|
LENS SOFTECHD DIOPTER+15.75(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 SOFTECHD DIOPTER+15.75(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 SOFTECHD DIOPTER +16.0 (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 +16.0 (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
|
|
|
LENS SOFTECHD DIOPTER+16.25(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 SOFTECHD DIOPTER+16.25(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 SOFTECHD DIOPTER+16.5 (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+16.5 (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 SOFTECHD DIOPTER+16.75(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 SOFTECHD DIOPTER+16.75(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 SOFTECHD DIOPTER+17.0 (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+17.0 (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
|
|
|
LENS SOFTECHD DIOPTER+17.25(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 SOFTECHD DIOPTER+17.25(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 SOFTECHD DIOPTER+17.5 (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 SOFTECHD DIOPTER+17.5 (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+17.75(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 SOFTECHD DIOPTER+17.75(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 SOFTECHD DIOPTER+18.0 (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+18.0 (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
|
|
|
LENS SOFTECHD DIOPTER+18.25(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 SOFTECHD DIOPTER+18.25(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 SOFTECHD DIOPTER+18.5 (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 SOFTECHD DIOPTER+18.5 (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+18.75(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
|
|
