|
LENS SN60WF DIOPTER 7.5 (S)
|
Facility
|
IP
|
$1,866.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
LENS SN60WF DIOPTER 7.5 (S)
|
Facility
|
OP
|
$1,866.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem Medicaid |
$641.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Humana KY Medicaid |
$641.79
|
| Rate for Payer: Kentucky WC Medicaid |
$648.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$654.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
LENS SN60WF DIOPTER 8.0 (S)
|
Facility
|
OP
|
$1,866.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem Medicaid |
$641.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Humana KY Medicaid |
$641.79
|
| Rate for Payer: Kentucky WC Medicaid |
$648.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$654.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
LENS SN60WF DIOPTER 8.0 (S)
|
Facility
|
IP
|
$1,866.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
LENS SN60WF DIOPTER +8.5 (S)
|
Facility
|
OP
|
$1,866.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem Medicaid |
$641.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Humana KY Medicaid |
$641.79
|
| Rate for Payer: Kentucky WC Medicaid |
$648.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$654.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
LENS SN60WF DIOPTER +8.5 (S)
|
Facility
|
IP
|
$1,866.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
LENS SN60WF DIOPTER 9.0 (S)
|
Facility
|
OP
|
$1,866.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem Medicaid |
$641.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Humana KY Medicaid |
$641.79
|
| Rate for Payer: Kentucky WC Medicaid |
$648.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$654.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
LENS SN60WF DIOPTER 9.0 (S)
|
Facility
|
IP
|
$1,866.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
LENS SN60WF DIOPTER 9.5 (S)
|
Facility
|
IP
|
$1,866.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
LENS SN60WF DIOPTER 9.5 (S)
|
Facility
|
OP
|
$1,866.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$559.86 |
| Max. Negotiated Rate |
$1,791.55 |
| Rate for Payer: Aetna Commercial |
$1,436.97
|
| Rate for Payer: Anthem Medicaid |
$641.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,455.64
|
| Rate for Payer: Cash Price |
$933.10
|
| Rate for Payer: Cigna Commercial |
$1,548.95
|
| Rate for Payer: First Health Commercial |
$1,772.89
|
| Rate for Payer: Humana Commercial |
$1,586.27
|
| Rate for Payer: Humana KY Medicaid |
$641.79
|
| Rate for Payer: Kentucky WC Medicaid |
$648.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,530.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,377.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$654.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,642.26
|
| Rate for Payer: Ohio Health Group HMO |
$1,399.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,492.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,623.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.68
|
| Rate for Payer: PHCS Commercial |
$1,791.55
|
| Rate for Payer: United Healthcare All Payer |
$1,642.26
|
|
|
LENS SN6AD1 DIOPTER 10.0 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem Medicaid |
$1,842.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Humana KY Medicaid |
$1,842.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,860.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,878.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 10.0 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 10.5 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 10.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem Medicaid |
$1,842.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Humana KY Medicaid |
$1,842.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,860.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,878.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 11.0 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem Medicaid |
$1,842.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Humana KY Medicaid |
$1,842.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,860.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,878.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 11.0 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 11.5 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 11.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem Medicaid |
$1,842.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Humana KY Medicaid |
$1,842.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,860.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,878.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 12.0 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 12.0 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem Medicaid |
$1,842.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Humana KY Medicaid |
$1,842.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,860.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,878.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 12.5 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 12.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem Medicaid |
$1,842.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Humana KY Medicaid |
$1,842.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,860.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,878.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 13.0 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem Medicaid |
$1,842.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Humana KY Medicaid |
$1,842.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,860.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,878.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 13.0 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SN6AD1 DIOPTER 13.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem Medicaid |
$1,842.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Humana KY Medicaid |
$1,842.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,860.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,878.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
