|
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
|
|
|
LENS SN60AT DIOPTER 33.0 (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 SN60AT DIOPTER 33.0 (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 SN60AT DIOPTER 34.0 (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 SN60AT DIOPTER 34.0 (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 SN60AT DIOPTER 35.0 (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 SN60AT DIOPTER 35.0 (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 SN60AT DIOPTER 36.0 (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 SN60AT DIOPTER 36.0 (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 SN60WF DIOPTER 10.0 (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 SN60WF DIOPTER 10.0 (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 SN60WF DIOPTER 10.5 (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 SN60WF DIOPTER 10.5 (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 SN60WF DIOPTER 11.0 (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 SN60WF DIOPTER 11.0 (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 SN60WF DIOPTER 11.5 (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 SN60WF DIOPTER 11.5 (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 SN60WF DIOPTER 12.0 (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 SN60WF DIOPTER 12.0 (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 SN60WF DIOPTER 12.5 (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 SN60WF DIOPTER 12.5 (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 SN60WF DIOPTER 13.0 (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 SN60WF DIOPTER 13.0 (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 SN60WF DIOPTER 13.5 (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 SN60WF DIOPTER 13.5 (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
|
|
