|
LENS SOFTECHD PLI DTR +18.75 (
|
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 SOFTECHD PLI DTR +18.75 (
|
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 SOFTECHD PLI DTR +19.0 (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 SOFTECHD PLI DTR +19.0 (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 SOFTECHD PLI DTR +20.25 (
|
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 SOFTECHD PLI DTR +20.25 (
|
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 SOFTECHD PLI DTR +21.0 (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 SOFTECHD PLI DTR +21.0 (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 SV25T0 DIOPTER 13.5 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 13.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 16.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 16.5 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 19.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 19.5 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 20.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 20.5 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 23.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 23.5 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 24.5 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 24.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 25.0 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
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 SV25T0 DIOPTER 25.0 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
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 SV25T0 DIOPTER 26.5 (P)
|
Facility
|
IP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T0 DIOPTER 26.5 (P)
|
Facility
|
OP
|
$5,356.25
|
|
|
Service Code
|
HCPCS V2632
|
| Hospital Charge Code |
27000071
|
|
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 SV25T2 DIOPTR 16.5 RESTOR
|
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
|
|
