Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC BRACE LSO SC CTRL RIGID AP PNL CSTM

Facility

$2,719.28

Service Code	HCPCS L0637
Hospital Charge Code	27400046
Hospital Revenue Code	274
Min. Negotiated Rate	$1,087.71
Max. Negotiated Rate	$2,447.35
Rate for Payer: Aetna Commercial	$2,311.39
Rate for Payer: Aetna Medicare	$1,359.64
Rate for Payer: Aetna New Business (MI Preferred)	$1,767.53
Rate for Payer: BCBS Complete	$1,087.71
Rate for Payer: Cash Price	$2,175.42
Rate for Payer: Cofinity Commercial	$1,903.50
Rate for Payer: Cofinity Commercial	$2,338.58
Rate for Payer: Cofinity Medicare Advantage	$1,903.50
Rate for Payer: Encore Health Key Benefits Commercial	$2,175.42
Rate for Payer: Healthscope Commercial	$2,447.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,311.39
Rate for Payer: PHP Commercial	$2,311.39
Rate for Payer: Priority Health Cigna Priority Health	$1,767.53
Rate for Payer: Priority Health SBD	$1,713.15

HC BRACE PAVLIK HARNESS CUSTOM

Facility

$371.81

Service Code	HCPCS L1620
Hospital Charge Code	27000010
Hospital Revenue Code	274
Min. Negotiated Rate	$234.24
Max. Negotiated Rate	$334.63
Rate for Payer: Aetna Commercial	$316.04
Rate for Payer: Aetna New Business (MI Preferred)	$241.68
Rate for Payer: Cash Price	$297.45
Rate for Payer: Cofinity Commercial	$260.27
Rate for Payer: Cofinity Commercial	$319.76
Rate for Payer: Cofinity Medicare Advantage	$260.27
Rate for Payer: Encore Health Key Benefits Commercial	$297.45
Rate for Payer: Healthscope Commercial	$334.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$316.04
Rate for Payer: PHP Commercial	$316.04
Rate for Payer: Priority Health Cigna Priority Health	$241.68
Rate for Payer: Priority Health SBD	$234.24

HC BRACE PAVLIK HARNESS CUSTOM

Facility

$371.81

Service Code	HCPCS L1620
Hospital Charge Code	27000010
Hospital Revenue Code	274
Min. Negotiated Rate	$148.72
Max. Negotiated Rate	$334.63
Rate for Payer: Aetna Commercial	$316.04
Rate for Payer: Aetna Medicare	$185.91
Rate for Payer: Aetna New Business (MI Preferred)	$241.68
Rate for Payer: BCBS Complete	$148.72
Rate for Payer: Cash Price	$297.45
Rate for Payer: Cofinity Commercial	$260.27
Rate for Payer: Cofinity Commercial	$319.76
Rate for Payer: Cofinity Medicare Advantage	$260.27
Rate for Payer: Encore Health Key Benefits Commercial	$297.45
Rate for Payer: Healthscope Commercial	$334.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$316.04
Rate for Payer: PHP Commercial	$316.04
Rate for Payer: Priority Health Cigna Priority Health	$241.68
Rate for Payer: Priority Health SBD	$234.24

HC BRACE PRAFO CUSTOM

Facility

$397.09

Service Code	HCPCS L4396
Hospital Charge Code	27000012
Hospital Revenue Code	274
Min. Negotiated Rate	$158.84
Max. Negotiated Rate	$357.38
Rate for Payer: Aetna Commercial	$337.53
Rate for Payer: Aetna Medicare	$198.54
Rate for Payer: Aetna New Business (MI Preferred)	$258.11
Rate for Payer: BCBS Complete	$158.84
Rate for Payer: Cash Price	$317.67
Rate for Payer: Cofinity Commercial	$277.96
Rate for Payer: Cofinity Commercial	$341.50
Rate for Payer: Cofinity Medicare Advantage	$277.96
Rate for Payer: Encore Health Key Benefits Commercial	$317.67
Rate for Payer: Healthscope Commercial	$357.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$337.53
Rate for Payer: PHP Commercial	$337.53
Rate for Payer: Priority Health Cigna Priority Health	$258.11
Rate for Payer: Priority Health SBD	$250.17

HC BRACE PRAFO CUSTOM

Facility

$397.09

Service Code	HCPCS L4396
Hospital Charge Code	27000012
Hospital Revenue Code	274
Min. Negotiated Rate	$250.17
Max. Negotiated Rate	$357.38
Rate for Payer: Aetna Commercial	$337.53
Rate for Payer: Aetna New Business (MI Preferred)	$258.11
Rate for Payer: Cash Price	$317.67
Rate for Payer: Cofinity Commercial	$277.96
Rate for Payer: Cofinity Commercial	$341.50
Rate for Payer: Cofinity Medicare Advantage	$277.96
Rate for Payer: Encore Health Key Benefits Commercial	$317.67
Rate for Payer: Healthscope Commercial	$357.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$337.53
Rate for Payer: PHP Commercial	$337.53
Rate for Payer: Priority Health Cigna Priority Health	$258.11
Rate for Payer: Priority Health SBD	$250.17

HC BRACE PRAFO OTS

Facility

$436.79

Service Code	HCPCS L4397
Hospital Charge Code	27000456
Hospital Revenue Code	274
Min. Negotiated Rate	$174.72
Max. Negotiated Rate	$393.11
Rate for Payer: Aetna Commercial	$371.27
Rate for Payer: Aetna Medicare	$218.40
Rate for Payer: Aetna New Business (MI Preferred)	$283.91
Rate for Payer: BCBS Complete	$174.72
Rate for Payer: Cash Price	$349.43
Rate for Payer: Cofinity Commercial	$305.75
Rate for Payer: Cofinity Commercial	$375.64
Rate for Payer: Cofinity Medicare Advantage	$305.75
Rate for Payer: Encore Health Key Benefits Commercial	$349.43
Rate for Payer: Healthscope Commercial	$393.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$371.27
Rate for Payer: PHP Commercial	$371.27
Rate for Payer: Priority Health Cigna Priority Health	$283.91
Rate for Payer: Priority Health SBD	$275.18

HC BRACE PRAFO OTS

Facility

$436.79

Service Code	HCPCS L4397
Hospital Charge Code	27000456
Hospital Revenue Code	274
Min. Negotiated Rate	$275.18
Max. Negotiated Rate	$393.11
Rate for Payer: Aetna Commercial	$371.27
Rate for Payer: Aetna New Business (MI Preferred)	$283.91
Rate for Payer: Cash Price	$349.43
Rate for Payer: Cofinity Commercial	$305.75
Rate for Payer: Cofinity Commercial	$375.64
Rate for Payer: Cofinity Medicare Advantage	$305.75
Rate for Payer: Encore Health Key Benefits Commercial	$349.43
Rate for Payer: Healthscope Commercial	$393.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$371.27
Rate for Payer: PHP Commercial	$371.27
Rate for Payer: Priority Health Cigna Priority Health	$283.91
Rate for Payer: Priority Health SBD	$275.18

HC BRACE RESTING NIGHTSPLINT CUSTOM

Facility

$538.45

Service Code	HCPCS L3807
Hospital Charge Code	27000200
Hospital Revenue Code	274
Min. Negotiated Rate	$339.22
Max. Negotiated Rate	$484.61
Rate for Payer: Aetna Commercial	$457.68
Rate for Payer: Aetna New Business (MI Preferred)	$349.99
Rate for Payer: Cash Price	$430.76
Rate for Payer: Cofinity Commercial	$376.92
Rate for Payer: Cofinity Commercial	$463.07
Rate for Payer: Cofinity Medicare Advantage	$376.92
Rate for Payer: Encore Health Key Benefits Commercial	$430.76
Rate for Payer: Healthscope Commercial	$484.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$457.68
Rate for Payer: PHP Commercial	$457.68
Rate for Payer: Priority Health Cigna Priority Health	$349.99
Rate for Payer: Priority Health SBD	$339.22

HC BRACE RESTING NIGHTSPLINT CUSTOM

Facility

$538.45

Service Code	HCPCS L3807
Hospital Charge Code	27000200
Hospital Revenue Code	274
Min. Negotiated Rate	$215.38
Max. Negotiated Rate	$484.61
Rate for Payer: Aetna Commercial	$457.68
Rate for Payer: Aetna Medicare	$269.23
Rate for Payer: Aetna New Business (MI Preferred)	$349.99
Rate for Payer: BCBS Complete	$215.38
Rate for Payer: Cash Price	$430.76
Rate for Payer: Cofinity Commercial	$376.92
Rate for Payer: Cofinity Commercial	$463.07
Rate for Payer: Cofinity Medicare Advantage	$376.92
Rate for Payer: Encore Health Key Benefits Commercial	$430.76
Rate for Payer: Healthscope Commercial	$484.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$457.68
Rate for Payer: PHP Commercial	$457.68
Rate for Payer: Priority Health Cigna Priority Health	$349.99
Rate for Payer: Priority Health SBD	$339.22

HC BRACE RIGID NECK

Facility

$185.06

Service Code	HCPCS L0140
Hospital Charge Code	27400009
Hospital Revenue Code	274
Min. Negotiated Rate	$116.59
Max. Negotiated Rate	$166.55
Rate for Payer: Aetna Commercial	$157.30
Rate for Payer: Aetna New Business (MI Preferred)	$120.29
Rate for Payer: Cash Price	$148.05
Rate for Payer: Cofinity Commercial	$129.54
Rate for Payer: Cofinity Commercial	$159.15
Rate for Payer: Cofinity Medicare Advantage	$129.54
Rate for Payer: Encore Health Key Benefits Commercial	$148.05
Rate for Payer: Healthscope Commercial	$166.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$157.30
Rate for Payer: PHP Commercial	$157.30
Rate for Payer: Priority Health Cigna Priority Health	$120.29
Rate for Payer: Priority Health SBD	$116.59

HC BRACE RIGID NECK

Facility

$185.06

Service Code	HCPCS L0140
Hospital Charge Code	27400009
Hospital Revenue Code	274
Min. Negotiated Rate	$74.02
Max. Negotiated Rate	$166.55
Rate for Payer: Aetna Commercial	$157.30
Rate for Payer: Aetna Medicare	$92.53
Rate for Payer: Aetna New Business (MI Preferred)	$120.29
Rate for Payer: BCBS Complete	$74.02
Rate for Payer: Cash Price	$148.05
Rate for Payer: Cofinity Commercial	$129.54
Rate for Payer: Cofinity Commercial	$159.15
Rate for Payer: Cofinity Medicare Advantage	$129.54
Rate for Payer: Encore Health Key Benefits Commercial	$148.05
Rate for Payer: Healthscope Commercial	$166.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$157.30
Rate for Payer: PHP Commercial	$157.30
Rate for Payer: Priority Health Cigna Priority Health	$120.29
Rate for Payer: Priority Health SBD	$116.59

HC BRACE SOCKET INSERT W/O LOCK MECH

Facility

$537.89

Service Code	HCPCS L5679
Hospital Charge Code	27400035
Hospital Revenue Code	274
Min. Negotiated Rate	$215.16
Max. Negotiated Rate	$484.10
Rate for Payer: Aetna Commercial	$457.21
Rate for Payer: Aetna Medicare	$268.94
Rate for Payer: Aetna New Business (MI Preferred)	$349.63
Rate for Payer: BCBS Complete	$215.16
Rate for Payer: Cash Price	$430.31
Rate for Payer: Cofinity Commercial	$376.52
Rate for Payer: Cofinity Commercial	$462.59
Rate for Payer: Cofinity Medicare Advantage	$376.52
Rate for Payer: Encore Health Key Benefits Commercial	$430.31
Rate for Payer: Healthscope Commercial	$484.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$457.21
Rate for Payer: PHP Commercial	$457.21
Rate for Payer: Priority Health Cigna Priority Health	$349.63
Rate for Payer: Priority Health SBD	$338.87

HC BRACE SOCKET INSERT W/O LOCK MECH

Facility

$537.89

Service Code	HCPCS L5679
Hospital Charge Code	27400035
Hospital Revenue Code	274
Min. Negotiated Rate	$338.87
Max. Negotiated Rate	$484.10
Rate for Payer: Aetna Commercial	$457.21
Rate for Payer: Aetna New Business (MI Preferred)	$349.63
Rate for Payer: Cash Price	$430.31
Rate for Payer: Cofinity Commercial	$376.52
Rate for Payer: Cofinity Commercial	$462.59
Rate for Payer: Cofinity Medicare Advantage	$376.52
Rate for Payer: Encore Health Key Benefits Commercial	$430.31
Rate for Payer: Healthscope Commercial	$484.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$457.21
Rate for Payer: PHP Commercial	$457.21
Rate for Payer: Priority Health Cigna Priority Health	$349.63
Rate for Payer: Priority Health SBD	$338.87

HC BRACE SOFT COLLAR

Facility

$60.66

Service Code	HCPCS L0120
Hospital Charge Code	27400010
Hospital Revenue Code	274
Min. Negotiated Rate	$24.26
Max. Negotiated Rate	$54.59
Rate for Payer: Aetna Commercial	$51.56
Rate for Payer: Aetna Medicare	$30.33
Rate for Payer: Aetna New Business (MI Preferred)	$39.43
Rate for Payer: BCBS Complete	$24.26
Rate for Payer: Cash Price	$48.53
Rate for Payer: Cofinity Commercial	$42.46
Rate for Payer: Cofinity Commercial	$52.17
Rate for Payer: Cofinity Medicare Advantage	$42.46
Rate for Payer: Encore Health Key Benefits Commercial	$48.53
Rate for Payer: Healthscope Commercial	$54.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$51.56
Rate for Payer: PHP Commercial	$51.56
Rate for Payer: Priority Health Cigna Priority Health	$39.43
Rate for Payer: Priority Health SBD	$38.22

HC BRACE SOFT COLLAR

Facility

$60.66

Service Code	HCPCS L0120
Hospital Charge Code	27400010
Hospital Revenue Code	274
Min. Negotiated Rate	$38.22
Max. Negotiated Rate	$54.59
Rate for Payer: Aetna Commercial	$51.56
Rate for Payer: Aetna New Business (MI Preferred)	$39.43
Rate for Payer: Cash Price	$48.53
Rate for Payer: Cofinity Commercial	$42.46
Rate for Payer: Cofinity Commercial	$52.17
Rate for Payer: Cofinity Medicare Advantage	$42.46
Rate for Payer: Encore Health Key Benefits Commercial	$48.53
Rate for Payer: Healthscope Commercial	$54.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$51.56
Rate for Payer: PHP Commercial	$51.56
Rate for Payer: Priority Health Cigna Priority Health	$39.43
Rate for Payer: Priority Health SBD	$38.22

HC BRACE SOFT HELMET

Facility

$315.66

Service Code	HCPCS A8000
Hospital Charge Code	27000006
Hospital Revenue Code	274
Min. Negotiated Rate	$198.87
Max. Negotiated Rate	$284.09
Rate for Payer: Aetna Commercial	$268.31
Rate for Payer: Aetna New Business (MI Preferred)	$205.18
Rate for Payer: Cash Price	$252.53
Rate for Payer: Cofinity Commercial	$220.96
Rate for Payer: Cofinity Commercial	$271.47
Rate for Payer: Cofinity Medicare Advantage	$220.96
Rate for Payer: Encore Health Key Benefits Commercial	$252.53
Rate for Payer: Healthscope Commercial	$284.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$268.31
Rate for Payer: PHP Commercial	$268.31
Rate for Payer: Priority Health Cigna Priority Health	$205.18
Rate for Payer: Priority Health SBD	$198.87

HC BRACE SOFT HELMET

Facility

$315.66

Service Code	HCPCS A8000
Hospital Charge Code	27000006
Hospital Revenue Code	274
Min. Negotiated Rate	$126.26
Max. Negotiated Rate	$284.09
Rate for Payer: Aetna Commercial	$268.31
Rate for Payer: Aetna Medicare	$157.83
Rate for Payer: Aetna New Business (MI Preferred)	$205.18
Rate for Payer: BCBS Complete	$126.26
Rate for Payer: Cash Price	$252.53
Rate for Payer: Cofinity Commercial	$220.96
Rate for Payer: Cofinity Commercial	$271.47
Rate for Payer: Cofinity Medicare Advantage	$220.96
Rate for Payer: Encore Health Key Benefits Commercial	$252.53
Rate for Payer: Healthscope Commercial	$284.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$268.31
Rate for Payer: PHP Commercial	$268.31
Rate for Payer: Priority Health Cigna Priority Health	$205.18
Rate for Payer: Priority Health SBD	$198.87

HC BRACE STUMP SHRINKER AK

Facility

$157.10

Service Code	HCPCS L8460
Hospital Charge Code	27000015
Hospital Revenue Code	274
Min. Negotiated Rate	$62.84
Max. Negotiated Rate	$141.39
Rate for Payer: Aetna Commercial	$133.53
Rate for Payer: Aetna Medicare	$78.55
Rate for Payer: Aetna New Business (MI Preferred)	$102.11
Rate for Payer: BCBS Complete	$62.84
Rate for Payer: Cash Price	$125.68
Rate for Payer: Cofinity Commercial	$109.97
Rate for Payer: Cofinity Commercial	$135.11
Rate for Payer: Cofinity Medicare Advantage	$109.97
Rate for Payer: Encore Health Key Benefits Commercial	$125.68
Rate for Payer: Healthscope Commercial	$141.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$133.53
Rate for Payer: PHP Commercial	$133.53
Rate for Payer: Priority Health Cigna Priority Health	$102.11
Rate for Payer: Priority Health SBD	$98.97

HC BRACE STUMP SHRINKER AK

Facility

$157.10

Service Code	HCPCS L8460
Hospital Charge Code	27000015
Hospital Revenue Code	274
Min. Negotiated Rate	$98.97
Max. Negotiated Rate	$141.39
Rate for Payer: Aetna Commercial	$133.53
Rate for Payer: Aetna New Business (MI Preferred)	$102.11
Rate for Payer: Cash Price	$125.68
Rate for Payer: Cofinity Commercial	$109.97
Rate for Payer: Cofinity Commercial	$135.11
Rate for Payer: Cofinity Medicare Advantage	$109.97
Rate for Payer: Encore Health Key Benefits Commercial	$125.68
Rate for Payer: Healthscope Commercial	$141.39
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$133.53
Rate for Payer: PHP Commercial	$133.53
Rate for Payer: Priority Health Cigna Priority Health	$102.11
Rate for Payer: Priority Health SBD	$98.97

HC BRACE STUMP SHRINKER BK

Facility

$110.53

Service Code	HCPCS L8440
Hospital Charge Code	27000016
Hospital Revenue Code	274
Min. Negotiated Rate	$44.21
Max. Negotiated Rate	$99.48
Rate for Payer: Aetna Commercial	$93.95
Rate for Payer: Aetna Medicare	$55.27
Rate for Payer: Aetna New Business (MI Preferred)	$71.84
Rate for Payer: BCBS Complete	$44.21
Rate for Payer: Cash Price	$88.42
Rate for Payer: Cofinity Commercial	$77.37
Rate for Payer: Cofinity Commercial	$95.06
Rate for Payer: Cofinity Medicare Advantage	$77.37
Rate for Payer: Encore Health Key Benefits Commercial	$88.42
Rate for Payer: Healthscope Commercial	$99.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$93.95
Rate for Payer: PHP Commercial	$93.95
Rate for Payer: Priority Health Cigna Priority Health	$71.84
Rate for Payer: Priority Health SBD	$69.63

HC BRACE STUMP SHRINKER BK

Facility

$110.53

Service Code	HCPCS L8440
Hospital Charge Code	27000016
Hospital Revenue Code	274
Min. Negotiated Rate	$69.63
Max. Negotiated Rate	$99.48
Rate for Payer: Aetna Commercial	$93.95
Rate for Payer: Aetna New Business (MI Preferred)	$71.84
Rate for Payer: Cash Price	$88.42
Rate for Payer: Cofinity Commercial	$77.37
Rate for Payer: Cofinity Commercial	$95.06
Rate for Payer: Cofinity Medicare Advantage	$77.37
Rate for Payer: Encore Health Key Benefits Commercial	$88.42
Rate for Payer: Healthscope Commercial	$99.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$93.95
Rate for Payer: PHP Commercial	$93.95
Rate for Payer: Priority Health Cigna Priority Health	$71.84
Rate for Payer: Priority Health SBD	$69.63

HC BRACE THUMB SPICA SPLINT

Facility

$98.42

Service Code	HCPCS L3908
Hospital Charge Code	27400017
Hospital Revenue Code	274
Min. Negotiated Rate	$39.37
Max. Negotiated Rate	$88.58
Rate for Payer: Aetna Commercial	$83.66
Rate for Payer: Aetna Medicare	$49.21
Rate for Payer: Aetna New Business (MI Preferred)	$63.97
Rate for Payer: BCBS Complete	$39.37
Rate for Payer: Cash Price	$78.74
Rate for Payer: Cofinity Commercial	$68.89
Rate for Payer: Cofinity Commercial	$84.64
Rate for Payer: Cofinity Medicare Advantage	$68.89
Rate for Payer: Encore Health Key Benefits Commercial	$78.74
Rate for Payer: Healthscope Commercial	$88.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$83.66
Rate for Payer: PHP Commercial	$83.66
Rate for Payer: Priority Health Cigna Priority Health	$63.97
Rate for Payer: Priority Health SBD	$62.00

HC BRACE THUMB SPICA SPLINT

Facility

$98.42

Service Code	HCPCS L3908
Hospital Charge Code	27400017
Hospital Revenue Code	274
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$88.58
Rate for Payer: Aetna Commercial	$83.66
Rate for Payer: Aetna New Business (MI Preferred)	$63.97
Rate for Payer: Cash Price	$78.74
Rate for Payer: Cofinity Commercial	$68.89
Rate for Payer: Cofinity Commercial	$84.64
Rate for Payer: Cofinity Medicare Advantage	$68.89
Rate for Payer: Encore Health Key Benefits Commercial	$78.74
Rate for Payer: Healthscope Commercial	$88.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$83.66
Rate for Payer: PHP Commercial	$83.66
Rate for Payer: Priority Health Cigna Priority Health	$63.97
Rate for Payer: Priority Health SBD	$62.00

HC BRACE TLSO

Facility

$3,264.00

Service Code	HCPCS L0486
Hospital Charge Code	27400007
Hospital Revenue Code	274
Min. Negotiated Rate	$2,056.32
Max. Negotiated Rate	$2,937.60
Rate for Payer: Aetna Commercial	$2,774.40
Rate for Payer: Aetna New Business (MI Preferred)	$2,121.60
Rate for Payer: Cash Price	$2,611.20
Rate for Payer: Cofinity Commercial	$2,284.80
Rate for Payer: Cofinity Commercial	$2,807.04
Rate for Payer: Cofinity Medicare Advantage	$2,284.80
Rate for Payer: Encore Health Key Benefits Commercial	$2,611.20
Rate for Payer: Healthscope Commercial	$2,937.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,774.40
Rate for Payer: PHP Commercial	$2,774.40
Rate for Payer: Priority Health Cigna Priority Health	$2,121.60
Rate for Payer: Priority Health SBD	$2,056.32

HC BRACE TLSO

Facility

$3,264.00

Service Code	HCPCS L0486
Hospital Charge Code	27400007
Hospital Revenue Code	274
Min. Negotiated Rate	$1,305.60
Max. Negotiated Rate	$2,937.60
Rate for Payer: Aetna Commercial	$2,774.40
Rate for Payer: Aetna Medicare	$1,632.00
Rate for Payer: Aetna New Business (MI Preferred)	$2,121.60
Rate for Payer: BCBS Complete	$1,305.60
Rate for Payer: Cash Price	$2,611.20
Rate for Payer: Cofinity Commercial	$2,284.80
Rate for Payer: Cofinity Commercial	$2,807.04
Rate for Payer: Cofinity Medicare Advantage	$2,284.80
Rate for Payer: Encore Health Key Benefits Commercial	$2,611.20
Rate for Payer: Healthscope Commercial	$2,937.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,774.40
Rate for Payer: PHP Commercial	$2,774.40
Rate for Payer: Priority Health Cigna Priority Health	$2,121.60
Rate for Payer: Priority Health SBD	$2,056.32

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