Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

HC OT Z SLEEVE OR GLOVE EA $100

Facility

$102.00

Service Code	HCPCS L3999
Hospital Charge Code	96000026
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 SLEEVE OR GLOVE EA $100

Facility

$102.00

Service Code	HCPCS L3999
Hospital Charge Code	96000026
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 SLEEVE OR GLOVE EA $125

Facility

$127.50

Service Code	HCPCS L3999
Hospital Charge Code	96000027
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 SLEEVE OR GLOVE EA $125

Facility

$127.50

Service Code	HCPCS L3999
Hospital Charge Code	96000027
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 SLEEVE OR GLOVE EA $150

Facility

$153.00

Service Code	HCPCS L3999
Hospital Charge Code	96000028
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 SLEEVE OR GLOVE EA $150

Facility

$153.00

Service Code	HCPCS L3999
Hospital Charge Code	96000028
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 SLEEVE OR GLOVE EA $175

Facility

$178.50

Service Code	HCPCS L3999
Hospital Charge Code	96000029
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 SLEEVE OR GLOVE EA $175

Facility

$178.50

Service Code	HCPCS L3999
Hospital Charge Code	96000029
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 SLEEVE OR GLOVE EA $20

Facility

$20.40

Service Code	HCPCS L3999
Hospital Charge Code	96000030
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 SLEEVE OR GLOVE EA $20

Facility

$20.40

Service Code	HCPCS L3999
Hospital Charge Code	96000030
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 SLEEVE OR GLOVE EA $200

Facility

$204.00

Service Code	HCPCS L3999
Hospital Charge Code	96000031
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 SLEEVE OR GLOVE EA $200

Facility

$204.00

Service Code	HCPCS L3999
Hospital Charge Code	96000031
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 SLEEVE OR GLOVE EA $225

Facility

$229.50

Service Code	HCPCS L3999
Hospital Charge Code	96000032
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 SLEEVE OR GLOVE EA $225

Facility

$229.50

Service Code	HCPCS L3999
Hospital Charge Code	96000032
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 SLEEVE OR GLOVE EA $250

Facility

$255.00

Service Code	HCPCS L3999
Hospital Charge Code	96000033
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

HC OT Z SLEEVE OR GLOVE EA $250

Facility

$255.00

Service Code	HCPCS L3999
Hospital Charge Code	96000033
Hospital Revenue Code	270
Min. Negotiated Rate	$102.00
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna Commercial	$216.75
Rate for Payer: Aetna Medicare	$127.50
Rate for Payer: Aetna New Business (MI Preferred)	$165.75
Rate for Payer: BCBS Complete	$102.00
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

HC OT Z SLEEVE OR GLOVE EA $275

Facility

$280.50

Service Code	HCPCS L3999
Hospital Charge Code	96000034
Hospital Revenue Code	270
Min. Negotiated Rate	$176.72
Max. Negotiated Rate	$252.45
Rate for Payer: Aetna Commercial	$238.43
Rate for Payer: Aetna New Business (MI Preferred)	$182.32
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cofinity Commercial	$196.35
Rate for Payer: Cofinity Commercial	$241.23
Rate for Payer: Cofinity Medicare Advantage	$196.35
Rate for Payer: Encore Health Key Benefits Commercial	$224.40
Rate for Payer: Healthscope Commercial	$252.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$238.43
Rate for Payer: PHP Commercial	$238.43
Rate for Payer: Priority Health Cigna Priority Health	$182.32
Rate for Payer: Priority Health SBD	$176.72

HC OT Z SLEEVE OR GLOVE EA $275

Facility

$280.50

Service Code	HCPCS L3999
Hospital Charge Code	96000034
Hospital Revenue Code	270
Min. Negotiated Rate	$112.20
Max. Negotiated Rate	$252.45
Rate for Payer: Aetna Commercial	$238.43
Rate for Payer: Aetna Medicare	$140.25
Rate for Payer: Aetna New Business (MI Preferred)	$182.32
Rate for Payer: BCBS Complete	$112.20
Rate for Payer: Cash Price	$224.40
Rate for Payer: Cofinity Commercial	$196.35
Rate for Payer: Cofinity Commercial	$241.23
Rate for Payer: Cofinity Medicare Advantage	$196.35
Rate for Payer: Encore Health Key Benefits Commercial	$224.40
Rate for Payer: Healthscope Commercial	$252.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$238.43
Rate for Payer: PHP Commercial	$238.43
Rate for Payer: Priority Health Cigna Priority Health	$182.32
Rate for Payer: Priority Health SBD	$176.72

HC OT Z SLEEVE OR GLOVE EA $300

Facility

$306.00

Service Code	HCPCS L3999
Hospital Charge Code	96000035
Hospital Revenue Code	270
Min. Negotiated Rate	$192.78
Max. Negotiated Rate	$275.40
Rate for Payer: Aetna Commercial	$260.10
Rate for Payer: Aetna New Business (MI Preferred)	$198.90
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cofinity Commercial	$214.20
Rate for Payer: Cofinity Commercial	$263.16
Rate for Payer: Cofinity Medicare Advantage	$214.20
Rate for Payer: Encore Health Key Benefits Commercial	$244.80
Rate for Payer: Healthscope Commercial	$275.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$260.10
Rate for Payer: PHP Commercial	$260.10
Rate for Payer: Priority Health Cigna Priority Health	$198.90
Rate for Payer: Priority Health SBD	$192.78

HC OT Z SLEEVE OR GLOVE EA $300

Facility

$306.00

Service Code	HCPCS L3999
Hospital Charge Code	96000035
Hospital Revenue Code	270
Min. Negotiated Rate	$122.40
Max. Negotiated Rate	$275.40
Rate for Payer: Aetna Commercial	$260.10
Rate for Payer: Aetna Medicare	$153.00
Rate for Payer: Aetna New Business (MI Preferred)	$198.90
Rate for Payer: BCBS Complete	$122.40
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cofinity Commercial	$214.20
Rate for Payer: Cofinity Commercial	$263.16
Rate for Payer: Cofinity Medicare Advantage	$214.20
Rate for Payer: Encore Health Key Benefits Commercial	$244.80
Rate for Payer: Healthscope Commercial	$275.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$260.10
Rate for Payer: PHP Commercial	$260.10
Rate for Payer: Priority Health Cigna Priority Health	$198.90
Rate for Payer: Priority Health SBD	$192.78

HC OT Z SLEEVE OR GLOVE EA $325

Facility

$331.50

Service Code	HCPCS L3999
Hospital Charge Code	96000036
Hospital Revenue Code	270
Min. Negotiated Rate	$208.84
Max. Negotiated Rate	$298.35
Rate for Payer: Aetna Commercial	$281.77
Rate for Payer: Aetna New Business (MI Preferred)	$215.47
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cofinity Commercial	$232.05
Rate for Payer: Cofinity Commercial	$285.09
Rate for Payer: Cofinity Medicare Advantage	$232.05
Rate for Payer: Encore Health Key Benefits Commercial	$265.20
Rate for Payer: Healthscope Commercial	$298.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$281.77
Rate for Payer: PHP Commercial	$281.77
Rate for Payer: Priority Health Cigna Priority Health	$215.47
Rate for Payer: Priority Health SBD	$208.84

HC OT Z SLEEVE OR GLOVE EA $325

Facility

$331.50

Service Code	HCPCS L3999
Hospital Charge Code	96000036
Hospital Revenue Code	270
Min. Negotiated Rate	$132.60
Max. Negotiated Rate	$298.35
Rate for Payer: Aetna Commercial	$281.77
Rate for Payer: Aetna Medicare	$165.75
Rate for Payer: Aetna New Business (MI Preferred)	$215.47
Rate for Payer: BCBS Complete	$132.60
Rate for Payer: Cash Price	$265.20
Rate for Payer: Cofinity Commercial	$232.05
Rate for Payer: Cofinity Commercial	$285.09
Rate for Payer: Cofinity Medicare Advantage	$232.05
Rate for Payer: Encore Health Key Benefits Commercial	$265.20
Rate for Payer: Healthscope Commercial	$298.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$281.77
Rate for Payer: PHP Commercial	$281.77
Rate for Payer: Priority Health Cigna Priority Health	$215.47
Rate for Payer: Priority Health SBD	$208.84

HC OT Z SLEEVE OR GLOVE EA $350

Facility

$357.00

Service Code	HCPCS L3999
Hospital Charge Code	96000037
Hospital Revenue Code	270
Min. Negotiated Rate	$224.91
Max. Negotiated Rate	$321.30
Rate for Payer: Aetna Commercial	$303.45
Rate for Payer: Aetna New Business (MI Preferred)	$232.05
Rate for Payer: Cash Price	$285.60
Rate for Payer: Cofinity Commercial	$249.90
Rate for Payer: Cofinity Commercial	$307.02
Rate for Payer: Cofinity Medicare Advantage	$249.90
Rate for Payer: Encore Health Key Benefits Commercial	$285.60
Rate for Payer: Healthscope Commercial	$321.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$303.45
Rate for Payer: PHP Commercial	$303.45
Rate for Payer: Priority Health Cigna Priority Health	$232.05
Rate for Payer: Priority Health SBD	$224.91

HC OT Z SLEEVE OR GLOVE EA $350

Facility

$357.00

Service Code	HCPCS L3999
Hospital Charge Code	96000037
Hospital Revenue Code	270
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$321.30
Rate for Payer: Aetna Commercial	$303.45
Rate for Payer: Aetna Medicare	$178.50
Rate for Payer: Aetna New Business (MI Preferred)	$232.05
Rate for Payer: BCBS Complete	$142.80
Rate for Payer: Cash Price	$285.60
Rate for Payer: Cofinity Commercial	$249.90
Rate for Payer: Cofinity Commercial	$307.02
Rate for Payer: Cofinity Medicare Advantage	$249.90
Rate for Payer: Encore Health Key Benefits Commercial	$285.60
Rate for Payer: Healthscope Commercial	$321.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$303.45
Rate for Payer: PHP Commercial	$303.45
Rate for Payer: Priority Health Cigna Priority Health	$232.05
Rate for Payer: Priority Health SBD	$224.91

HC OT Z SLEEVE OR GLOVE EA $375

Facility

$382.50

Service Code	HCPCS L3999
Hospital Charge Code	96000038
Hospital Revenue Code	270
Min. Negotiated Rate	$240.97
Max. Negotiated Rate	$344.25
Rate for Payer: Aetna Commercial	$325.12
Rate for Payer: Aetna New Business (MI Preferred)	$248.62
Rate for Payer: Cash Price	$306.00
Rate for Payer: Cofinity Commercial	$267.75
Rate for Payer: Cofinity Commercial	$328.95
Rate for Payer: Cofinity Medicare Advantage	$267.75
Rate for Payer: Encore Health Key Benefits Commercial	$306.00
Rate for Payer: Healthscope Commercial	$344.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$325.12
Rate for Payer: PHP Commercial	$325.12
Rate for Payer: Priority Health Cigna Priority Health	$248.62
Rate for Payer: Priority Health SBD	$240.97

Know your out-of-pocket cost for care.

All Charges