Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$340.00
Rate for Payer: Aetna New Business (MI Preferred)	$260.00
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

HC OT Z SLEEVE OR GLOVE EA $425

Facility

$425.00

Service Code	HCPCS L3999
Hospital Charge Code	96000041
Hospital Revenue Code	270
Min. Negotiated Rate	$267.75
Max. Negotiated Rate	$382.50
Rate for Payer: Aetna Commercial	$361.25
Rate for Payer: Aetna New Business (MI Preferred)	$276.25
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cofinity Commercial	$297.50
Rate for Payer: Cofinity Commercial	$365.50
Rate for Payer: Healthscope Commercial	$382.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$361.25
Rate for Payer: PHP Commercial	$361.25
Rate for Payer: Priority Health Cigna Priority Health	$297.50
Rate for Payer: Priority Health SBD	$267.75

HC OT Z SLEEVE OR GLOVE EA $425

Facility

$425.00

Service Code	HCPCS L3999
Hospital Charge Code	96000041
Hospital Revenue Code	270
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$361.25
Rate for Payer: Aetna New Business (MI Preferred)	$276.25
Rate for Payer: BCBS Complete	$170.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cofinity Commercial	$365.50
Rate for Payer: Cofinity Commercial	$297.50
Rate for Payer: Healthscope Commercial	$382.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$361.25
Rate for Payer: PHP Commercial	$361.25
Rate for Payer: Priority Health Cigna Priority Health	$297.50
Rate for Payer: Priority Health SBD	$267.75

HC OT Z SLEEVE OR GLOVE EA $450

Facility

$450.00

Service Code	HCPCS L3999
Hospital Charge Code	96000042
Hospital Revenue Code	270
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$382.50
Rate for Payer: Aetna New Business (MI Preferred)	$292.50
Rate for Payer: BCBS Complete	$180.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cofinity Commercial	$315.00
Rate for Payer: Cofinity Commercial	$387.00
Rate for Payer: Healthscope Commercial	$405.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$382.50
Rate for Payer: PHP Commercial	$382.50
Rate for Payer: Priority Health Cigna Priority Health	$315.00
Rate for Payer: Priority Health SBD	$283.50

HC OT Z SLEEVE OR GLOVE EA $450

Facility

$450.00

Service Code	HCPCS L3999
Hospital Charge Code	96000042
Hospital Revenue Code	270
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$405.00
Rate for Payer: Aetna Commercial	$382.50
Rate for Payer: Aetna New Business (MI Preferred)	$292.50
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cofinity Commercial	$315.00
Rate for Payer: Cofinity Commercial	$387.00
Rate for Payer: Healthscope Commercial	$405.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$382.50
Rate for Payer: PHP Commercial	$382.50
Rate for Payer: Priority Health Cigna Priority Health	$315.00
Rate for Payer: Priority Health SBD	$283.50

HC OT Z SLEEVE OR GLOVE EA $50

Facility

$50.00

Service Code	HCPCS L3999
Hospital Charge Code	96000043
Hospital Revenue Code	270
Min. Negotiated Rate	$20.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$42.50
Rate for Payer: Aetna New Business (MI Preferred)	$32.50
Rate for Payer: BCBS Complete	$20.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cofinity Commercial	$35.00
Rate for Payer: Cofinity Commercial	$43.00
Rate for Payer: Healthscope Commercial	$45.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$42.50
Rate for Payer: PHP Commercial	$42.50
Rate for Payer: Priority Health Cigna Priority Health	$35.00
Rate for Payer: Priority Health SBD	$31.50

HC OT Z SLEEVE OR GLOVE EA $50

Facility

$50.00

Service Code	HCPCS L3999
Hospital Charge Code	96000043
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.50
Rate for Payer: Aetna New Business (MI Preferred)	$32.50
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cofinity Commercial	$35.00
Rate for Payer: Cofinity Commercial	$43.00
Rate for Payer: Healthscope Commercial	$45.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$42.50
Rate for Payer: PHP Commercial	$42.50
Rate for Payer: Priority Health Cigna Priority Health	$35.00
Rate for Payer: Priority Health SBD	$31.50

HC OT Z SLEEVE OR GLOVE EA $60

Facility

$60.00

Service Code	HCPCS L3999
Hospital Charge Code	96000044
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.00
Rate for Payer: Aetna New Business (MI Preferred)	$39.00
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cofinity Commercial	$42.00
Rate for Payer: Cofinity Commercial	$51.60
Rate for Payer: Healthscope Commercial	$54.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$51.00
Rate for Payer: PHP Commercial	$51.00
Rate for Payer: Priority Health Cigna Priority Health	$42.00
Rate for Payer: Priority Health SBD	$37.80

HC OT Z SLEEVE OR GLOVE EA $60

Facility

$60.00

Service Code	HCPCS L3999
Hospital Charge Code	96000044
Hospital Revenue Code	270
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$51.00
Rate for Payer: Aetna New Business (MI Preferred)	$39.00
Rate for Payer: BCBS Complete	$24.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cofinity Commercial	$51.60
Rate for Payer: Cofinity Commercial	$42.00
Rate for Payer: Healthscope Commercial	$54.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$51.00
Rate for Payer: PHP Commercial	$51.00
Rate for Payer: Priority Health Cigna Priority Health	$42.00
Rate for Payer: Priority Health SBD	$37.80

HC OT Z SLEEVE OR GLOVE EA $70

Facility

$70.00

Service Code	HCPCS L3999
Hospital Charge Code	96000045
Hospital Revenue Code	960
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$59.50
Rate for Payer: Aetna New Business (MI Preferred)	$45.50
Rate for Payer: BCBS Complete	$28.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$49.00
Rate for Payer: Cofinity Commercial	$60.20
Rate for Payer: Healthscope Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.50
Rate for Payer: PHP Commercial	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$49.00
Rate for Payer: Priority Health SBD	$44.10

HC OT Z SLEEVE OR GLOVE EA $70

Facility

$70.00

Service Code	HCPCS L3999
Hospital Charge Code	96000045
Hospital Revenue Code	960
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.50
Rate for Payer: Aetna New Business (MI Preferred)	$45.50
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$49.00
Rate for Payer: Cofinity Commercial	$60.20
Rate for Payer: Healthscope Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.50
Rate for Payer: PHP Commercial	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$49.00
Rate for Payer: Priority Health SBD	$44.10

HC OT Z SLEEVE OR GLOVE EA $80

Facility

$80.00

Service Code	HCPCS L3999
Hospital Charge Code	96000046
Hospital Revenue Code	270
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.00
Rate for Payer: Aetna New Business (MI Preferred)	$52.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cofinity Commercial	$56.00
Rate for Payer: Cofinity Commercial	$68.80
Rate for Payer: Healthscope Commercial	$72.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$68.00
Rate for Payer: PHP Commercial	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$56.00
Rate for Payer: Priority Health SBD	$50.40

HC OT Z SLEEVE OR GLOVE EA $80

Facility

$80.00

Service Code	HCPCS L3999
Hospital Charge Code	96000046
Hospital Revenue Code	270
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$68.00
Rate for Payer: Aetna New Business (MI Preferred)	$52.00
Rate for Payer: BCBS Complete	$32.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cofinity Commercial	$68.80
Rate for Payer: Cofinity Commercial	$56.00
Rate for Payer: Healthscope Commercial	$72.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$68.00
Rate for Payer: PHP Commercial	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$56.00
Rate for Payer: Priority Health SBD	$50.40

HC OT Z SLEEVE OR GLOVE EA $90

Facility

$90.00

Service Code	HCPCS L3999
Hospital Charge Code	96000047
Hospital Revenue Code	270
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$715.62
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: Aetna New Business (MI Preferred)	$58.50
Rate for Payer: BCBS Complete	$36.00
Rate for Payer: BCBS Trust/PPO	$715.62
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cofinity Commercial	$63.00
Rate for Payer: Cofinity Commercial	$77.40
Rate for Payer: Healthscope Commercial	$81.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$76.50
Rate for Payer: PHP Commercial	$76.50
Rate for Payer: Priority Health Cigna Priority Health	$63.00
Rate for Payer: Priority Health SBD	$56.70

HC OT Z SLEEVE OR GLOVE EA $90

Facility

$90.00

Service Code	HCPCS L3999
Hospital Charge Code	96000047
Hospital Revenue Code	270
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.50
Rate for Payer: Aetna New Business (MI Preferred)	$58.50
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cofinity Commercial	$63.00
Rate for Payer: Cofinity Commercial	$77.40
Rate for Payer: Healthscope Commercial	$81.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$76.50
Rate for Payer: PHP Commercial	$76.50
Rate for Payer: Priority Health Cigna Priority Health	$63.00
Rate for Payer: Priority Health SBD	$56.70

HC OT Z STOCKINGS CUSTOM EA $100

Facility

$100.00

Service Code	HCPCS A6549
Hospital Charge Code	98300094
Hospital Revenue Code	270
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$381.58
Rate for Payer: Aetna Commercial	$85.00
Rate for Payer: Aetna New Business (MI Preferred)	$65.00
Rate for Payer: BCBS Complete	$40.00
Rate for Payer: BCBS Trust/PPO	$381.58
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cofinity Commercial	$70.00
Rate for Payer: Cofinity Commercial	$86.00
Rate for Payer: Healthscope Commercial	$90.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$85.00
Rate for Payer: PHP Commercial	$85.00
Rate for Payer: Priority Health Cigna Priority Health	$70.00
Rate for Payer: Priority Health SBD	$63.00

HC OT Z STOCKINGS CUSTOM EA $100

Facility

$100.00

Service Code	HCPCS A6549
Hospital Charge Code	98300094
Hospital Revenue Code	270
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.00
Rate for Payer: Aetna New Business (MI Preferred)	$65.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cofinity Commercial	$70.00
Rate for Payer: Cofinity Commercial	$86.00
Rate for Payer: Healthscope Commercial	$90.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$85.00
Rate for Payer: PHP Commercial	$85.00
Rate for Payer: Priority Health Cigna Priority Health	$70.00
Rate for Payer: Priority Health SBD	$63.00

HC OT Z STOCKINGS CUSTOM EA $125

Facility

$125.00

Service Code	HCPCS A6549
Hospital Charge Code	98300095
Hospital Revenue Code	270
Min. Negotiated Rate	$78.75
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna Commercial	$106.25
Rate for Payer: Aetna New Business (MI Preferred)	$81.25
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cofinity Commercial	$107.50
Rate for Payer: Cofinity Commercial	$87.50
Rate for Payer: Healthscope Commercial	$112.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$106.25
Rate for Payer: PHP Commercial	$106.25
Rate for Payer: Priority Health Cigna Priority Health	$87.50
Rate for Payer: Priority Health SBD	$78.75

HC OT Z STOCKINGS CUSTOM EA $125

Facility

$125.00

Service Code	HCPCS A6549
Hospital Charge Code	98300095
Hospital Revenue Code	270
Min. Negotiated Rate	$50.00
Max. Negotiated Rate	$381.58
Rate for Payer: Aetna Commercial	$106.25
Rate for Payer: Aetna New Business (MI Preferred)	$81.25
Rate for Payer: BCBS Complete	$50.00
Rate for Payer: BCBS Trust/PPO	$381.58
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cofinity Commercial	$87.50
Rate for Payer: Cofinity Commercial	$107.50
Rate for Payer: Healthscope Commercial	$112.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$106.25
Rate for Payer: PHP Commercial	$106.25
Rate for Payer: Priority Health Cigna Priority Health	$87.50
Rate for Payer: Priority Health SBD	$78.75

HC OT Z STOCKINGS CUSTOM EA $150

Facility

$150.00

Service Code	HCPCS A6549
Hospital Charge Code	98300096
Hospital Revenue Code	270
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$381.58
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	$381.58
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 STOCKINGS CUSTOM EA $150

Facility

$150.00

Service Code	HCPCS A6549
Hospital Charge Code	98300096
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	$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 STOCKINGS CUSTOM EA $175

Facility

$175.00

Service Code	HCPCS A6549
Hospital Charge Code	98300097
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 STOCKINGS CUSTOM EA $175

Facility

$175.00

Service Code	HCPCS A6549
Hospital Charge Code	98300097
Hospital Revenue Code	270
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$381.58
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	$381.58
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cofinity Commercial	$150.50
Rate for Payer: Cofinity Commercial	$122.50
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 STOCKINGS CUSTOM EA $200

Facility

$200.00

Service Code	HCPCS A6549
Hospital Charge Code	98300098
Hospital Revenue Code	270
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$381.58
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	$381.58
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 STOCKINGS CUSTOM EA $200

Facility

$200.00

Service Code	HCPCS A6549
Hospital Charge Code	98300098
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

Know your out-of-pocket cost for care.

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