|
LENS SN6AD3 DIOPTER 26.0 (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 SN6AD3 DIOPTER 26.5 (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 SN6AD3 DIOPTER 26.5 (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 SN6AD3 DIOPTER 27.0 (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 SN6AD3 DIOPTER 27.0 (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 SN6AD3 DIOPTER 27.5 (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 SN6AD3 DIOPTER 27.5 (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 SN6AD3 DIOPTER 28.0 (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 SN6AD3 DIOPTER 28.0 (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 SN6AD3 DIOPTER 28.5 (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 SN6AD3 DIOPTER 28.5 (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 SN6AD3 DIOPTER 29.0 (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 SN6AD3 DIOPTER 29.0 (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 SN6AD3 DIOPTER 29.5 (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 SN6AD3 DIOPTER 29.5 (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 SN6AD3 DIOPTER 30.0 (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 SN6AD3 DIOPTER 30.0 (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 SN6AT3 DIOPTER 17.0 (T)
|
Facility
|
IP
|
$3,932.50
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
|
LENS SN6AT3 DIOPTER 17.0 (T)
|
Facility
|
OP
|
$3,932.50
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem Medicaid |
$1,352.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Humana KY Medicaid |
$1,352.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,366.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,379.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
|
LENS SN6AT3 DIOPTER 18.0 (T)
|
Facility
|
IP
|
$3,932.50
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
|
LENS SN6AT3 DIOPTER 18.0 (T)
|
Facility
|
OP
|
$3,932.50
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem Medicaid |
$1,352.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Humana KY Medicaid |
$1,352.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,366.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,379.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
|
LENS SN6AT3 DIOPTER 21.0 (T)
|
Facility
|
OP
|
$3,932.50
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem Medicaid |
$1,352.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Humana KY Medicaid |
$1,352.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,366.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,379.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
|
LENS SN6AT3 DIOPTER 21.0 (T)
|
Facility
|
IP
|
$3,932.50
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
|
LENS SN6AT3 DIOPTER 22.0 (T)
|
Facility
|
IP
|
$3,932.50
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
|
LENS SN6AT3 DIOPTER 22.0 (T)
|
Facility
|
OP
|
$3,932.50
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem Medicaid |
$1,352.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Humana KY Medicaid |
$1,352.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,366.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,379.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
