|
LENS MA60AC DIOPTER 23.5 (S)
|
Facility
|
OP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 MA60AC DIOPTER 23.5 (S)
|
Facility
|
IP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 MA60AC DIOPTER 24.0 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 24.0 (S)
|
Facility
|
IP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 24.5 (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 MA60AC DIOPTER 24.5 (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 MA60AC DIOPTER 25.0 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 25.0 (S)
|
Facility
|
IP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 25.5 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 25.5 (S)
|
Facility
|
IP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 26.0 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 26.0 (S)
|
Facility
|
IP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 26.5 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 26.5 (S)
|
Facility
|
IP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 27.0 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 27.0 (S)
|
Facility
|
IP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 27.5 (S)
|
Facility
|
IP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 27.5 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 28.0 (S)
|
Facility
|
IP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 28.0 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 28.5 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 28.5 (S)
|
Facility
|
IP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 29.0 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 29.0 (S)
|
Facility
|
IP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
|
LENS MA60AC DIOPTER 29.5 (S)
|
Facility
|
OP
|
$1,784.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$231.92 |
| Max. Negotiated Rate |
$1,712.64 |
| Rate for Payer: Aetna Commercial |
$1,373.68
|
| Rate for Payer: Anthem Medicaid |
$613.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,391.52
|
| Rate for Payer: Cash Price |
$892.00
|
| Rate for Payer: Cigna Commercial |
$1,480.72
|
| Rate for Payer: First Health Commercial |
$1,694.80
|
| Rate for Payer: Humana Commercial |
$1,516.40
|
| Rate for Payer: Humana KY Medicaid |
$613.52
|
| Rate for Payer: Kentucky WC Medicaid |
$619.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,462.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,316.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$535.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$625.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,569.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,338.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$553.04
|
| Rate for Payer: PHCS Commercial |
$1,712.64
|
| Rate for Payer: United Healthcare All Payer |
$1,569.92
|
|
