|
LENS AU00T0 PL DIOPTER 6.5 (S)
|
Facility
|
OP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem Medicaid |
$643.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Humana KY Medicaid |
$643.61
|
| Rate for Payer: Kentucky WC Medicaid |
$650.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 7.0 (S)
|
Facility
|
OP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem Medicaid |
$643.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Humana KY Medicaid |
$643.61
|
| Rate for Payer: Kentucky WC Medicaid |
$650.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 7.0 (S)
|
Facility
|
IP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 7.5 (S)
|
Facility
|
IP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 7.5 (S)
|
Facility
|
OP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem Medicaid |
$643.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Humana KY Medicaid |
$643.61
|
| Rate for Payer: Kentucky WC Medicaid |
$650.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 8.0 (S)
|
Facility
|
OP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem Medicaid |
$643.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Humana KY Medicaid |
$643.61
|
| Rate for Payer: Kentucky WC Medicaid |
$650.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 8.0 (S)
|
Facility
|
IP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 8.5 (S)
|
Facility
|
IP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 8.5 (S)
|
Facility
|
OP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem Medicaid |
$643.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Humana KY Medicaid |
$643.61
|
| Rate for Payer: Kentucky WC Medicaid |
$650.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 9.0 (S)
|
Facility
|
OP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem Medicaid |
$643.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Humana KY Medicaid |
$643.61
|
| Rate for Payer: Kentucky WC Medicaid |
$650.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 9.0 (S)
|
Facility
|
IP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 9.5 (S)
|
Facility
|
IP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS AU00T0 PL DIOPTER 9.5 (S)
|
Facility
|
OP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem Medicaid |
$643.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Humana KY Medicaid |
$643.61
|
| Rate for Payer: Kentucky WC Medicaid |
$650.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS CLAREON IOL SY60WF 9.0
|
Facility
|
OP
|
$1,882.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem Medicaid |
$647.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Humana KY Medicaid |
$647.22
|
| Rate for Payer: Kentucky WC Medicaid |
$653.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$660.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
LENS CLAREON IOL SY60WF 9.0
|
Facility
|
IP
|
$1,882.00
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
LENS CNA0T0 PL DIOPTER 10.0
|
Facility
|
OP
|
$1,892.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$246.02 |
| Max. Negotiated Rate |
$1,816.80 |
| Rate for Payer: Aetna Commercial |
$1,457.22
|
| Rate for Payer: Anthem Medicaid |
$650.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.15
|
| Rate for Payer: Cash Price |
$946.25
|
| Rate for Payer: Cigna Commercial |
$1,570.78
|
| Rate for Payer: First Health Commercial |
$1,797.88
|
| Rate for Payer: Humana Commercial |
$1,608.62
|
| Rate for Payer: Humana KY Medicaid |
$650.83
|
| Rate for Payer: Kentucky WC Medicaid |
$657.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,551.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$663.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.68
|
| Rate for Payer: PHCS Commercial |
$1,816.80
|
| Rate for Payer: United Healthcare All Payer |
$1,665.40
|
|
|
LENS CNA0T0 PL DIOPTER 10.0
|
Facility
|
IP
|
$1,892.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$246.02 |
| Max. Negotiated Rate |
$1,816.80 |
| Rate for Payer: Aetna Commercial |
$1,457.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.15
|
| Rate for Payer: Cash Price |
$946.25
|
| Rate for Payer: Cigna Commercial |
$1,570.78
|
| Rate for Payer: First Health Commercial |
$1,797.88
|
| Rate for Payer: Humana Commercial |
$1,608.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,551.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.68
|
| Rate for Payer: PHCS Commercial |
$1,816.80
|
| Rate for Payer: United Healthcare All Payer |
$1,665.40
|
|
|
LENS CNA0T0 PL DIOPTER 10.5
|
Facility
|
IP
|
$1,892.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$246.02 |
| Max. Negotiated Rate |
$1,816.80 |
| Rate for Payer: Aetna Commercial |
$1,457.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.15
|
| Rate for Payer: Cash Price |
$946.25
|
| Rate for Payer: Cigna Commercial |
$1,570.78
|
| Rate for Payer: First Health Commercial |
$1,797.88
|
| Rate for Payer: Humana Commercial |
$1,608.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,551.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.68
|
| Rate for Payer: PHCS Commercial |
$1,816.80
|
| Rate for Payer: United Healthcare All Payer |
$1,665.40
|
|
|
LENS CNA0T0 PL DIOPTER 10.5
|
Facility
|
OP
|
$1,892.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$246.02 |
| Max. Negotiated Rate |
$1,816.80 |
| Rate for Payer: Aetna Commercial |
$1,457.22
|
| Rate for Payer: Anthem Medicaid |
$650.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.15
|
| Rate for Payer: Cash Price |
$946.25
|
| Rate for Payer: Cigna Commercial |
$1,570.78
|
| Rate for Payer: First Health Commercial |
$1,797.88
|
| Rate for Payer: Humana Commercial |
$1,608.62
|
| Rate for Payer: Humana KY Medicaid |
$650.83
|
| Rate for Payer: Kentucky WC Medicaid |
$657.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,551.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$663.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.68
|
| Rate for Payer: PHCS Commercial |
$1,816.80
|
| Rate for Payer: United Healthcare All Payer |
$1,665.40
|
|
|
LENS CNA0T0 PL DIOPTER 11.0
|
Facility
|
IP
|
$1,892.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$246.02 |
| Max. Negotiated Rate |
$1,816.80 |
| Rate for Payer: Aetna Commercial |
$1,457.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.15
|
| Rate for Payer: Cash Price |
$946.25
|
| Rate for Payer: Cigna Commercial |
$1,570.78
|
| Rate for Payer: First Health Commercial |
$1,797.88
|
| Rate for Payer: Humana Commercial |
$1,608.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,551.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.68
|
| Rate for Payer: PHCS Commercial |
$1,816.80
|
| Rate for Payer: United Healthcare All Payer |
$1,665.40
|
|
|
LENS CNA0T0 PL DIOPTER 11.0
|
Facility
|
OP
|
$1,892.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$246.02 |
| Max. Negotiated Rate |
$1,816.80 |
| Rate for Payer: Aetna Commercial |
$1,457.22
|
| Rate for Payer: Anthem Medicaid |
$650.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.15
|
| Rate for Payer: Cash Price |
$946.25
|
| Rate for Payer: Cigna Commercial |
$1,570.78
|
| Rate for Payer: First Health Commercial |
$1,797.88
|
| Rate for Payer: Humana Commercial |
$1,608.62
|
| Rate for Payer: Humana KY Medicaid |
$650.83
|
| Rate for Payer: Kentucky WC Medicaid |
$657.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,551.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$663.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.68
|
| Rate for Payer: PHCS Commercial |
$1,816.80
|
| Rate for Payer: United Healthcare All Payer |
$1,665.40
|
|
|
LENS CNA0T0 PL DIOPTER 11.5
|
Facility
|
OP
|
$1,892.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$246.02 |
| Max. Negotiated Rate |
$1,816.80 |
| Rate for Payer: Aetna Commercial |
$1,457.22
|
| Rate for Payer: Anthem Medicaid |
$650.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.15
|
| Rate for Payer: Cash Price |
$946.25
|
| Rate for Payer: Cigna Commercial |
$1,570.78
|
| Rate for Payer: First Health Commercial |
$1,797.88
|
| Rate for Payer: Humana Commercial |
$1,608.62
|
| Rate for Payer: Humana KY Medicaid |
$650.83
|
| Rate for Payer: Kentucky WC Medicaid |
$657.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,551.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$663.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.68
|
| Rate for Payer: PHCS Commercial |
$1,816.80
|
| Rate for Payer: United Healthcare All Payer |
$1,665.40
|
|
|
LENS CNA0T0 PL DIOPTER 11.5
|
Facility
|
IP
|
$1,892.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$246.02 |
| Max. Negotiated Rate |
$1,816.80 |
| Rate for Payer: Aetna Commercial |
$1,457.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.15
|
| Rate for Payer: Cash Price |
$946.25
|
| Rate for Payer: Cigna Commercial |
$1,570.78
|
| Rate for Payer: First Health Commercial |
$1,797.88
|
| Rate for Payer: Humana Commercial |
$1,608.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,551.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.68
|
| Rate for Payer: PHCS Commercial |
$1,816.80
|
| Rate for Payer: United Healthcare All Payer |
$1,665.40
|
|
|
LENS CNA0T0 PL DIOPTER 12.00
|
Facility
|
OP
|
$1,892.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$246.02 |
| Max. Negotiated Rate |
$1,816.80 |
| Rate for Payer: Aetna Commercial |
$1,457.22
|
| Rate for Payer: Anthem Medicaid |
$650.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.15
|
| Rate for Payer: Cash Price |
$946.25
|
| Rate for Payer: Cigna Commercial |
$1,570.78
|
| Rate for Payer: First Health Commercial |
$1,797.88
|
| Rate for Payer: Humana Commercial |
$1,608.62
|
| Rate for Payer: Humana KY Medicaid |
$650.83
|
| Rate for Payer: Kentucky WC Medicaid |
$657.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,551.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$663.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.68
|
| Rate for Payer: PHCS Commercial |
$1,816.80
|
| Rate for Payer: United Healthcare All Payer |
$1,665.40
|
|
|
LENS CNA0T0 PL DIOPTER 12.00
|
Facility
|
IP
|
$1,892.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$246.02 |
| Max. Negotiated Rate |
$1,816.80 |
| Rate for Payer: Aetna Commercial |
$1,457.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.15
|
| Rate for Payer: Cash Price |
$946.25
|
| Rate for Payer: Cigna Commercial |
$1,570.78
|
| Rate for Payer: First Health Commercial |
$1,797.88
|
| Rate for Payer: Humana Commercial |
$1,608.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,551.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.68
|
| Rate for Payer: PHCS Commercial |
$1,816.80
|
| Rate for Payer: United Healthcare All Payer |
$1,665.40
|
|
