Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC BOTTLE A/B CDI 500

Facility

$201.96

Hospital Charge Code	27000684
Hospital Revenue Code	270
Min. Negotiated Rate	$80.78
Max. Negotiated Rate	$181.76
Rate for Payer: Aetna Commercial	$171.67
Rate for Payer: Aetna Medicare	$100.98
Rate for Payer: Aetna New Business (MI Preferred)	$131.27
Rate for Payer: BCBS Complete	$80.78
Rate for Payer: Cash Price	$161.57
Rate for Payer: Cofinity Commercial	$141.37
Rate for Payer: Cofinity Commercial	$173.69
Rate for Payer: Cofinity Medicare Advantage	$141.37
Rate for Payer: Encore Health Key Benefits Commercial	$161.57
Rate for Payer: Healthscope Commercial	$181.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$171.67
Rate for Payer: PHP Commercial	$171.67
Rate for Payer: Priority Health Cigna Priority Health	$131.27
Rate for Payer: Priority Health SBD	$127.23

HC BOTTLE A/B CDI 500

Facility

$201.96

Hospital Charge Code	27000684
Hospital Revenue Code	270
Min. Negotiated Rate	$127.23
Max. Negotiated Rate	$181.76
Rate for Payer: Aetna Commercial	$171.67
Rate for Payer: Aetna New Business (MI Preferred)	$131.27
Rate for Payer: Cash Price	$161.57
Rate for Payer: Cofinity Commercial	$141.37
Rate for Payer: Cofinity Commercial	$173.69
Rate for Payer: Cofinity Medicare Advantage	$141.37
Rate for Payer: Encore Health Key Benefits Commercial	$161.57
Rate for Payer: Healthscope Commercial	$181.76
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$171.67
Rate for Payer: PHP Commercial	$171.67
Rate for Payer: Priority Health Cigna Priority Health	$131.27
Rate for Payer: Priority Health SBD	$127.23

HC BOWL

Facility

$229.50

Hospital Charge Code	27000091
Hospital Revenue Code	270
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$206.55
Rate for Payer: Aetna Commercial	$195.08
Rate for Payer: Aetna Medicare	$114.75
Rate for Payer: Aetna New Business (MI Preferred)	$149.18
Rate for Payer: BCBS Complete	$91.80
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cofinity Commercial	$160.65
Rate for Payer: Cofinity Commercial	$197.37
Rate for Payer: Cofinity Medicare Advantage	$160.65
Rate for Payer: Encore Health Key Benefits Commercial	$183.60
Rate for Payer: Healthscope Commercial	$206.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$195.08
Rate for Payer: PHP Commercial	$195.08
Rate for Payer: Priority Health Cigna Priority Health	$149.18
Rate for Payer: Priority Health SBD	$144.58

HC BOWL

Facility

$229.50

Hospital Charge Code	27000091
Hospital Revenue Code	270
Min. Negotiated Rate	$144.58
Max. Negotiated Rate	$206.55
Rate for Payer: Aetna Commercial	$195.08
Rate for Payer: Aetna New Business (MI Preferred)	$149.18
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cofinity Commercial	$160.65
Rate for Payer: Cofinity Commercial	$197.37
Rate for Payer: Cofinity Medicare Advantage	$160.65
Rate for Payer: Encore Health Key Benefits Commercial	$183.60
Rate for Payer: Healthscope Commercial	$206.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$195.08
Rate for Payer: PHP Commercial	$195.08
Rate for Payer: Priority Health Cigna Priority Health	$149.18
Rate for Payer: Priority Health SBD	$144.58

HC BOWL ATS 55 ML

Facility

$253.47

Hospital Charge Code	27000283
Hospital Revenue Code	270
Min. Negotiated Rate	$159.69
Max. Negotiated Rate	$228.12
Rate for Payer: Aetna Commercial	$215.45
Rate for Payer: Aetna New Business (MI Preferred)	$164.76
Rate for Payer: Cash Price	$202.78
Rate for Payer: Cofinity Commercial	$177.43
Rate for Payer: Cofinity Commercial	$217.98
Rate for Payer: Cofinity Medicare Advantage	$177.43
Rate for Payer: Encore Health Key Benefits Commercial	$202.78
Rate for Payer: Healthscope Commercial	$228.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$215.45
Rate for Payer: PHP Commercial	$215.45
Rate for Payer: Priority Health Cigna Priority Health	$164.76
Rate for Payer: Priority Health SBD	$159.69

HC BOWL ATS 55 ML

Facility

$253.47

Hospital Charge Code	27000283
Hospital Revenue Code	270
Min. Negotiated Rate	$101.39
Max. Negotiated Rate	$228.12
Rate for Payer: Aetna Commercial	$215.45
Rate for Payer: Aetna Medicare	$126.74
Rate for Payer: Aetna New Business (MI Preferred)	$164.76
Rate for Payer: BCBS Complete	$101.39
Rate for Payer: Cash Price	$202.78
Rate for Payer: Cofinity Commercial	$177.43
Rate for Payer: Cofinity Commercial	$217.98
Rate for Payer: Cofinity Medicare Advantage	$177.43
Rate for Payer: Encore Health Key Benefits Commercial	$202.78
Rate for Payer: Healthscope Commercial	$228.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$215.45
Rate for Payer: PHP Commercial	$215.45
Rate for Payer: Priority Health Cigna Priority Health	$164.76
Rate for Payer: Priority Health SBD	$159.69

HC B. PARAPERTUSSIS BY PCR CMPT

Facility

$52.44

Service Code	CPT 87798
Hospital Charge Code	30600219
Hospital Revenue Code	306
Min. Negotiated Rate	$33.04
Max. Negotiated Rate	$47.20
Rate for Payer: Aetna Commercial	$44.57
Rate for Payer: Aetna New Business (MI Preferred)	$34.09
Rate for Payer: Cash Price	$41.95
Rate for Payer: Cofinity Commercial	$36.71
Rate for Payer: Cofinity Commercial	$45.10
Rate for Payer: Cofinity Medicare Advantage	$36.71
Rate for Payer: Encore Health Key Benefits Commercial	$41.95
Rate for Payer: Healthscope Commercial	$47.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$44.57
Rate for Payer: PHP Commercial	$44.57
Rate for Payer: Priority Health Cigna Priority Health	$34.09
Rate for Payer: Priority Health SBD	$33.04

HC B. PARAPERTUSSIS BY PCR CMPT

Facility

$52.44

Service Code	CPT 87798
Hospital Charge Code	30600219
Hospital Revenue Code	306
Min. Negotiated Rate	$18.81
Max. Negotiated Rate	$52.64
Rate for Payer: Aetna Commercial	$44.57
Rate for Payer: Aetna Medicare	$36.49
Rate for Payer: Aetna New Business (MI Preferred)	$34.09
Rate for Payer: Allen County Amish Medical Aid Commercial	$43.86
Rate for Payer: Amish Plain Church Group Commercial	$43.86
Rate for Payer: BCBS Complete	$19.75
Rate for Payer: BCBS MAPPO	$35.09
Rate for Payer: BCBS Trust/PPO	$31.07
Rate for Payer: BCN Commercial	$31.07
Rate for Payer: BCN Medicare Advantage	$35.09
Rate for Payer: Cash Price	$41.95
Rate for Payer: Cash Price	$41.95
Rate for Payer: Cofinity Commercial	$36.71
Rate for Payer: Cofinity Commercial	$45.10
Rate for Payer: Cofinity Medicare Advantage	$36.71
Rate for Payer: Encore Health Key Benefits Commercial	$41.95
Rate for Payer: Health Alliance Plan Medicare Advantage	$35.09
Rate for Payer: Healthscope Commercial	$47.20
Rate for Payer: Mclaren Medicaid	$18.81
Rate for Payer: Mclaren Medicare	$35.09
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$36.84
Rate for Payer: Meridian Medicaid	$19.75
Rate for Payer: MI Amish Medical Board Commercial	$40.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$44.57
Rate for Payer: Nomi Health Commercial	$52.64
Rate for Payer: PACE Medicare	$33.34
Rate for Payer: PACE SWMI	$35.09
Rate for Payer: PHP Commercial	$44.57
Rate for Payer: PHP Medicare Advantage	$35.09
Rate for Payer: Priority Health Choice Medicaid	$18.81
Rate for Payer: Priority Health Cigna Priority Health	$34.09
Rate for Payer: Priority Health Medicare	$35.09
Rate for Payer: Priority Health SBD	$33.04
Rate for Payer: Railroad Medicare Medicare	$35.09
Rate for Payer: UHC All Payor (Choice/PPO)	$42.11
Rate for Payer: UHC Dual Complete DSNP	$35.09
Rate for Payer: UHC Medicare Advantage	$35.09
Rate for Payer: UHCCP Medicaid	$19.76
Rate for Payer: VA VA	$35.09

HC B.PERTUSSIS BY PCR

Facility

$57.40

Service Code	CPT 87798
Hospital Charge Code	30600218
Hospital Revenue Code	306
Min. Negotiated Rate	$18.81
Max. Negotiated Rate	$52.64
Rate for Payer: Aetna Commercial	$48.79
Rate for Payer: Aetna Medicare	$36.49
Rate for Payer: Aetna New Business (MI Preferred)	$37.31
Rate for Payer: Allen County Amish Medical Aid Commercial	$43.86
Rate for Payer: Amish Plain Church Group Commercial	$43.86
Rate for Payer: BCBS Complete	$19.75
Rate for Payer: BCBS MAPPO	$35.09
Rate for Payer: BCBS Trust/PPO	$31.07
Rate for Payer: BCN Commercial	$31.07
Rate for Payer: BCN Medicare Advantage	$35.09
Rate for Payer: Cash Price	$45.92
Rate for Payer: Cash Price	$45.92
Rate for Payer: Cofinity Commercial	$40.18
Rate for Payer: Cofinity Commercial	$49.36
Rate for Payer: Cofinity Medicare Advantage	$40.18
Rate for Payer: Encore Health Key Benefits Commercial	$45.92
Rate for Payer: Health Alliance Plan Medicare Advantage	$35.09
Rate for Payer: Healthscope Commercial	$51.66
Rate for Payer: Mclaren Medicaid	$18.81
Rate for Payer: Mclaren Medicare	$35.09
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$36.84
Rate for Payer: Meridian Medicaid	$19.75
Rate for Payer: MI Amish Medical Board Commercial	$40.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$48.79
Rate for Payer: Nomi Health Commercial	$52.64
Rate for Payer: PACE Medicare	$33.34
Rate for Payer: PACE SWMI	$35.09
Rate for Payer: PHP Commercial	$48.79
Rate for Payer: PHP Medicare Advantage	$35.09
Rate for Payer: Priority Health Choice Medicaid	$18.81
Rate for Payer: Priority Health Cigna Priority Health	$37.31
Rate for Payer: Priority Health Medicare	$35.09
Rate for Payer: Priority Health SBD	$36.16
Rate for Payer: Railroad Medicare Medicare	$35.09
Rate for Payer: UHC All Payor (Choice/PPO)	$42.11
Rate for Payer: UHC Dual Complete DSNP	$35.09
Rate for Payer: UHC Medicare Advantage	$35.09
Rate for Payer: UHCCP Medicaid	$19.76
Rate for Payer: VA VA	$35.09

HC B.PERTUSSIS BY PCR

Facility

$57.40

Service Code	CPT 87798
Hospital Charge Code	30600218
Hospital Revenue Code	306
Min. Negotiated Rate	$36.16
Max. Negotiated Rate	$51.66
Rate for Payer: Aetna Commercial	$48.79
Rate for Payer: Aetna New Business (MI Preferred)	$37.31
Rate for Payer: Cash Price	$45.92
Rate for Payer: Cofinity Commercial	$40.18
Rate for Payer: Cofinity Commercial	$49.36
Rate for Payer: Cofinity Medicare Advantage	$40.18
Rate for Payer: Encore Health Key Benefits Commercial	$45.92
Rate for Payer: Healthscope Commercial	$51.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$48.79
Rate for Payer: PHP Commercial	$48.79
Rate for Payer: Priority Health Cigna Priority Health	$37.31
Rate for Payer: Priority Health SBD	$36.16

HC BRACE ADD TO LE PELVIC CONTROL HIP JOINT

Facility

$972.10

Service Code	HCPCS L2624
Hospital Charge Code	27400039
Hospital Revenue Code	274
Min. Negotiated Rate	$612.42
Max. Negotiated Rate	$874.89
Rate for Payer: Aetna Commercial	$826.28
Rate for Payer: Aetna New Business (MI Preferred)	$631.86
Rate for Payer: Cash Price	$777.68
Rate for Payer: Cofinity Commercial	$680.47
Rate for Payer: Cofinity Commercial	$836.01
Rate for Payer: Cofinity Medicare Advantage	$680.47
Rate for Payer: Encore Health Key Benefits Commercial	$777.68
Rate for Payer: Healthscope Commercial	$874.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$826.28
Rate for Payer: PHP Commercial	$826.28
Rate for Payer: Priority Health Cigna Priority Health	$631.86
Rate for Payer: Priority Health SBD	$612.42

HC BRACE ADD TO LE PELVIC CONTROL HIP JOINT

Facility

$972.10

Service Code	HCPCS L2624
Hospital Charge Code	27400039
Hospital Revenue Code	274
Min. Negotiated Rate	$376.10
Max. Negotiated Rate	$1,272.85
Rate for Payer: Aetna Commercial	$826.28
Rate for Payer: Aetna Medicare	$486.05
Rate for Payer: Aetna New Business (MI Preferred)	$631.86
Rate for Payer: BCBS Complete	$388.84
Rate for Payer: BCBS Trust/PPO	$1,272.85
Rate for Payer: BCN Commercial	$1,272.85
Rate for Payer: Cash Price	$777.68
Rate for Payer: Cash Price	$777.68
Rate for Payer: Cofinity Commercial	$680.47
Rate for Payer: Cofinity Commercial	$836.01
Rate for Payer: Cofinity Medicare Advantage	$680.47
Rate for Payer: Encore Health Key Benefits Commercial	$777.68
Rate for Payer: Healthscope Commercial	$874.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$826.28
Rate for Payer: PHP Commercial	$826.28
Rate for Payer: Priority Health Cigna Priority Health	$631.86
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$470.12
Rate for Payer: Priority Health Narrow Network	$376.10
Rate for Payer: Priority Health SBD	$612.42

HC BRACE AFO

Facility

$596.14

Service Code	HCPCS L1930
Hospital Charge Code	27000002
Hospital Revenue Code	274
Min. Negotiated Rate	$238.46
Max. Negotiated Rate	$821.82
Rate for Payer: Aetna Commercial	$506.72
Rate for Payer: Aetna Medicare	$298.07
Rate for Payer: Aetna New Business (MI Preferred)	$387.49
Rate for Payer: BCBS Complete	$238.46
Rate for Payer: BCBS Trust/PPO	$821.82
Rate for Payer: BCN Commercial	$821.82
Rate for Payer: Cash Price	$476.91
Rate for Payer: Cash Price	$476.91
Rate for Payer: Cofinity Commercial	$512.68
Rate for Payer: Cofinity Commercial	$417.30
Rate for Payer: Cofinity Medicare Advantage	$417.30
Rate for Payer: Encore Health Key Benefits Commercial	$476.91
Rate for Payer: Healthscope Commercial	$536.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$506.72
Rate for Payer: PHP Commercial	$506.72
Rate for Payer: Priority Health Cigna Priority Health	$387.49
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$303.53
Rate for Payer: Priority Health Narrow Network	$242.82
Rate for Payer: Priority Health SBD	$375.57

HC BRACE AFO

Facility

$596.14

Service Code	HCPCS L1930
Hospital Charge Code	27000002
Hospital Revenue Code	274
Min. Negotiated Rate	$375.57
Max. Negotiated Rate	$536.53
Rate for Payer: Aetna Commercial	$506.72
Rate for Payer: Aetna New Business (MI Preferred)	$387.49
Rate for Payer: Cash Price	$476.91
Rate for Payer: Cofinity Commercial	$417.30
Rate for Payer: Cofinity Commercial	$512.68
Rate for Payer: Cofinity Medicare Advantage	$417.30
Rate for Payer: Encore Health Key Benefits Commercial	$476.91
Rate for Payer: Healthscope Commercial	$536.53
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$506.72
Rate for Payer: PHP Commercial	$506.72
Rate for Payer: Priority Health Cigna Priority Health	$387.49
Rate for Payer: Priority Health SBD	$375.57

HC BRACE AFO WITH INTERFACE

Facility

$1,466.73

Service Code	HCPCS L1960
Hospital Charge Code	27000003
Hospital Revenue Code	274
Min. Negotiated Rate	$586.69
Max. Negotiated Rate	$2,022.15
Rate for Payer: Aetna Commercial	$1,246.72
Rate for Payer: Aetna Medicare	$733.36
Rate for Payer: Aetna New Business (MI Preferred)	$953.37
Rate for Payer: BCBS Complete	$586.69
Rate for Payer: BCBS Trust/PPO	$2,022.15
Rate for Payer: BCN Commercial	$2,022.15
Rate for Payer: Cash Price	$1,173.38
Rate for Payer: Cash Price	$1,173.38
Rate for Payer: Cofinity Commercial	$1,261.39
Rate for Payer: Cofinity Commercial	$1,026.71
Rate for Payer: Cofinity Medicare Advantage	$1,026.71
Rate for Payer: Encore Health Key Benefits Commercial	$1,173.38
Rate for Payer: Healthscope Commercial	$1,320.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,246.72
Rate for Payer: PHP Commercial	$1,246.72
Rate for Payer: Priority Health Cigna Priority Health	$953.37
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$746.86
Rate for Payer: Priority Health Narrow Network	$597.49
Rate for Payer: Priority Health SBD	$924.04
Rate for Payer: UHC All Payor (Choice/PPO)	$875.23

HC BRACE AFO WITH INTERFACE

Facility

$1,466.73

Service Code	HCPCS L1960
Hospital Charge Code	27000003
Hospital Revenue Code	274
Min. Negotiated Rate	$924.04
Max. Negotiated Rate	$1,320.06
Rate for Payer: Aetna Commercial	$1,246.72
Rate for Payer: Aetna New Business (MI Preferred)	$953.37
Rate for Payer: Cash Price	$1,173.38
Rate for Payer: Cofinity Commercial	$1,026.71
Rate for Payer: Cofinity Commercial	$1,261.39
Rate for Payer: Cofinity Medicare Advantage	$1,026.71
Rate for Payer: Encore Health Key Benefits Commercial	$1,173.38
Rate for Payer: Healthscope Commercial	$1,320.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,246.72
Rate for Payer: PHP Commercial	$1,246.72
Rate for Payer: Priority Health Cigna Priority Health	$953.37
Rate for Payer: Priority Health SBD	$924.04

HC BRACE AK PELVIC CONTROL BELT LIGHT

Facility

$329.81

Service Code	HCPCS L5692
Hospital Charge Code	27400038
Hospital Revenue Code	274
Min. Negotiated Rate	$127.58
Max. Negotiated Rate	$431.82
Rate for Payer: Aetna Commercial	$280.34
Rate for Payer: Aetna Medicare	$164.90
Rate for Payer: Aetna New Business (MI Preferred)	$214.38
Rate for Payer: BCBS Complete	$131.92
Rate for Payer: BCBS Trust/PPO	$431.82
Rate for Payer: BCN Commercial	$431.82
Rate for Payer: Cash Price	$263.85
Rate for Payer: Cash Price	$263.85
Rate for Payer: Cofinity Commercial	$283.64
Rate for Payer: Cofinity Commercial	$230.87
Rate for Payer: Cofinity Medicare Advantage	$230.87
Rate for Payer: Encore Health Key Benefits Commercial	$263.85
Rate for Payer: Healthscope Commercial	$296.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$280.34
Rate for Payer: PHP Commercial	$280.34
Rate for Payer: Priority Health Cigna Priority Health	$214.38
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$159.48
Rate for Payer: Priority Health Narrow Network	$127.58
Rate for Payer: Priority Health SBD	$207.78

HC BRACE AK PELVIC CONTROL BELT LIGHT

Facility

$329.81

Service Code	HCPCS L5692
Hospital Charge Code	27400038
Hospital Revenue Code	274
Min. Negotiated Rate	$207.78
Max. Negotiated Rate	$296.83
Rate for Payer: Aetna Commercial	$280.34
Rate for Payer: Aetna New Business (MI Preferred)	$214.38
Rate for Payer: Cash Price	$263.85
Rate for Payer: Cofinity Commercial	$230.87
Rate for Payer: Cofinity Commercial	$283.64
Rate for Payer: Cofinity Medicare Advantage	$230.87
Rate for Payer: Encore Health Key Benefits Commercial	$263.85
Rate for Payer: Healthscope Commercial	$296.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$280.34
Rate for Payer: PHP Commercial	$280.34
Rate for Payer: Priority Health Cigna Priority Health	$214.38
Rate for Payer: Priority Health SBD	$207.78

HC BRACE AK PROSTH SOCK SINGLE-PLY/6

Facility

$132.50

Service Code	HCPCS L8480
Hospital Charge Code	27400034
Hospital Revenue Code	274
Min. Negotiated Rate	$83.48
Max. Negotiated Rate	$119.25
Rate for Payer: Aetna Commercial	$112.62
Rate for Payer: Aetna New Business (MI Preferred)	$86.12
Rate for Payer: Cash Price	$106.00
Rate for Payer: Cofinity Commercial	$113.95
Rate for Payer: Cofinity Commercial	$92.75
Rate for Payer: Cofinity Medicare Advantage	$92.75
Rate for Payer: Encore Health Key Benefits Commercial	$106.00
Rate for Payer: Healthscope Commercial	$119.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$112.62
Rate for Payer: PHP Commercial	$112.62
Rate for Payer: Priority Health Cigna Priority Health	$86.12
Rate for Payer: Priority Health SBD	$83.48

HC BRACE AK PROSTH SOCK SINGLE-PLY/6

Facility

$132.50

Service Code	HCPCS L8480
Hospital Charge Code	27400034
Hospital Revenue Code	274
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$119.25
Rate for Payer: Aetna Commercial	$112.62
Rate for Payer: Aetna Medicare	$66.25
Rate for Payer: Aetna New Business (MI Preferred)	$86.12
Rate for Payer: BCBS Complete	$53.00
Rate for Payer: BCBS Trust/PPO	$29.92
Rate for Payer: BCN Commercial	$29.92
Rate for Payer: Cash Price	$106.00
Rate for Payer: Cash Price	$106.00
Rate for Payer: Cofinity Commercial	$113.95
Rate for Payer: Cofinity Commercial	$92.75
Rate for Payer: Cofinity Medicare Advantage	$92.75
Rate for Payer: Encore Health Key Benefits Commercial	$106.00
Rate for Payer: Healthscope Commercial	$119.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$112.62
Rate for Payer: PHP Commercial	$112.62
Rate for Payer: Priority Health Cigna Priority Health	$86.12
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11.05
Rate for Payer: Priority Health Narrow Network	$8.84
Rate for Payer: Priority Health SBD	$83.48

HC BRACE AK RIGID DRESSING NWB

Facility

$1,497.14

Service Code	HCPCS L5460
Hospital Charge Code	27400033
Hospital Revenue Code	274
Min. Negotiated Rate	$943.20
Max. Negotiated Rate	$1,347.43
Rate for Payer: Aetna Commercial	$1,272.57
Rate for Payer: Aetna New Business (MI Preferred)	$973.14
Rate for Payer: Cash Price	$1,197.71
Rate for Payer: Cofinity Commercial	$1,048.00
Rate for Payer: Cofinity Commercial	$1,287.54
Rate for Payer: Cofinity Medicare Advantage	$1,048.00
Rate for Payer: Encore Health Key Benefits Commercial	$1,197.71
Rate for Payer: Healthscope Commercial	$1,347.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,272.57
Rate for Payer: PHP Commercial	$1,272.57
Rate for Payer: Priority Health Cigna Priority Health	$973.14
Rate for Payer: Priority Health SBD	$943.20

HC BRACE AK RIGID DRESSING NWB

Facility

$1,497.14

Service Code	HCPCS L5460
Hospital Charge Code	27400033
Hospital Revenue Code	274
Min. Negotiated Rate	$598.86
Max. Negotiated Rate	$2,027.50
Rate for Payer: Aetna Commercial	$1,272.57
Rate for Payer: Aetna Medicare	$748.57
Rate for Payer: Aetna New Business (MI Preferred)	$973.14
Rate for Payer: BCBS Complete	$598.86
Rate for Payer: BCBS Trust/PPO	$2,027.50
Rate for Payer: BCN Commercial	$2,027.50
Rate for Payer: Cash Price	$1,197.71
Rate for Payer: Cash Price	$1,197.71
Rate for Payer: Cofinity Commercial	$1,287.54
Rate for Payer: Cofinity Commercial	$1,048.00
Rate for Payer: Cofinity Medicare Advantage	$1,048.00
Rate for Payer: Encore Health Key Benefits Commercial	$1,197.71
Rate for Payer: Healthscope Commercial	$1,347.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,272.57
Rate for Payer: PHP Commercial	$1,272.57
Rate for Payer: Priority Health Cigna Priority Health	$973.14
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$748.84
Rate for Payer: Priority Health Narrow Network	$599.07
Rate for Payer: Priority Health SBD	$943.20

HC BRACE ANKLE STIRRUP SPLINT

Facility

$147.44

Service Code	HCPCS L4350
Hospital Charge Code	27400001
Hospital Revenue Code	274
Min. Negotiated Rate	$92.89
Max. Negotiated Rate	$132.70
Rate for Payer: Aetna Commercial	$125.32
Rate for Payer: Aetna New Business (MI Preferred)	$95.84
Rate for Payer: Cash Price	$117.95
Rate for Payer: Cofinity Commercial	$103.21
Rate for Payer: Cofinity Commercial	$126.80
Rate for Payer: Cofinity Medicare Advantage	$103.21
Rate for Payer: Encore Health Key Benefits Commercial	$117.95
Rate for Payer: Healthscope Commercial	$132.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.32
Rate for Payer: PHP Commercial	$125.32
Rate for Payer: Priority Health Cigna Priority Health	$95.84
Rate for Payer: Priority Health SBD	$92.89

HC BRACE ANKLE STIRRUP SPLINT

Facility

$147.44

Service Code	HCPCS L4350
Hospital Charge Code	27400001
Hospital Revenue Code	274
Min. Negotiated Rate	$58.98
Max. Negotiated Rate	$315.62
Rate for Payer: Aetna Commercial	$125.32
Rate for Payer: Aetna Medicare	$73.72
Rate for Payer: Aetna New Business (MI Preferred)	$95.84
Rate for Payer: BCBS Complete	$58.98
Rate for Payer: BCBS Trust/PPO	$315.62
Rate for Payer: BCN Commercial	$315.62
Rate for Payer: Cash Price	$117.95
Rate for Payer: Cash Price	$117.95
Rate for Payer: Cofinity Commercial	$126.80
Rate for Payer: Cofinity Commercial	$103.21
Rate for Payer: Cofinity Medicare Advantage	$103.21
Rate for Payer: Encore Health Key Benefits Commercial	$117.95
Rate for Payer: Healthscope Commercial	$132.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.32
Rate for Payer: PHP Commercial	$125.32
Rate for Payer: Priority Health Cigna Priority Health	$95.84
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$116.57
Rate for Payer: Priority Health Narrow Network	$93.26
Rate for Payer: Priority Health SBD	$92.89
Rate for Payer: UHC All Payor (Choice/PPO)	$136.61

HC BRACE ASPEN COLLAR

Facility

$341.80

Service Code	HCPCS L0172
Hospital Charge Code	27000011
Hospital Revenue Code	274
Min. Negotiated Rate	$136.51
Max. Negotiated Rate	$462.01
Rate for Payer: Aetna Commercial	$290.53
Rate for Payer: Aetna Medicare	$170.90
Rate for Payer: Aetna New Business (MI Preferred)	$222.17
Rate for Payer: BCBS Complete	$136.72
Rate for Payer: BCBS Trust/PPO	$462.01
Rate for Payer: BCN Commercial	$462.01
Rate for Payer: Cash Price	$273.44
Rate for Payer: Cash Price	$273.44
Rate for Payer: Cofinity Commercial	$293.95
Rate for Payer: Cofinity Commercial	$239.26
Rate for Payer: Cofinity Medicare Advantage	$239.26
Rate for Payer: Encore Health Key Benefits Commercial	$273.44
Rate for Payer: Healthscope Commercial	$307.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$290.53
Rate for Payer: PHP Commercial	$290.53
Rate for Payer: Priority Health Cigna Priority Health	$222.17
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$170.64
Rate for Payer: Priority Health Narrow Network	$136.51
Rate for Payer: Priority Health SBD	$215.33

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