|
LENS 6.0 TFNT30
|
Facility
|
OP
|
$1,181.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
5885630
|
|
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 6.0 TFNT30
|
Facility
|
IP
|
$1,181.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
5885630
|
|
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 6.5 MA60AC
|
Facility
|
OP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964565
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$690.48 |
| Max. Negotiated Rate |
$9,864.00 |
| Rate for Payer: Aetna Commercial |
$2,219.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,120.76
|
| Rate for Payer: Aetna Managed Medicare |
$690.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,602.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,233.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,183.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,306.98
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna Commercial |
$2,268.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,379.97
|
| Rate for Payer: Health EOS Commercial |
$2,194.74
|
| Rate for Payer: HFN Commercial |
$2,268.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,849.50
|
| Rate for Payer: Multiplan Commercial |
$1,972.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,479.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,268.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,208.34
|
| Rate for Payer: Quartz Commercial |
$1,602.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,479.60
|
| Rate for Payer: The Alliance Commercial |
$9,864.00
|
| Rate for Payer: WEA Trust Commercial |
$1,356.30
|
| Rate for Payer: WPS Commercial |
$1,826.57
|
|
|
LENS 6.5 MA60AC
|
Facility
|
IP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964565
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,208.34 |
| Max. Negotiated Rate |
$2,268.72 |
| Rate for Payer: Aetna Commercial |
$2,219.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,120.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,306.98
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna Commercial |
$2,268.72
|
| Rate for Payer: Health EOS Commercial |
$2,194.74
|
| Rate for Payer: HFN Commercial |
$2,268.72
|
| Rate for Payer: Multiplan Commercial |
$1,972.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,479.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,268.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,208.34
|
| Rate for Payer: Quartz Commercial |
$1,479.60
|
| Rate for Payer: WEA Trust Commercial |
$1,356.30
|
| Rate for Payer: WPS Commercial |
$1,826.57
|
|
|
LENS 6.5 MTA3UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964572
|
|
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 6.5 MTA3UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964572
|
|
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 6.5 MTA4UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964578
|
|
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 6.5 MTA4UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964578
|
|
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 6.5 MTA5UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964586
|
|
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 6.5 MTA5UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964586
|
|
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 6.5 SN60WF
|
Facility
|
OP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964591
|
|
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 6.5 SN60WF
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964591
|
|
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 7.0 AU00T0
|
Facility
|
OP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4998747
|
|
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 7.0 AU00T0
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4998747
|
|
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 7.0 CLAREON PANOPTIX CNWTT470
|
Facility
|
OP
|
$1,113.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
6196980
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$311.64 |
| Max. Negotiated Rate |
$4,452.00 |
| Rate for Payer: Aetna Commercial |
$1,001.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$957.18
|
| Rate for Payer: Aetna Managed Medicare |
$311.64
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$723.45
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$556.50
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$534.24
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$589.89
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: Cigna Commercial |
$1,023.96
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$622.83
|
| Rate for Payer: Health EOS Commercial |
$990.57
|
| Rate for Payer: HFN Commercial |
$1,023.96
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$834.75
|
| Rate for Payer: Multiplan Commercial |
$890.40
|
| Rate for Payer: NAPHCARE Commercial |
$667.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,023.96
|
| Rate for Payer: Quartz Beloit One Network |
$545.37
|
| Rate for Payer: Quartz Commercial |
$723.45
|
| Rate for Payer: Quartz Medicare Advantage |
$667.80
|
| Rate for Payer: The Alliance Commercial |
$4,452.00
|
| Rate for Payer: WEA Trust Commercial |
$612.15
|
| Rate for Payer: WPS Commercial |
$824.40
|
|
|
LENS 7.0 CLAREON PANOPTIX CNWTT470
|
Facility
|
IP
|
$1,113.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
6196980
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$545.37 |
| Max. Negotiated Rate |
$1,023.96 |
| Rate for Payer: Aetna Commercial |
$1,001.70
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$957.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$589.89
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: Cigna Commercial |
$1,023.96
|
| Rate for Payer: Health EOS Commercial |
$990.57
|
| Rate for Payer: HFN Commercial |
$1,023.96
|
| Rate for Payer: Multiplan Commercial |
$890.40
|
| Rate for Payer: NAPHCARE Commercial |
$667.80
|
| Rate for Payer: Preferred Network Access Commercial |
$1,023.96
|
| Rate for Payer: Quartz Beloit One Network |
$545.37
|
| Rate for Payer: Quartz Commercial |
$667.80
|
| Rate for Payer: WEA Trust Commercial |
$612.15
|
| Rate for Payer: WPS Commercial |
$824.40
|
|
|
LENS 7.0 MA60AC
|
Facility
|
IP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4437152
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,208.34 |
| Max. Negotiated Rate |
$2,268.72 |
| Rate for Payer: Aetna Commercial |
$2,219.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,120.76
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,306.98
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna Commercial |
$2,268.72
|
| Rate for Payer: Health EOS Commercial |
$2,194.74
|
| Rate for Payer: HFN Commercial |
$2,268.72
|
| Rate for Payer: Multiplan Commercial |
$1,972.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,479.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,268.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,208.34
|
| Rate for Payer: Quartz Commercial |
$1,479.60
|
| Rate for Payer: WEA Trust Commercial |
$1,356.30
|
| Rate for Payer: WPS Commercial |
$1,826.57
|
|
|
LENS 7.0 MA60AC
|
Facility
|
OP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4437152
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$690.48 |
| Max. Negotiated Rate |
$9,864.00 |
| Rate for Payer: Aetna Commercial |
$2,219.40
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,120.76
|
| Rate for Payer: Aetna Managed Medicare |
$690.48
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,602.90
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,233.00
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,183.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,306.98
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna Commercial |
$2,268.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,379.97
|
| Rate for Payer: Health EOS Commercial |
$2,194.74
|
| Rate for Payer: HFN Commercial |
$2,268.72
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,849.50
|
| Rate for Payer: Multiplan Commercial |
$1,972.80
|
| Rate for Payer: NAPHCARE Commercial |
$1,479.60
|
| Rate for Payer: Preferred Network Access Commercial |
$2,268.72
|
| Rate for Payer: Quartz Beloit One Network |
$1,208.34
|
| Rate for Payer: Quartz Commercial |
$1,602.90
|
| Rate for Payer: Quartz Medicare Advantage |
$1,479.60
|
| Rate for Payer: The Alliance Commercial |
$9,864.00
|
| Rate for Payer: WEA Trust Commercial |
$1,356.30
|
| Rate for Payer: WPS Commercial |
$1,826.57
|
|
|
LENS 7.0 MTA3UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3072597
|
|
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 7.0 MTA3UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3072597
|
|
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 7.0 MTA4UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964579
|
|
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 7.0 MTA4UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964579
|
|
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 7.0 MTA5UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964587
|
|
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 7.0 MTA5UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964587
|
|
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 7.0 SN60WF
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
3204826
|
|
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
|
|
