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1 | hospital_name | last_updated_on | version | location_name | hospital_address | license_number | AK | type_2_npi | To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula. | attester_name | |||||||||||||||||||
2 | SOUTH PENINSULA HOSPITAL INC | 8/24/2026 | 3.0.0 | SOUTH PENINSULA HOSPITAL INC | 4300 Bartlett St Homer AK 99603 | GACH010 | 1093968372 | TRUE | Anna Hermanson | |||||||||||||||||||
3 | description | code|1 | code|1|type | code|2 | code|2|type | code|3 | code|3|type | code|4 | code|4|type | setting | drug_unit_of_measurement | drug_type_of_measurement | standard_charge|gross | standard_charge|discounted_cash | payer_name | plan_name | modifiers | standard_charge|negotiated_dollar | standard_charge|negotiated_percentage | standard_charge|negotiated_algorithm | median_amount | 10th_percentile | 90th_percentile | count | standard_charge|min | standard_charge|max | standard_charge|methodology | additional_generic_notes |
4 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | ADVENTIST [503] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
5 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | AMERIBENS SOLUTIONS [508] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
6 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | ASEA [510] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
7 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | AETNA [511] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
8 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | MODA [512] | HB CC ASP MODA | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
9 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | BEECH STREET [515] | HB CC ASP BEECHSTREET | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
10 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | TRUSTMARK [524] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
11 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | FIRST CHOICE [528] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
12 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | CIGNA [533] | HB CC ASP CIGNA | 1428.14 | 80.8 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
13 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | HEALTHCARE MGNT ADMIN [540] | HB CC ASP PREMERA BLUE CROSS | 1643.78 | 93 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
14 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | UNITED HEALTHCARE [578] | HB CC ASP UHC | 1365.39 | 77.25 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
15 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | WELFARE AND PENSION [583] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
16 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | HEALTHSMART [584] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
17 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | ZENITH ADMINISTRATORS [586] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
18 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | MUTUAL OF OMAHA [587] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
19 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | UMR [596] | HB CC ASP UHC | 1365.39 | 77.25 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
20 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | NW SHEET METAL WORKERS [597] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
21 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | MEDI SHARE [1032] | HB CC ASP MULTIPLAN | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
22 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | HEALTHNET [1083] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
23 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | LIFEWISE [1108] | HB CC ASP PREMERA BLUE CROSS | 1643.78 | 93 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
24 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | LOOMIS BENEFITS WEST COMM [1109] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
25 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | MULTIPLAN [1131] | HB CC ASP MULTIPLAN | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
26 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | OPERATING ENGINEERS [1144] | HB CC ASP PREMERA BLUE CROSS | 1643.78 | 93 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
27 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | OR PROCESSORS TRUST COMM [1145] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
28 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | PACIFICSOURCE [1148] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
29 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | TUALITY HLTHCARE COMM [1197] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
30 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | UFCW WELFARE TRUST [1200] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
31 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | CYPRESS BENEFIT ADMIN [1213] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
32 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | WILLIAM EARHART CO [1236] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
33 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | NW ADMINISTRATORS [1238] | HB CC ASP BEECHSTREET | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
34 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | NW ADMINISTRATORS [1238] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
35 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | ILWU-PMA [1241] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
36 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | ALLEGIANCE [1245] | HB CC ASP CIGNA | 1428.14 | 80.8 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
37 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | A AND I BENEFIT PLAN ADMIN INC [1246] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
38 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | ALLIED BENEFIT SYSTEMS [1254] | HB CC ASP CIGNA | 1428.14 | 80.8 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
39 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | ALLIED BENEFIT SYSTEMS [1254] | HB CC ASP MULTIPLAN | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
40 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | BCBS [1263] | HB CC ASP PREMERA BLUE CROSS | 1643.78 | 93 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
41 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | BENEFIT ADMIN [1268] | HB CC ASP CIGNA | 1428.14 | 80.8 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
42 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | BRMS [1270] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
43 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | FIRST CHOICE HEALTH ADMIN [1294] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
44 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | HEALTHPARTNERS [1299] | HB CC ASP CIGNA | 1428.14 | 80.8 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
45 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | HERE HEALTH TRUST [1302] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
46 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | IU OPERATING ENG [1307] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
47 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | MEDICA [1320] | HB CC ASP UHC | 1365.39 | 77.25 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
48 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | NATIONAL RURAL ELEC [1328] | HB CC ASP NAT'L RURAL ELECTRIC COOP ASSOC | 1643.78 | 93 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
49 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | NW PLUMBING PIPEFITTERS [1331] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
50 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | OXFORD HEALTH [1334] | HB CC ASP UHC | 1365.39 | 77.25 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
51 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | PHCS [1340] | HB CC ASP MULTIPLAN | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
52 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | PREMERA [1344] | HB CC ASP PREMERA BLUE CROSS | 1643.78 | 93 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
53 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | QVI RISK SOLULTIONS [1349] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
54 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | SCREEN ACTORS GUILD [1356] | HB CC ASP PREMERA BLUE CROSS | 1643.78 | 93 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
55 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | TRUSTEED PLANS SERV [1373] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
56 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | WEBTPA [1381] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
57 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | WESTERN MUTUAL [1383] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
58 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | UNITED HEALTHCARE MEDICAID HMO [1457] | HB CC ASP UHC | 1365.39 | 77.25 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
59 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | ALASKA ELECTRICAL [1616] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
60 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | INLAND EMP ELCTRCL WRKS TR [1685] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
61 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | MULTIPLAN WC [1698] | HB CC ASP MULTIPLAN | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
62 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | FIREMANS FUND [1741] | HB CC ASP PREMERA BLUE CROSS | 1643.78 | 93 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
63 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | LINECO [1931] | HB CC ASP PREMERA BLUE CROSS | 1643.78 | 93 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
64 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | SAMARITAN HEALTH PLAN [2022] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
65 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | LAIKA LLC [2161] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
66 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | SUMMIT AMERICA [2210] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
67 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | MT RETAIL STORE EMP HLTH WELFARE TRUST [2218] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
68 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | CITY OF PASCO [2247] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
69 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | COASTAL ADMINSTRATIVE SERVICES [2269] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
70 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | HEALTHSHARE [2537] | HB CC ASP MULTIPLAN | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
71 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | MARPAI HEALTH [2563] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
72 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | HEALTH NOW OTHER GOVERNMENT [2614] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
73 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | ALASKA PUBLIC EMPLOYEES [2640] | HB CC ASP AETNA | 1417.54 | 80.2 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
74 | CON LENS TORIC | SUP-CNW0T_ | CDM | V2787 | HCPCS | 276 | RC | both | 1767.5 | 1767.5 | ALASKA NATIVE TRIBAL HEALTH [2682] | HB CC ASP FIRST CHOICE | 1679.13 | 95 | 0 | $ 1,365.39 | $ 1,679.13 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
75 | Post chmbr intraocular lens | PX-70169938ASP | CDM | V2632 | HCPCS | 276 | RC | both | 962.33 | 962.33 | ADVENTIST [503] | HB CC ASP FIRST CHOICE | 914.21 | 95 | 0 | $ 743.40 | $ 914.21 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
76 | CON LENS SY60WF CLAREON IOL | SUP-SY60WF | CDM | V2632 | HCPCS | 276 | RC | both | 612 | 612 | ADVENTIST [503] | HB CC ASP FIRST CHOICE | 581.4 | 95 | 0 | $ 472.77 | $ 581.40 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
77 | CON LENS SN60WF IQ | SUP-SN60WF | CDM | V2632 | HCPCS | 276 | RC | both | 600 | 600 | ADVENTIST [503] | HB CC ASP FIRST CHOICE | 570 | 95 | 0 | $ 463.50 | $ 570.00 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
78 | Post chmbr intraocular lens | PX-70169938ASP | CDM | V2632 | HCPCS | 276 | RC | both | 962.33 | 962.33 | AMERIBENS SOLUTIONS [508] | HB CC ASP FIRST CHOICE | 914.21 | 95 | 0 | $ 743.40 | $ 914.21 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
79 | CON LENS SY60WF CLAREON IOL | SUP-SY60WF | CDM | V2632 | HCPCS | 276 | RC | both | 612 | 612 | AMERIBENS SOLUTIONS [508] | HB CC ASP FIRST CHOICE | 581.4 | 95 | 0 | $ 472.77 | $ 581.40 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
80 | CON LENS SN60WF IQ | SUP-SN60WF | CDM | V2632 | HCPCS | 276 | RC | both | 600 | 600 | AMERIBENS SOLUTIONS [508] | HB CC ASP FIRST CHOICE | 570 | 95 | 0 | $ 463.50 | $ 570.00 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
81 | Post chmbr intraocular lens | PX-70169938ASP | CDM | V2632 | HCPCS | 276 | RC | both | 962.33 | 962.33 | ASEA [510] | HB CC ASP AETNA | 771.79 | 80.2 | 0 | $ 743.40 | $ 914.21 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
82 | CON LENS SY60WF CLAREON IOL | SUP-SY60WF | CDM | V2632 | HCPCS | 276 | RC | both | 612 | 612 | ASEA [510] | HB CC ASP AETNA | 490.82 | 80.2 | 0 | $ 472.77 | $ 581.40 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
83 | CON LENS SN60WF IQ | SUP-SN60WF | CDM | V2632 | HCPCS | 276 | RC | both | 600 | 600 | ASEA [510] | HB CC ASP AETNA | 481.2 | 80.2 | 0 | $ 463.50 | $ 570.00 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
84 | Post chmbr intraocular lens | PX-70169938ASP | CDM | V2632 | HCPCS | 276 | RC | both | 962.33 | 962.33 | AETNA [511] | HB CC ASP AETNA | 771.79 | 80.2 | 0 | $ 743.40 | $ 914.21 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
85 | CON LENS SY60WF CLAREON IOL | SUP-SY60WF | CDM | V2632 | HCPCS | 276 | RC | both | 612 | 612 | AETNA [511] | HB CC ASP AETNA | 490.82 | 80.2 | 0 | $ 472.77 | $ 581.40 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
86 | CON LENS SN60WF IQ | SUP-SN60WF | CDM | V2632 | HCPCS | 276 | RC | both | 600 | 600 | AETNA [511] | HB CC ASP AETNA | 481.2 | 80.2 | 0 | $ 463.50 | $ 570.00 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
87 | Post chmbr intraocular lens | PX-70169938ASP | CDM | V2632 | HCPCS | 276 | RC | both | 962.33 | 962.33 | MODA [512] | HB CC ASP MODA | 914.21 | 95 | 0 | $ 743.40 | $ 914.21 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
88 | CON LENS SY60WF CLAREON IOL | SUP-SY60WF | CDM | V2632 | HCPCS | 276 | RC | both | 612 | 612 | MODA [512] | HB CC ASP MODA | 581.4 | 95 | 0 | $ 472.77 | $ 581.40 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
89 | CON LENS SN60WF IQ | SUP-SN60WF | CDM | V2632 | HCPCS | 276 | RC | both | 600 | 600 | MODA [512] | HB CC ASP MODA | 570 | 95 | 0 | $ 463.50 | $ 570.00 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
90 | Post chmbr intraocular lens | PX-70169938ASP | CDM | V2632 | HCPCS | 276 | RC | both | 962.33 | 962.33 | BEECH STREET [515] | HB CC ASP BEECHSTREET | 914.21 | 95 | 0 | $ 743.40 | $ 914.21 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
91 | CON LENS SY60WF CLAREON IOL | SUP-SY60WF | CDM | V2632 | HCPCS | 276 | RC | both | 612 | 612 | BEECH STREET [515] | HB CC ASP BEECHSTREET | 581.4 | 95 | 0 | $ 472.77 | $ 581.40 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
92 | CON LENS SN60WF IQ | SUP-SN60WF | CDM | V2632 | HCPCS | 276 | RC | both | 600 | 600 | BEECH STREET [515] | HB CC ASP BEECHSTREET | 570 | 95 | 0 | $ 463.50 | $ 570.00 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
93 | Post chmbr intraocular lens | PX-70169938ASP | CDM | V2632 | HCPCS | 276 | RC | both | 962.33 | 962.33 | TRUSTMARK [524] | HB CC ASP AETNA | 771.79 | 80.2 | 0 | $ 743.40 | $ 914.21 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
94 | CON LENS SY60WF CLAREON IOL | SUP-SY60WF | CDM | V2632 | HCPCS | 276 | RC | both | 612 | 612 | TRUSTMARK [524] | HB CC ASP AETNA | 490.82 | 80.2 | 0 | $ 472.77 | $ 581.40 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
95 | CON LENS SN60WF IQ | SUP-SN60WF | CDM | V2632 | HCPCS | 276 | RC | both | 600 | 600 | TRUSTMARK [524] | HB CC ASP AETNA | 481.2 | 80.2 | 0 | $ 463.50 | $ 570.00 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
96 | Post chmbr intraocular lens | PX-70169938ASP | CDM | V2632 | HCPCS | 276 | RC | both | 962.33 | 962.33 | FIRST CHOICE [528] | HB CC ASP FIRST CHOICE | 914.21 | 95 | 0 | $ 743.40 | $ 914.21 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
97 | CON LENS SY60WF CLAREON IOL | SUP-SY60WF | CDM | V2632 | HCPCS | 276 | RC | both | 612 | 612 | FIRST CHOICE [528] | HB CC ASP FIRST CHOICE | 581.4 | 95 | 0 | $ 472.77 | $ 581.40 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
98 | CON LENS SN60WF IQ | SUP-SN60WF | CDM | V2632 | HCPCS | 276 | RC | both | 600 | 600 | FIRST CHOICE [528] | HB CC ASP FIRST CHOICE | 570 | 95 | 0 | $ 463.50 | $ 570.00 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
99 | Post chmbr intraocular lens | PX-70169938ASP | CDM | V2632 | HCPCS | 276 | RC | both | 962.33 | 962.33 | CIGNA [533] | HB CC ASP CIGNA | 777.56 | 80.8 | 0 | $ 743.40 | $ 914.21 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. | |||||||||
100 | CON LENS SY60WF CLAREON IOL | SUP-SY60WF | CDM | V2632 | HCPCS | 276 | RC | both | 612 | 612 | CIGNA [533] | HB CC ASP CIGNA | 494.5 | 80.8 | 0 | $ 472.77 | $ 581.40 | percent of total billed charges | Zero final payments for the item or service in the 15 months prior to posting the file. |