|
LENS PANOPTIX TFNT30 +21.0 (T)
|
Facility
|
IP
|
$3,941.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$512.36 |
| Max. Negotiated Rate |
$3,783.60 |
| Rate for Payer: Aetna Commercial |
$3,034.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,074.18
|
| Rate for Payer: Cash Price |
$1,970.62
|
| Rate for Payer: Cigna Commercial |
$3,271.24
|
| Rate for Payer: First Health Commercial |
$3,744.19
|
| Rate for Payer: Humana Commercial |
$3,350.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,231.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,908.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,182.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,468.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,955.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$788.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$512.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,221.79
|
| Rate for Payer: PHCS Commercial |
$3,783.60
|
| Rate for Payer: United Healthcare All Payer |
$3,468.30
|
|
|
LENS PANOPTIX TFNT30 +21.0 (T)
|
Facility
|
OP
|
$3,941.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$512.36 |
| Max. Negotiated Rate |
$3,783.60 |
| Rate for Payer: Aetna Commercial |
$3,034.76
|
| Rate for Payer: Anthem Medicaid |
$1,355.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,074.18
|
| Rate for Payer: Cash Price |
$1,970.62
|
| Rate for Payer: Cigna Commercial |
$3,271.24
|
| Rate for Payer: First Health Commercial |
$3,744.19
|
| Rate for Payer: Humana Commercial |
$3,350.06
|
| Rate for Payer: Humana KY Medicaid |
$1,355.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,369.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,231.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,908.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,182.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,382.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,468.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,955.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$788.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$512.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,221.79
|
| Rate for Payer: PHCS Commercial |
$3,783.60
|
| Rate for Payer: United Healthcare All Payer |
$3,468.30
|
|
|
LENS PANOPTIX TFNT30 +22.0 (T)
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT30 +22.0 (T)
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT40 +13.0
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT40 +13.0
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT40 13.5
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT40 13.5
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT40 +17.5 (T)
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT40 +17.5 (T)
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT40+18.5
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT40+18.5
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT40 31.0
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT40 31.0
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT50 +12.0 (T)
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT50 +12.0 (T)
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT50 +13.0 (T)
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PANOPTIX TFNT50 +13.0 (T)
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS PREMIUM V2788
|
Facility
|
IP
|
$1,045.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$135.85 |
| Max. Negotiated Rate |
$1,003.20 |
| Rate for Payer: Aetna Commercial |
$804.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$815.10
|
| Rate for Payer: Cash Price |
$522.50
|
| Rate for Payer: Cigna Commercial |
$867.35
|
| Rate for Payer: First Health Commercial |
$992.75
|
| Rate for Payer: Humana Commercial |
$888.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$856.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$771.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$313.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$919.60
|
| Rate for Payer: Ohio Health Group HMO |
$783.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$209.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$323.95
|
| Rate for Payer: PHCS Commercial |
$1,003.20
|
| Rate for Payer: United Healthcare All Payer |
$919.60
|
|
|
LENS PREMIUM V2788
|
Facility
|
OP
|
$1,045.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$135.85 |
| Max. Negotiated Rate |
$1,003.20 |
| Rate for Payer: Aetna Commercial |
$804.65
|
| Rate for Payer: Anthem Medicaid |
$359.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$815.10
|
| Rate for Payer: Cash Price |
$522.50
|
| Rate for Payer: Cigna Commercial |
$867.35
|
| Rate for Payer: First Health Commercial |
$992.75
|
| Rate for Payer: Humana Commercial |
$888.25
|
| Rate for Payer: Humana KY Medicaid |
$359.38
|
| Rate for Payer: Kentucky WC Medicaid |
$363.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$856.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$771.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$313.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$366.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$919.60
|
| Rate for Payer: Ohio Health Group HMO |
$783.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$209.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$323.95
|
| Rate for Payer: PHCS Commercial |
$1,003.20
|
| Rate for Payer: United Healthcare All Payer |
$919.60
|
|
|
LENS SA60AT+33.0
|
Facility
|
OP
|
$3,512.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$456.62 |
| Max. Negotiated Rate |
$3,372.00 |
| Rate for Payer: Aetna Commercial |
$2,704.62
|
| Rate for Payer: Anthem Medicaid |
$1,207.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,739.75
|
| Rate for Payer: Cash Price |
$1,756.25
|
| Rate for Payer: Cigna Commercial |
$2,915.38
|
| Rate for Payer: First Health Commercial |
$3,336.88
|
| Rate for Payer: Humana Commercial |
$2,985.62
|
| Rate for Payer: Humana KY Medicaid |
$1,207.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,220.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,880.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,592.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,232.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,091.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,634.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$702.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$456.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,088.88
|
| Rate for Payer: PHCS Commercial |
$3,372.00
|
| Rate for Payer: United Healthcare All Payer |
$3,091.00
|
|
|
LENS SA60AT+33.0
|
Facility
|
IP
|
$3,512.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$456.62 |
| Max. Negotiated Rate |
$3,372.00 |
| Rate for Payer: Aetna Commercial |
$2,704.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,739.75
|
| Rate for Payer: Cash Price |
$1,756.25
|
| Rate for Payer: Cigna Commercial |
$2,915.38
|
| Rate for Payer: First Health Commercial |
$3,336.88
|
| Rate for Payer: Humana Commercial |
$2,985.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,880.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,592.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,091.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,634.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$702.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$456.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,088.88
|
| Rate for Payer: PHCS Commercial |
$3,372.00
|
| Rate for Payer: United Healthcare All Payer |
$3,091.00
|
|
|
LENS SN60AT DIOPTER 21.0
|
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 SN60AT DIOPTER 21.0
|
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 SN60AT DIOPTER 32.0 (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
|
|
