Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC OT Z SLEEVE OR GLOVE EA $150

Facility

$150.00

Service Code	HCPCS L3999
Hospital Charge Code	96000028
Hospital Revenue Code	270
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$127.50
Rate for Payer: Aetna New Business (MI Preferred)	$97.50
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cofinity Commercial	$129.00
Rate for Payer: Cofinity Commercial	$105.00
Rate for Payer: Healthscope Commercial	$135.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$127.50
Rate for Payer: PHP Commercial	$127.50
Rate for Payer: Priority Health Cigna Priority Health	$105.00
Rate for Payer: Priority Health SBD	$94.50

HC OT Z SLEEVE OR GLOVE EA $150

Facility

$150.00

Service Code	HCPCS L3999
Hospital Charge Code	96000028
Hospital Revenue Code	270
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$127.50
Rate for Payer: Aetna New Business (MI Preferred)	$97.50
Rate for Payer: BCBS Complete	$60.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cofinity Commercial	$105.00
Rate for Payer: Cofinity Commercial	$129.00
Rate for Payer: Healthscope Commercial	$135.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$127.50
Rate for Payer: PHP Commercial	$127.50
Rate for Payer: Priority Health Cigna Priority Health	$105.00
Rate for Payer: Priority Health SBD	$94.50

HC OT Z SLEEVE OR GLOVE EA $175

Facility

$175.00

Service Code	HCPCS L3999
Hospital Charge Code	96000029
Hospital Revenue Code	270
Min. Negotiated Rate	$110.25
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna Commercial	$148.75
Rate for Payer: Aetna New Business (MI Preferred)	$113.75
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cofinity Commercial	$122.50
Rate for Payer: Cofinity Commercial	$150.50
Rate for Payer: Healthscope Commercial	$157.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$148.75
Rate for Payer: PHP Commercial	$148.75
Rate for Payer: Priority Health Cigna Priority Health	$122.50
Rate for Payer: Priority Health SBD	$110.25

HC OT Z SLEEVE OR GLOVE EA $175

Facility

$175.00

Service Code	HCPCS L3999
Hospital Charge Code	96000029
Hospital Revenue Code	270
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$148.75
Rate for Payer: Aetna New Business (MI Preferred)	$113.75
Rate for Payer: BCBS Complete	$70.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cofinity Commercial	$122.50
Rate for Payer: Cofinity Commercial	$150.50
Rate for Payer: Healthscope Commercial	$157.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$148.75
Rate for Payer: PHP Commercial	$148.75
Rate for Payer: Priority Health Cigna Priority Health	$122.50
Rate for Payer: Priority Health SBD	$110.25

HC OT Z SLEEVE OR GLOVE EA $20

Facility

$20.00

Service Code	HCPCS L3999
Hospital Charge Code	96000030
Hospital Revenue Code	270
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$17.00
Rate for Payer: Aetna New Business (MI Preferred)	$13.00
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Commercial	$14.00
Rate for Payer: Cofinity Commercial	$17.20
Rate for Payer: Healthscope Commercial	$18.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.00
Rate for Payer: PHP Commercial	$17.00
Rate for Payer: Priority Health Cigna Priority Health	$14.00
Rate for Payer: Priority Health SBD	$12.60

HC OT Z SLEEVE OR GLOVE EA $20

Facility

$20.00

Service Code	HCPCS L3999
Hospital Charge Code	96000030
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.00
Rate for Payer: Aetna New Business (MI Preferred)	$13.00
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Commercial	$14.00
Rate for Payer: Cofinity Commercial	$17.20
Rate for Payer: Healthscope Commercial	$18.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.00
Rate for Payer: PHP Commercial	$17.00
Rate for Payer: Priority Health Cigna Priority Health	$14.00
Rate for Payer: Priority Health SBD	$12.60

HC OT Z SLEEVE OR GLOVE EA $200

Facility

$200.00

Service Code	HCPCS L3999
Hospital Charge Code	96000031
Hospital Revenue Code	270
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$170.00
Rate for Payer: Aetna New Business (MI Preferred)	$130.00
Rate for Payer: BCBS Complete	$80.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cofinity Commercial	$140.00
Rate for Payer: Cofinity Commercial	$172.00
Rate for Payer: Healthscope Commercial	$180.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$170.00
Rate for Payer: PHP Commercial	$170.00
Rate for Payer: Priority Health Cigna Priority Health	$140.00
Rate for Payer: Priority Health SBD	$126.00

HC OT Z SLEEVE OR GLOVE EA $200

Facility

$200.00

Service Code	HCPCS L3999
Hospital Charge Code	96000031
Hospital Revenue Code	270
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$170.00
Rate for Payer: Aetna New Business (MI Preferred)	$130.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cofinity Commercial	$172.00
Rate for Payer: Cofinity Commercial	$140.00
Rate for Payer: Healthscope Commercial	$180.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$170.00
Rate for Payer: PHP Commercial	$170.00
Rate for Payer: Priority Health Cigna Priority Health	$140.00
Rate for Payer: Priority Health SBD	$126.00

HC OT Z SLEEVE OR GLOVE EA $225

Facility

$225.00

Service Code	HCPCS L3999
Hospital Charge Code	96000032
Hospital Revenue Code	270
Min. Negotiated Rate	$141.75
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna Commercial	$191.25
Rate for Payer: Aetna New Business (MI Preferred)	$146.25
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cofinity Commercial	$193.50
Rate for Payer: Cofinity Commercial	$157.50
Rate for Payer: Healthscope Commercial	$202.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$191.25
Rate for Payer: PHP Commercial	$191.25
Rate for Payer: Priority Health Cigna Priority Health	$157.50
Rate for Payer: Priority Health SBD	$141.75

HC OT Z SLEEVE OR GLOVE EA $225

Facility

$225.00

Service Code	HCPCS L3999
Hospital Charge Code	96000032
Hospital Revenue Code	270
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$191.25
Rate for Payer: Aetna New Business (MI Preferred)	$146.25
Rate for Payer: BCBS Complete	$90.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cofinity Commercial	$157.50
Rate for Payer: Cofinity Commercial	$193.50
Rate for Payer: Healthscope Commercial	$202.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$191.25
Rate for Payer: PHP Commercial	$191.25
Rate for Payer: Priority Health Cigna Priority Health	$157.50
Rate for Payer: Priority Health SBD	$141.75

HC OT Z SLEEVE OR GLOVE EA $250

Facility

$250.00

Service Code	HCPCS L3999
Hospital Charge Code	96000033
Hospital Revenue Code	270
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$212.50
Rate for Payer: Aetna New Business (MI Preferred)	$162.50
Rate for Payer: BCBS Complete	$100.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cofinity Commercial	$215.00
Rate for Payer: Cofinity Commercial	$175.00
Rate for Payer: Healthscope Commercial	$225.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$212.50
Rate for Payer: PHP Commercial	$212.50
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: Priority Health SBD	$157.50

HC OT Z SLEEVE OR GLOVE EA $250

Facility

$250.00

Service Code	HCPCS L3999
Hospital Charge Code	96000033
Hospital Revenue Code	270
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna Commercial	$212.50
Rate for Payer: Aetna New Business (MI Preferred)	$162.50
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cofinity Commercial	$175.00
Rate for Payer: Cofinity Commercial	$215.00
Rate for Payer: Healthscope Commercial	$225.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$212.50
Rate for Payer: PHP Commercial	$212.50
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: Priority Health SBD	$157.50

HC OT Z SLEEVE OR GLOVE EA $275

Facility

$275.00

Service Code	HCPCS L3999
Hospital Charge Code	96000034
Hospital Revenue Code	270
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$233.75
Rate for Payer: Aetna New Business (MI Preferred)	$178.75
Rate for Payer: BCBS Complete	$110.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cofinity Commercial	$236.50
Rate for Payer: Cofinity Commercial	$192.50
Rate for Payer: Healthscope Commercial	$247.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$233.75
Rate for Payer: PHP Commercial	$233.75
Rate for Payer: Priority Health Cigna Priority Health	$192.50
Rate for Payer: Priority Health SBD	$173.25

HC OT Z SLEEVE OR GLOVE EA $275

Facility

$275.00

Service Code	HCPCS L3999
Hospital Charge Code	96000034
Hospital Revenue Code	270
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$247.50
Rate for Payer: Aetna Commercial	$233.75
Rate for Payer: Aetna New Business (MI Preferred)	$178.75
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cofinity Commercial	$192.50
Rate for Payer: Cofinity Commercial	$236.50
Rate for Payer: Healthscope Commercial	$247.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$233.75
Rate for Payer: PHP Commercial	$233.75
Rate for Payer: Priority Health Cigna Priority Health	$192.50
Rate for Payer: Priority Health SBD	$173.25

HC OT Z SLEEVE OR GLOVE EA $300

Facility

$300.00

Service Code	HCPCS L3999
Hospital Charge Code	96000035
Hospital Revenue Code	270
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$255.00
Rate for Payer: Aetna New Business (MI Preferred)	$195.00
Rate for Payer: BCBS Complete	$120.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cofinity Commercial	$210.00
Rate for Payer: Cofinity Commercial	$258.00
Rate for Payer: Healthscope Commercial	$270.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$255.00
Rate for Payer: PHP Commercial	$255.00
Rate for Payer: Priority Health Cigna Priority Health	$210.00
Rate for Payer: Priority Health SBD	$189.00

HC OT Z SLEEVE OR GLOVE EA $300

Facility

$300.00

Service Code	HCPCS L3999
Hospital Charge Code	96000035
Hospital Revenue Code	270
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$255.00
Rate for Payer: Aetna New Business (MI Preferred)	$195.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cofinity Commercial	$210.00
Rate for Payer: Cofinity Commercial	$258.00
Rate for Payer: Healthscope Commercial	$270.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$255.00
Rate for Payer: PHP Commercial	$255.00
Rate for Payer: Priority Health Cigna Priority Health	$210.00
Rate for Payer: Priority Health SBD	$189.00

HC OT Z SLEEVE OR GLOVE EA $325

Facility

$325.00

Service Code	HCPCS L3999
Hospital Charge Code	96000036
Hospital Revenue Code	270
Min. Negotiated Rate	$204.75
Max. Negotiated Rate	$292.50
Rate for Payer: Aetna Commercial	$276.25
Rate for Payer: Aetna New Business (MI Preferred)	$211.25
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cofinity Commercial	$227.50
Rate for Payer: Cofinity Commercial	$279.50
Rate for Payer: Healthscope Commercial	$292.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$276.25
Rate for Payer: PHP Commercial	$276.25
Rate for Payer: Priority Health Cigna Priority Health	$227.50
Rate for Payer: Priority Health SBD	$204.75

HC OT Z SLEEVE OR GLOVE EA $325

Facility

$325.00

Service Code	HCPCS L3999
Hospital Charge Code	96000036
Hospital Revenue Code	270
Min. Negotiated Rate	$130.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$276.25
Rate for Payer: Aetna New Business (MI Preferred)	$211.25
Rate for Payer: BCBS Complete	$130.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cofinity Commercial	$227.50
Rate for Payer: Cofinity Commercial	$279.50
Rate for Payer: Healthscope Commercial	$292.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$276.25
Rate for Payer: PHP Commercial	$276.25
Rate for Payer: Priority Health Cigna Priority Health	$227.50
Rate for Payer: Priority Health SBD	$204.75

HC OT Z SLEEVE OR GLOVE EA $350

Facility

$350.00

Service Code	HCPCS L3999
Hospital Charge Code	96000037
Hospital Revenue Code	270
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$297.50
Rate for Payer: Aetna New Business (MI Preferred)	$227.50
Rate for Payer: BCBS Complete	$140.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cofinity Commercial	$245.00
Rate for Payer: Cofinity Commercial	$301.00
Rate for Payer: Healthscope Commercial	$315.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$297.50
Rate for Payer: PHP Commercial	$297.50
Rate for Payer: Priority Health Cigna Priority Health	$245.00
Rate for Payer: Priority Health SBD	$220.50

HC OT Z SLEEVE OR GLOVE EA $350

Facility

$350.00

Service Code	HCPCS L3999
Hospital Charge Code	96000037
Hospital Revenue Code	270
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna Commercial	$297.50
Rate for Payer: Aetna New Business (MI Preferred)	$227.50
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cofinity Commercial	$245.00
Rate for Payer: Cofinity Commercial	$301.00
Rate for Payer: Healthscope Commercial	$315.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$297.50
Rate for Payer: PHP Commercial	$297.50
Rate for Payer: Priority Health Cigna Priority Health	$245.00
Rate for Payer: Priority Health SBD	$220.50

HC OT Z SLEEVE OR GLOVE EA $375

Facility

$375.00

Service Code	HCPCS L3999
Hospital Charge Code	96000038
Hospital Revenue Code	270
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$318.75
Rate for Payer: Aetna New Business (MI Preferred)	$243.75
Rate for Payer: BCBS Complete	$150.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cofinity Commercial	$262.50
Rate for Payer: Cofinity Commercial	$322.50
Rate for Payer: Healthscope Commercial	$337.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$318.75
Rate for Payer: PHP Commercial	$318.75
Rate for Payer: Priority Health Cigna Priority Health	$262.50
Rate for Payer: Priority Health SBD	$236.25

HC OT Z SLEEVE OR GLOVE EA $375

Facility

$375.00

Service Code	HCPCS L3999
Hospital Charge Code	96000038
Hospital Revenue Code	270
Min. Negotiated Rate	$236.25
Max. Negotiated Rate	$337.50
Rate for Payer: Aetna Commercial	$318.75
Rate for Payer: Aetna New Business (MI Preferred)	$243.75
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cofinity Commercial	$262.50
Rate for Payer: Cofinity Commercial	$322.50
Rate for Payer: Healthscope Commercial	$337.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$318.75
Rate for Payer: PHP Commercial	$318.75
Rate for Payer: Priority Health Cigna Priority Health	$262.50
Rate for Payer: Priority Health SBD	$236.25

HC OT Z SLEEVE OR GLOVE EA $40

Facility

$40.00

Service Code	HCPCS L3999
Hospital Charge Code	96000039
Hospital Revenue Code	270
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$34.00
Rate for Payer: Aetna New Business (MI Preferred)	$26.00
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cofinity Commercial	$28.00
Rate for Payer: Cofinity Commercial	$34.40
Rate for Payer: Healthscope Commercial	$36.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$34.00
Rate for Payer: PHP Commercial	$34.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: Priority Health SBD	$25.20

HC OT Z SLEEVE OR GLOVE EA $40

Facility

$40.00

Service Code	HCPCS L3999
Hospital Charge Code	96000039
Hospital Revenue Code	270
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.00
Rate for Payer: Aetna New Business (MI Preferred)	$26.00
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cofinity Commercial	$28.00
Rate for Payer: Cofinity Commercial	$34.40
Rate for Payer: Healthscope Commercial	$36.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$34.00
Rate for Payer: PHP Commercial	$34.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: Priority Health SBD	$25.20

HC OT Z SLEEVE OR GLOVE EA $400

Facility

$400.00

Service Code	HCPCS L3999
Hospital Charge Code	96000040
Hospital Revenue Code	270
Min. Negotiated Rate	$160.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$340.00
Rate for Payer: Aetna New Business (MI Preferred)	$260.00
Rate for Payer: BCBS Complete	$160.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$320.00
Rate for Payer: Cash Price	$320.00
Rate for Payer: Cofinity Commercial	$280.00
Rate for Payer: Cofinity Commercial	$344.00
Rate for Payer: Healthscope Commercial	$360.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$340.00
Rate for Payer: PHP Commercial	$340.00
Rate for Payer: Priority Health Cigna Priority Health	$280.00
Rate for Payer: Priority Health SBD	$252.00

Know your out-of-pocket cost for care.

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