|
LENS MA60AC DIOPTER 29.0 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 29.0 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 29.5 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 29.5 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 30.0 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 30.0 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 6.0 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 6.0 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 6.5 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 6.5 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 7.0 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 7.0 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 7.5 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 7.5 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 8.0 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 8.0 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 8.5 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 8.5 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 9.0 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 9.0 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 9.5 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60AC DIOPTER 9.5 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60MA DIOPTER 4.0 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60MA DIOPTER 4.0 (S)
|
Facility
|
IP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
|
LENS MA60MA DIOPTER -5 (S)
|
Facility
|
OP
|
$1,771.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$531.36 |
| Max. Negotiated Rate |
$1,700.35 |
| Rate for Payer: Aetna Commercial |
$1,363.82
|
| Rate for Payer: Anthem Medicaid |
$609.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,381.54
|
| Rate for Payer: Cash Price |
$885.60
|
| Rate for Payer: Cigna Commercial |
$1,470.10
|
| Rate for Payer: First Health Commercial |
$1,682.64
|
| Rate for Payer: Humana Commercial |
$1,505.52
|
| Rate for Payer: Humana KY Medicaid |
$609.12
|
| Rate for Payer: Kentucky WC Medicaid |
$615.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,452.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,307.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$531.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$621.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,558.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,328.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,416.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,540.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,222.13
|
| Rate for Payer: PHCS Commercial |
$1,700.35
|
| Rate for Payer: United Healthcare All Payer |
$1,558.66
|
|
