|
LENS SN6CWS DIOPTER 7.0 (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 7.5 (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 7.5 (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 8.0 (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 8.0 (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 8.5 (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 8.5 (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 9.0 (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 9.0 (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 9.5 (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 9.5 (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 SND1T5 DIOPTER 9.0 (T)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SND1T5 DIOPTER 9.0 (T)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2787
|
| Hospital Charge Code |
27000070
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,606.88 |
| Max. Negotiated Rate |
$5,142.00 |
| Rate for Payer: Aetna Commercial |
$4,124.31
|
| Rate for Payer: Anthem Medicaid |
$1,842.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,177.88
|
| Rate for Payer: Cash Price |
$2,678.12
|
| Rate for Payer: Cigna Commercial |
$4,445.69
|
| Rate for Payer: First Health Commercial |
$5,088.44
|
| Rate for Payer: Humana Commercial |
$4,552.81
|
| Rate for Payer: Humana KY Medicaid |
$1,842.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,860.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,392.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,952.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,606.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,878.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,713.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,017.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,285.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,659.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,695.81
|
| Rate for Payer: PHCS Commercial |
$5,142.00
|
| Rate for Payer: United Healthcare All Payer |
$4,713.50
|
|
|
LENS SOFTCHD PLI DPTR+14.25(S)
|
Facility
|
OP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem Medicaid |
$616.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Humana KY Medicaid |
$616.96
|
| Rate for Payer: Kentucky WC Medicaid |
$623.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$629.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+14.25(S)
|
Facility
|
IP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+14.75(S)
|
Facility
|
IP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+14.75(S)
|
Facility
|
OP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem Medicaid |
$616.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Humana KY Medicaid |
$616.96
|
| Rate for Payer: Kentucky WC Medicaid |
$623.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$629.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+15.50(S)
|
Facility
|
IP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+15.50(S)
|
Facility
|
OP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem Medicaid |
$616.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Humana KY Medicaid |
$616.96
|
| Rate for Payer: Kentucky WC Medicaid |
$623.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$629.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+23.50(S)
|
Facility
|
IP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+23.50(S)
|
Facility
|
OP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem Medicaid |
$616.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Humana KY Medicaid |
$616.96
|
| Rate for Payer: Kentucky WC Medicaid |
$623.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$629.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+24.75(S)
|
Facility
|
OP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem Medicaid |
$616.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Humana KY Medicaid |
$616.96
|
| Rate for Payer: Kentucky WC Medicaid |
$623.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$629.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+24.75(S)
|
Facility
|
IP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+25.25(S)
|
Facility
|
IP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
|
LENS SOFTCHD PLI DPTR+25.25(S)
|
Facility
|
OP
|
$1,794.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$538.20 |
| Max. Negotiated Rate |
$1,722.24 |
| Rate for Payer: Aetna Commercial |
$1,381.38
|
| Rate for Payer: Anthem Medicaid |
$616.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,399.32
|
| Rate for Payer: Cash Price |
$897.00
|
| Rate for Payer: Cigna Commercial |
$1,489.02
|
| Rate for Payer: First Health Commercial |
$1,704.30
|
| Rate for Payer: Humana Commercial |
$1,524.90
|
| Rate for Payer: Humana KY Medicaid |
$616.96
|
| Rate for Payer: Kentucky WC Medicaid |
$623.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,471.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,323.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$538.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$629.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,578.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,345.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,560.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.86
|
| Rate for Payer: PHCS Commercial |
$1,722.24
|
| Rate for Payer: United Healthcare All Payer |
$1,578.72
|
|
