|
LENS SN6CWS DIOPTER 9.0 (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 9.0 (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 9.5 (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 9.5 (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 SND1T5 DIOPTER 9.0 (T)
|
Facility
|
OP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
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 SND1T5 DIOPTER 9.0 (T)
|
Facility
|
IP
|
$5,332.50
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
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 SOFTCHD PLI DPTR+14.25(S)
|
Facility
|
OP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem Medicaid |
$620.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Humana KY Medicaid |
$620.74
|
| Rate for Payer: Kentucky WC Medicaid |
$627.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$633.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+14.25(S)
|
Facility
|
IP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+14.75(S)
|
Facility
|
OP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem Medicaid |
$620.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Humana KY Medicaid |
$620.74
|
| Rate for Payer: Kentucky WC Medicaid |
$627.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$633.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+14.75(S)
|
Facility
|
IP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+15.50(S)
|
Facility
|
OP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem Medicaid |
$620.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Humana KY Medicaid |
$620.74
|
| Rate for Payer: Kentucky WC Medicaid |
$627.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$633.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+15.50(S)
|
Facility
|
IP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+23.50(S)
|
Facility
|
IP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+23.50(S)
|
Facility
|
OP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem Medicaid |
$620.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Humana KY Medicaid |
$620.74
|
| Rate for Payer: Kentucky WC Medicaid |
$627.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$633.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+24.75(S)
|
Facility
|
OP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem Medicaid |
$620.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Humana KY Medicaid |
$620.74
|
| Rate for Payer: Kentucky WC Medicaid |
$627.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$633.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+24.75(S)
|
Facility
|
IP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+25.25(S)
|
Facility
|
IP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+25.25(S)
|
Facility
|
OP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem Medicaid |
$620.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Humana KY Medicaid |
$620.74
|
| Rate for Payer: Kentucky WC Medicaid |
$627.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$633.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+25.75(S)
|
Facility
|
IP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+25.75(S)
|
Facility
|
OP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem Medicaid |
$620.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Humana KY Medicaid |
$620.74
|
| Rate for Payer: Kentucky WC Medicaid |
$627.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$633.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+27.50(S)
|
Facility
|
OP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem Medicaid |
$620.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Humana KY Medicaid |
$620.74
|
| Rate for Payer: Kentucky WC Medicaid |
$627.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$633.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+27.50(S)
|
Facility
|
IP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+28.00(S)
|
Facility
|
IP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTCHD PLI DPTR+28.00(S)
|
Facility
|
OP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem Medicaid |
$620.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Humana KY Medicaid |
$620.74
|
| Rate for Payer: Kentucky WC Medicaid |
$627.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$633.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
|
LENS SOFTECHD DIOPTER +10.0 (S
|
Facility
|
IP
|
$1,805.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$234.65 |
| Max. Negotiated Rate |
$1,732.80 |
| Rate for Payer: Aetna Commercial |
$1,389.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,407.90
|
| Rate for Payer: Cash Price |
$902.50
|
| Rate for Payer: Cigna Commercial |
$1,498.15
|
| Rate for Payer: First Health Commercial |
$1,714.75
|
| Rate for Payer: Humana Commercial |
$1,534.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,480.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,332.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$541.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,588.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,353.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$361.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$559.55
|
| Rate for Payer: PHCS Commercial |
$1,732.80
|
| Rate for Payer: United Healthcare All Payer |
$1,588.40
|
|
