|
LENS SN60WF DIOPTER 9.0 (S)
|
Facility
|
IP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS SN60WF DIOPTER 9.5 (S)
|
Facility
|
OP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem Medicaid |
$643.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Humana KY Medicaid |
$643.61
|
| Rate for Payer: Kentucky WC Medicaid |
$650.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS SN60WF DIOPTER 9.5 (S)
|
Facility
|
IP
|
$1,871.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.30 |
| Max. Negotiated Rate |
$1,796.64 |
| Rate for Payer: Aetna Commercial |
$1,441.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,459.77
|
| Rate for Payer: Cash Price |
$935.75
|
| Rate for Payer: Cigna Commercial |
$1,553.34
|
| Rate for Payer: First Health Commercial |
$1,777.92
|
| Rate for Payer: Humana Commercial |
$1,590.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,534.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,646.92
|
| Rate for Payer: Ohio Health Group HMO |
$1,403.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.16
|
| Rate for Payer: PHCS Commercial |
$1,796.64
|
| Rate for Payer: United Healthcare All Payer |
$1,646.92
|
|
|
LENS SN6AD1 DIOPTER 10.0 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 10.0 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 10.5 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 10.5 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 11.0 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 11.0 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 11.5 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 11.5 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 12.0 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 12.0 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 12.5 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 12.5 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 13.0 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 13.0 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 13.5 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 13.5 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 14.0 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 14.0 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 14.5 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 14.5 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 15.0 (P)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
|
LENS SN6AD1 DIOPTER 15.0 (P)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$693.22 |
| Max. Negotiated Rate |
$5,119.20 |
| Rate for Payer: Aetna Commercial |
$4,106.02
|
| Rate for Payer: Anthem Medicaid |
$1,833.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,159.35
|
| Rate for Payer: Cash Price |
$2,666.25
|
| Rate for Payer: Cigna Commercial |
$4,425.98
|
| Rate for Payer: First Health Commercial |
$5,065.88
|
| Rate for Payer: Humana Commercial |
$4,532.62
|
| Rate for Payer: Humana KY Medicaid |
$1,833.85
|
| Rate for Payer: Kentucky WC Medicaid |
$1,852.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,372.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,935.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,599.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,870.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,692.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,999.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,653.08
|
| Rate for Payer: PHCS Commercial |
$5,119.20
|
| Rate for Payer: United Healthcare All Payer |
$4,692.60
|
|
