|
LENS SN6AT9 DIOPTER 24.5 (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 SN6AT9 DIOPTER 24.5 (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 SN6AT 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 SN6AT 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 SN6CWS DIOPTER 10.0 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 10.0 (S)
|
Facility
|
IP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 10.5 (S)
|
Facility
|
IP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 10.5 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 11.0 (S)
|
Facility
|
IP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 11.0 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 11.5 (S)
|
Facility
|
IP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 11.5 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 12.0 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 12.0 (S)
|
Facility
|
IP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 12.5 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 12.5 (S)
|
Facility
|
IP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 13.0 (S)
|
Facility
|
IP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 13.0 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 13.5 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 13.5 (S)
|
Facility
|
IP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 14.0 (S)
|
Facility
|
IP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 14.0 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 14.5 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 14.5 (S)
|
Facility
|
IP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
|
LENS SN6CWS DIOPTER 15.0 (S)
|
Facility
|
OP
|
$1,906.50
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$247.84 |
| Max. Negotiated Rate |
$1,830.24 |
| Rate for Payer: Aetna Commercial |
$1,468.00
|
| Rate for Payer: Anthem Medicaid |
$655.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Cash Price |
$953.25
|
| Rate for Payer: Cigna Commercial |
$1,582.40
|
| Rate for Payer: First Health Commercial |
$1,811.18
|
| Rate for Payer: Humana Commercial |
$1,620.52
|
| Rate for Payer: Humana KY Medicaid |
$655.65
|
| Rate for Payer: Kentucky WC Medicaid |
$662.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,563.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,407.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$668.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,677.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,429.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$381.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$247.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$591.02
|
| Rate for Payer: PHCS Commercial |
$1,830.24
|
| Rate for Payer: United Healthcare All Payer |
$1,677.72
|
|
