|
LENS SN6AT8 DIOPTER 17.5 (T)
|
Facility
|
IP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6AT8 DIOPTER 21.0 (T)
|
Facility
|
OP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem Medicaid |
$1,326.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Humana KY Medicaid |
$1,326.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,339.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,352.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6AT8 DIOPTER 21.0 (T)
|
Facility
|
IP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6AT9 DIOPTER 10.0 (T)
|
Facility
|
IP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6AT9 DIOPTER 10.0 (T)
|
Facility
|
OP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem Medicaid |
$1,326.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Humana KY Medicaid |
$1,326.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,339.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,352.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6AT9 DIOPTER 11.5 (T)
|
Facility
|
OP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem Medicaid |
$1,326.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Humana KY Medicaid |
$1,326.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,339.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,352.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6AT9 DIOPTER 11.5 (T)
|
Facility
|
IP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6AT9 DIOPTER 24.5 (T)
|
Facility
|
IP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6AT9 DIOPTER 24.5 (T)
|
Facility
|
OP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem Medicaid |
$1,326.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Humana KY Medicaid |
$1,326.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,339.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,352.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6AT DIOPTER 18.0 (T)
|
Facility
|
IP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6AT DIOPTER 18.0 (T)
|
Facility
|
OP
|
$3,856.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,156.88 |
| Max. Negotiated Rate |
$3,702.00 |
| Rate for Payer: Aetna Commercial |
$2,969.31
|
| Rate for Payer: Anthem Medicaid |
$1,326.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,007.88
|
| Rate for Payer: Cash Price |
$1,928.12
|
| Rate for Payer: Cigna Commercial |
$3,200.69
|
| Rate for Payer: First Health Commercial |
$3,663.44
|
| Rate for Payer: Humana Commercial |
$3,277.81
|
| Rate for Payer: Humana KY Medicaid |
$1,326.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,339.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,162.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,845.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,156.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,352.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,393.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,892.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,085.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,354.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,660.81
|
| Rate for Payer: PHCS Commercial |
$3,702.00
|
| Rate for Payer: United Healthcare All Payer |
$3,393.50
|
|
|
LENS SN6CWS DIOPTER 10.0 (S)
|
Facility
|
OP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem Medicaid |
$654.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Humana KY Medicaid |
$654.85
|
| Rate for Payer: Kentucky WC Medicaid |
$661.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$667.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 10.0 (S)
|
Facility
|
IP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 10.5 (S)
|
Facility
|
OP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem Medicaid |
$654.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Humana KY Medicaid |
$654.85
|
| Rate for Payer: Kentucky WC Medicaid |
$661.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$667.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 10.5 (S)
|
Facility
|
IP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 11.0 (S)
|
Facility
|
OP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem Medicaid |
$654.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Humana KY Medicaid |
$654.85
|
| Rate for Payer: Kentucky WC Medicaid |
$661.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$667.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 11.0 (S)
|
Facility
|
IP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 11.5 (S)
|
Facility
|
OP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem Medicaid |
$654.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Humana KY Medicaid |
$654.85
|
| Rate for Payer: Kentucky WC Medicaid |
$661.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$667.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 11.5 (S)
|
Facility
|
IP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 12.0 (S)
|
Facility
|
OP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem Medicaid |
$654.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Humana KY Medicaid |
$654.85
|
| Rate for Payer: Kentucky WC Medicaid |
$661.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$667.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 12.0 (S)
|
Facility
|
IP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 12.5 (S)
|
Facility
|
IP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 12.5 (S)
|
Facility
|
OP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem Medicaid |
$654.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Humana KY Medicaid |
$654.85
|
| Rate for Payer: Kentucky WC Medicaid |
$661.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$667.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 13.0 (S)
|
Facility
|
IP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
|
LENS SN6CWS DIOPTER 13.0 (S)
|
Facility
|
OP
|
$1,904.20
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$571.26 |
| Max. Negotiated Rate |
$1,828.03 |
| Rate for Payer: Aetna Commercial |
$1,466.23
|
| Rate for Payer: Anthem Medicaid |
$654.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,485.28
|
| Rate for Payer: Cash Price |
$952.10
|
| Rate for Payer: Cigna Commercial |
$1,580.49
|
| Rate for Payer: First Health Commercial |
$1,808.99
|
| Rate for Payer: Humana Commercial |
$1,618.57
|
| Rate for Payer: Humana KY Medicaid |
$654.85
|
| Rate for Payer: Kentucky WC Medicaid |
$661.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,561.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,405.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$571.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$667.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,675.70
|
| Rate for Payer: Ohio Health Group HMO |
$1,428.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,523.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,656.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,313.90
|
| Rate for Payer: PHCS Commercial |
$1,828.03
|
| Rate for Payer: United Healthcare All Payer |
$1,675.70
|
|
