|
LENS 6.5 MTA4UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964578
|
|
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 6.5 MTA5UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964586
|
|
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 6.5 MTA5UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964586
|
|
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 6.5 SN60WF
|
Facility
|
OP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964591
|
|
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 6.5 SN60WF
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964591
|
|
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 7.0 AU00T0
|
Facility
|
OP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4998747
|
|
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 7.0 AU00T0
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4998747
|
|
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 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 |
$567.18 |
| Max. Negotiated Rate |
$1,064.92 |
| Rate for Payer: Aetna Commercial |
$1,041.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$995.47
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$613.49
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: Cigna Commercial |
$1,064.92
|
| Rate for Payer: Health EOS Commercial |
$1,030.19
|
| Rate for Payer: HFN Commercial |
$1,064.92
|
| Rate for Payer: Multiplan Commercial |
$926.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,064.92
|
| Rate for Payer: Quartz Beloit One Network |
$567.18
|
| Rate for Payer: Quartz Commercial |
$694.51
|
| Rate for Payer: WEA Trust Commercial |
$636.64
|
| Rate for Payer: WPS Commercial |
$857.34
|
|
|
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 |
$324.11 |
| Max. Negotiated Rate |
$1,064.92 |
| Rate for Payer: Aetna Commercial |
$1,041.77
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$995.47
|
| Rate for Payer: Aetna Managed Medicare |
$324.11
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$752.39
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$578.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$555.61
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$613.49
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: Cigna Commercial |
$1,064.92
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$647.77
|
| Rate for Payer: Health EOS Commercial |
$1,030.19
|
| Rate for Payer: HFN Commercial |
$1,064.92
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$868.14
|
| Rate for Payer: Multiplan Commercial |
$926.02
|
| Rate for Payer: NAPHCARE Commercial |
$694.51
|
| Rate for Payer: Preferred Network Access Commercial |
$1,064.92
|
| Rate for Payer: Quartz Beloit One Network |
$567.18
|
| Rate for Payer: Quartz Commercial |
$752.39
|
| Rate for Payer: Quartz Medicare Advantage |
$694.51
|
| Rate for Payer: The Alliance Commercial |
$578.76
|
| Rate for Payer: WEA Trust Commercial |
$636.64
|
| Rate for Payer: WPS Commercial |
$857.34
|
|
|
LENS 7.0 MA60AC
|
Facility
|
IP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4437152
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,256.67 |
| Max. Negotiated Rate |
$2,359.47 |
| Rate for Payer: Aetna Commercial |
$2,308.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,205.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,359.26
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna Commercial |
$2,359.47
|
| Rate for Payer: Health EOS Commercial |
$2,282.53
|
| Rate for Payer: HFN Commercial |
$2,359.47
|
| Rate for Payer: Multiplan Commercial |
$2,051.71
|
| Rate for Payer: Preferred Network Access Commercial |
$2,359.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.67
|
| Rate for Payer: Quartz Commercial |
$1,538.78
|
| Rate for Payer: WEA Trust Commercial |
$1,410.55
|
| Rate for Payer: WPS Commercial |
$1,899.56
|
|
|
LENS 7.0 MA60AC
|
Facility
|
OP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
4437152
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$606.24 |
| Max. Negotiated Rate |
$2,359.47 |
| Rate for Payer: Aetna Commercial |
$2,308.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,205.59
|
| Rate for Payer: Aetna Managed Medicare |
$718.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,667.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,282.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,231.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,359.26
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna Commercial |
$2,359.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,435.21
|
| Rate for Payer: Health EOS Commercial |
$2,282.53
|
| Rate for Payer: HFN Commercial |
$2,359.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,923.48
|
| Rate for Payer: Multiplan Commercial |
$2,051.71
|
| Rate for Payer: NAPHCARE Commercial |
$1,538.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,359.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.67
|
| Rate for Payer: Quartz Commercial |
$1,667.02
|
| Rate for Payer: Quartz Medicare Advantage |
$1,538.78
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$1,410.55
|
| Rate for Payer: WPS Commercial |
$1,899.56
|
|
|
LENS 7.0 MTA3UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3072597
|
|
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 7.0 MTA3UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3072597
|
|
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 7.0 MTA4UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964579
|
|
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 7.0 MTA4UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964579
|
|
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 7.0 MTA5UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964587
|
|
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 7.0 MTA5UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964587
|
|
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 7.0 SN60WF
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
3204826
|
|
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 7.0 SN60WF
|
Facility
|
OP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
3204826
|
|
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 7.5 MA60AC
|
Facility
|
IP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964566
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,256.67 |
| Max. Negotiated Rate |
$2,359.47 |
| Rate for Payer: Aetna Commercial |
$2,308.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,205.59
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,359.26
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna Commercial |
$2,359.47
|
| Rate for Payer: Health EOS Commercial |
$2,282.53
|
| Rate for Payer: HFN Commercial |
$2,359.47
|
| Rate for Payer: Multiplan Commercial |
$2,051.71
|
| Rate for Payer: Preferred Network Access Commercial |
$2,359.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.67
|
| Rate for Payer: Quartz Commercial |
$1,538.78
|
| Rate for Payer: WEA Trust Commercial |
$1,410.55
|
| Rate for Payer: WPS Commercial |
$1,899.56
|
|
|
LENS 7.5 MA60AC
|
Facility
|
OP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964566
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$606.24 |
| Max. Negotiated Rate |
$2,359.47 |
| Rate for Payer: Aetna Commercial |
$2,308.18
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,205.59
|
| Rate for Payer: Aetna Managed Medicare |
$718.10
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,667.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,282.32
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,231.03
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,359.26
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cash Price |
$739.80
|
| Rate for Payer: Cigna Commercial |
$2,359.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,435.21
|
| Rate for Payer: Health EOS Commercial |
$2,282.53
|
| Rate for Payer: HFN Commercial |
$2,359.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,923.48
|
| Rate for Payer: Multiplan Commercial |
$2,051.71
|
| Rate for Payer: NAPHCARE Commercial |
$1,538.78
|
| Rate for Payer: Preferred Network Access Commercial |
$2,359.47
|
| Rate for Payer: Quartz Beloit One Network |
$1,256.67
|
| Rate for Payer: Quartz Commercial |
$1,667.02
|
| Rate for Payer: Quartz Medicare Advantage |
$1,538.78
|
| Rate for Payer: The Alliance Commercial |
$606.24
|
| Rate for Payer: WEA Trust Commercial |
$1,410.55
|
| Rate for Payer: WPS Commercial |
$1,899.56
|
|
|
LENS 7.5 MTA3UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3794199
|
|
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 7.5 MTA3UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3794199
|
|
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 7.5 MTA4UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964580
|
|
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 7.5 MTA4UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964580
|
|
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
|
|
