Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

CAST SUP LNG LEG CYLINDER PL

Professional

Both

$60.00

Service Code	HCPCS Q4033
Hospital Charge Code	27000161
Hospital Revenue Code	272
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$32.02
Rate for Payer: Buckeye Medicare Advantage	$60.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$28.93
Rate for Payer: Multiplan PHCS	$36.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$42.00
Rate for Payer: UHCCP Medicaid	$21.00

CAST SUP LNGLEG CYLNDR PED F

Professional

Both

$60.00

Service Code	HCPCS Q4036
Hospital Charge Code	27000164
Hospital Revenue Code	272
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$52.83
Rate for Payer: Buckeye Medicare Advantage	$60.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Cash Price	$30.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$35.99
Rate for Payer: Multiplan PHCS	$36.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$42.00
Rate for Payer: UHCCP Medicaid	$21.00

CAST SUP LNGLEG CYLNDR PED P

Professional

Both

$35.00

Service Code	HCPCS Q4035
Hospital Charge Code	27000163
Hospital Revenue Code	272
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$32.02
Rate for Payer: Buckeye Medicare Advantage	$35.00
Rate for Payer: Cash Price	$17.50
Rate for Payer: Cash Price	$17.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$14.48
Rate for Payer: Multiplan PHCS	$21.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$24.50
Rate for Payer: UHCCP Medicaid	$12.25

CAST SUP LNG LEG PED FBRGLS

Professional

Both

$70.00

Service Code	HCPCS Q4032
Hospital Charge Code	27000160
Hospital Revenue Code	272
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$52.83
Rate for Payer: Buckeye Medicare Advantage	$70.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$40.83
Rate for Payer: Multiplan PHCS	$42.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$49.00
Rate for Payer: UHCCP Medicaid	$24.50

CAST SUP LNG LEG PED PLASTER

Professional

Both

$40.00

Service Code	HCPCS Q4031
Hospital Charge Code	27000159
Hospital Revenue Code	272
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$32.02
Rate for Payer: Buckeye Medicare Advantage	$40.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$15.51
Rate for Payer: Multiplan PHCS	$24.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$28.00
Rate for Payer: UHCCP Medicaid	$14.00

CAST SUP LNG LEG SPLNT FBRGL

Professional

Both

$90.00

Service Code	HCPCS Q4042
Hospital Charge Code	27000170
Hospital Revenue Code	272
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$52.83
Rate for Payer: Buckeye Medicare Advantage	$90.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$36.64
Rate for Payer: Multiplan PHCS	$54.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$63.00
Rate for Payer: UHCCP Medicaid	$31.50

CAST SUP LNG LEG SPLNT PED F

Professional

Both

$50.00

Service Code	HCPCS Q4044
Hospital Charge Code	27000172
Hospital Revenue Code	272
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$52.83
Rate for Payer: Aetna Commercial	$52.83
Rate for Payer: Buckeye Medicare Advantage	$50.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$18.32
Rate for Payer: Multiplan PHCS	$30.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$35.00
Rate for Payer: UHCCP Medicaid	$17.50

CAST SUP LNG LEG SPLNT PED P

Professional

Both

$35.00

Service Code	HCPCS Q4043
Hospital Charge Code	27000171
Hospital Revenue Code	272
Min. Negotiated Rate	$10.73
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$32.02
Rate for Payer: Buckeye Medicare Advantage	$35.00
Rate for Payer: Cash Price	$17.50
Rate for Payer: Cash Price	$17.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$10.73
Rate for Payer: Multiplan PHCS	$21.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$24.50
Rate for Payer: UHCCP Medicaid	$12.25

CAST SUP LNG LEG SPLNT PLSTR

Professional

Both

$50.00

Service Code	HCPCS Q4041
Hospital Charge Code	27000169
Hospital Revenue Code	272
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$32.02
Rate for Payer: Buckeye Medicare Advantage	$50.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$21.46
Rate for Payer: Multiplan PHCS	$30.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$35.00
Rate for Payer: UHCCP Medicaid	$17.50

CAST SUP LONG ARM ADULT FBRG

Professional

Both

$100.00

Service Code	HCPCS Q4006
Hospital Charge Code	27000136
Hospital Revenue Code	272
Min. Negotiated Rate	$31.35
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$52.83
Rate for Payer: Buckeye Medicare Advantage	$100.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Cash Price	$50.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$31.35
Rate for Payer: Multiplan PHCS	$60.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$70.00
Rate for Payer: UHCCP Medicaid	$35.00

CAST SUP LONG ARM ADULT PLST

Professional

Both

$50.00

Service Code	HCPCS Q4005
Hospital Charge Code	27000135
Hospital Revenue Code	272
Min. Negotiated Rate	$13.91
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$32.02
Rate for Payer: Buckeye Medicare Advantage	$50.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Cash Price	$25.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$13.91
Rate for Payer: Multiplan PHCS	$30.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$35.00
Rate for Payer: UHCCP Medicaid	$17.50

CAST SUP LONG ARM PED FBRGLS

Professional

Both

$55.00

Service Code	HCPCS Q4008
Hospital Charge Code	27000138
Hospital Revenue Code	272
Min. Negotiated Rate	$15.68
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.83
Rate for Payer: Buckeye Medicare Advantage	$55.00
Rate for Payer: Cash Price	$27.50
Rate for Payer: Cash Price	$27.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$15.68
Rate for Payer: Multiplan PHCS	$33.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$38.50
Rate for Payer: UHCCP Medicaid	$19.25

CAST SUP LONG ARM PED PLSTER

Professional

Both

$35.00

Service Code	HCPCS Q4007
Hospital Charge Code	27000137
Hospital Revenue Code	272
Min. Negotiated Rate	$6.96
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$32.02
Rate for Payer: Buckeye Medicare Advantage	$35.00
Rate for Payer: Cash Price	$17.50
Rate for Payer: Cash Price	$17.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$6.96
Rate for Payer: Multiplan PHCS	$21.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$24.50
Rate for Payer: UHCCP Medicaid	$12.25

CAST SUP LONG LEG FIBERGLASS

Professional

Both

$135.00

Service Code	HCPCS Q4030
Hospital Charge Code	27000158
Hospital Revenue Code	272
Min. Negotiated Rate	$47.25
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$52.83
Rate for Payer: Buckeye Medicare Advantage	$135.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cash Price	$67.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$81.65
Rate for Payer: Multiplan PHCS	$81.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$94.50
Rate for Payer: UHCCP Medicaid	$47.25

CAST SUP LONG LEG PLASTER

Professional

Both

$70.00

Service Code	HCPCS Q4029
Hospital Charge Code	27000157
Hospital Revenue Code	272
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$32.02
Rate for Payer: Buckeye Medicare Advantage	$70.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Cash Price	$35.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$31.01
Rate for Payer: Multiplan PHCS	$42.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$49.00
Rate for Payer: UHCCP Medicaid	$24.50

CAST SUPPLIES UNLISTED

Professional

Both

$35.00

Service Code	HCPCS Q4050
Hospital Charge Code	27000177
Hospital Revenue Code	272
Min. Negotiated Rate	$11.34
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$32.02
Rate for Payer: Buckeye Medicare Advantage	$35.00
Rate for Payer: Cash Price	$17.50
Rate for Payer: Cash Price	$17.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$11.34
Rate for Payer: Multiplan PHCS	$21.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$24.50
Rate for Payer: UHCCP Medicaid	$12.25

CAST SUP SHOULDER CAST FBRGL

Professional

Both

$170.00

Service Code	HCPCS Q4004
Hospital Charge Code	27000134
Hospital Revenue Code	272
Min. Negotiated Rate	$52.83
Max. Negotiated Rate	$170.00
Rate for Payer: Aetna Commercial	$52.83
Rate for Payer: Buckeye Medicare Advantage	$170.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Cash Price	$85.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$130.65
Rate for Payer: Multiplan PHCS	$102.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$119.00
Rate for Payer: UHCCP Medicaid	$59.50

CAST SUP SHOULDER CAST PLSTR

Professional

Both

$85.00

Service Code	HCPCS Q4003
Hospital Charge Code	27000133
Hospital Revenue Code	272
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$85.00
Rate for Payer: Aetna Commercial	$32.02
Rate for Payer: Buckeye Medicare Advantage	$85.00
Rate for Payer: Cash Price	$42.50
Rate for Payer: Cash Price	$42.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$37.74
Rate for Payer: Multiplan PHCS	$51.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$59.50
Rate for Payer: UHCCP Medicaid	$29.75

CAST SUP SHRT LEG FIBERGLASS

Professional

Both

$150.00

Service Code	HCPCS Q4038
Hospital Charge Code	27000166
Hospital Revenue Code	272
Min. Negotiated Rate	$44.22
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$48.02
Rate for Payer: Buckeye Medicare Advantage	$150.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$44.22
Rate for Payer: Multiplan PHCS	$90.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$105.00
Rate for Payer: UHCCP Medicaid	$52.50

CAST SUP SHRT LEG PED FBRGLS

Professional

Both

$80.00

Service Code	HCPCS Q4040
Hospital Charge Code	27000168
Hospital Revenue Code	272
Min. Negotiated Rate	$22.12
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$48.02
Rate for Payer: Buckeye Medicare Advantage	$80.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$22.12
Rate for Payer: Multiplan PHCS	$48.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$56.00
Rate for Payer: UHCCP Medicaid	$28.00

CAST SUP SHRT LEG PED PLSTER

Professional

Both

$45.00

Service Code	HCPCS Q4039
Hospital Charge Code	27000167
Hospital Revenue Code	272
Min. Negotiated Rate	$8.83
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$28.81
Rate for Payer: Buckeye Medicare Advantage	$45.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$8.83
Rate for Payer: Multiplan PHCS	$27.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$31.50
Rate for Payer: UHCCP Medicaid	$15.75

CAST SUP SHRT LEG PLASTER

Professional

Both

$75.00

Service Code	HCPCS Q4037
Hospital Charge Code	27000165
Hospital Revenue Code	272
Min. Negotiated Rate	$17.66
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$28.81
Rate for Payer: Buckeye Medicare Advantage	$75.00
Rate for Payer: Cash Price	$37.50
Rate for Payer: Cash Price	$37.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$17.66
Rate for Payer: Multiplan PHCS	$45.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$52.50
Rate for Payer: UHCCP Medicaid	$26.25

CAST SUP SHT ARM ADULT FBRGL

Professional

Both

$80.00

Service Code	HCPCS Q4010
Hospital Charge Code	27000140
Hospital Revenue Code	272
Min. Negotiated Rate	$20.90
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$48.02
Rate for Payer: Buckeye Medicare Advantage	$80.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$20.90
Rate for Payer: Multiplan PHCS	$48.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$56.00
Rate for Payer: UHCCP Medicaid	$28.00

CAST SUP SHT ARM ADULT PLSTR

Professional

Both

$40.00

Service Code	HCPCS Q4009
Hospital Charge Code	27000139
Hospital Revenue Code	272
Min. Negotiated Rate	$9.27
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$28.81
Rate for Payer: Buckeye Medicare Advantage	$40.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$9.27
Rate for Payer: Multiplan PHCS	$24.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$28.00
Rate for Payer: UHCCP Medicaid	$14.00

CAST SUP SHT ARM PED FBRGLAS

Professional

Both

$45.00

Service Code	HCPCS Q4012
Hospital Charge Code	27000142
Hospital Revenue Code	272
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$48.02
Rate for Payer: Aetna Commercial	$48.02
Rate for Payer: Buckeye Medicare Advantage	$45.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$10.45
Rate for Payer: Multiplan PHCS	$27.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$31.50
Rate for Payer: UHCCP Medicaid	$15.75

Know your out-of-pocket cost for care.

All Charges