Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

CLOSED REDUCT TEMPOROMANDIB

Facility

$1,065.00

Service Code	HCPCS 21480
Hospital Charge Code	76100389
Hospital Revenue Code	761
Min. Negotiated Rate	$221.64
Max. Negotiated Rate	$1,022.40
Rate for Payer: Aetna Commercial	$820.05
Rate for Payer: Anthem Medicaid	$366.25
Rate for Payer: Anthem Medicare Advantage/PPO	$221.64
Rate for Payer: Anthem POS/PPO/Traditional	$830.70
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$310.30
Rate for Payer: CareSource Just4Me Medicare	$299.21
Rate for Payer: Cash Price	$532.50
Rate for Payer: Cash Price	$532.50
Rate for Payer: Cigna Commercial	$883.95
Rate for Payer: First Health Commercial	$1,011.75
Rate for Payer: Humana Commercial	$905.25
Rate for Payer: Humana KY Medicaid	$366.25
Rate for Payer: Humana Medicare Advantage	$221.64
Rate for Payer: Kentucky WC Medicaid	$369.98
Rate for Payer: Medical Mutual Of Ohio HMO	$873.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$785.97
Rate for Payer: Molina Healthcare Benefit Exchange	$265.97
Rate for Payer: Molina Healthcare Medicaid	$373.60
Rate for Payer: Ohio Health Choice Commercial	$937.20
Rate for Payer: Ohio Health Group HMO	$798.75
Rate for Payer: Ohio Health Group PPO Differential	$852.00
Rate for Payer: Ohio Health Group PPO No Differential	$926.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$734.85
Rate for Payer: PHCS Commercial	$1,022.40
Rate for Payer: United Healthcare All Payer	$937.20

CLOSED REDUCT TEMPOROMANDIB

Facility

$1,065.00

Service Code	HCPCS 21480
Hospital Charge Code	76100389
Hospital Revenue Code	761
Min. Negotiated Rate	$319.50
Max. Negotiated Rate	$1,022.40
Rate for Payer: Aetna Commercial	$820.05
Rate for Payer: Anthem POS/PPO/Traditional	$830.70
Rate for Payer: Cash Price	$532.50
Rate for Payer: Cigna Commercial	$883.95
Rate for Payer: First Health Commercial	$1,011.75
Rate for Payer: Humana Commercial	$905.25
Rate for Payer: Medical Mutual Of Ohio HMO	$873.30
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$785.97
Rate for Payer: Molina Healthcare Benefit Exchange	$319.50
Rate for Payer: Ohio Health Choice Commercial	$937.20
Rate for Payer: Ohio Health Group HMO	$798.75
Rate for Payer: Ohio Health Group PPO Differential	$852.00
Rate for Payer: Ohio Health Group PPO No Differential	$926.55
Rate for Payer: Ohio Health Group PPO SOMC Employees	$734.85
Rate for Payer: PHCS Commercial	$1,022.40
Rate for Payer: United Healthcare All Payer	$937.20

CLOSED REDUCT TEMPOROMANDIB

Professional

Both

$1,065.00

Service Code	HCPCS 21480
Hospital Charge Code	76100389
Hospital Revenue Code	761
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$639.00
Rate for Payer: Aetna Commercial	$49.11
Rate for Payer: Ambetter Exchange	$30.26
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$20.50
Rate for Payer: Anthem Medicaid	$41.01
Rate for Payer: Buckeye Individual/Medicaid	$30.26
Rate for Payer: Buckeye Medicare Advantage	$30.26
Rate for Payer: CareSource Just4Me Medicare	$36.31
Rate for Payer: Cash Price	$532.50
Rate for Payer: Cash Price	$532.50
Rate for Payer: Cigna Commercial	$146.52
Rate for Payer: Healthspan PPO	$111.88
Rate for Payer: Humana Medicaid	$41.01
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$40.86
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$30.26
Rate for Payer: Molina Healthcare Benefit Exchange	$30.26
Rate for Payer: Molina Healthcare CHIP/Medicaid	$41.83
Rate for Payer: Molina Healthcare Passport	$41.01
Rate for Payer: Multiplan PHCS	$639.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$39.34
Rate for Payer: UHCCP Medicaid	$21.52
Rate for Payer: Wellcare CHIP/Medicaid	$41.42
Rate for Payer: Wellcare Medicare Advantage	$30.26

CLOSED REDUCT TEMPOROMANDIB

Facility

$750.00

Service Code	HCPCS 21480
Hospital Charge Code	45000103
Hospital Revenue Code	450
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$720.00
Rate for Payer: Aetna Commercial	$577.50
Rate for Payer: Anthem POS/PPO/Traditional	$585.00
Rate for Payer: Cash Price	$375.00
Rate for Payer: Cigna Commercial	$622.50
Rate for Payer: First Health Commercial	$712.50
Rate for Payer: Humana Commercial	$637.50
Rate for Payer: Medical Mutual Of Ohio HMO	$615.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$553.50
Rate for Payer: Molina Healthcare Benefit Exchange	$225.00
Rate for Payer: Ohio Health Choice Commercial	$660.00
Rate for Payer: Ohio Health Group HMO	$562.50
Rate for Payer: Ohio Health Group PPO Differential	$600.00
Rate for Payer: Ohio Health Group PPO No Differential	$652.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$517.50
Rate for Payer: PHCS Commercial	$720.00
Rate for Payer: United Healthcare All Payer	$660.00

CLOSED REDUCT TEMPOROMANDIB(P

Professional

Both

$315.00

Service Code	HCPCS 21480
Hospital Charge Code	761P0389
Hospital Revenue Code	761
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna Commercial	$49.11
Rate for Payer: Ambetter Exchange	$30.26
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$20.50
Rate for Payer: Anthem Medicaid	$41.01
Rate for Payer: Buckeye Individual/Medicaid	$30.26
Rate for Payer: Buckeye Medicare Advantage	$30.26
Rate for Payer: CareSource Just4Me Medicare	$36.31
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$146.52
Rate for Payer: Healthspan PPO	$111.88
Rate for Payer: Humana Medicaid	$41.01
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$40.86
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$30.26
Rate for Payer: Molina Healthcare Benefit Exchange	$30.26
Rate for Payer: Molina Healthcare CHIP/Medicaid	$41.83
Rate for Payer: Molina Healthcare Passport	$41.01
Rate for Payer: Multiplan PHCS	$189.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$39.34
Rate for Payer: UHCCP Medicaid	$21.52
Rate for Payer: Wellcare CHIP/Medicaid	$41.42
Rate for Payer: Wellcare Medicare Advantage	$30.26

CLOSED REDUCT TEMPOROMANDIB(T

Facility

$750.00

Service Code	HCPCS 21480
Hospital Charge Code	761T0389
Hospital Revenue Code	761
Min. Negotiated Rate	$221.64
Max. Negotiated Rate	$720.00
Rate for Payer: Aetna Commercial	$577.50
Rate for Payer: Anthem Medicaid	$257.93
Rate for Payer: Anthem Medicare Advantage/PPO	$221.64
Rate for Payer: Anthem POS/PPO/Traditional	$585.00
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$310.30
Rate for Payer: CareSource Just4Me Medicare	$299.21
Rate for Payer: Cash Price	$375.00
Rate for Payer: Cash Price	$375.00
Rate for Payer: Cigna Commercial	$622.50
Rate for Payer: First Health Commercial	$712.50
Rate for Payer: Humana Commercial	$637.50
Rate for Payer: Humana KY Medicaid	$257.93
Rate for Payer: Humana Medicare Advantage	$221.64
Rate for Payer: Kentucky WC Medicaid	$260.55
Rate for Payer: Medical Mutual Of Ohio HMO	$615.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$553.50
Rate for Payer: Molina Healthcare Benefit Exchange	$265.97
Rate for Payer: Molina Healthcare Medicaid	$263.10
Rate for Payer: Ohio Health Choice Commercial	$660.00
Rate for Payer: Ohio Health Group HMO	$562.50
Rate for Payer: Ohio Health Group PPO Differential	$600.00
Rate for Payer: Ohio Health Group PPO No Differential	$652.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$517.50
Rate for Payer: PHCS Commercial	$720.00
Rate for Payer: United Healthcare All Payer	$660.00

CLOSED REDUCT TEMPOROMANDIB(T

Facility

$750.00

Service Code	HCPCS 21480
Hospital Charge Code	761T0389
Hospital Revenue Code	761
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$720.00
Rate for Payer: Aetna Commercial	$577.50
Rate for Payer: Anthem POS/PPO/Traditional	$585.00
Rate for Payer: Cash Price	$375.00
Rate for Payer: Cigna Commercial	$622.50
Rate for Payer: First Health Commercial	$712.50
Rate for Payer: Humana Commercial	$637.50
Rate for Payer: Medical Mutual Of Ohio HMO	$615.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$553.50
Rate for Payer: Molina Healthcare Benefit Exchange	$225.00
Rate for Payer: Ohio Health Choice Commercial	$660.00
Rate for Payer: Ohio Health Group HMO	$562.50
Rate for Payer: Ohio Health Group PPO Differential	$600.00
Rate for Payer: Ohio Health Group PPO No Differential	$652.50
Rate for Payer: Ohio Health Group PPO SOMC Employees	$517.50
Rate for Payer: PHCS Commercial	$720.00
Rate for Payer: United Healthcare All Payer	$660.00

CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION

Facility

$2,070.25

Service Code	CPT 26645
Hospital Revenue Code	360
Min. Negotiated Rate	$1,478.75
Max. Negotiated Rate	$2,070.25
Rate for Payer: Anthem Medicare Advantage/PPO	$1,478.75
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,070.25
Rate for Payer: CareSource Just4Me Medicare	$1,996.31
Rate for Payer: Humana Medicare Advantage	$1,478.75
Rate for Payer: Molina Healthcare Benefit Exchange	$1,774.50

CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER)

Facility

$2,070.25

Service Code	CPT 26432
Hospital Revenue Code	360
Min. Negotiated Rate	$1,478.75
Max. Negotiated Rate	$2,070.25
Rate for Payer: Anthem Medicare Advantage/PPO	$1,478.75
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,070.25
Rate for Payer: CareSource Just4Me Medicare	$1,996.31
Rate for Payer: Humana Medicare Advantage	$1,478.75
Rate for Payer: Molina Healthcare Benefit Exchange	$1,774.50

CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION

Facility

$2,070.25

Service Code	CPT 25605
Hospital Revenue Code	360
Min. Negotiated Rate	$1,478.75
Max. Negotiated Rate	$2,070.25
Rate for Payer: Anthem Medicare Advantage/PPO	$1,478.75
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,070.25
Rate for Payer: CareSource Just4Me Medicare	$1,996.31
Rate for Payer: Humana Medicare Advantage	$1,478.75
Rate for Payer: Molina Healthcare Benefit Exchange	$1,774.50

CLOSED TREATMENT OF NASAL BONE FRACTURE WITH MANIPULATION; WITH STABILIZATION

Facility

$4,195.14

Service Code	CPT 21320
Hospital Revenue Code	360
Min. Negotiated Rate	$2,996.53
Max. Negotiated Rate	$4,195.14
Rate for Payer: Anthem Medicare Advantage/PPO	$2,996.53
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,195.14
Rate for Payer: CareSource Just4Me Medicare	$4,045.32
Rate for Payer: Humana Medicare Advantage	$2,996.53
Rate for Payer: Molina Healthcare Benefit Exchange	$3,595.84

CLOSED TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR WITHOUT STABILIZATION

Facility

$4,195.14

Service Code	CPT 21337
Hospital Revenue Code	360
Min. Negotiated Rate	$2,996.53
Max. Negotiated Rate	$4,195.14
Rate for Payer: Anthem Medicare Advantage/PPO	$2,996.53
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,195.14
Rate for Payer: CareSource Just4Me Medicare	$4,045.32
Rate for Payer: Humana Medicare Advantage	$2,996.53
Rate for Payer: Molina Healthcare Benefit Exchange	$3,595.84

CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING REGIONAL OR GENERAL ANESTHESIA

Facility

$2,070.25

Service Code	CPT 27266
Hospital Revenue Code	360
Min. Negotiated Rate	$1,478.75
Max. Negotiated Rate	$2,070.25
Rate for Payer: Anthem Medicare Advantage/PPO	$1,478.75
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,070.25
Rate for Payer: CareSource Just4Me Medicare	$1,996.31
Rate for Payer: Humana Medicare Advantage	$1,478.75
Rate for Payer: Molina Healthcare Benefit Exchange	$1,774.50

CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION

Facility

$2,070.25

Service Code	CPT 25565
Hospital Revenue Code	360
Min. Negotiated Rate	$1,478.75
Max. Negotiated Rate	$2,070.25
Rate for Payer: Anthem Medicare Advantage/PPO	$1,478.75
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,070.25
Rate for Payer: CareSource Just4Me Medicare	$1,996.31
Rate for Payer: Humana Medicare Advantage	$1,478.75
Rate for Payer: Molina Healthcare Benefit Exchange	$1,774.50

CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; REQUIRING ANESTHESIA

Facility

$2,070.25

Service Code	CPT 23655
Hospital Revenue Code	360
Min. Negotiated Rate	$1,478.75
Max. Negotiated Rate	$2,070.25
Rate for Payer: Anthem Medicare Advantage/PPO	$1,478.75
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,070.25
Rate for Payer: CareSource Just4Me Medicare	$1,996.31
Rate for Payer: Humana Medicare Advantage	$1,478.75
Rate for Payer: Molina Healthcare Benefit Exchange	$1,774.50

CLOSED TREATMENT OF ULNAR SHAFT FRACTURE; WITH MANIPULATION

Facility

$310.30

Service Code	CPT 25535
Hospital Revenue Code	360
Min. Negotiated Rate	$221.64
Max. Negotiated Rate	$310.30
Rate for Payer: Anthem Medicare Advantage/PPO	$221.64
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$310.30
Rate for Payer: CareSource Just4Me Medicare	$299.21
Rate for Payer: Humana Medicare Advantage	$221.64
Rate for Payer: Molina Healthcare Benefit Exchange	$265.97

CLOSED TRMT ULNAR FX PROX

Professional

Both

$1,562.00

Service Code	HCPCS 24670
Hospital Charge Code	76100561
Hospital Revenue Code	761
Min. Negotiated Rate	$128.99
Max. Negotiated Rate	$937.20
Rate for Payer: Aetna Commercial	$347.87
Rate for Payer: Ambetter Exchange	$260.31
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$140.02
Rate for Payer: Anthem Medicaid	$128.99
Rate for Payer: Buckeye Individual/Medicaid	$260.31
Rate for Payer: Buckeye Medicare Advantage	$260.31
Rate for Payer: CareSource Just4Me Medicare	$312.37
Rate for Payer: Cash Price	$781.00
Rate for Payer: Cash Price	$781.00
Rate for Payer: Cigna Commercial	$433.03
Rate for Payer: Healthspan PPO	$348.06
Rate for Payer: Humana Medicaid	$128.99
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$308.41
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$260.31
Rate for Payer: Molina Healthcare Benefit Exchange	$260.31
Rate for Payer: Molina Healthcare CHIP/Medicaid	$131.57
Rate for Payer: Molina Healthcare Passport	$128.99
Rate for Payer: Multiplan PHCS	$937.20
Rate for Payer: Ohio Health Choice Preferred Health Choice	$338.40
Rate for Payer: UHCCP Medicaid	$147.02
Rate for Payer: Wellcare CHIP/Medicaid	$130.28
Rate for Payer: Wellcare Medicare Advantage	$260.31

CLOSED TRMT ULNAR FX PROX

Facility

$1,562.00

Service Code	HCPCS 24670
Hospital Charge Code	76100561
Hospital Revenue Code	761
Min. Negotiated Rate	$221.64
Max. Negotiated Rate	$1,499.52
Rate for Payer: Aetna Commercial	$1,202.74
Rate for Payer: Anthem Medicaid	$537.17
Rate for Payer: Anthem Medicare Advantage/PPO	$221.64
Rate for Payer: Anthem POS/PPO/Traditional	$1,218.36
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$310.30
Rate for Payer: CareSource Just4Me Medicare	$299.21
Rate for Payer: Cash Price	$781.00
Rate for Payer: Cash Price	$781.00
Rate for Payer: Cigna Commercial	$1,296.46
Rate for Payer: First Health Commercial	$1,483.90
Rate for Payer: Humana Commercial	$1,327.70
Rate for Payer: Humana KY Medicaid	$537.17
Rate for Payer: Humana Medicare Advantage	$221.64
Rate for Payer: Kentucky WC Medicaid	$542.64
Rate for Payer: Medical Mutual Of Ohio HMO	$1,280.84
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,152.76
Rate for Payer: Molina Healthcare Benefit Exchange	$265.97
Rate for Payer: Molina Healthcare Medicaid	$547.95
Rate for Payer: Ohio Health Choice Commercial	$1,374.56
Rate for Payer: Ohio Health Group HMO	$1,171.50
Rate for Payer: Ohio Health Group PPO Differential	$1,249.60
Rate for Payer: Ohio Health Group PPO No Differential	$1,358.94
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,077.78
Rate for Payer: PHCS Commercial	$1,499.52
Rate for Payer: United Healthcare All Payer	$1,374.56

CLOSED TRMT ULNAR FX PROX

Facility

$1,562.00

Service Code	HCPCS 24670
Hospital Charge Code	76100561
Hospital Revenue Code	761
Min. Negotiated Rate	$468.60
Max. Negotiated Rate	$1,499.52
Rate for Payer: Aetna Commercial	$1,202.74
Rate for Payer: Anthem POS/PPO/Traditional	$1,218.36
Rate for Payer: Cash Price	$781.00
Rate for Payer: Cigna Commercial	$1,296.46
Rate for Payer: First Health Commercial	$1,483.90
Rate for Payer: Humana Commercial	$1,327.70
Rate for Payer: Medical Mutual Of Ohio HMO	$1,280.84
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,152.76
Rate for Payer: Molina Healthcare Benefit Exchange	$468.60
Rate for Payer: Ohio Health Choice Commercial	$1,374.56
Rate for Payer: Ohio Health Group HMO	$1,171.50
Rate for Payer: Ohio Health Group PPO Differential	$1,249.60
Rate for Payer: Ohio Health Group PPO No Differential	$1,358.94
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,077.78
Rate for Payer: PHCS Commercial	$1,499.52
Rate for Payer: United Healthcare All Payer	$1,374.56

CLOSED TRMT ULNAR FX PROX(P

Professional

Both

$603.00

Service Code	HCPCS 24670
Hospital Charge Code	761P0561
Hospital Revenue Code	761
Min. Negotiated Rate	$128.99
Max. Negotiated Rate	$433.03
Rate for Payer: Aetna Commercial	$347.87
Rate for Payer: Ambetter Exchange	$260.31
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$140.02
Rate for Payer: Anthem Medicaid	$128.99
Rate for Payer: Buckeye Individual/Medicaid	$260.31
Rate for Payer: Buckeye Medicare Advantage	$260.31
Rate for Payer: CareSource Just4Me Medicare	$312.37
Rate for Payer: Cash Price	$301.50
Rate for Payer: Cash Price	$301.50
Rate for Payer: Cigna Commercial	$433.03
Rate for Payer: Healthspan PPO	$348.06
Rate for Payer: Humana Medicaid	$128.99
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$308.41
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$260.31
Rate for Payer: Molina Healthcare Benefit Exchange	$260.31
Rate for Payer: Molina Healthcare CHIP/Medicaid	$131.57
Rate for Payer: Molina Healthcare Passport	$128.99
Rate for Payer: Multiplan PHCS	$361.80
Rate for Payer: Ohio Health Choice Preferred Health Choice	$338.40
Rate for Payer: UHCCP Medicaid	$147.02
Rate for Payer: Wellcare CHIP/Medicaid	$130.28
Rate for Payer: Wellcare Medicare Advantage	$260.31

CLOSED TRMT ULNAR FX PROX(T

Facility

$959.00

Service Code	HCPCS 24670
Hospital Charge Code	761T0561
Hospital Revenue Code	761
Min. Negotiated Rate	$287.70
Max. Negotiated Rate	$920.64
Rate for Payer: Aetna Commercial	$738.43
Rate for Payer: Anthem POS/PPO/Traditional	$748.02
Rate for Payer: Cash Price	$479.50
Rate for Payer: Cigna Commercial	$795.97
Rate for Payer: First Health Commercial	$911.05
Rate for Payer: Humana Commercial	$815.15
Rate for Payer: Medical Mutual Of Ohio HMO	$786.38
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$707.74
Rate for Payer: Molina Healthcare Benefit Exchange	$287.70
Rate for Payer: Ohio Health Choice Commercial	$843.92
Rate for Payer: Ohio Health Group HMO	$719.25
Rate for Payer: Ohio Health Group PPO Differential	$767.20
Rate for Payer: Ohio Health Group PPO No Differential	$834.33
Rate for Payer: Ohio Health Group PPO SOMC Employees	$661.71
Rate for Payer: PHCS Commercial	$920.64
Rate for Payer: United Healthcare All Payer	$843.92

CLOSED TRMT ULNAR FX PROX(T

Facility

$959.00

Service Code	HCPCS 24670
Hospital Charge Code	761T0561
Hospital Revenue Code	761
Min. Negotiated Rate	$221.64
Max. Negotiated Rate	$920.64
Rate for Payer: Aetna Commercial	$738.43
Rate for Payer: Anthem Medicaid	$329.80
Rate for Payer: Anthem Medicare Advantage/PPO	$221.64
Rate for Payer: Anthem POS/PPO/Traditional	$748.02
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$310.30
Rate for Payer: CareSource Just4Me Medicare	$299.21
Rate for Payer: Cash Price	$479.50
Rate for Payer: Cash Price	$479.50
Rate for Payer: Cigna Commercial	$795.97
Rate for Payer: First Health Commercial	$911.05
Rate for Payer: Humana Commercial	$815.15
Rate for Payer: Humana KY Medicaid	$329.80
Rate for Payer: Humana Medicare Advantage	$221.64
Rate for Payer: Kentucky WC Medicaid	$333.16
Rate for Payer: Medical Mutual Of Ohio HMO	$786.38
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$707.74
Rate for Payer: Molina Healthcare Benefit Exchange	$265.97
Rate for Payer: Molina Healthcare Medicaid	$336.42
Rate for Payer: Ohio Health Choice Commercial	$843.92
Rate for Payer: Ohio Health Group HMO	$719.25
Rate for Payer: Ohio Health Group PPO Differential	$767.20
Rate for Payer: Ohio Health Group PPO No Differential	$834.33
Rate for Payer: Ohio Health Group PPO SOMC Employees	$661.71
Rate for Payer: PHCS Commercial	$920.64
Rate for Payer: United Healthcare All Payer	$843.92

CLOSED TX FEMORAL SHAFT FX

Facility

$1,170.00

Service Code	HCPCS 27500
Hospital Charge Code	76100856
Hospital Revenue Code	761
Min. Negotiated Rate	$351.00
Max. Negotiated Rate	$1,123.20
Rate for Payer: Aetna Commercial	$900.90
Rate for Payer: Anthem POS/PPO/Traditional	$912.60
Rate for Payer: Cash Price	$585.00
Rate for Payer: Cigna Commercial	$971.10
Rate for Payer: First Health Commercial	$1,111.50
Rate for Payer: Humana Commercial	$994.50
Rate for Payer: Medical Mutual Of Ohio HMO	$959.40
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$863.46
Rate for Payer: Molina Healthcare Benefit Exchange	$351.00
Rate for Payer: Ohio Health Choice Commercial	$1,029.60
Rate for Payer: Ohio Health Group HMO	$877.50
Rate for Payer: Ohio Health Group PPO Differential	$936.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,017.90
Rate for Payer: Ohio Health Group PPO SOMC Employees	$807.30
Rate for Payer: PHCS Commercial	$1,123.20
Rate for Payer: United Healthcare All Payer	$1,029.60

CLOSED TX FEMORAL SHAFT FX

Facility

$1,170.00

Service Code	HCPCS 27500
Hospital Charge Code	76100856
Hospital Revenue Code	761
Min. Negotiated Rate	$221.64
Max. Negotiated Rate	$1,123.20
Rate for Payer: Aetna Commercial	$900.90
Rate for Payer: Anthem Medicaid	$402.36
Rate for Payer: Anthem Medicare Advantage/PPO	$221.64
Rate for Payer: Anthem POS/PPO/Traditional	$912.60
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$310.30
Rate for Payer: CareSource Just4Me Medicare	$299.21
Rate for Payer: Cash Price	$585.00
Rate for Payer: Cash Price	$585.00
Rate for Payer: Cigna Commercial	$971.10
Rate for Payer: First Health Commercial	$1,111.50
Rate for Payer: Humana Commercial	$994.50
Rate for Payer: Humana KY Medicaid	$402.36
Rate for Payer: Humana Medicare Advantage	$221.64
Rate for Payer: Kentucky WC Medicaid	$406.46
Rate for Payer: Medical Mutual Of Ohio HMO	$959.40
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$863.46
Rate for Payer: Molina Healthcare Benefit Exchange	$265.97
Rate for Payer: Molina Healthcare Medicaid	$410.44
Rate for Payer: Ohio Health Choice Commercial	$1,029.60
Rate for Payer: Ohio Health Group HMO	$877.50
Rate for Payer: Ohio Health Group PPO Differential	$936.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,017.90
Rate for Payer: Ohio Health Group PPO SOMC Employees	$807.30
Rate for Payer: PHCS Commercial	$1,123.20
Rate for Payer: United Healthcare All Payer	$1,029.60

CLOSED TX FEMORAL SHAFT FX

Professional

Both

$1,170.00

Service Code	HCPCS 27500
Hospital Charge Code	76100856
Hospital Revenue Code	761
Min. Negotiated Rate	$320.26
Max. Negotiated Rate	$809.33
Rate for Payer: Aetna Commercial	$687.46
Rate for Payer: Ambetter Exchange	$460.45
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$325.86
Rate for Payer: Anthem Medicaid	$320.26
Rate for Payer: Buckeye Individual/Medicaid	$460.45
Rate for Payer: Buckeye Medicare Advantage	$460.45
Rate for Payer: CareSource Just4Me Medicare	$552.54
Rate for Payer: Cash Price	$585.00
Rate for Payer: Cash Price	$585.00
Rate for Payer: Cigna Commercial	$809.33
Rate for Payer: Healthspan PPO	$664.39
Rate for Payer: Humana Medicaid	$320.26
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$586.62
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$460.45
Rate for Payer: Molina Healthcare Benefit Exchange	$460.45
Rate for Payer: Molina Healthcare CHIP/Medicaid	$326.67
Rate for Payer: Molina Healthcare Passport	$320.26
Rate for Payer: Multiplan PHCS	$702.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$598.59
Rate for Payer: UHCCP Medicaid	$342.15
Rate for Payer: Wellcare CHIP/Medicaid	$323.46
Rate for Payer: Wellcare Medicare Advantage	$460.45

Know your out-of-pocket cost for care.

All Charges