Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

OPEN PROX HUM FX PROSTH RPLCMT

Professional

Both

$3,800.00

Service Code	HCPCS 23616
Hospital Charge Code	76100481
Hospital Revenue Code	761
Min. Negotiated Rate	$1,268.03
Max. Negotiated Rate	$3,800.00
Rate for Payer: Aetna Commercial	$1,940.67
Rate for Payer: Anthem Medicaid	$1,268.03
Rate for Payer: Buckeye Medicare Advantage	$3,800.00
Rate for Payer: Cash Price	$1,900.00
Rate for Payer: Cash Price	$1,900.00
Rate for Payer: Cigna Commercial	$2,380.63
Rate for Payer: Healthspan PPO	$1,757.84
Rate for Payer: Humana Medicaid	$1,268.03
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,568.63
Rate for Payer: Molina Healthcare CHIP/Medicaid	$1,293.39
Rate for Payer: Molina Healthcare Passport	$1,268.03
Rate for Payer: Multiplan PHCS	$2,280.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,660.00
Rate for Payer: UHCCP Medicaid	$1,330.00
Rate for Payer: Wellcare CHIP/Medicaid	$1,280.71

OPEN PROX HUM FX PROSTH RPLCMT

Professional

Both

$3,800.00

Service Code	HCPCS 23616
Hospital Charge Code	761P0481
Hospital Revenue Code	761
Min. Negotiated Rate	$1,268.03
Max. Negotiated Rate	$3,800.00
Rate for Payer: Aetna Commercial	$1,940.67
Rate for Payer: Anthem Medicaid	$1,268.03
Rate for Payer: Buckeye Medicare Advantage	$3,800.00
Rate for Payer: Cash Price	$1,900.00
Rate for Payer: Cash Price	$1,900.00
Rate for Payer: Cigna Commercial	$2,380.63
Rate for Payer: Healthspan PPO	$1,757.84
Rate for Payer: Humana Medicaid	$1,268.03
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,568.63
Rate for Payer: Molina Healthcare CHIP/Medicaid	$1,293.39
Rate for Payer: Molina Healthcare Passport	$1,268.03
Rate for Payer: Multiplan PHCS	$2,280.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$2,660.00
Rate for Payer: UHCCP Medicaid	$1,330.00
Rate for Payer: Wellcare CHIP/Medicaid	$1,280.71

OPEN REPAIR RT HIP ABD TENDON

Facility

$1,850.00

Service Code	HCPCS 27299
Hospital Charge Code	76102903
Hospital Revenue Code	761
Min. Negotiated Rate	$240.50
Max. Negotiated Rate	$1,776.00
Rate for Payer: Aetna Commercial	$1,424.50
Rate for Payer: Anthem POS/PPO/Traditional	$1,443.00
Rate for Payer: Cash Price	$925.00
Rate for Payer: Cigna Commercial	$1,535.50
Rate for Payer: First Health Commercial	$1,757.50
Rate for Payer: Humana Commercial	$1,572.50
Rate for Payer: Medical Mutual Of Ohio HMO	$1,517.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,365.30
Rate for Payer: Molina Healthcare Benefit Exchange	$555.00
Rate for Payer: Ohio Health Choice Commercial	$1,628.00
Rate for Payer: Ohio Health Group HMO	$1,387.50
Rate for Payer: Ohio Health Group PPO Differential	$370.00
Rate for Payer: Ohio Health Group PPO No Differential	$240.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$573.50
Rate for Payer: PHCS Commercial	$1,776.00
Rate for Payer: United Healthcare All Payer	$1,628.00

OPEN REPAIR RT HIP ABD TENDON

Professional

Both

$1,850.00

Service Code	HCPCS 27299
Hospital Charge Code	76102903
Hospital Revenue Code	761
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1,850.00
Rate for Payer: Anthem Medicaid	$800.00
Rate for Payer: Buckeye Medicare Advantage	$1,850.00
Rate for Payer: Cash Price	$925.00
Rate for Payer: Cash Price	$925.00
Rate for Payer: Healthspan PPO	$0.60
Rate for Payer: Humana Medicaid	$800.00
Rate for Payer: Molina Healthcare CHIP/Medicaid	$816.00
Rate for Payer: Molina Healthcare Passport	$800.00
Rate for Payer: Multiplan PHCS	$1,110.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,295.00
Rate for Payer: UHCCP Medicaid	$647.50
Rate for Payer: Wellcare CHIP/Medicaid	$808.00

OPEN REPAIR RT HIP ABD TENDON

Facility

$1,850.00

Service Code	HCPCS 27299
Hospital Charge Code	76102903
Hospital Revenue Code	761
Min. Negotiated Rate	$203.93
Max. Negotiated Rate	$1,776.00
Rate for Payer: Aetna Commercial	$1,424.50
Rate for Payer: Anthem Medicaid	$636.22
Rate for Payer: Anthem Medicare Advantage/PPO	$203.93
Rate for Payer: Anthem POS/PPO/Traditional	$1,443.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$285.50
Rate for Payer: CareSource Just4Me Medicare	$275.31
Rate for Payer: Cash Price	$925.00
Rate for Payer: Cash Price	$925.00
Rate for Payer: Cigna Commercial	$1,535.50
Rate for Payer: First Health Commercial	$1,757.50
Rate for Payer: Humana Commercial	$1,572.50
Rate for Payer: Humana KY Medicaid	$636.22
Rate for Payer: Humana Medicare Advantage	$203.93
Rate for Payer: Kentucky WC Medicaid	$642.69
Rate for Payer: Medical Mutual Of Ohio HMO	$1,517.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,365.30
Rate for Payer: Molina Healthcare Benefit Exchange	$244.72
Rate for Payer: Molina Healthcare Medicaid	$648.98
Rate for Payer: Ohio Health Choice Commercial	$1,628.00
Rate for Payer: Ohio Health Group HMO	$1,387.50
Rate for Payer: Ohio Health Group PPO Differential	$370.00
Rate for Payer: Ohio Health Group PPO No Differential	$240.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$573.50
Rate for Payer: PHCS Commercial	$1,776.00
Rate for Payer: United Healthcare All Payer	$1,628.00

OPEN TREAT DEPRESS ARCH FRAC(P

Professional

Both

$1,000.00

Service Code	HCPCS 21356
Hospital Charge Code	761P0386
Hospital Revenue Code	761
Min. Negotiated Rate	$207.29
Max. Negotiated Rate	$1,000.00
Rate for Payer: Aetna Commercial	$530.48
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$207.29
Rate for Payer: Anthem Medicaid	$268.52
Rate for Payer: Buckeye Medicare Advantage	$1,000.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Cigna Commercial	$586.67
Rate for Payer: Healthspan PPO	$614.79
Rate for Payer: Humana Medicaid	$268.52
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$466.32
Rate for Payer: Molina Healthcare CHIP/Medicaid	$273.89
Rate for Payer: Molina Healthcare Passport	$268.52
Rate for Payer: Multiplan PHCS	$600.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$700.00
Rate for Payer: UHCCP Medicaid	$217.65
Rate for Payer: Wellcare CHIP/Medicaid	$271.21

OPEN TREAT DEPRESS ARCH FRAC(T

Facility

$7,909.05

Service Code	HCPCS 21356
Hospital Charge Code	761T0386
Hospital Revenue Code	761
Min. Negotiated Rate	$1,028.18
Max. Negotiated Rate	$7,592.69
Rate for Payer: Aetna Commercial	$6,089.97
Rate for Payer: Anthem POS/PPO/Traditional	$6,169.06
Rate for Payer: Cash Price	$3,954.52
Rate for Payer: Cigna Commercial	$6,564.51
Rate for Payer: First Health Commercial	$7,513.60
Rate for Payer: Humana Commercial	$6,722.69
Rate for Payer: Medical Mutual Of Ohio HMO	$6,485.42
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,836.88
Rate for Payer: Molina Healthcare Benefit Exchange	$2,372.72
Rate for Payer: Ohio Health Choice Commercial	$6,959.96
Rate for Payer: Ohio Health Group HMO	$5,931.79
Rate for Payer: Ohio Health Group PPO Differential	$1,581.81
Rate for Payer: Ohio Health Group PPO No Differential	$1,028.18
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,451.81
Rate for Payer: PHCS Commercial	$7,592.69
Rate for Payer: United Healthcare All Payer	$6,959.96

OPEN TREAT DEPRESS ARCH FRAC(T

Facility

$7,909.05

Service Code	HCPCS 21356
Hospital Charge Code	761T0386
Hospital Revenue Code	761
Min. Negotiated Rate	$1,028.18
Max. Negotiated Rate	$7,592.69
Rate for Payer: Aetna Commercial	$6,089.97
Rate for Payer: Anthem Medicaid	$2,719.92
Rate for Payer: Anthem Medicare Advantage/PPO	$5,064.14
Rate for Payer: Anthem POS/PPO/Traditional	$6,169.06
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,089.80
Rate for Payer: CareSource Just4Me Medicare	$6,836.59
Rate for Payer: Cash Price	$3,954.52
Rate for Payer: Cash Price	$3,954.52
Rate for Payer: Cigna Commercial	$6,564.51
Rate for Payer: First Health Commercial	$7,513.60
Rate for Payer: Humana Commercial	$6,722.69
Rate for Payer: Humana KY Medicaid	$2,719.92
Rate for Payer: Humana Medicare Advantage	$5,064.14
Rate for Payer: Kentucky WC Medicaid	$2,747.60
Rate for Payer: Medical Mutual Of Ohio HMO	$6,485.42
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$5,836.88
Rate for Payer: Molina Healthcare Benefit Exchange	$6,076.97
Rate for Payer: Molina Healthcare Medicaid	$2,774.49
Rate for Payer: Ohio Health Choice Commercial	$6,959.96
Rate for Payer: Ohio Health Group HMO	$5,931.79
Rate for Payer: Ohio Health Group PPO Differential	$1,581.81
Rate for Payer: Ohio Health Group PPO No Differential	$1,028.18
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,451.81
Rate for Payer: PHCS Commercial	$7,592.69
Rate for Payer: United Healthcare All Payer	$6,959.96

OPEN TREAT DEPRESS ARCH FRACT

Facility

$8,909.05

Service Code	HCPCS 21356
Hospital Charge Code	76100386
Hospital Revenue Code	761
Min. Negotiated Rate	$1,158.18
Max. Negotiated Rate	$8,552.69
Rate for Payer: Aetna Commercial	$6,859.97
Rate for Payer: Anthem POS/PPO/Traditional	$6,949.06
Rate for Payer: Cash Price	$4,454.52
Rate for Payer: Cigna Commercial	$7,394.51
Rate for Payer: First Health Commercial	$8,463.60
Rate for Payer: Humana Commercial	$7,572.69
Rate for Payer: Medical Mutual Of Ohio HMO	$7,305.42
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,574.88
Rate for Payer: Molina Healthcare Benefit Exchange	$2,672.72
Rate for Payer: Ohio Health Choice Commercial	$7,839.96
Rate for Payer: Ohio Health Group HMO	$6,681.79
Rate for Payer: Ohio Health Group PPO Differential	$1,781.81
Rate for Payer: Ohio Health Group PPO No Differential	$1,158.18
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,761.81
Rate for Payer: PHCS Commercial	$8,552.69
Rate for Payer: United Healthcare All Payer	$7,839.96

OPEN TREAT DEPRESS ARCH FRACT

Professional

Both

$8,909.05

Service Code	HCPCS 21356
Hospital Charge Code	76100386
Hospital Revenue Code	761
Min. Negotiated Rate	$207.29
Max. Negotiated Rate	$8,909.05
Rate for Payer: Aetna Commercial	$530.48
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$207.29
Rate for Payer: Anthem Medicaid	$268.52
Rate for Payer: Buckeye Medicare Advantage	$8,909.05
Rate for Payer: Cash Price	$4,454.52
Rate for Payer: Cash Price	$4,454.52
Rate for Payer: Cigna Commercial	$586.67
Rate for Payer: Healthspan PPO	$614.79
Rate for Payer: Humana Medicaid	$268.52
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$466.32
Rate for Payer: Molina Healthcare CHIP/Medicaid	$273.89
Rate for Payer: Molina Healthcare Passport	$268.52
Rate for Payer: Multiplan PHCS	$5,345.43
Rate for Payer: Ohio Health Choice Preferred Health Choice	$6,236.34
Rate for Payer: UHCCP Medicaid	$217.65
Rate for Payer: Wellcare CHIP/Medicaid	$271.21

OPEN TREAT DEPRESS ARCH FRACT

Facility

$8,909.05

Service Code	HCPCS 21356
Hospital Charge Code	76100386
Hospital Revenue Code	761
Min. Negotiated Rate	$1,158.18
Max. Negotiated Rate	$8,552.69
Rate for Payer: Aetna Commercial	$6,859.97
Rate for Payer: Anthem Medicaid	$3,063.82
Rate for Payer: Anthem Medicare Advantage/PPO	$5,064.14
Rate for Payer: Anthem POS/PPO/Traditional	$6,949.06
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$7,089.80
Rate for Payer: CareSource Just4Me Medicare	$6,836.59
Rate for Payer: Cash Price	$4,454.52
Rate for Payer: Cash Price	$4,454.52
Rate for Payer: Cigna Commercial	$7,394.51
Rate for Payer: First Health Commercial	$8,463.60
Rate for Payer: Humana Commercial	$7,572.69
Rate for Payer: Humana KY Medicaid	$3,063.82
Rate for Payer: Humana Medicare Advantage	$5,064.14
Rate for Payer: Kentucky WC Medicaid	$3,095.00
Rate for Payer: Medical Mutual Of Ohio HMO	$7,305.42
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$6,574.88
Rate for Payer: Molina Healthcare Benefit Exchange	$6,076.97
Rate for Payer: Molina Healthcare Medicaid	$3,125.29
Rate for Payer: Ohio Health Choice Commercial	$7,839.96
Rate for Payer: Ohio Health Group HMO	$6,681.79
Rate for Payer: Ohio Health Group PPO Differential	$1,781.81
Rate for Payer: Ohio Health Group PPO No Differential	$1,158.18
Rate for Payer: Ohio Health Group PPO SOMC Employees	$2,761.81
Rate for Payer: PHCS Commercial	$8,552.69
Rate for Payer: United Healthcare All Payer	$7,839.96

OPEN TREATMENT CALCANEAL FX

Professional

Both

$2,550.00

Service Code	HCPCS 28415
Hospital Charge Code	76101013
Hospital Revenue Code	761
Min. Negotiated Rate	$665.39
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,704.94
Rate for Payer: Anthem Medicaid	$665.39
Rate for Payer: Buckeye Medicare Advantage	$2,550.00
Rate for Payer: Cash Price	$1,275.00
Rate for Payer: Cash Price	$1,275.00
Rate for Payer: Cigna Commercial	$2,016.52
Rate for Payer: Healthspan PPO	$1,544.31
Rate for Payer: Humana Medicaid	$665.39
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,403.67
Rate for Payer: Molina Healthcare CHIP/Medicaid	$678.70
Rate for Payer: Molina Healthcare Passport	$665.39
Rate for Payer: Multiplan PHCS	$1,530.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,785.00
Rate for Payer: UHCCP Medicaid	$892.50
Rate for Payer: Wellcare CHIP/Medicaid	$672.04

OPEN TREATMENT CALCANEAL FX

Facility

$2,550.00

Service Code	HCPCS 28415
Hospital Charge Code	76101013
Hospital Revenue Code	761
Min. Negotiated Rate	$331.50
Max. Negotiated Rate	$2,448.00
Rate for Payer: Aetna Commercial	$1,963.50
Rate for Payer: Anthem POS/PPO/Traditional	$1,989.00
Rate for Payer: Cash Price	$1,275.00
Rate for Payer: Cigna Commercial	$2,116.50
Rate for Payer: First Health Commercial	$2,422.50
Rate for Payer: Humana Commercial	$2,167.50
Rate for Payer: Medical Mutual Of Ohio HMO	$2,091.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,881.90
Rate for Payer: Molina Healthcare Benefit Exchange	$765.00
Rate for Payer: Ohio Health Choice Commercial	$2,244.00
Rate for Payer: Ohio Health Group HMO	$1,912.50
Rate for Payer: Ohio Health Group PPO Differential	$510.00
Rate for Payer: Ohio Health Group PPO No Differential	$331.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$790.50
Rate for Payer: PHCS Commercial	$2,448.00
Rate for Payer: United Healthcare All Payer	$2,244.00

OPEN TREATMENT CALCANEAL FX

Facility

$2,550.00

Service Code	HCPCS 28415
Hospital Charge Code	76101013
Hospital Revenue Code	761
Min. Negotiated Rate	$331.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Aetna Commercial	$1,963.50
Rate for Payer: Anthem Medicaid	$876.94
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Anthem POS/PPO/Traditional	$1,989.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Cash Price	$1,275.00
Rate for Payer: Cash Price	$1,275.00
Rate for Payer: Cigna Commercial	$2,116.50
Rate for Payer: First Health Commercial	$2,422.50
Rate for Payer: Humana Commercial	$2,167.50
Rate for Payer: Humana KY Medicaid	$876.94
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Kentucky WC Medicaid	$885.87
Rate for Payer: Medical Mutual Of Ohio HMO	$2,091.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,881.90
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80
Rate for Payer: Molina Healthcare Medicaid	$894.54
Rate for Payer: Ohio Health Choice Commercial	$2,244.00
Rate for Payer: Ohio Health Group HMO	$1,912.50
Rate for Payer: Ohio Health Group PPO Differential	$510.00
Rate for Payer: Ohio Health Group PPO No Differential	$331.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$790.50
Rate for Payer: PHCS Commercial	$2,448.00
Rate for Payer: United Healthcare All Payer	$2,244.00

OPEN TREATMENT CALCANEAL FX(P

Professional

Both

$2,550.00

Service Code	HCPCS 28415
Hospital Charge Code	761P1013
Hospital Revenue Code	761
Min. Negotiated Rate	$665.39
Max. Negotiated Rate	$2,550.00
Rate for Payer: Aetna Commercial	$1,704.94
Rate for Payer: Anthem Medicaid	$665.39
Rate for Payer: Buckeye Medicare Advantage	$2,550.00
Rate for Payer: Cash Price	$1,275.00
Rate for Payer: Cash Price	$1,275.00
Rate for Payer: Cigna Commercial	$2,016.52
Rate for Payer: Healthspan PPO	$1,544.31
Rate for Payer: Humana Medicaid	$665.39
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,403.67
Rate for Payer: Molina Healthcare CHIP/Medicaid	$678.70
Rate for Payer: Molina Healthcare Passport	$665.39
Rate for Payer: Multiplan PHCS	$1,530.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,785.00
Rate for Payer: UHCCP Medicaid	$892.50
Rate for Payer: Wellcare CHIP/Medicaid	$672.04

OPEN TREATMENT METATARSAL FX

Professional

Both

$1,300.00

Service Code	HCPCS 28485
Hospital Charge Code	76101022
Hospital Revenue Code	761
Min. Negotiated Rate	$295.92
Max. Negotiated Rate	$1,300.00
Rate for Payer: Aetna Commercial	$774.27
Rate for Payer: Anthem Medicaid	$295.92
Rate for Payer: Buckeye Medicare Advantage	$1,300.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cigna Commercial	$725.58
Rate for Payer: Healthspan PPO	$701.32
Rate for Payer: Humana Medicaid	$295.92
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$653.48
Rate for Payer: Molina Healthcare CHIP/Medicaid	$301.84
Rate for Payer: Molina Healthcare Passport	$295.92
Rate for Payer: Multiplan PHCS	$780.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$910.00
Rate for Payer: UHCCP Medicaid	$455.00
Rate for Payer: Wellcare CHIP/Medicaid	$298.88

OPEN TREATMENT METATARSAL FX

Facility

$1,300.00

Service Code	HCPCS 28485
Hospital Charge Code	76101022
Hospital Revenue Code	761
Min. Negotiated Rate	$169.00
Max. Negotiated Rate	$1,248.00
Rate for Payer: Aetna Commercial	$1,001.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,014.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cigna Commercial	$1,079.00
Rate for Payer: First Health Commercial	$1,235.00
Rate for Payer: Humana Commercial	$1,105.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,066.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$959.40
Rate for Payer: Molina Healthcare Benefit Exchange	$390.00
Rate for Payer: Ohio Health Choice Commercial	$1,144.00
Rate for Payer: Ohio Health Group HMO	$975.00
Rate for Payer: Ohio Health Group PPO Differential	$260.00
Rate for Payer: Ohio Health Group PPO No Differential	$169.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$403.00
Rate for Payer: PHCS Commercial	$1,248.00
Rate for Payer: United Healthcare All Payer	$1,144.00

OPEN TREATMENT METATARSAL FX

Facility

$1,300.00

Service Code	HCPCS 28485
Hospital Charge Code	76101022
Hospital Revenue Code	761
Min. Negotiated Rate	$169.00
Max. Negotiated Rate	$8,661.10
Rate for Payer: Aetna Commercial	$1,001.00
Rate for Payer: Anthem Medicaid	$447.07
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Anthem POS/PPO/Traditional	$1,014.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cigna Commercial	$1,079.00
Rate for Payer: First Health Commercial	$1,235.00
Rate for Payer: Humana Commercial	$1,105.00
Rate for Payer: Humana KY Medicaid	$447.07
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Kentucky WC Medicaid	$451.62
Rate for Payer: Medical Mutual Of Ohio HMO	$1,066.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$959.40
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80
Rate for Payer: Molina Healthcare Medicaid	$456.04
Rate for Payer: Ohio Health Choice Commercial	$1,144.00
Rate for Payer: Ohio Health Group HMO	$975.00
Rate for Payer: Ohio Health Group PPO Differential	$260.00
Rate for Payer: Ohio Health Group PPO No Differential	$169.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$403.00
Rate for Payer: PHCS Commercial	$1,248.00
Rate for Payer: United Healthcare All Payer	$1,144.00

OPEN TREATMENT METATARSAL FX(P

Professional

Both

$1,300.00

Service Code	HCPCS 28485
Hospital Charge Code	761P1022
Hospital Revenue Code	761
Min. Negotiated Rate	$295.92
Max. Negotiated Rate	$1,300.00
Rate for Payer: Aetna Commercial	$774.27
Rate for Payer: Anthem Medicaid	$295.92
Rate for Payer: Buckeye Medicare Advantage	$1,300.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cash Price	$650.00
Rate for Payer: Cigna Commercial	$725.58
Rate for Payer: Healthspan PPO	$701.32
Rate for Payer: Humana Medicaid	$295.92
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$653.48
Rate for Payer: Molina Healthcare CHIP/Medicaid	$301.84
Rate for Payer: Molina Healthcare Passport	$295.92
Rate for Payer: Multiplan PHCS	$780.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$910.00
Rate for Payer: UHCCP Medicaid	$455.00
Rate for Payer: Wellcare CHIP/Medicaid	$298.88

OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC;

Facility

$8,661.10

Service Code	CPT 23550
Hospital Revenue Code	360
Min. Negotiated Rate	$6,186.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80

OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC; WITH FASCIAL GRAFT (INCLUDES OBTAINING GRAFT)

Facility

$8,661.10

Service Code	CPT 23552
Hospital Revenue Code	360
Min. Negotiated Rate	$6,186.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80

OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$8,661.10

Service Code	CPT 27814
Hospital Revenue Code	360
Min. Negotiated Rate	$6,186.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80

OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED;

Facility

$8,661.10

Service Code	CPT 28415
Hospital Revenue Code	360
Min. Negotiated Rate	$6,186.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80

OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$8,661.10

Service Code	CPT 23515
Hospital Revenue Code	360
Min. Negotiated Rate	$6,186.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80

OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED

Facility

$8,661.10

Service Code	CPT 27792
Hospital Revenue Code	360
Min. Negotiated Rate	$6,186.50
Max. Negotiated Rate	$8,661.10
Rate for Payer: Anthem Medicare Advantage/PPO	$6,186.50
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$8,661.10
Rate for Payer: CareSource Just4Me Medicare	$8,351.78
Rate for Payer: Humana Medicare Advantage	$6,186.50
Rate for Payer: Molina Healthcare Benefit Exchange	$7,423.80

Know your out-of-pocket cost for care.

All Charges