplan Commercial |
$1,366.98
|
| Rate for Payer: Preferred Network Access Commercial |
$1,572.02
|
| Rate for Payer: Quartz Beloit One Network |
$837.27
|
| Rate for Payer: Quartz Commercial |
$1,025.23
|
| Rate for Payer: WEA Trust Commercial |
$939.80
|
| Rate for Payer: WPS Commercial |
$1,265.60
|
|
|
LENS 22.5 MTA5UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964430
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$478.44 |
| Max. Negotiated Rate |
$1,572.02 |
| Rate for Payer: Aetna Commercial |
$1,537.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,469.50
|
| Rate for Payer: Aetna Managed Medicare |
$478.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$820.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.62
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,572.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$956.23
|
| Rate for Payer: Health EOS Commercial |
$1,520.76
|
| Rate for Payer: HFN Commercial |
$1,572.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.54
|
| Rate for Payer: Multiplan Commercial |
$1,366.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,025.23
|
| Rate for Payer: Preferred Network Access Commercial |
$1,572.02
|
| Rate for Payer: Quartz Beloit One Network |
$837.27
|
| Rate for Payer: Quartz Commercial |
$1,110.67
|
| Rate for Payer: Quartz Medicare Advantage |
$1,025.23
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$939.80
|
| Rate for Payer: WPS Commercial |
$1,265.60
|
|
|
LENS 22.5 SN60WF
|
Facility
|
OP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964262
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$606.24 |
| Max. Negotiated Rate |
$2,752.71 |
| Rate for Payer: Aetna Commercial |
$2,692.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,573.19
|
| Rate for Payer: Aetna Managed Medicare |
$837.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,944.85
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,496.04
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,436.20
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,585.80
|
| Rate for Payer: Cash Price |
$863.10
|
| Rate for Payer: Cash Price |
$863.10
|
| Rate for Payer: Cigna Commercial |
$2,752.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,674.41
|
| Rate for Payer: Health EOS Commercial |
$2,662.95
|
| Rate for Payer: HFN Commercial |
$2,752.71
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,244.06
|
| Rate for Payer: Multiplan Commercial |
$2,393.66
|
| Rate for Payer: NAPHCARE Commercial |
$1,795.25
|
| Rate for Payer: Preferred Network Access Commercial |
$2,752.71
|
| Rate for Payer: Quartz Beloit One Network |
$1,466.12
|
| Rate for Payer: Quartz Commercial |
$1,944.85
|
| Rate for Payer: Quartz Medicare Advantage |
$1,795.25
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$1,645.64
|
| Rate for Payer: WPS Commercial |
$2,216.15
|
|
|
LENS 22.5 SN60WF
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964262
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,466.12 |
| Max. Negotiated Rate |
$2,752.71 |
| Rate for Payer: Aetna Commercial |
$2,692.87
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,573.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,585.80
|
| Rate for Payer: Cash Price |
$863.10
|
| Rate for Payer: Cigna Commercial |
$2,752.71
|
| Rate for Payer: Health EOS Commercial |
$2,662.95
|
| Rate for Payer: HFN Commercial |
$2,752.71
|
| Rate for Payer: Multiplan Commercial |
$2,393.66
|
| Rate for Payer: Preferred Network Access Commercial |
$2,752.71
|
| Rate for Payer: Quartz Beloit One Network |
$1,466.12
|
| Rate for Payer: Quartz Commercial |
$1,795.25
|
| Rate for Payer: WEA Trust Commercial |
$1,645.64
|
| Rate for Payer: WPS Commercial |
$2,216.15
|
|
|
LENS 22.5 SN6AT4 TORIC
|
Facility
|
IP
|
$944.00
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
2964500
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$481.06 |
| Max. Negotiated Rate |
$903.22 |
| Rate for Payer: Aetna Commercial |
$883.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$844.31
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$520.33
|
| Rate for Payer: Cash Price |
$283.20
|
| Rate for Payer: Cigna Commercial |
$903.22
|
| Rate for Payer: Health EOS Commercial |
$873.77
|
| Rate for Payer: HFN Commercial |
$903.22
|
| Rate for Payer: Multiplan Commercial |
$785.41
|
| Rate for Payer: Preferred Network Access Commercial |
$903.22
|
| Rate for Payer: Quartz Beloit One Network |
$481.06
|
| Rate for Payer: Quartz Commercial |
$589.06
|
| Rate for Payer: WEA Trust Commercial |
$539.97
|
| Rate for Payer: WPS Commercial |
$727.16
|
|
|
LENS 22.5 SN6AT4 TORIC
|
Facility
|
OP
|
$944.00
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
2964500
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$274.89 |
| Max. Negotiated Rate |
$903.22 |
| Rate for Payer: Aetna Commercial |
$883.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$844.31
|
| Rate for Payer: Aetna Managed Medicare |
$274.89
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$638.14
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$490.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$471.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$520.33
|
| Rate for Payer: Cash Price |
$283.20
|
| Rate for Payer: Cigna Commercial |
$903.22
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$549.41
|
| Rate for Payer: Health EOS Commercial |
$873.77
|
| Rate for Payer: HFN Commercial |
$903.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$736.32
|
| Rate for Payer: Multiplan Commercial |
$785.41
|
| Rate for Payer: NAPHCARE Commercial |
$589.06
|
| Rate for Payer: Preferred Network Access Commercial |
$903.22
|
| Rate for Payer: Quartz Beloit One Network |
$481.06
|
| Rate for Payer: Quartz Commercial |
$638.14
|
| Rate for Payer: Quartz Medicare Advantage |
$589.06
|
| Rate for Payer: The Alliance Commercial |
$490.88
|
| Rate for Payer: WEA Trust Commercial |
$539.97
|
| Rate for Payer: WPS Commercial |
$727.16
|
|
|
LENS 22.5 TFNT00
|
Facility
|
IP
|
$1,341.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
5547312
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$683.37 |
| Max. Negotiated Rate |
$1,283.07 |
| Rate for Payer: Aetna Commercial |
$1,255.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,199.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$739.16
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,283.07
|
| Rate for Payer: Health EOS Commercial |
$1,241.23
|
| Rate for Payer: HFN Commercial |
$1,283.07
|
| Rate for Payer: Multiplan Commercial |
$1,115.71
|
| Rate for Payer: Preferred Network Access Commercial |
$1,283.07
|
| Rate for Payer: Quartz Beloit One Network |
$683.37
|
| Rate for Payer: Quartz Commercial |
$836.78
|
| Rate for Payer: WEA Trust Commercial |
$767.05
|
| Rate for Payer: WPS Commercial |
$1,032.97
|
|
|
LENS 22.5 TFNT00
|
Facility
|
OP
|
$1,341.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
5547312
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$390.50 |
| Max. Negotiated Rate |
$1,283.07 |
| Rate for Payer: Aetna Commercial |
$1,255.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,199.39
|
| Rate for Payer: Aetna Managed Medicare |
$390.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$906.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$697.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$669.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$739.16
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,283.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$780.46
|
| Rate for Payer: Health EOS Commercial |
$1,241.23
|
| Rate for Payer: HFN Commercial |
$1,283.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,045.98
|
| Rate for Payer: Multiplan Commercial |
$1,115.71
|
| Rate for Payer: NAPHCARE Commercial |
$836.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,283.07
|
| Rate for Payer: Quartz Beloit One Network |
$683.37
|
| Rate for Payer: Quartz Commercial |
$906.52
|
| Rate for Payer: Quartz Medicare Advantage |
$836.78
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$767.05
|
| Rate for Payer: WPS Commercial |
$1,032.97
|
|
|
LENS 22.5 TFNT30
|
Facility
|
IP
|
$1,341.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
5563580
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$683.37 |
| Max. Negotiated Rate |
$1,283.07 |
| Rate for Payer: Aetna Commercial |
$1,255.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,199.39
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$739.16
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,283.07
|
| Rate for Payer: Health EOS Commercial |
$1,241.23
|
| Rate for Payer: HFN Commercial |
$1,283.07
|
| Rate for Payer: Multiplan Commercial |
$1,115.71
|
| Rate for Payer: Preferred Network Access Commercial |
$1,283.07
|
| Rate for Payer: Quartz Beloit One Network |
$683.37
|
| Rate for Payer: Quartz Commercial |
$836.78
|
| Rate for Payer: WEA Trust Commercial |
$767.05
|
| Rate for Payer: WPS Commercial |
$1,032.97
|
|
|
LENS 22.5 TFNT30
|
Facility
|
OP
|
$1,341.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
5563580
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$390.50 |
| Max. Negotiated Rate |
$1,283.07 |
| Rate for Payer: Aetna Commercial |
$1,255.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,199.39
|
| Rate for Payer: Aetna Managed Medicare |
$390.50
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$906.52
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$697.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$669.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$739.16
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cash Price |
$402.30
|
| Rate for Payer: Cigna Commercial |
$1,283.07
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$780.46
|
| Rate for Payer: Health EOS Commercial |
$1,241.23
|
| Rate for Payer: HFN Commercial |
$1,283.07
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,045.98
|
| Rate for Payer: Multiplan Commercial |
$1,115.71
|
| Rate for Payer: NAPHCARE Commercial |
$836.78
|
| Rate for Payer: Preferred Network Access Commercial |
$1,283.07
|
| Rate for Payer: Quartz Beloit One Network |
$683.37
|
| Rate for Payer: Quartz Commercial |
$906.52
|
| Rate for Payer: Quartz Medicare Advantage |
$836.78
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$767.05
|
| Rate for Payer: WPS Commercial |
$1,032.97
|
|
|
LENS 22.5 TFNT40
|
Facility
|
OP
|
$1,181.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
5885631
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$343.91 |
| Max. Negotiated Rate |
$1,129.98 |
| Rate for Payer: Aetna Commercial |
$1,105.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,056.29
|
| Rate for Payer: Aetna Managed Medicare |
$343.91
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$798.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$614.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$589.56
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$650.97
|
| Rate for Payer: Cash Price |
$354.30
|
| Rate for Payer: Cigna Commercial |
$1,129.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$687.34
|
| Rate for Payer: Health EOS Commercial |
$1,093.13
|
| Rate for Payer: HFN Commercial |
$1,129.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$921.18
|
| Rate for Payer: Multiplan Commercial |
$982.59
|
| Rate for Payer: NAPHCARE Commercial |
$736.94
|
| Rate for Payer: Preferred Network Access Commercial |
$1,129.98
|
| Rate for Payer: Quartz Beloit One Network |
$601.84
|
| Rate for Payer: Quartz Commercial |
$798.36
|
| Rate for Payer: Quartz Medicare Advantage |
$736.94
|
| Rate for Payer: The Alliance Commercial |
$614.12
|
| Rate for Payer: WEA Trust Commercial |
$675.53
|
| Rate for Payer: WPS Commercial |
$909.72
|
|
|
LENS 22.5 TFNT40
|
Facility
|
IP
|
$1,181.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
5885631
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$601.84 |
| Max. Negotiated Rate |
$1,129.98 |
| Rate for Payer: Aetna Commercial |
$1,105.42
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,056.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$650.97
|
| Rate for Payer: Cash Price |
$354.30
|
| Rate for Payer: Cigna Commercial |
$1,129.98
|
| Rate for Payer: Health EOS Commercial |
$1,093.13
|
| Rate for Payer: HFN Commercial |
$1,129.98
|
| Rate for Payer: Multiplan Commercial |
$982.59
|
| Rate for Payer: Preferred Network Access Commercial |
$1,129.98
|
| Rate for Payer: Quartz Beloit One Network |
$601.84
|
| Rate for Payer: Quartz Commercial |
$736.94
|
| Rate for Payer: WEA Trust Commercial |
$675.53
|
| Rate for Payer: WPS Commercial |
$909.72
|
|
|
LENS 22.5 VIVITY DFT515.225
|
Facility
|
OP
|
$1,136.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
5947640
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$330.80 |
| Max. Negotiated Rate |
$1,086.92 |
| Rate for Payer: Aetna Commercial |
$1,063.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.04
|
| Rate for Payer: Aetna Managed Medicare |
$330.80
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$767.94
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$590.72
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$567.09
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$626.16
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,086.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$661.15
|
| Rate for Payer: Health EOS Commercial |
$1,051.48
|
| Rate for Payer: HFN Commercial |
$1,086.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$886.08
|
| Rate for Payer: Multiplan Commercial |
$945.15
|
| Rate for Payer: NAPHCARE Commercial |
$708.86
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.92
|
| Rate for Payer: Quartz Beloit One Network |
$578.91
|
| Rate for Payer: Quartz Commercial |
$767.94
|
| Rate for Payer: Quartz Medicare Advantage |
$708.86
|
| Rate for Payer: The Alliance Commercial |
$590.72
|
| Rate for Payer: WEA Trust Commercial |
$649.79
|
| Rate for Payer: WPS Commercial |
$875.06
|
|
|
LENS 22.5 VIVITY DFT515.225
|
Facility
|
IP
|
$1,136.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
5947640
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$578.91 |
| Max. Negotiated Rate |
$1,086.92 |
| Rate for Payer: Aetna Commercial |
$1,063.30
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,016.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$626.16
|
| Rate for Payer: Cash Price |
$340.80
|
| Rate for Payer: Cigna Commercial |
$1,086.92
|
| Rate for Payer: Health EOS Commercial |
$1,051.48
|
| Rate for Payer: HFN Commercial |
$1,086.92
|
| Rate for Payer: Multiplan Commercial |
$945.15
|
| Rate for Payer: Preferred Network Access Commercial |
$1,086.92
|
| Rate for Payer: Quartz Beloit One Network |
$578.91
|
| Rate for Payer: Quartz Commercial |
$708.86
|
| Rate for Payer: WEA Trust Commercial |
$649.79
|
| Rate for Payer: WPS Commercial |
$875.06
|
|
|
LENS 23.0 AU00T0
|
Facility
|
OP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4595146
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$606.24 |
| Max. Negotiated Rate |
$2,859.88 |
| Rate for Payer: Aetna Commercial |
$2,797.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,673.36
|
| Rate for Payer: Aetna Managed Medicare |
$870.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,020.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,554.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,492.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,647.54
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,859.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,739.60
|
| Rate for Payer: Health EOS Commercial |
$2,766.62
|
| Rate for Payer: HFN Commercial |
$2,859.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,331.42
|
| Rate for Payer: Multiplan Commercial |
$2,486.85
|
| Rate for Payer: NAPHCARE Commercial |
$1,865.14
|
| Rate for Payer: Preferred Network Access Commercial |
$2,859.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.19
|
| Rate for Payer: Quartz Commercial |
$2,020.56
|
| Rate for Payer: Quartz Medicare Advantage |
$1,865.14
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$1,709.71
|
| Rate for Payer: WPS Commercial |
$2,302.43
|
|
|
LENS 23.0 AU00T0
|
Facility
|
IP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4595146
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,523.19 |
| Max. Negotiated Rate |
$2,859.88 |
| Rate for Payer: Aetna Commercial |
$2,797.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,673.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,647.54
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,859.88
|
| Rate for Payer: Health EOS Commercial |
$2,766.62
|
| Rate for Payer: HFN Commercial |
$2,859.88
|
| Rate for Payer: Multiplan Commercial |
$2,486.85
|
| Rate for Payer: Preferred Network Access Commercial |
$2,859.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.19
|
| Rate for Payer: Quartz Commercial |
$1,865.14
|
| Rate for Payer: WEA Trust Commercial |
$1,709.71
|
| Rate for Payer: WPS Commercial |
$2,302.43
|
|
|
LENS 23.0 CLAREON CNA0T0.230
|
Facility
|
IP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
6172589
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,523.19 |
| Max. Negotiated Rate |
$2,859.88 |
| Rate for Payer: Aetna Commercial |
$2,797.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,673.36
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,647.54
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,859.88
|
| Rate for Payer: Health EOS Commercial |
$2,766.62
|
| Rate for Payer: HFN Commercial |
$2,859.88
|
| Rate for Payer: Multiplan Commercial |
$2,486.85
|
| Rate for Payer: Preferred Network Access Commercial |
$2,859.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.19
|
| Rate for Payer: Quartz Commercial |
$1,865.14
|
| Rate for Payer: WEA Trust Commercial |
$1,709.71
|
| Rate for Payer: WPS Commercial |
$2,302.43
|
|
|
LENS 23.0 CLAREON CNA0T0.230
|
Facility
|
OP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
6172589
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$606.24 |
| Max. Negotiated Rate |
$2,859.88 |
| Rate for Payer: Aetna Commercial |
$2,797.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,673.36
|
| Rate for Payer: Aetna Managed Medicare |
$870.40
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,020.56
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,554.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,492.11
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,647.54
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cash Price |
$896.70
|
| Rate for Payer: Cigna Commercial |
$2,859.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,739.60
|
| Rate for Payer: Health EOS Commercial |
$2,766.62
|
| Rate for Payer: HFN Commercial |
$2,859.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,331.42
|
| Rate for Payer: Multiplan Commercial |
$2,486.85
|
| Rate for Payer: NAPHCARE Commercial |
$1,865.14
|
| Rate for Payer: Preferred Network Access Commercial |
$2,859.88
|
| Rate for Payer: Quartz Beloit One Network |
$1,523.19
|
| Rate for Payer: Quartz Commercial |
$2,020.56
|
| Rate for Payer: Quartz Medicare Advantage |
$1,865.14
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$1,709.71
|
| Rate for Payer: WPS Commercial |
$2,302.43
|
|
|
LENS 23.0 MA60AC
|
Facility
|
IP
|
$2,562.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964335
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,305.60 |
| Max. Negotiated Rate |
$2,451.32 |
| Rate for Payer: Aetna Commercial |
$2,398.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,291.45
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,412.17
|
| Rate for Payer: Cash Price |
$768.60
|
| Rate for Payer: Cigna Commercial |
$2,451.32
|
| Rate for Payer: Health EOS Commercial |
$2,371.39
|
| Rate for Payer: HFN Commercial |
$2,451.32
|
| Rate for Payer: Multiplan Commercial |
$2,131.58
|
| Rate for Payer: Preferred Network Access Commercial |
$2,451.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,305.60
|
| Rate for Payer: Quartz Commercial |
$1,598.69
|
| Rate for Payer: WEA Trust Commercial |
$1,465.46
|
| Rate for Payer: WPS Commercial |
$1,973.51
|
|
|
LENS 23.0 MA60AC
|
Facility
|
OP
|
$2,562.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964335
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$606.24 |
| Max. Negotiated Rate |
$2,451.32 |
| Rate for Payer: Aetna Commercial |
$2,398.03
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,291.45
|
| Rate for Payer: Aetna Managed Medicare |
$746.05
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,731.91
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,332.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,278.95
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,412.17
|
| Rate for Payer: Cash Price |
$768.60
|
| Rate for Payer: Cash Price |
$768.60
|
| Rate for Payer: Cigna Commercial |
$2,451.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,491.08
|
| Rate for Payer: Health EOS Commercial |
$2,371.39
|
| Rate for Payer: HFN Commercial |
$2,451.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,998.36
|
| Rate for Payer: Multiplan Commercial |
$2,131.58
|
| Rate for Payer: NAPHCARE Commercial |
$1,598.69
|
| Rate for Payer: Preferred Network Access Commercial |
$2,451.32
|
| Rate for Payer: Quartz Beloit One Network |
$1,305.60
|
| Rate for Payer: Quartz Commercial |
$1,731.91
|
| Rate for Payer: Quartz Medicare Advantage |
$1,598.69
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$1,465.46
|
| Rate for Payer: WPS Commercial |
$1,973.51
|
|
|
LENS 23.0 MTA3UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964373
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$478.44 |
| Max. Negotiated Rate |
$1,572.02 |
| Rate for Payer: Aetna Commercial |
$1,537.85
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,469.50
|
| Rate for Payer: Aetna Managed Medicare |
$478.44
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,110.67
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$854.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$820.19
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$905.62
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cash Price |
$492.90
|
| Rate for Payer: Cigna Commercial |
$1,572.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$956.23
|
| Rate for Payer: Health EOS Commercial |
$1,520.76
|
| Rate for Payer: HFN Commercial |
$1,572.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,281.54
|
| Rate for Payer: Multiplan Commercial |
$1,366.98
|
| Rate for Payer: NAPHCARE Commercial |
$1,025.23
|
| Rate for Payer: Preferred Network Access Commercial |
$1,572.02
|
| Rate for Payer: Quartz Beloit One Network |
$837.27
|
| Rate for Payer: Quartz Commercial |
$1,110.67
|
| Rate for Payer: Quartz Medicare Advantage |
$1,025.23
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$939.80
|
| Rate for Payer: WPS Commercial |
$1,265.60
|
|
