|
LENS VIVITY CNWET0+6.50
|
Facility
|
OP
|
$6,704.75
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2,011.42 |
| Max. Negotiated Rate |
$6,436.56 |
| Rate for Payer: Aetna Commercial |
$5,162.66
|
| Rate for Payer: Anthem Medicaid |
$2,305.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,229.70
|
| Rate for Payer: Cash Price |
$3,352.38
|
| Rate for Payer: Cigna Commercial |
$5,564.94
|
| Rate for Payer: First Health Commercial |
$6,369.51
|
| Rate for Payer: Humana Commercial |
$5,699.04
|
| Rate for Payer: Humana KY Medicaid |
$2,305.76
|
| Rate for Payer: Kentucky WC Medicaid |
$2,329.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,497.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,948.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,352.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,900.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,028.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,363.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,833.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,626.28
|
| Rate for Payer: PHCS Commercial |
$6,436.56
|
| Rate for Payer: United Healthcare All Payer |
$5,900.18
|
|
|
LENS VIVITY CNWET0+6.50
|
Facility
|
IP
|
$6,704.75
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2,011.42 |
| Max. Negotiated Rate |
$6,436.56 |
| Rate for Payer: Aetna Commercial |
$5,162.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,229.70
|
| Rate for Payer: Cash Price |
$3,352.38
|
| Rate for Payer: Cigna Commercial |
$5,564.94
|
| Rate for Payer: First Health Commercial |
$6,369.51
|
| Rate for Payer: Humana Commercial |
$5,699.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,497.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,948.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,900.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,028.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,363.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,833.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,626.28
|
| Rate for Payer: PHCS Commercial |
$6,436.56
|
| Rate for Payer: United Healthcare All Payer |
$5,900.18
|
|
|
LENS VIVITY CNWET3 11.50
|
Facility
|
IP
|
$3,903.12
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,170.94 |
| Max. Negotiated Rate |
$3,747.00 |
| Rate for Payer: Aetna Commercial |
$3,005.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,044.43
|
| Rate for Payer: Cash Price |
$1,951.56
|
| Rate for Payer: Cigna Commercial |
$3,239.59
|
| Rate for Payer: First Health Commercial |
$3,707.96
|
| Rate for Payer: Humana Commercial |
$3,317.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,200.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,880.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,434.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,927.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,122.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,395.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,693.15
|
| Rate for Payer: PHCS Commercial |
$3,747.00
|
| Rate for Payer: United Healthcare All Payer |
$3,434.75
|
|
|
LENS VIVITY CNWET3 11.50
|
Facility
|
OP
|
$3,903.12
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,170.94 |
| Max. Negotiated Rate |
$3,747.00 |
| Rate for Payer: Aetna Commercial |
$3,005.40
|
| Rate for Payer: Anthem Medicaid |
$1,342.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,044.43
|
| Rate for Payer: Cash Price |
$1,951.56
|
| Rate for Payer: Cigna Commercial |
$3,239.59
|
| Rate for Payer: First Health Commercial |
$3,707.96
|
| Rate for Payer: Humana Commercial |
$3,317.65
|
| Rate for Payer: Humana KY Medicaid |
$1,342.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1,355.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,200.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,880.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,369.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,434.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,927.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,122.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,395.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,693.15
|
| Rate for Payer: PHCS Commercial |
$3,747.00
|
| Rate for Payer: United Healthcare All Payer |
$3,434.75
|
|
|
LENS VIVITY CNWET3+20.0
|
Facility
|
IP
|
$5,375.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
LENS VIVITY CNWET3+20.0
|
Facility
|
OP
|
$5,375.00
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,612.50 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna Commercial |
$4,138.75
|
| Rate for Payer: Anthem Medicaid |
$1,848.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,192.50
|
| Rate for Payer: Cash Price |
$2,687.50
|
| Rate for Payer: Cigna Commercial |
$4,461.25
|
| Rate for Payer: First Health Commercial |
$5,106.25
|
| Rate for Payer: Humana Commercial |
$4,568.75
|
| Rate for Payer: Humana KY Medicaid |
$1,848.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,867.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,407.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,966.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,612.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,885.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,730.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,031.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,676.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,708.75
|
| Rate for Payer: PHCS Commercial |
$5,160.00
|
| Rate for Payer: United Healthcare All Payer |
$4,730.00
|
|
|
LENS VIVITY CNWET3 23.0
|
Facility
|
IP
|
$6,704.75
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2,011.42 |
| Max. Negotiated Rate |
$6,436.56 |
| Rate for Payer: Aetna Commercial |
$5,162.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,229.70
|
| Rate for Payer: Cash Price |
$3,352.38
|
| Rate for Payer: Cigna Commercial |
$5,564.94
|
| Rate for Payer: First Health Commercial |
$6,369.51
|
| Rate for Payer: Humana Commercial |
$5,699.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,497.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,948.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,900.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,028.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,363.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,833.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,626.28
|
| Rate for Payer: PHCS Commercial |
$6,436.56
|
| Rate for Payer: United Healthcare All Payer |
$5,900.18
|
|
|
LENS VIVITY CNWET3 23.0
|
Facility
|
OP
|
$6,704.75
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2,011.42 |
| Max. Negotiated Rate |
$6,436.56 |
| Rate for Payer: Aetna Commercial |
$5,162.66
|
| Rate for Payer: Anthem Medicaid |
$2,305.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,229.70
|
| Rate for Payer: Cash Price |
$3,352.38
|
| Rate for Payer: Cigna Commercial |
$5,564.94
|
| Rate for Payer: First Health Commercial |
$6,369.51
|
| Rate for Payer: Humana Commercial |
$5,699.04
|
| Rate for Payer: Humana KY Medicaid |
$2,305.76
|
| Rate for Payer: Kentucky WC Medicaid |
$2,329.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,497.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,948.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,352.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,900.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,028.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,363.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,833.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,626.28
|
| Rate for Payer: PHCS Commercial |
$6,436.56
|
| Rate for Payer: United Healthcare All Payer |
$5,900.18
|
|
|
LENS VIVITY CNWET4+13.0
|
Facility
|
IP
|
$3,903.12
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,170.94 |
| Max. Negotiated Rate |
$3,747.00 |
| Rate for Payer: Aetna Commercial |
$3,005.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,044.43
|
| Rate for Payer: Cash Price |
$1,951.56
|
| Rate for Payer: Cigna Commercial |
$3,239.59
|
| Rate for Payer: First Health Commercial |
$3,707.96
|
| Rate for Payer: Humana Commercial |
$3,317.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,200.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,880.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,434.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,927.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,122.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,395.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,693.15
|
| Rate for Payer: PHCS Commercial |
$3,747.00
|
| Rate for Payer: United Healthcare All Payer |
$3,434.75
|
|
|
LENS VIVITY CNWET4+13.0
|
Facility
|
OP
|
$3,903.12
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,170.94 |
| Max. Negotiated Rate |
$3,747.00 |
| Rate for Payer: Aetna Commercial |
$3,005.40
|
| Rate for Payer: Anthem Medicaid |
$1,342.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,044.43
|
| Rate for Payer: Cash Price |
$1,951.56
|
| Rate for Payer: Cigna Commercial |
$3,239.59
|
| Rate for Payer: First Health Commercial |
$3,707.96
|
| Rate for Payer: Humana Commercial |
$3,317.65
|
| Rate for Payer: Humana KY Medicaid |
$1,342.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1,355.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,200.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,880.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,369.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,434.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,927.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,122.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,395.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,693.15
|
| Rate for Payer: PHCS Commercial |
$3,747.00
|
| Rate for Payer: United Healthcare All Payer |
$3,434.75
|
|
|
LENS VIVITY CNWET4+14.5
|
Facility
|
IP
|
$6,704.75
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2,011.42 |
| Max. Negotiated Rate |
$6,436.56 |
| Rate for Payer: Aetna Commercial |
$5,162.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,229.70
|
| Rate for Payer: Cash Price |
$3,352.38
|
| Rate for Payer: Cigna Commercial |
$5,564.94
|
| Rate for Payer: First Health Commercial |
$6,369.51
|
| Rate for Payer: Humana Commercial |
$5,699.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,497.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,948.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,900.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,028.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,363.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,833.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,626.28
|
| Rate for Payer: PHCS Commercial |
$6,436.56
|
| Rate for Payer: United Healthcare All Payer |
$5,900.18
|
|
|
LENS VIVITY CNWET4+14.5
|
Facility
|
OP
|
$6,704.75
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2,011.42 |
| Max. Negotiated Rate |
$6,436.56 |
| Rate for Payer: Aetna Commercial |
$5,162.66
|
| Rate for Payer: Anthem Medicaid |
$2,305.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,229.70
|
| Rate for Payer: Cash Price |
$3,352.38
|
| Rate for Payer: Cigna Commercial |
$5,564.94
|
| Rate for Payer: First Health Commercial |
$6,369.51
|
| Rate for Payer: Humana Commercial |
$5,699.04
|
| Rate for Payer: Humana KY Medicaid |
$2,305.76
|
| Rate for Payer: Kentucky WC Medicaid |
$2,329.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,497.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,948.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,352.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,900.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,028.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,363.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,833.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,626.28
|
| Rate for Payer: PHCS Commercial |
$6,436.56
|
| Rate for Payer: United Healthcare All Payer |
$5,900.18
|
|
|
LENS VIVITY CNWET6+31.0
|
Facility
|
OP
|
$6,704.75
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2,011.42 |
| Max. Negotiated Rate |
$6,436.56 |
| Rate for Payer: Aetna Commercial |
$5,162.66
|
| Rate for Payer: Anthem Medicaid |
$2,305.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,229.70
|
| Rate for Payer: Cash Price |
$3,352.38
|
| Rate for Payer: Cigna Commercial |
$5,564.94
|
| Rate for Payer: First Health Commercial |
$6,369.51
|
| Rate for Payer: Humana Commercial |
$5,699.04
|
| Rate for Payer: Humana KY Medicaid |
$2,305.76
|
| Rate for Payer: Kentucky WC Medicaid |
$2,329.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,497.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,948.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,352.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,900.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,028.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,363.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,833.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,626.28
|
| Rate for Payer: PHCS Commercial |
$6,436.56
|
| Rate for Payer: United Healthcare All Payer |
$5,900.18
|
|
|
LENS VIVITY CNWET6+31.0
|
Facility
|
IP
|
$6,704.75
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$2,011.42 |
| Max. Negotiated Rate |
$6,436.56 |
| Rate for Payer: Aetna Commercial |
$5,162.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,229.70
|
| Rate for Payer: Cash Price |
$3,352.38
|
| Rate for Payer: Cigna Commercial |
$5,564.94
|
| Rate for Payer: First Health Commercial |
$6,369.51
|
| Rate for Payer: Humana Commercial |
$5,699.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,497.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,948.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,900.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,028.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,363.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,833.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,626.28
|
| Rate for Payer: PHCS Commercial |
$6,436.56
|
| Rate for Payer: United Healthcare All Payer |
$5,900.18
|
|
|
LENS VIVITY CNWETE 22.0
|
Facility
|
IP
|
$3,903.12
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,170.94 |
| Max. Negotiated Rate |
$3,747.00 |
| Rate for Payer: Aetna Commercial |
$3,005.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,044.43
|
| Rate for Payer: Cash Price |
$1,951.56
|
| Rate for Payer: Cigna Commercial |
$3,239.59
|
| Rate for Payer: First Health Commercial |
$3,707.96
|
| Rate for Payer: Humana Commercial |
$3,317.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,200.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,880.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,434.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,927.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,122.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,395.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,693.15
|
| Rate for Payer: PHCS Commercial |
$3,747.00
|
| Rate for Payer: United Healthcare All Payer |
$3,434.75
|
|
|
LENS VIVITY CNWETE 22.0
|
Facility
|
OP
|
$3,903.12
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,170.94 |
| Max. Negotiated Rate |
$3,747.00 |
| Rate for Payer: Aetna Commercial |
$3,005.40
|
| Rate for Payer: Anthem Medicaid |
$1,342.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,044.43
|
| Rate for Payer: Cash Price |
$1,951.56
|
| Rate for Payer: Cigna Commercial |
$3,239.59
|
| Rate for Payer: First Health Commercial |
$3,707.96
|
| Rate for Payer: Humana Commercial |
$3,317.65
|
| Rate for Payer: Humana KY Medicaid |
$1,342.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1,355.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,200.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,880.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,369.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,434.75
|
| Rate for Payer: Ohio Health Group HMO |
$2,927.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,122.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,395.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,693.15
|
| Rate for Payer: PHCS Commercial |
$3,747.00
|
| Rate for Payer: United Healthcare All Payer |
$3,434.75
|
|
|
LENS VIVITY DFT 015*13.5
|
Facility
|
OP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem Medicaid |
$1,970.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Humana KY Medicaid |
$1,970.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,991.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,010.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
LENS VIVITY DFT 015*13.5
|
Facility
|
IP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
LENS VIVITY DFT 015*17.5
|
Facility
|
OP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem Medicaid |
$1,970.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Humana KY Medicaid |
$1,970.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,991.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,010.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
LENS VIVITY DFT 015*17.5
|
Facility
|
IP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
LENS VIVITY DFT 015*19.0
|
Facility
|
IP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
LENS VIVITY DFT 015*19.0
|
Facility
|
OP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem Medicaid |
$1,970.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Humana KY Medicaid |
$1,970.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,991.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,010.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
LENS VIVITY DFT 015*19.5
|
Facility
|
IP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
LENS VIVITY DFT 015*19.5
|
Facility
|
OP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem Medicaid |
$1,970.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Humana KY Medicaid |
$1,970.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,991.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,010.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
LENS VIVITY DFT015 20.0
|
Facility
|
IP
|
$5,731.25
|
|
|
Service Code
|
HCPCS V2788
|
| Hospital Charge Code |
27000231
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
