Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC OT Z SLEEVE OR GLOVE EA $20

Facility

$20.81

Service Code	HCPCS L3999
Hospital Charge Code	96000030
Hospital Revenue Code	270
Min. Negotiated Rate	$13.11
Max. Negotiated Rate	$18.73
Rate for Payer: Aetna Commercial	$17.69
Rate for Payer: Aetna New Business (MI Preferred)	$13.53
Rate for Payer: Cash Price	$16.65
Rate for Payer: Cofinity Advantage	$14.57
Rate for Payer: Cofinity Commercial	$17.90
Rate for Payer: Encore Health Key Benefits Commercial	$16.65
Rate for Payer: Healthscope Commercial	$18.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.69
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.61
Rate for Payer: PHP Commercial	$17.69
Rate for Payer: Priority Health SBD	$13.11

HC OT Z SLEEVE OR GLOVE EA $20

Facility

$20.81

Service Code	HCPCS L3999
Hospital Charge Code	96000030
Hospital Revenue Code	270
Min. Negotiated Rate	$8.18
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$17.69
Rate for Payer: Aetna Medicare	$10.40
Rate for Payer: Aetna New Business (MI Preferred)	$13.53
Rate for Payer: BCBS Complete	$8.32
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$16.65
Rate for Payer: Cash Price	$16.65
Rate for Payer: Cofinity Advantage	$14.57
Rate for Payer: Cofinity Commercial	$17.90
Rate for Payer: Encore Health Key Benefits Commercial	$16.65
Rate for Payer: Healthscope Commercial	$18.73
Rate for Payer: MI Amish Medical Board Commercial	$16.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.69
Rate for Payer: Opus (Opus Packaging Group) HMA	$15.61
Rate for Payer: PHP Commercial	$17.69
Rate for Payer: Priority Health SBD	$13.11
Rate for Payer: UHC All Payor (Choice/PPO)	$13.53
Rate for Payer: UHC Core	$10.84
Rate for Payer: UHC Exchange	$8.18

HC OT Z SLEEVE OR GLOVE EA $200

Facility

$208.08

Service Code	HCPCS L3999
Hospital Charge Code	96000031
Hospital Revenue Code	270
Min. Negotiated Rate	$131.09
Max. Negotiated Rate	$187.27
Rate for Payer: Aetna Commercial	$176.87
Rate for Payer: Aetna New Business (MI Preferred)	$135.25
Rate for Payer: Cash Price	$166.46
Rate for Payer: Cofinity Advantage	$145.66
Rate for Payer: Cofinity Commercial	$178.95
Rate for Payer: Encore Health Key Benefits Commercial	$166.46
Rate for Payer: Healthscope Commercial	$187.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$176.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$156.06
Rate for Payer: PHP Commercial	$176.87
Rate for Payer: Priority Health SBD	$131.09

HC OT Z SLEEVE OR GLOVE EA $200

Facility

$208.08

Service Code	HCPCS L3999
Hospital Charge Code	96000031
Hospital Revenue Code	270
Min. Negotiated Rate	$81.78
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$176.87
Rate for Payer: Aetna Medicare	$104.04
Rate for Payer: Aetna New Business (MI Preferred)	$135.25
Rate for Payer: BCBS Complete	$83.23
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$166.46
Rate for Payer: Cash Price	$166.46
Rate for Payer: Cofinity Advantage	$145.66
Rate for Payer: Cofinity Commercial	$178.95
Rate for Payer: Encore Health Key Benefits Commercial	$166.46
Rate for Payer: Healthscope Commercial	$187.27
Rate for Payer: MI Amish Medical Board Commercial	$166.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$176.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$156.06
Rate for Payer: PHP Commercial	$176.87
Rate for Payer: Priority Health SBD	$131.09
Rate for Payer: UHC All Payor (Choice/PPO)	$135.25
Rate for Payer: UHC Core	$108.41
Rate for Payer: UHC Exchange	$81.78

HC OT Z SLEEVE OR GLOVE EA $225

Facility

$234.09

Service Code	HCPCS L3999
Hospital Charge Code	96000032
Hospital Revenue Code	270
Min. Negotiated Rate	$147.48
Max. Negotiated Rate	$210.68
Rate for Payer: Aetna Commercial	$198.98
Rate for Payer: Aetna New Business (MI Preferred)	$152.16
Rate for Payer: Cash Price	$187.27
Rate for Payer: Cofinity Advantage	$163.86
Rate for Payer: Cofinity Commercial	$201.32
Rate for Payer: Encore Health Key Benefits Commercial	$187.27
Rate for Payer: Healthscope Commercial	$210.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$198.98
Rate for Payer: Opus (Opus Packaging Group) HMA	$175.57
Rate for Payer: PHP Commercial	$198.98
Rate for Payer: Priority Health SBD	$147.48

HC OT Z SLEEVE OR GLOVE EA $225

Facility

$234.09

Service Code	HCPCS L3999
Hospital Charge Code	96000032
Hospital Revenue Code	270
Min. Negotiated Rate	$92.00
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$198.98
Rate for Payer: Aetna Medicare	$117.05
Rate for Payer: Aetna New Business (MI Preferred)	$152.16
Rate for Payer: BCBS Complete	$93.64
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$187.27
Rate for Payer: Cash Price	$187.27
Rate for Payer: Cofinity Advantage	$163.86
Rate for Payer: Cofinity Commercial	$201.32
Rate for Payer: Encore Health Key Benefits Commercial	$187.27
Rate for Payer: Healthscope Commercial	$210.68
Rate for Payer: MI Amish Medical Board Commercial	$187.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$198.98
Rate for Payer: Opus (Opus Packaging Group) HMA	$175.57
Rate for Payer: PHP Commercial	$198.98
Rate for Payer: Priority Health SBD	$147.48
Rate for Payer: UHC All Payor (Choice/PPO)	$152.16
Rate for Payer: UHC Core	$121.96
Rate for Payer: UHC Exchange	$92.00

HC OT Z SLEEVE OR GLOVE EA $250

Facility

$260.10

Service Code	HCPCS L3999
Hospital Charge Code	96000033
Hospital Revenue Code	270
Min. Negotiated Rate	$163.86
Max. Negotiated Rate	$234.09
Rate for Payer: Aetna Commercial	$221.09
Rate for Payer: Aetna New Business (MI Preferred)	$169.06
Rate for Payer: Cash Price	$208.08
Rate for Payer: Cofinity Advantage	$182.07
Rate for Payer: Cofinity Commercial	$223.69
Rate for Payer: Encore Health Key Benefits Commercial	$208.08
Rate for Payer: Healthscope Commercial	$234.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$221.09
Rate for Payer: Opus (Opus Packaging Group) HMA	$195.07
Rate for Payer: PHP Commercial	$221.09
Rate for Payer: Priority Health SBD	$163.86

HC OT Z SLEEVE OR GLOVE EA $250

Facility

$260.10

Service Code	HCPCS L3999
Hospital Charge Code	96000033
Hospital Revenue Code	270
Min. Negotiated Rate	$102.22
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$221.09
Rate for Payer: Aetna Medicare	$130.05
Rate for Payer: Aetna New Business (MI Preferred)	$169.06
Rate for Payer: BCBS Complete	$104.04
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$208.08
Rate for Payer: Cash Price	$208.08
Rate for Payer: Cofinity Advantage	$182.07
Rate for Payer: Cofinity Commercial	$223.69
Rate for Payer: Encore Health Key Benefits Commercial	$208.08
Rate for Payer: Healthscope Commercial	$234.09
Rate for Payer: MI Amish Medical Board Commercial	$208.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$221.09
Rate for Payer: Opus (Opus Packaging Group) HMA	$195.07
Rate for Payer: PHP Commercial	$221.09
Rate for Payer: Priority Health SBD	$163.86
Rate for Payer: UHC All Payor (Choice/PPO)	$169.06
Rate for Payer: UHC Core	$135.51
Rate for Payer: UHC Exchange	$102.22

HC OT Z SLEEVE OR GLOVE EA $275

Facility

$286.11

Service Code	HCPCS L3999
Hospital Charge Code	96000034
Hospital Revenue Code	270
Min. Negotiated Rate	$112.44
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$243.19
Rate for Payer: Aetna Medicare	$143.06
Rate for Payer: Aetna New Business (MI Preferred)	$185.97
Rate for Payer: BCBS Complete	$114.44
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$228.89
Rate for Payer: Cash Price	$228.89
Rate for Payer: Cofinity Advantage	$200.28
Rate for Payer: Cofinity Commercial	$246.05
Rate for Payer: Encore Health Key Benefits Commercial	$228.89
Rate for Payer: Healthscope Commercial	$257.50
Rate for Payer: MI Amish Medical Board Commercial	$228.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$243.19
Rate for Payer: Opus (Opus Packaging Group) HMA	$214.58
Rate for Payer: PHP Commercial	$243.19
Rate for Payer: Priority Health SBD	$180.25
Rate for Payer: UHC All Payor (Choice/PPO)	$185.97
Rate for Payer: UHC Core	$149.06
Rate for Payer: UHC Exchange	$112.44

HC OT Z SLEEVE OR GLOVE EA $275

Facility

$286.11

Service Code	HCPCS L3999
Hospital Charge Code	96000034
Hospital Revenue Code	270
Min. Negotiated Rate	$180.25
Max. Negotiated Rate	$257.50
Rate for Payer: Aetna Commercial	$243.19
Rate for Payer: Aetna New Business (MI Preferred)	$185.97
Rate for Payer: Cash Price	$228.89
Rate for Payer: Cofinity Advantage	$200.28
Rate for Payer: Cofinity Commercial	$246.05
Rate for Payer: Encore Health Key Benefits Commercial	$228.89
Rate for Payer: Healthscope Commercial	$257.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$243.19
Rate for Payer: Opus (Opus Packaging Group) HMA	$214.58
Rate for Payer: PHP Commercial	$243.19
Rate for Payer: Priority Health SBD	$180.25

HC OT Z SLEEVE OR GLOVE EA $300

Facility

$312.12

Service Code	HCPCS L3999
Hospital Charge Code	96000035
Hospital Revenue Code	270
Min. Negotiated Rate	$122.66
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$265.30
Rate for Payer: Aetna Medicare	$156.06
Rate for Payer: Aetna New Business (MI Preferred)	$202.88
Rate for Payer: BCBS Complete	$124.85
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$249.70
Rate for Payer: Cash Price	$249.70
Rate for Payer: Cofinity Advantage	$218.48
Rate for Payer: Cofinity Commercial	$268.42
Rate for Payer: Encore Health Key Benefits Commercial	$249.70
Rate for Payer: Healthscope Commercial	$280.91
Rate for Payer: MI Amish Medical Board Commercial	$249.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$265.30
Rate for Payer: Opus (Opus Packaging Group) HMA	$234.09
Rate for Payer: PHP Commercial	$265.30
Rate for Payer: Priority Health SBD	$196.64
Rate for Payer: UHC All Payor (Choice/PPO)	$202.88
Rate for Payer: UHC Core	$162.61
Rate for Payer: UHC Exchange	$122.66

HC OT Z SLEEVE OR GLOVE EA $300

Facility

$312.12

Service Code	HCPCS L3999
Hospital Charge Code	96000035
Hospital Revenue Code	270
Min. Negotiated Rate	$196.64
Max. Negotiated Rate	$280.91
Rate for Payer: Aetna Commercial	$265.30
Rate for Payer: Aetna New Business (MI Preferred)	$202.88
Rate for Payer: Cash Price	$249.70
Rate for Payer: Cofinity Advantage	$218.48
Rate for Payer: Cofinity Commercial	$268.42
Rate for Payer: Encore Health Key Benefits Commercial	$249.70
Rate for Payer: Healthscope Commercial	$280.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$265.30
Rate for Payer: Opus (Opus Packaging Group) HMA	$234.09
Rate for Payer: PHP Commercial	$265.30
Rate for Payer: Priority Health SBD	$196.64

HC OT Z SLEEVE OR GLOVE EA $325

Facility

$338.13

Service Code	HCPCS L3999
Hospital Charge Code	96000036
Hospital Revenue Code	270
Min. Negotiated Rate	$132.89
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$287.41
Rate for Payer: Aetna Medicare	$169.06
Rate for Payer: Aetna New Business (MI Preferred)	$219.78
Rate for Payer: BCBS Complete	$135.25
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$270.50
Rate for Payer: Cash Price	$270.50
Rate for Payer: Cofinity Advantage	$236.69
Rate for Payer: Cofinity Commercial	$290.79
Rate for Payer: Encore Health Key Benefits Commercial	$270.50
Rate for Payer: Healthscope Commercial	$304.32
Rate for Payer: MI Amish Medical Board Commercial	$270.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$287.41
Rate for Payer: Opus (Opus Packaging Group) HMA	$253.60
Rate for Payer: PHP Commercial	$287.41
Rate for Payer: Priority Health SBD	$213.02
Rate for Payer: UHC All Payor (Choice/PPO)	$219.78
Rate for Payer: UHC Core	$176.17
Rate for Payer: UHC Exchange	$132.89

HC OT Z SLEEVE OR GLOVE EA $325

Facility

$338.13

Service Code	HCPCS L3999
Hospital Charge Code	96000036
Hospital Revenue Code	270
Min. Negotiated Rate	$213.02
Max. Negotiated Rate	$304.32
Rate for Payer: Aetna Commercial	$287.41
Rate for Payer: Aetna New Business (MI Preferred)	$219.78
Rate for Payer: Cash Price	$270.50
Rate for Payer: Cofinity Advantage	$236.69
Rate for Payer: Cofinity Commercial	$290.79
Rate for Payer: Encore Health Key Benefits Commercial	$270.50
Rate for Payer: Healthscope Commercial	$304.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$287.41
Rate for Payer: Opus (Opus Packaging Group) HMA	$253.60
Rate for Payer: PHP Commercial	$287.41
Rate for Payer: Priority Health SBD	$213.02

HC OT Z SLEEVE OR GLOVE EA $350

Facility

$364.14

Service Code	HCPCS L3999
Hospital Charge Code	96000037
Hospital Revenue Code	270
Min. Negotiated Rate	$229.41
Max. Negotiated Rate	$327.73
Rate for Payer: Aetna Commercial	$309.52
Rate for Payer: Aetna New Business (MI Preferred)	$236.69
Rate for Payer: Cash Price	$291.31
Rate for Payer: Cofinity Advantage	$254.90
Rate for Payer: Cofinity Commercial	$313.16
Rate for Payer: Encore Health Key Benefits Commercial	$291.31
Rate for Payer: Healthscope Commercial	$327.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$309.52
Rate for Payer: Opus (Opus Packaging Group) HMA	$273.11
Rate for Payer: PHP Commercial	$309.52
Rate for Payer: Priority Health SBD	$229.41

HC OT Z SLEEVE OR GLOVE EA $350

Facility

$364.14

Service Code	HCPCS L3999
Hospital Charge Code	96000037
Hospital Revenue Code	270
Min. Negotiated Rate	$143.11
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$309.52
Rate for Payer: Aetna Medicare	$182.07
Rate for Payer: Aetna New Business (MI Preferred)	$236.69
Rate for Payer: BCBS Complete	$145.66
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$291.31
Rate for Payer: Cash Price	$291.31
Rate for Payer: Cofinity Advantage	$254.90
Rate for Payer: Cofinity Commercial	$313.16
Rate for Payer: Encore Health Key Benefits Commercial	$291.31
Rate for Payer: Healthscope Commercial	$327.73
Rate for Payer: MI Amish Medical Board Commercial	$291.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$309.52
Rate for Payer: Opus (Opus Packaging Group) HMA	$273.11
Rate for Payer: PHP Commercial	$309.52
Rate for Payer: Priority Health SBD	$229.41
Rate for Payer: UHC All Payor (Choice/PPO)	$236.69
Rate for Payer: UHC Core	$189.72
Rate for Payer: UHC Exchange	$143.11

HC OT Z SLEEVE OR GLOVE EA $375

Facility

$390.15

Service Code	HCPCS L3999
Hospital Charge Code	96000038
Hospital Revenue Code	270
Min. Negotiated Rate	$153.33
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$331.63
Rate for Payer: Aetna Medicare	$195.07
Rate for Payer: Aetna New Business (MI Preferred)	$253.60
Rate for Payer: BCBS Complete	$156.06
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$312.12
Rate for Payer: Cash Price	$312.12
Rate for Payer: Cofinity Advantage	$273.11
Rate for Payer: Cofinity Commercial	$335.53
Rate for Payer: Encore Health Key Benefits Commercial	$312.12
Rate for Payer: Healthscope Commercial	$351.13
Rate for Payer: MI Amish Medical Board Commercial	$312.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$331.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$292.61
Rate for Payer: PHP Commercial	$331.63
Rate for Payer: Priority Health SBD	$245.79
Rate for Payer: UHC All Payor (Choice/PPO)	$253.60
Rate for Payer: UHC Core	$203.27
Rate for Payer: UHC Exchange	$153.33

HC OT Z SLEEVE OR GLOVE EA $375

Facility

$390.15

Service Code	HCPCS L3999
Hospital Charge Code	96000038
Hospital Revenue Code	270
Min. Negotiated Rate	$245.79
Max. Negotiated Rate	$351.13
Rate for Payer: Aetna Commercial	$331.63
Rate for Payer: Aetna New Business (MI Preferred)	$253.60
Rate for Payer: Cash Price	$312.12
Rate for Payer: Cofinity Advantage	$273.11
Rate for Payer: Cofinity Commercial	$335.53
Rate for Payer: Encore Health Key Benefits Commercial	$312.12
Rate for Payer: Healthscope Commercial	$351.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$331.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$292.61
Rate for Payer: PHP Commercial	$331.63
Rate for Payer: Priority Health SBD	$245.79

HC OT Z SLEEVE OR GLOVE EA $40

Facility

$41.62

Service Code	HCPCS L3999
Hospital Charge Code	96000039
Hospital Revenue Code	270
Min. Negotiated Rate	$26.22
Max. Negotiated Rate	$37.46
Rate for Payer: Aetna Commercial	$35.38
Rate for Payer: Aetna New Business (MI Preferred)	$27.05
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cofinity Advantage	$29.13
Rate for Payer: Cofinity Commercial	$35.79
Rate for Payer: Encore Health Key Benefits Commercial	$33.30
Rate for Payer: Healthscope Commercial	$37.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.21
Rate for Payer: PHP Commercial	$35.38
Rate for Payer: Priority Health SBD	$26.22

HC OT Z SLEEVE OR GLOVE EA $40

Facility

$41.62

Service Code	HCPCS L3999
Hospital Charge Code	96000039
Hospital Revenue Code	270
Min. Negotiated Rate	$16.36
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$35.38
Rate for Payer: Aetna Medicare	$20.81
Rate for Payer: Aetna New Business (MI Preferred)	$27.05
Rate for Payer: BCBS Complete	$16.65
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cofinity Advantage	$29.13
Rate for Payer: Cofinity Commercial	$35.79
Rate for Payer: Encore Health Key Benefits Commercial	$33.30
Rate for Payer: Healthscope Commercial	$37.46
Rate for Payer: MI Amish Medical Board Commercial	$33.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$31.21
Rate for Payer: PHP Commercial	$35.38
Rate for Payer: Priority Health SBD	$26.22
Rate for Payer: UHC All Payor (Choice/PPO)	$27.05
Rate for Payer: UHC Core	$21.68
Rate for Payer: UHC Exchange	$16.36

HC OT Z SLEEVE OR GLOVE EA $400

Facility

$416.16

Service Code	HCPCS L3999
Hospital Charge Code	96000040
Hospital Revenue Code	270
Min. Negotiated Rate	$262.18
Max. Negotiated Rate	$374.54
Rate for Payer: Aetna Commercial	$353.74
Rate for Payer: Aetna New Business (MI Preferred)	$270.50
Rate for Payer: Cash Price	$332.93
Rate for Payer: Cofinity Advantage	$291.31
Rate for Payer: Cofinity Commercial	$357.90
Rate for Payer: Encore Health Key Benefits Commercial	$332.93
Rate for Payer: Healthscope Commercial	$374.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$353.74
Rate for Payer: Opus (Opus Packaging Group) HMA	$312.12
Rate for Payer: PHP Commercial	$353.74
Rate for Payer: Priority Health SBD	$262.18

HC OT Z SLEEVE OR GLOVE EA $400

Facility

$416.16

Service Code	HCPCS L3999
Hospital Charge Code	96000040
Hospital Revenue Code	270
Min. Negotiated Rate	$163.55
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$353.74
Rate for Payer: Aetna Medicare	$208.08
Rate for Payer: Aetna New Business (MI Preferred)	$270.50
Rate for Payer: BCBS Complete	$166.46
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$332.93
Rate for Payer: Cash Price	$332.93
Rate for Payer: Cofinity Advantage	$291.31
Rate for Payer: Cofinity Commercial	$357.90
Rate for Payer: Encore Health Key Benefits Commercial	$332.93
Rate for Payer: Healthscope Commercial	$374.54
Rate for Payer: MI Amish Medical Board Commercial	$332.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$353.74
Rate for Payer: Opus (Opus Packaging Group) HMA	$312.12
Rate for Payer: PHP Commercial	$353.74
Rate for Payer: Priority Health SBD	$262.18
Rate for Payer: UHC All Payor (Choice/PPO)	$270.50
Rate for Payer: UHC Core	$216.82
Rate for Payer: UHC Exchange	$163.55

HC OT Z SLEEVE OR GLOVE EA $425

Facility

$442.17

Service Code	HCPCS L3999
Hospital Charge Code	96000041
Hospital Revenue Code	270
Min. Negotiated Rate	$278.57
Max. Negotiated Rate	$397.95
Rate for Payer: Aetna Commercial	$375.84
Rate for Payer: Aetna New Business (MI Preferred)	$287.41
Rate for Payer: Cash Price	$353.74
Rate for Payer: Cofinity Advantage	$309.52
Rate for Payer: Cofinity Commercial	$380.27
Rate for Payer: Encore Health Key Benefits Commercial	$353.74
Rate for Payer: Healthscope Commercial	$397.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$375.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$331.63
Rate for Payer: PHP Commercial	$375.84
Rate for Payer: Priority Health SBD	$278.57

HC OT Z SLEEVE OR GLOVE EA $425

Facility

$442.17

Service Code	HCPCS L3999
Hospital Charge Code	96000041
Hospital Revenue Code	270
Min. Negotiated Rate	$173.77
Max. Negotiated Rate	$684.58
Rate for Payer: Aetna Commercial	$375.84
Rate for Payer: Aetna Medicare	$221.09
Rate for Payer: Aetna New Business (MI Preferred)	$287.41
Rate for Payer: BCBS Complete	$176.87
Rate for Payer: BCBS Trust/PPO	$684.58
Rate for Payer: BCN Commercial	$684.58
Rate for Payer: Cash Price	$353.74
Rate for Payer: Cash Price	$353.74
Rate for Payer: Cofinity Advantage	$309.52
Rate for Payer: Cofinity Commercial	$380.27
Rate for Payer: Encore Health Key Benefits Commercial	$353.74
Rate for Payer: Healthscope Commercial	$397.95
Rate for Payer: MI Amish Medical Board Commercial	$353.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$375.84
Rate for Payer: Opus (Opus Packaging Group) HMA	$331.63
Rate for Payer: PHP Commercial	$375.84
Rate for Payer: Priority Health SBD	$278.57
Rate for Payer: UHC All Payor (Choice/PPO)	$287.41
Rate for Payer: UHC Core	$230.37
Rate for Payer: UHC Exchange	$173.77

HC OT Z SLEEVE OR GLOVE EA $450

Facility

$468.18

Service Code	HCPCS L3999
Hospital Charge Code	96000042
Hospital Revenue Code	270
Min. Negotiated Rate	$294.95
Max. Negotiated Rate	$421.36
Rate for Payer: Aetna Commercial	$397.95
Rate for Payer: Aetna New Business (MI Preferred)	$304.32
Rate for Payer: Cash Price	$374.54
Rate for Payer: Cofinity Advantage	$327.73
Rate for Payer: Cofinity Commercial	$402.63
Rate for Payer: Encore Health Key Benefits Commercial	$374.54
Rate for Payer: Healthscope Commercial	$421.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$397.95
Rate for Payer: Opus (Opus Packaging Group) HMA	$351.13
Rate for Payer: PHP Commercial	$397.95
Rate for Payer: Priority Health SBD	$294.95

Know your out-of-pocket cost for care.

All Charges