Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC OSU OBSERVATION PER HOUR

Facility

$145.08

Service Code	HCPCS G0378
Hospital Charge Code	76200009
Hospital Revenue Code	762
Min. Negotiated Rate	$91.40
Max. Negotiated Rate	$130.57
Rate for Payer: Aetna Commercial	$123.32
Rate for Payer: Aetna New Business (MI Preferred)	$94.30
Rate for Payer: Cash Price	$116.06
Rate for Payer: Cofinity Commercial	$101.56
Rate for Payer: Cofinity Commercial	$124.77
Rate for Payer: Cofinity Medicare Advantage	$101.56
Rate for Payer: Encore Health Key Benefits Commercial	$116.06
Rate for Payer: Healthscope Commercial	$130.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$123.32
Rate for Payer: PHP Commercial	$123.32
Rate for Payer: Priority Health Cigna Priority Health	$94.30
Rate for Payer: Priority Health SBD	$91.40

HC OSU OBSERVATION PER HOUR

Facility

$145.08

Service Code	HCPCS G0378
Hospital Charge Code	76200009
Hospital Revenue Code	762
Min. Negotiated Rate	$58.03
Max. Negotiated Rate	$1,000.00
Rate for Payer: Aetna Commercial	$123.32
Rate for Payer: Aetna Medicare	$72.54
Rate for Payer: Aetna New Business (MI Preferred)	$94.30
Rate for Payer: BCBS Complete	$58.03
Rate for Payer: Cash Price	$116.06
Rate for Payer: Cash Price	$116.06
Rate for Payer: Cofinity Commercial	$101.56
Rate for Payer: Cofinity Commercial	$124.77
Rate for Payer: Cofinity Medicare Advantage	$101.56
Rate for Payer: Encore Health Key Benefits Commercial	$116.06
Rate for Payer: Healthscope Commercial	$130.57
Rate for Payer: Meridian Medicaid	$1,000.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$123.32
Rate for Payer: PHP Commercial	$123.32
Rate for Payer: Priority Health Cigna Priority Health	$94.30
Rate for Payer: Priority Health SBD	$91.40
Rate for Payer: UHC Core	$107.36
Rate for Payer: UHC Exchange	$107.36

HC OT EVAL HIGH COMPLEXITY

Facility

$279.25

Service Code	CPT 97167
Hospital Charge Code	43400009
Hospital Revenue Code	434
Min. Negotiated Rate	$111.70
Max. Negotiated Rate	$251.32
Rate for Payer: Aetna Commercial	$237.36
Rate for Payer: Aetna Medicare	$139.62
Rate for Payer: Aetna New Business (MI Preferred)	$181.51
Rate for Payer: BCBS Complete	$111.70
Rate for Payer: Cash Price	$223.40
Rate for Payer: Cash Price	$223.40
Rate for Payer: Cofinity Commercial	$240.16
Rate for Payer: Cofinity Commercial	$195.47
Rate for Payer: Cofinity Medicare Advantage	$195.47
Rate for Payer: Encore Health Key Benefits Commercial	$223.40
Rate for Payer: Healthscope Commercial	$251.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$237.36
Rate for Payer: Nomi Health Commercial	$135.00
Rate for Payer: PHP Commercial	$237.36
Rate for Payer: Priority Health Cigna Priority Health	$181.51
Rate for Payer: Priority Health SBD	$175.93
Rate for Payer: UHC Core	$206.65
Rate for Payer: UHC Exchange	$206.65

HC OT EVAL HIGH COMPLEXITY

Facility

$279.25

Service Code	CPT 97167
Hospital Charge Code	43400009
Hospital Revenue Code	434
Min. Negotiated Rate	$175.93
Max. Negotiated Rate	$251.32
Rate for Payer: Aetna Commercial	$237.36
Rate for Payer: Aetna New Business (MI Preferred)	$181.51
Rate for Payer: Cash Price	$223.40
Rate for Payer: Cofinity Commercial	$195.47
Rate for Payer: Cofinity Commercial	$240.16
Rate for Payer: Cofinity Medicare Advantage	$195.47
Rate for Payer: Encore Health Key Benefits Commercial	$223.40
Rate for Payer: Healthscope Commercial	$251.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$237.36
Rate for Payer: PHP Commercial	$237.36
Rate for Payer: Priority Health Cigna Priority Health	$181.51
Rate for Payer: Priority Health SBD	$175.93

HC OT EVAL LOW COMPLEXITY

Facility

$228.47

Service Code	CPT 97165
Hospital Charge Code	43400007
Hospital Revenue Code	434
Min. Negotiated Rate	$143.94
Max. Negotiated Rate	$205.62
Rate for Payer: Aetna Commercial	$194.20
Rate for Payer: Aetna New Business (MI Preferred)	$148.51
Rate for Payer: Cash Price	$182.78
Rate for Payer: Cofinity Commercial	$159.93
Rate for Payer: Cofinity Commercial	$196.48
Rate for Payer: Cofinity Medicare Advantage	$159.93
Rate for Payer: Encore Health Key Benefits Commercial	$182.78
Rate for Payer: Healthscope Commercial	$205.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$194.20
Rate for Payer: PHP Commercial	$194.20
Rate for Payer: Priority Health Cigna Priority Health	$148.51
Rate for Payer: Priority Health SBD	$143.94

HC OT EVAL LOW COMPLEXITY

Facility

$228.47

Service Code	CPT 97165
Hospital Charge Code	43400007
Hospital Revenue Code	434
Min. Negotiated Rate	$91.39
Max. Negotiated Rate	$205.62
Rate for Payer: Aetna Commercial	$194.20
Rate for Payer: Aetna Medicare	$114.23
Rate for Payer: Aetna New Business (MI Preferred)	$148.51
Rate for Payer: BCBS Complete	$91.39
Rate for Payer: Cash Price	$182.78
Rate for Payer: Cash Price	$182.78
Rate for Payer: Cofinity Commercial	$196.48
Rate for Payer: Cofinity Commercial	$159.93
Rate for Payer: Cofinity Medicare Advantage	$159.93
Rate for Payer: Encore Health Key Benefits Commercial	$182.78
Rate for Payer: Healthscope Commercial	$205.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$194.20
Rate for Payer: Nomi Health Commercial	$135.00
Rate for Payer: PHP Commercial	$194.20
Rate for Payer: Priority Health Cigna Priority Health	$148.51
Rate for Payer: Priority Health SBD	$143.94
Rate for Payer: UHC Core	$169.07
Rate for Payer: UHC Exchange	$169.07

HC OT EVAL MODERATE COMPLEXITY

Facility

$253.86

Service Code	CPT 97166
Hospital Charge Code	43400008
Hospital Revenue Code	434
Min. Negotiated Rate	$101.54
Max. Negotiated Rate	$228.47
Rate for Payer: Aetna Commercial	$215.78
Rate for Payer: Aetna Medicare	$126.93
Rate for Payer: Aetna New Business (MI Preferred)	$165.01
Rate for Payer: BCBS Complete	$101.54
Rate for Payer: Cash Price	$203.09
Rate for Payer: Cash Price	$203.09
Rate for Payer: Cofinity Commercial	$218.32
Rate for Payer: Cofinity Commercial	$177.70
Rate for Payer: Cofinity Medicare Advantage	$177.70
Rate for Payer: Encore Health Key Benefits Commercial	$203.09
Rate for Payer: Healthscope Commercial	$228.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$215.78
Rate for Payer: Nomi Health Commercial	$135.00
Rate for Payer: PHP Commercial	$215.78
Rate for Payer: Priority Health Cigna Priority Health	$165.01
Rate for Payer: Priority Health SBD	$159.93
Rate for Payer: UHC Core	$187.86
Rate for Payer: UHC Exchange	$187.86

HC OT EVAL MODERATE COMPLEXITY

Facility

$253.86

Service Code	CPT 97166
Hospital Charge Code	43400008
Hospital Revenue Code	434
Min. Negotiated Rate	$159.93
Max. Negotiated Rate	$228.47
Rate for Payer: Aetna Commercial	$215.78
Rate for Payer: Aetna New Business (MI Preferred)	$165.01
Rate for Payer: Cash Price	$203.09
Rate for Payer: Cofinity Commercial	$177.70
Rate for Payer: Cofinity Commercial	$218.32
Rate for Payer: Cofinity Medicare Advantage	$177.70
Rate for Payer: Encore Health Key Benefits Commercial	$203.09
Rate for Payer: Healthscope Commercial	$228.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$215.78
Rate for Payer: PHP Commercial	$215.78
Rate for Payer: Priority Health Cigna Priority Health	$165.01
Rate for Payer: Priority Health SBD	$159.93

HC OT RE-EVALUATION

Facility

$120.36

Service Code	CPT 97168
Hospital Charge Code	43400010
Hospital Revenue Code	434
Min. Negotiated Rate	$48.14
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$102.31
Rate for Payer: Aetna Medicare	$60.18
Rate for Payer: Aetna New Business (MI Preferred)	$78.23
Rate for Payer: BCBS Complete	$48.14
Rate for Payer: Cash Price	$96.29
Rate for Payer: Cash Price	$96.29
Rate for Payer: Cofinity Commercial	$84.25
Rate for Payer: Cofinity Commercial	$103.51
Rate for Payer: Cofinity Medicare Advantage	$84.25
Rate for Payer: Encore Health Key Benefits Commercial	$96.29
Rate for Payer: Healthscope Commercial	$108.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$102.31
Rate for Payer: Nomi Health Commercial	$135.00
Rate for Payer: PHP Commercial	$102.31
Rate for Payer: Priority Health Cigna Priority Health	$78.23
Rate for Payer: Priority Health SBD	$75.83
Rate for Payer: UHC Core	$89.07
Rate for Payer: UHC Exchange	$89.07

HC OT RE-EVALUATION

Facility

$120.36

Service Code	CPT 97168
Hospital Charge Code	43400010
Hospital Revenue Code	434
Min. Negotiated Rate	$75.83
Max. Negotiated Rate	$108.32
Rate for Payer: Aetna Commercial	$102.31
Rate for Payer: Aetna New Business (MI Preferred)	$78.23
Rate for Payer: Cash Price	$96.29
Rate for Payer: Cofinity Commercial	$103.51
Rate for Payer: Cofinity Commercial	$84.25
Rate for Payer: Cofinity Medicare Advantage	$84.25
Rate for Payer: Encore Health Key Benefits Commercial	$96.29
Rate for Payer: Healthscope Commercial	$108.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$102.31
Rate for Payer: PHP Commercial	$102.31
Rate for Payer: Priority Health Cigna Priority Health	$78.23
Rate for Payer: Priority Health SBD	$75.83

HC OT Z GAUNTLET EA $100

Facility

$102.00

Service Code	HCPCS A6549
Hospital Charge Code	98300074
Hospital Revenue Code	270
Min. Negotiated Rate	$64.26
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna Commercial	$86.70
Rate for Payer: Aetna New Business (MI Preferred)	$66.30
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cofinity Commercial	$71.40
Rate for Payer: Cofinity Commercial	$87.72
Rate for Payer: Cofinity Medicare Advantage	$71.40
Rate for Payer: Encore Health Key Benefits Commercial	$81.60
Rate for Payer: Healthscope Commercial	$91.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.70
Rate for Payer: PHP Commercial	$86.70
Rate for Payer: Priority Health Cigna Priority Health	$66.30
Rate for Payer: Priority Health SBD	$64.26

HC OT Z GAUNTLET EA $100

Facility

$102.00

Service Code	HCPCS A6549
Hospital Charge Code	98300074
Hospital Revenue Code	270
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna Commercial	$86.70
Rate for Payer: Aetna Medicare	$51.00
Rate for Payer: Aetna New Business (MI Preferred)	$66.30
Rate for Payer: BCBS Complete	$40.80
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cofinity Commercial	$71.40
Rate for Payer: Cofinity Commercial	$87.72
Rate for Payer: Cofinity Medicare Advantage	$71.40
Rate for Payer: Encore Health Key Benefits Commercial	$81.60
Rate for Payer: Healthscope Commercial	$91.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.70
Rate for Payer: PHP Commercial	$86.70
Rate for Payer: Priority Health Cigna Priority Health	$66.30
Rate for Payer: Priority Health SBD	$64.26

HC OT Z GAUNTLET EA $125

Facility

$127.50

Service Code	HCPCS A6549
Hospital Charge Code	98300075
Hospital Revenue Code	270
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$114.75
Rate for Payer: Aetna Commercial	$108.38
Rate for Payer: Aetna Medicare	$63.75
Rate for Payer: Aetna New Business (MI Preferred)	$82.88
Rate for Payer: BCBS Complete	$51.00
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cofinity Commercial	$109.65
Rate for Payer: Cofinity Commercial	$89.25
Rate for Payer: Cofinity Medicare Advantage	$89.25
Rate for Payer: Encore Health Key Benefits Commercial	$102.00
Rate for Payer: Healthscope Commercial	$114.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$108.38
Rate for Payer: PHP Commercial	$108.38
Rate for Payer: Priority Health Cigna Priority Health	$82.88
Rate for Payer: Priority Health SBD	$80.33

HC OT Z GAUNTLET EA $125

Facility

$127.50

Service Code	HCPCS A6549
Hospital Charge Code	98300075
Hospital Revenue Code	270
Min. Negotiated Rate	$80.33
Max. Negotiated Rate	$114.75
Rate for Payer: Aetna Commercial	$108.38
Rate for Payer: Aetna New Business (MI Preferred)	$82.88
Rate for Payer: Cash Price	$102.00
Rate for Payer: Cofinity Commercial	$109.65
Rate for Payer: Cofinity Commercial	$89.25
Rate for Payer: Cofinity Medicare Advantage	$89.25
Rate for Payer: Encore Health Key Benefits Commercial	$102.00
Rate for Payer: Healthscope Commercial	$114.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$108.38
Rate for Payer: PHP Commercial	$108.38
Rate for Payer: Priority Health Cigna Priority Health	$82.88
Rate for Payer: Priority Health SBD	$80.33

HC OT Z GAUNTLET EA $150

Facility

$153.00

Service Code	HCPCS A6549
Hospital Charge Code	98300076
Hospital Revenue Code	270
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna Commercial	$130.05
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: Aetna New Business (MI Preferred)	$99.45
Rate for Payer: BCBS Complete	$61.20
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cofinity Commercial	$107.10
Rate for Payer: Cofinity Commercial	$131.58
Rate for Payer: Cofinity Medicare Advantage	$107.10
Rate for Payer: Encore Health Key Benefits Commercial	$122.40
Rate for Payer: Healthscope Commercial	$137.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$130.05
Rate for Payer: PHP Commercial	$130.05
Rate for Payer: Priority Health Cigna Priority Health	$99.45
Rate for Payer: Priority Health SBD	$96.39

HC OT Z GAUNTLET EA $150

Facility

$153.00

Service Code	HCPCS A6549
Hospital Charge Code	98300076
Hospital Revenue Code	270
Min. Negotiated Rate	$96.39
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna Commercial	$130.05
Rate for Payer: Aetna New Business (MI Preferred)	$99.45
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cofinity Commercial	$107.10
Rate for Payer: Cofinity Commercial	$131.58
Rate for Payer: Cofinity Medicare Advantage	$107.10
Rate for Payer: Encore Health Key Benefits Commercial	$122.40
Rate for Payer: Healthscope Commercial	$137.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$130.05
Rate for Payer: PHP Commercial	$130.05
Rate for Payer: Priority Health Cigna Priority Health	$99.45
Rate for Payer: Priority Health SBD	$96.39

HC OT Z GAUNTLET EA $175

Facility

$178.50

Service Code	HCPCS A6549
Hospital Charge Code	98300077
Hospital Revenue Code	270
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$160.65
Rate for Payer: Aetna Commercial	$151.72
Rate for Payer: Aetna Medicare	$89.25
Rate for Payer: Aetna New Business (MI Preferred)	$116.03
Rate for Payer: BCBS Complete	$71.40
Rate for Payer: Cash Price	$142.80
Rate for Payer: Cofinity Commercial	$124.95
Rate for Payer: Cofinity Commercial	$153.51
Rate for Payer: Cofinity Medicare Advantage	$124.95
Rate for Payer: Encore Health Key Benefits Commercial	$142.80
Rate for Payer: Healthscope Commercial	$160.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$151.72
Rate for Payer: PHP Commercial	$151.72
Rate for Payer: Priority Health Cigna Priority Health	$116.03
Rate for Payer: Priority Health SBD	$112.45

HC OT Z GAUNTLET EA $175

Facility

$178.50

Service Code	HCPCS A6549
Hospital Charge Code	98300077
Hospital Revenue Code	270
Min. Negotiated Rate	$112.45
Max. Negotiated Rate	$160.65
Rate for Payer: Aetna Commercial	$151.72
Rate for Payer: Aetna New Business (MI Preferred)	$116.03
Rate for Payer: Cash Price	$142.80
Rate for Payer: Cofinity Commercial	$124.95
Rate for Payer: Cofinity Commercial	$153.51
Rate for Payer: Cofinity Medicare Advantage	$124.95
Rate for Payer: Encore Health Key Benefits Commercial	$142.80
Rate for Payer: Healthscope Commercial	$160.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$151.72
Rate for Payer: PHP Commercial	$151.72
Rate for Payer: Priority Health Cigna Priority Health	$116.03
Rate for Payer: Priority Health SBD	$112.45

HC OT Z GAUNTLET EA $20

Facility

$20.40

Service Code	HCPCS A6549
Hospital Charge Code	98300078
Hospital Revenue Code	270
Min. Negotiated Rate	$12.85
Max. Negotiated Rate	$18.36
Rate for Payer: Aetna Commercial	$17.34
Rate for Payer: Aetna New Business (MI Preferred)	$13.26
Rate for Payer: Cash Price	$16.32
Rate for Payer: Cofinity Commercial	$14.28
Rate for Payer: Cofinity Commercial	$17.54
Rate for Payer: Cofinity Medicare Advantage	$14.28
Rate for Payer: Encore Health Key Benefits Commercial	$16.32
Rate for Payer: Healthscope Commercial	$18.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.34
Rate for Payer: PHP Commercial	$17.34
Rate for Payer: Priority Health Cigna Priority Health	$13.26
Rate for Payer: Priority Health SBD	$12.85

HC OT Z GAUNTLET EA $20

Facility

$20.40

Service Code	HCPCS A6549
Hospital Charge Code	98300078
Hospital Revenue Code	270
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$18.36
Rate for Payer: Aetna Commercial	$17.34
Rate for Payer: Aetna Medicare	$10.20
Rate for Payer: Aetna New Business (MI Preferred)	$13.26
Rate for Payer: BCBS Complete	$8.16
Rate for Payer: Cash Price	$16.32
Rate for Payer: Cofinity Commercial	$14.28
Rate for Payer: Cofinity Commercial	$17.54
Rate for Payer: Cofinity Medicare Advantage	$14.28
Rate for Payer: Encore Health Key Benefits Commercial	$16.32
Rate for Payer: Healthscope Commercial	$18.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.34
Rate for Payer: PHP Commercial	$17.34
Rate for Payer: Priority Health Cigna Priority Health	$13.26
Rate for Payer: Priority Health SBD	$12.85

HC OT Z GAUNTLET EA $200

Facility

$204.00

Service Code	HCPCS A6549
Hospital Charge Code	98300079
Hospital Revenue Code	270
Min. Negotiated Rate	$128.52
Max. Negotiated Rate	$183.60
Rate for Payer: Aetna Commercial	$173.40
Rate for Payer: Aetna New Business (MI Preferred)	$132.60
Rate for Payer: Cash Price	$163.20
Rate for Payer: Cofinity Commercial	$142.80
Rate for Payer: Cofinity Commercial	$175.44
Rate for Payer: Cofinity Medicare Advantage	$142.80
Rate for Payer: Encore Health Key Benefits Commercial	$163.20
Rate for Payer: Healthscope Commercial	$183.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$173.40
Rate for Payer: PHP Commercial	$173.40
Rate for Payer: Priority Health Cigna Priority Health	$132.60
Rate for Payer: Priority Health SBD	$128.52

HC OT Z GAUNTLET EA $200

Facility

$204.00

Service Code	HCPCS A6549
Hospital Charge Code	98300079
Hospital Revenue Code	270
Min. Negotiated Rate	$81.60
Max. Negotiated Rate	$183.60
Rate for Payer: Aetna Commercial	$173.40
Rate for Payer: Aetna Medicare	$102.00
Rate for Payer: Aetna New Business (MI Preferred)	$132.60
Rate for Payer: BCBS Complete	$81.60
Rate for Payer: Cash Price	$163.20
Rate for Payer: Cofinity Commercial	$142.80
Rate for Payer: Cofinity Commercial	$175.44
Rate for Payer: Cofinity Medicare Advantage	$142.80
Rate for Payer: Encore Health Key Benefits Commercial	$163.20
Rate for Payer: Healthscope Commercial	$183.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$173.40
Rate for Payer: PHP Commercial	$173.40
Rate for Payer: Priority Health Cigna Priority Health	$132.60
Rate for Payer: Priority Health SBD	$128.52

HC OT Z GAUNTLET EA $225

Facility

$229.50

Service Code	HCPCS A6549
Hospital Charge Code	98300080
Hospital Revenue Code	270
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$206.55
Rate for Payer: Aetna Commercial	$195.07
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	$195.07
Rate for Payer: PHP Commercial	$195.07
Rate for Payer: Priority Health Cigna Priority Health	$149.18
Rate for Payer: Priority Health SBD	$144.59

HC OT Z GAUNTLET EA $225

Facility

$229.50

Service Code	HCPCS A6549
Hospital Charge Code	98300080
Hospital Revenue Code	270
Min. Negotiated Rate	$144.59
Max. Negotiated Rate	$206.55
Rate for Payer: Aetna Commercial	$195.07
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	$195.07
Rate for Payer: PHP Commercial	$195.07
Rate for Payer: Priority Health Cigna Priority Health	$149.18
Rate for Payer: Priority Health SBD	$144.59

HC OT Z GAUNTLET EA $250

Facility

$255.00

Service Code	HCPCS A6549
Hospital Charge Code	98300081
Hospital Revenue Code	270
Min. Negotiated Rate	$160.65
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna Commercial	$216.75
Rate for Payer: Aetna New Business (MI Preferred)	$165.75
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cofinity Commercial	$178.50
Rate for Payer: Cofinity Commercial	$219.30
Rate for Payer: Cofinity Medicare Advantage	$178.50
Rate for Payer: Encore Health Key Benefits Commercial	$204.00
Rate for Payer: Healthscope Commercial	$229.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$216.75
Rate for Payer: PHP Commercial	$216.75
Rate for Payer: Priority Health Cigna Priority Health	$165.75
Rate for Payer: Priority Health SBD	$160.65

Know your out-of-pocket cost for care.

All Charges