|
LENS VIVITY DFT 015*13.5
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT 015*17.5
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT 015*17.5
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT 015*19.0
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT 015*19.0
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT 015*19.5
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT 015*19.5
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT015 20.0
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT015 20.0
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT015+20.5
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
LENS VIVITY DFT015+20.5
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
LENS VIVITY DFT015 21.5
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT015 21.5
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT 315*13.5
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT 315*13.5
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT 315* 18.5
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT 315* 18.5
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT315 24.0
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT315 24.0
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT415+12.0
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT415+12.0
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT415 22.0
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT415 22.0
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT515 14.0
|
Facility
|
OP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem Medicaid |
$1,954.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Humana KY Medicaid |
$1,954.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,974.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,993.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
|
LENS VIVITY DFT515 14.0
|
Facility
|
IP
|
$5,682.50
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$738.72 |
| Max. Negotiated Rate |
$5,455.20 |
| Rate for Payer: Aetna Commercial |
$4,375.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,432.35
|
| Rate for Payer: Cash Price |
$2,841.25
|
| Rate for Payer: Cigna Commercial |
$4,716.48
|
| Rate for Payer: First Health Commercial |
$5,398.38
|
| Rate for Payer: Humana Commercial |
$4,830.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,659.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,193.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,704.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,000.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,261.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,136.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,761.58
|
| Rate for Payer: PHCS Commercial |
$5,455.20
|
| Rate for Payer: United Healthcare All Payer |
$5,000.60
|
|
