|
LENS SN6CWS DIOPTER 19.5 (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 20.0 (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 20.0 (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 20.5 (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 20.5 (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 21.0 (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 21.0 (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 21.5 (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 21.5 (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 22.0 (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 22.0 (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 22.5 (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 22.5 (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 23.0 (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 23.0 (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 23.5 (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 23.5 (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 24.0 (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 24.0 (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 24.5 (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 24.5 (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 25.0 (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 25.0 (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 25.5 (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 25.5 (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
|
|
