|
LENS 9.5 MA60AC
|
Facility
|
OP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964569
|
|
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 9.5 MA60AC
|
Facility
|
IP
|
$2,466.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964569
|
|
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 9.5 MTA3UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3381514
|
|
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 9.5 MTA3UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3381514
|
|
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 9.5 MTA3UO 9.5
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3209461
|
|
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 9.5 MTA3UO 9.5
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3209461
|
|
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 9.5 MTA4UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964584
|
|
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 9.5 MTA4UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
2964584
|
|
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 9.5 MTA5UO
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3209462
|
|
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 9.5 MTA5UO
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
3209462
|
|
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 9.5 SN60WF
|
Facility
|
OP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964595
|
|
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 9.5 SN60WF
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964595
|
|
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
|
|
|
LENSECTOMY
|
Facility
|
OP
|
$5,256.00
|
|
| Hospital Charge Code |
2960199
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,530.55 |
| Max. Negotiated Rate |
$5,028.94 |
| Rate for Payer: Aetna Commercial |
$4,919.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,700.97
|
| Rate for Payer: Aetna Managed Medicare |
$1,530.55
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$3,553.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,733.12
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$2,623.80
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,897.11
|
| Rate for Payer: Cash Price |
$1,576.80
|
| Rate for Payer: Cigna Commercial |
$5,028.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$3,058.99
|
| Rate for Payer: Health EOS Commercial |
$4,864.95
|
| Rate for Payer: HFN Commercial |
$5,028.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$4,099.68
|
| Rate for Payer: Multiplan Commercial |
$4,372.99
|
| Rate for Payer: NAPHCARE Commercial |
$3,279.74
|
| Rate for Payer: Preferred Network Access Commercial |
$5,028.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,678.46
|
| Rate for Payer: Quartz Commercial |
$3,553.06
|
| Rate for Payer: Quartz Medicare Advantage |
$3,279.74
|
| Rate for Payer: The Alliance Commercial |
$2,733.12
|
| Rate for Payer: WEA Trust Commercial |
$3,006.43
|
| Rate for Payer: WPS Commercial |
$4,048.70
|
|
|
LENSECTOMY
|
Facility
|
IP
|
$5,256.00
|
|
| Hospital Charge Code |
2960199
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,678.46 |
| Max. Negotiated Rate |
$5,028.94 |
| Rate for Payer: Aetna Commercial |
$4,919.62
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,700.97
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,897.11
|
| Rate for Payer: Cash Price |
$1,576.80
|
| Rate for Payer: Cigna Commercial |
$5,028.94
|
| Rate for Payer: Health EOS Commercial |
$4,864.95
|
| Rate for Payer: HFN Commercial |
$5,028.94
|
| Rate for Payer: Multiplan Commercial |
$4,372.99
|
| Rate for Payer: Preferred Network Access Commercial |
$5,028.94
|
| Rate for Payer: Quartz Beloit One Network |
$2,678.46
|
| Rate for Payer: Quartz Commercial |
$3,279.74
|
| Rate for Payer: WEA Trust Commercial |
$3,006.43
|
| Rate for Payer: WPS Commercial |
$4,048.70
|
|
|
LENS GLIDE 30MM X6 MIL FICHMAN 581049
|
Facility
|
IP
|
$69.00
|
|
| Hospital Charge Code |
2964799
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$66.02 |
| Rate for Payer: Aetna Commercial |
$64.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.03
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$66.02
|
| Rate for Payer: Health EOS Commercial |
$63.87
|
| Rate for Payer: HFN Commercial |
$66.02
|
| Rate for Payer: Multiplan Commercial |
$57.41
|
| Rate for Payer: Preferred Network Access Commercial |
$66.02
|
| Rate for Payer: Quartz Beloit One Network |
$35.16
|
| Rate for Payer: Quartz Commercial |
$43.06
|
| Rate for Payer: WEA Trust Commercial |
$39.47
|
| Rate for Payer: WPS Commercial |
$53.15
|
|
|
LENS GLIDE 30MM X6 MIL FICHMAN 581049
|
Facility
|
OP
|
$69.00
|
|
| Hospital Charge Code |
2964799
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.09 |
| Max. Negotiated Rate |
$66.02 |
| Rate for Payer: Aetna Commercial |
$64.58
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$61.71
|
| Rate for Payer: Aetna Managed Medicare |
$20.09
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35.88
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34.44
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$38.03
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna Commercial |
$66.02
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$40.16
|
| Rate for Payer: Health EOS Commercial |
$63.87
|
| Rate for Payer: HFN Commercial |
$66.02
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$53.82
|
| Rate for Payer: Multiplan Commercial |
$57.41
|
| Rate for Payer: NAPHCARE Commercial |
$43.06
|
| Rate for Payer: Preferred Network Access Commercial |
$66.02
|
| Rate for Payer: Quartz Beloit One Network |
$35.16
|
| Rate for Payer: Quartz Commercial |
$46.64
|
| Rate for Payer: Quartz Medicare Advantage |
$43.06
|
| Rate for Payer: The Alliance Commercial |
$35.88
|
| Rate for Payer: WEA Trust Commercial |
$39.47
|
| Rate for Payer: WPS Commercial |
$53.15
|
|
|
LENS GLIDE SHEETS 581033
|
Facility
|
IP
|
$145.00
|
|
| Hospital Charge Code |
2964798
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$73.89 |
| Max. Negotiated Rate |
$138.74 |
| Rate for Payer: Aetna Commercial |
$135.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.92
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$138.74
|
| Rate for Payer: Health EOS Commercial |
$134.21
|
| Rate for Payer: HFN Commercial |
$138.74
|
| Rate for Payer: Multiplan Commercial |
$120.64
|
| Rate for Payer: Preferred Network Access Commercial |
$138.74
|
| Rate for Payer: Quartz Beloit One Network |
$73.89
|
| Rate for Payer: Quartz Commercial |
$90.48
|
| Rate for Payer: WEA Trust Commercial |
$82.94
|
| Rate for Payer: WPS Commercial |
$111.69
|
|
|
LENS GLIDE SHEETS 581033
|
Facility
|
OP
|
$145.00
|
|
| Hospital Charge Code |
2964798
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$138.74 |
| Rate for Payer: Aetna Commercial |
$135.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$129.69
|
| Rate for Payer: Aetna Managed Medicare |
$42.22
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$98.02
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$75.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$72.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$79.92
|
| Rate for Payer: Cash Price |
$43.50
|
| Rate for Payer: Cigna Commercial |
$138.74
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$84.39
|
| Rate for Payer: Health EOS Commercial |
$134.21
|
| Rate for Payer: HFN Commercial |
$138.74
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$113.10
|
| Rate for Payer: Multiplan Commercial |
$120.64
|
| Rate for Payer: NAPHCARE Commercial |
$90.48
|
| Rate for Payer: Preferred Network Access Commercial |
$138.74
|
| Rate for Payer: Quartz Beloit One Network |
$73.89
|
| Rate for Payer: Quartz Commercial |
$98.02
|
| Rate for Payer: Quartz Medicare Advantage |
$90.48
|
| Rate for Payer: The Alliance Commercial |
$75.40
|
| Rate for Payer: WEA Trust Commercial |
$82.94
|
| Rate for Payer: WPS Commercial |
$111.69
|
|
|
LENS SN60AT 30.0
|
Facility
|
IP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2975070
|
|
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 SN60AT 30.0
|
Facility
|
OP
|
$2,877.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2975070
|
|
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 SN60AT 33.0
|
Facility
|
IP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964590
|
|
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 SN60AT 33.0
|
Facility
|
OP
|
$2,989.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
2964590
|
|
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 THERAPUTIC MORGAN
|
Facility
|
IP
|
$397.00
|
|
| Hospital Charge Code |
2963015
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$202.31 |
| Max. Negotiated Rate |
$379.85 |
| Rate for Payer: Aetna Commercial |
$371.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.08
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.83
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$379.85
|
| Rate for Payer: Health EOS Commercial |
$367.46
|
| Rate for Payer: HFN Commercial |
$379.85
|
| Rate for Payer: Multiplan Commercial |
$330.30
|
| Rate for Payer: Preferred Network Access Commercial |
$379.85
|
| Rate for Payer: Quartz Beloit One Network |
$202.31
|
| Rate for Payer: Quartz Commercial |
$247.73
|
| Rate for Payer: WEA Trust Commercial |
$227.08
|
| Rate for Payer: WPS Commercial |
$305.81
|
|
|
LENS THERAPUTIC MORGAN
|
Facility
|
OP
|
$397.00
|
|
| Hospital Charge Code |
2963015
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$115.61 |
| Max. Negotiated Rate |
$379.85 |
| Rate for Payer: Aetna Commercial |
$371.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$355.08
|
| Rate for Payer: Aetna Managed Medicare |
$115.61
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$268.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$206.44
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$198.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$218.83
|
| Rate for Payer: Cash Price |
$119.10
|
| Rate for Payer: Cigna Commercial |
$379.85
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$231.05
|
| Rate for Payer: Health EOS Commercial |
$367.46
|
| Rate for Payer: HFN Commercial |
$379.85
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$309.66
|
| Rate for Payer: Multiplan Commercial |
$330.30
|
| Rate for Payer: NAPHCARE Commercial |
$247.73
|
| Rate for Payer: Preferred Network Access Commercial |
$379.85
|
| Rate for Payer: Quartz Beloit One Network |
$202.31
|
| Rate for Payer: Quartz Commercial |
$268.37
|
| Rate for Payer: Quartz Medicare Advantage |
$247.73
|
| Rate for Payer: The Alliance Commercial |
$206.44
|
| Rate for Payer: WEA Trust Commercial |
$227.08
|
| Rate for Payer: WPS Commercial |
$305.81
|
|
|
Leptin
|
Professional
|
Both
|
$141.00
|
|
|
Service Code
|
CPT 82397
|
| Hospital Charge Code |
4163507
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.68 |
| Max. Negotiated Rate |
$139.31 |
| Rate for Payer: Aetna Commercial |
$139.31
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$126.11
|
| Rate for Payer: Aetna Managed Medicare |
$14.68
|
| Rate for Payer: Anthem Medicare Advantage |
$14.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.68
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.68
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cash Price |
$42.30
|
| Rate for Payer: Cigna Commercial |
$139.31
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$73.32
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.68
|
| Rate for Payer: Health EOS Commercial |
$133.44
|
| Rate for Payer: HFN Commercial |
$139.31
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.83
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.83
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.68
|
| Rate for Payer: Multiplan Commercial |
$117.31
|
| Rate for Payer: NAPHCARE Commercial |
$22.03
|
| Rate for Payer: Preferred Network Access Commercial |
$139.31
|
| Rate for Payer: Quartz Beloit One Network |
$64.52
|
| Rate for Payer: Quartz Commercial |
$83.58
|
| Rate for Payer: Quartz Medicare Advantage |
$14.68
|
| Rate for Payer: The Alliance Commercial |
$58.00
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.68
|
| Rate for Payer: WEA Trust Commercial |
$80.65
|
| Rate for Payer: WPS Commercial |
$64.61
|
|
