Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC BRACE AK PROSTH SOCK SINGLE-PLY/6

Facility

$129.90

Service Code	HCPCS L8480
Hospital Charge Code	27400034
Hospital Revenue Code	274
Min. Negotiated Rate	$90.93
Max. Negotiated Rate	$129.90
Rate for Payer: Aetna Commercial	$116.91
Rate for Payer: ASR ASR	$126.00
Rate for Payer: BCBS Trust/PPO	$100.71
Rate for Payer: BCN Commercial	$100.71
Rate for Payer: Cash Price	$103.92
Rate for Payer: Cofinity Commercial	$122.11
Rate for Payer: Encore Health Key Benefits Commercial	$103.92
Rate for Payer: Healthscope Commercial	$129.90
Rate for Payer: Healthscope Whirlpool	$126.00
Rate for Payer: Mclaren Commercial	$116.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$110.42
Rate for Payer: Priority Health Cigna Priority Health	$90.93
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$114.31

HC BRACE AK PROSTH SOCK SINGLE-PLY/6

Facility

$129.90

Service Code	HCPCS L8480
Hospital Charge Code	27400034
Hospital Revenue Code	274
Min. Negotiated Rate	$51.96
Max. Negotiated Rate	$129.90
Rate for Payer: Aetna Commercial	$116.91
Rate for Payer: ASR ASR	$126.00
Rate for Payer: BCBS Complete	$51.96
Rate for Payer: BCBS Trust/PPO	$100.71
Rate for Payer: BCN Commercial	$100.71
Rate for Payer: Cash Price	$103.92
Rate for Payer: Cofinity Commercial	$122.11
Rate for Payer: Encore Health Key Benefits Commercial	$103.92
Rate for Payer: Healthscope Commercial	$129.90
Rate for Payer: Healthscope Whirlpool	$126.00
Rate for Payer: Mclaren Commercial	$116.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$110.42
Rate for Payer: Priority Health Cigna Priority Health	$90.93
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$118.21
Rate for Payer: Priority Health Narrow Network	$92.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$114.31

HC BRACE AK RIGID DRESSING NWB

Facility

$1,467.78

Service Code	HCPCS L5460
Hospital Charge Code	27400033
Hospital Revenue Code	274
Min. Negotiated Rate	$1,027.45
Max. Negotiated Rate	$1,467.78
Rate for Payer: Aetna Commercial	$1,321.00
Rate for Payer: ASR ASR	$1,423.75
Rate for Payer: BCBS Trust/PPO	$1,137.97
Rate for Payer: BCN Commercial	$1,137.97
Rate for Payer: Cash Price	$1,174.22
Rate for Payer: Cofinity Commercial	$1,379.71
Rate for Payer: Encore Health Key Benefits Commercial	$1,174.22
Rate for Payer: Healthscope Commercial	$1,467.78
Rate for Payer: Healthscope Whirlpool	$1,423.75
Rate for Payer: Mclaren Commercial	$1,321.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,247.61
Rate for Payer: Priority Health Cigna Priority Health	$1,027.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,291.65

HC BRACE AK RIGID DRESSING NWB

Facility

$1,467.78

Service Code	HCPCS L5460
Hospital Charge Code	27400033
Hospital Revenue Code	274
Min. Negotiated Rate	$587.11
Max. Negotiated Rate	$1,467.78
Rate for Payer: Aetna Commercial	$1,321.00
Rate for Payer: ASR ASR	$1,423.75
Rate for Payer: BCBS Complete	$587.11
Rate for Payer: BCBS Trust/PPO	$1,137.97
Rate for Payer: BCN Commercial	$1,137.97
Rate for Payer: Cash Price	$1,174.22
Rate for Payer: Cofinity Commercial	$1,379.71
Rate for Payer: Encore Health Key Benefits Commercial	$1,174.22
Rate for Payer: Healthscope Commercial	$1,467.78
Rate for Payer: Healthscope Whirlpool	$1,423.75
Rate for Payer: Mclaren Commercial	$1,321.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,247.61
Rate for Payer: Priority Health Cigna Priority Health	$1,027.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,335.68
Rate for Payer: Priority Health Narrow Network	$1,042.12
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,291.65

HC BRACE ANKLE STIRRUP SPLINT

Facility

$144.55

Service Code	HCPCS L4350
Hospital Charge Code	27400001
Hospital Revenue Code	274
Min. Negotiated Rate	$57.82
Max. Negotiated Rate	$144.55
Rate for Payer: Aetna Commercial	$130.10
Rate for Payer: ASR ASR	$140.21
Rate for Payer: BCBS Complete	$57.82
Rate for Payer: BCBS Trust/PPO	$112.07
Rate for Payer: BCN Commercial	$112.07
Rate for Payer: Cash Price	$115.64
Rate for Payer: Cofinity Commercial	$135.88
Rate for Payer: Encore Health Key Benefits Commercial	$115.64
Rate for Payer: Healthscope Commercial	$144.55
Rate for Payer: Healthscope Whirlpool	$140.21
Rate for Payer: Mclaren Commercial	$130.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$122.87
Rate for Payer: Priority Health Cigna Priority Health	$101.18
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$131.54
Rate for Payer: Priority Health Narrow Network	$102.63
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$127.20

HC BRACE ANKLE STIRRUP SPLINT

Facility

$144.55

Service Code	HCPCS L4350
Hospital Charge Code	27400001
Hospital Revenue Code	274
Min. Negotiated Rate	$101.18
Max. Negotiated Rate	$144.55
Rate for Payer: Aetna Commercial	$130.10
Rate for Payer: ASR ASR	$140.21
Rate for Payer: BCBS Trust/PPO	$112.07
Rate for Payer: BCN Commercial	$112.07
Rate for Payer: Cash Price	$115.64
Rate for Payer: Cofinity Commercial	$135.88
Rate for Payer: Encore Health Key Benefits Commercial	$115.64
Rate for Payer: Healthscope Commercial	$144.55
Rate for Payer: Healthscope Whirlpool	$140.21
Rate for Payer: Mclaren Commercial	$130.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$122.87
Rate for Payer: Priority Health Cigna Priority Health	$101.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$127.20

HC BRACE ASPEN COLLAR

Facility

$335.10

Service Code	HCPCS L0172
Hospital Charge Code	27000011
Hospital Revenue Code	274
Min. Negotiated Rate	$134.04
Max. Negotiated Rate	$335.10
Rate for Payer: Aetna Commercial	$301.59
Rate for Payer: ASR ASR	$325.05
Rate for Payer: BCBS Complete	$134.04
Rate for Payer: BCBS Trust/PPO	$259.80
Rate for Payer: BCN Commercial	$259.80
Rate for Payer: Cash Price	$268.08
Rate for Payer: Cofinity Commercial	$314.99
Rate for Payer: Encore Health Key Benefits Commercial	$268.08
Rate for Payer: Healthscope Commercial	$335.10
Rate for Payer: Healthscope Whirlpool	$325.05
Rate for Payer: Mclaren Commercial	$301.59
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$284.84
Rate for Payer: Priority Health Cigna Priority Health	$234.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$304.94
Rate for Payer: Priority Health Narrow Network	$237.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$294.89

HC BRACE ASPEN COLLAR

Facility

$335.10

Service Code	HCPCS L0172
Hospital Charge Code	27000011
Hospital Revenue Code	274
Min. Negotiated Rate	$234.57
Max. Negotiated Rate	$335.10
Rate for Payer: Aetna Commercial	$301.59
Rate for Payer: ASR ASR	$325.05
Rate for Payer: BCBS Trust/PPO	$259.80
Rate for Payer: BCN Commercial	$259.80
Rate for Payer: Cash Price	$268.08
Rate for Payer: Cofinity Commercial	$314.99
Rate for Payer: Encore Health Key Benefits Commercial	$268.08
Rate for Payer: Healthscope Commercial	$335.10
Rate for Payer: Healthscope Whirlpool	$325.05
Rate for Payer: Mclaren Commercial	$301.59
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$284.84
Rate for Payer: Priority Health Cigna Priority Health	$234.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$294.89

HC BRACE BK PROSTH SOCK MULTI-PLY/6

Facility

$296.10

Service Code	HCPCS L8420
Hospital Charge Code	27400024
Hospital Revenue Code	274
Min. Negotiated Rate	$207.27
Max. Negotiated Rate	$296.10
Rate for Payer: Aetna Commercial	$266.49
Rate for Payer: ASR ASR	$287.22
Rate for Payer: BCBS Trust/PPO	$229.57
Rate for Payer: BCN Commercial	$229.57
Rate for Payer: Cash Price	$236.88
Rate for Payer: Cofinity Commercial	$278.33
Rate for Payer: Encore Health Key Benefits Commercial	$236.88
Rate for Payer: Healthscope Commercial	$296.10
Rate for Payer: Healthscope Whirlpool	$287.22
Rate for Payer: Mclaren Commercial	$266.49
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$251.68
Rate for Payer: Priority Health Cigna Priority Health	$207.27
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$260.57

HC BRACE BK PROSTH SOCK MULTI-PLY/6

Facility

$296.10

Service Code	HCPCS L8420
Hospital Charge Code	27400024
Hospital Revenue Code	274
Min. Negotiated Rate	$118.44
Max. Negotiated Rate	$296.10
Rate for Payer: Aetna Commercial	$266.49
Rate for Payer: ASR ASR	$287.22
Rate for Payer: BCBS Complete	$118.44
Rate for Payer: BCBS Trust/PPO	$229.57
Rate for Payer: BCN Commercial	$229.57
Rate for Payer: Cash Price	$236.88
Rate for Payer: Cofinity Commercial	$278.33
Rate for Payer: Encore Health Key Benefits Commercial	$236.88
Rate for Payer: Healthscope Commercial	$296.10
Rate for Payer: Healthscope Whirlpool	$287.22
Rate for Payer: Mclaren Commercial	$266.49
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$251.68
Rate for Payer: Priority Health Cigna Priority Health	$207.27
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$269.45
Rate for Payer: Priority Health Narrow Network	$210.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$260.57

HC BRACE BK PROSTH SOCK SINGLE-PLY/6

Facility

$94.17

Service Code	HCPCS L8470
Hospital Charge Code	27400032
Hospital Revenue Code	274
Min. Negotiated Rate	$37.67
Max. Negotiated Rate	$94.17
Rate for Payer: Aetna Commercial	$84.75
Rate for Payer: ASR ASR	$91.34
Rate for Payer: BCBS Complete	$37.67
Rate for Payer: BCBS Trust/PPO	$73.01
Rate for Payer: BCN Commercial	$73.01
Rate for Payer: Cash Price	$75.34
Rate for Payer: Cofinity Commercial	$88.52
Rate for Payer: Encore Health Key Benefits Commercial	$75.34
Rate for Payer: Healthscope Commercial	$94.17
Rate for Payer: Healthscope Whirlpool	$91.34
Rate for Payer: Mclaren Commercial	$84.75
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$80.04
Rate for Payer: Priority Health Cigna Priority Health	$65.92
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$85.69
Rate for Payer: Priority Health Narrow Network	$66.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$82.87

HC BRACE BK PROSTH SOCK SINGLE-PLY/6

Facility

$94.17

Service Code	HCPCS L8470
Hospital Charge Code	27400032
Hospital Revenue Code	274
Min. Negotiated Rate	$65.92
Max. Negotiated Rate	$94.17
Rate for Payer: Aetna Commercial	$84.75
Rate for Payer: ASR ASR	$91.34
Rate for Payer: BCBS Trust/PPO	$73.01
Rate for Payer: BCN Commercial	$73.01
Rate for Payer: Cash Price	$75.34
Rate for Payer: Cofinity Commercial	$88.52
Rate for Payer: Encore Health Key Benefits Commercial	$75.34
Rate for Payer: Healthscope Commercial	$94.17
Rate for Payer: Healthscope Whirlpool	$91.34
Rate for Payer: Mclaren Commercial	$84.75
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$80.04
Rate for Payer: Priority Health Cigna Priority Health	$65.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$82.87

HC BRACE BK RIGID DRESSING NWB

Facility

$1,099.28

Service Code	HCPCS L5450
Hospital Charge Code	27000013
Hospital Revenue Code	274
Min. Negotiated Rate	$439.71
Max. Negotiated Rate	$1,099.28
Rate for Payer: Aetna Commercial	$989.35
Rate for Payer: ASR ASR	$1,066.30
Rate for Payer: BCBS Complete	$439.71
Rate for Payer: BCBS Trust/PPO	$852.27
Rate for Payer: BCN Commercial	$852.27
Rate for Payer: Cash Price	$879.42
Rate for Payer: Cofinity Commercial	$1,033.32
Rate for Payer: Encore Health Key Benefits Commercial	$879.42
Rate for Payer: Healthscope Commercial	$1,099.28
Rate for Payer: Healthscope Whirlpool	$1,066.30
Rate for Payer: Mclaren Commercial	$989.35
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$934.39
Rate for Payer: Priority Health Cigna Priority Health	$769.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,000.34
Rate for Payer: Priority Health Narrow Network	$780.49
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$967.37

HC BRACE BK RIGID DRESSING NWB

Facility

$1,099.28

Service Code	HCPCS L5450
Hospital Charge Code	27000013
Hospital Revenue Code	274
Min. Negotiated Rate	$769.50
Max. Negotiated Rate	$1,099.28
Rate for Payer: Aetna Commercial	$989.35
Rate for Payer: ASR ASR	$1,066.30
Rate for Payer: BCBS Trust/PPO	$852.27
Rate for Payer: BCN Commercial	$852.27
Rate for Payer: Cash Price	$879.42
Rate for Payer: Cofinity Commercial	$1,033.32
Rate for Payer: Encore Health Key Benefits Commercial	$879.42
Rate for Payer: Healthscope Commercial	$1,099.28
Rate for Payer: Healthscope Whirlpool	$1,066.30
Rate for Payer: Mclaren Commercial	$989.35
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$934.39
Rate for Payer: Priority Health Cigna Priority Health	$769.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$967.37

HC BRACE CERVICAL COLLAR CUSTOM

Facility

$1,234.33

Service Code	HCPCS L0190
Hospital Charge Code	27000014
Hospital Revenue Code	274
Min. Negotiated Rate	$493.73
Max. Negotiated Rate	$1,234.33
Rate for Payer: Aetna Commercial	$1,110.90
Rate for Payer: ASR ASR	$1,197.30
Rate for Payer: BCBS Complete	$493.73
Rate for Payer: BCBS Trust/PPO	$956.98
Rate for Payer: BCN Commercial	$956.98
Rate for Payer: Cash Price	$987.46
Rate for Payer: Cofinity Commercial	$1,160.27
Rate for Payer: Encore Health Key Benefits Commercial	$987.46
Rate for Payer: Healthscope Commercial	$1,234.33
Rate for Payer: Healthscope Whirlpool	$1,197.30
Rate for Payer: Mclaren Commercial	$1,110.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,049.18
Rate for Payer: Priority Health Cigna Priority Health	$864.03
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,123.24
Rate for Payer: Priority Health Narrow Network	$876.37
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,086.21

HC BRACE CERVICAL COLLAR CUSTOM

Facility

$1,234.33

Service Code	HCPCS L0190
Hospital Charge Code	27000014
Hospital Revenue Code	274
Min. Negotiated Rate	$864.03
Max. Negotiated Rate	$1,234.33
Rate for Payer: Aetna Commercial	$1,110.90
Rate for Payer: ASR ASR	$1,197.30
Rate for Payer: BCBS Trust/PPO	$956.98
Rate for Payer: BCN Commercial	$956.98
Rate for Payer: Cash Price	$987.46
Rate for Payer: Cofinity Commercial	$1,160.27
Rate for Payer: Encore Health Key Benefits Commercial	$987.46
Rate for Payer: Healthscope Commercial	$1,234.33
Rate for Payer: Healthscope Whirlpool	$1,197.30
Rate for Payer: Mclaren Commercial	$1,110.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,049.18
Rate for Payer: Priority Health Cigna Priority Health	$864.03
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,086.21

HC BRACE CERVICAL THORA EXTENSION

Facility

$1,050.00

Service Code	HCPCS L1499
Hospital Charge Code	27400030
Hospital Revenue Code	274
Min. Negotiated Rate	$420.00
Max. Negotiated Rate	$1,050.00
Rate for Payer: Aetna Commercial	$945.00
Rate for Payer: ASR ASR	$1,018.50
Rate for Payer: BCBS Complete	$420.00
Rate for Payer: BCBS Trust/PPO	$814.06
Rate for Payer: BCN Commercial	$814.06
Rate for Payer: Cash Price	$840.00
Rate for Payer: Cofinity Commercial	$987.00
Rate for Payer: Encore Health Key Benefits Commercial	$840.00
Rate for Payer: Healthscope Commercial	$1,050.00
Rate for Payer: Healthscope Whirlpool	$1,018.50
Rate for Payer: Mclaren Commercial	$945.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$892.50
Rate for Payer: Priority Health Cigna Priority Health	$735.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$955.50
Rate for Payer: Priority Health Narrow Network	$745.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$924.00

HC BRACE CERVICAL THORA EXTENSION

Facility

$1,050.00

Service Code	HCPCS L1499
Hospital Charge Code	27400030
Hospital Revenue Code	274
Min. Negotiated Rate	$735.00
Max. Negotiated Rate	$1,050.00
Rate for Payer: Aetna Commercial	$945.00
Rate for Payer: ASR ASR	$1,018.50
Rate for Payer: BCBS Trust/PPO	$814.06
Rate for Payer: BCN Commercial	$814.06
Rate for Payer: Cash Price	$840.00
Rate for Payer: Cofinity Commercial	$987.00
Rate for Payer: Encore Health Key Benefits Commercial	$840.00
Rate for Payer: Healthscope Commercial	$1,050.00
Rate for Payer: Healthscope Whirlpool	$1,018.50
Rate for Payer: Mclaren Commercial	$945.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$892.50
Rate for Payer: Priority Health Cigna Priority Health	$735.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$924.00

HC BRACE CTLSO CUSTOM

Facility

$5,767.38

Hospital Charge Code	27000032
Hospital Revenue Code	274
Min. Negotiated Rate	$4,037.17
Max. Negotiated Rate	$5,767.38
Rate for Payer: Aetna Commercial	$5,190.64
Rate for Payer: ASR ASR	$5,594.36
Rate for Payer: BCBS Trust/PPO	$4,471.45
Rate for Payer: BCN Commercial	$4,471.45
Rate for Payer: Cash Price	$4,613.90
Rate for Payer: Cofinity Commercial	$5,421.34
Rate for Payer: Encore Health Key Benefits Commercial	$4,613.90
Rate for Payer: Healthscope Commercial	$5,767.38
Rate for Payer: Healthscope Whirlpool	$5,594.36
Rate for Payer: Mclaren Commercial	$5,190.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4,902.27
Rate for Payer: Priority Health Cigna Priority Health	$4,037.17
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5,075.29

HC BRACE CTLSO CUSTOM

Facility

$5,767.38

Hospital Charge Code	27000032
Hospital Revenue Code	274
Min. Negotiated Rate	$2,306.95
Max. Negotiated Rate	$5,767.38
Rate for Payer: Aetna Commercial	$5,190.64
Rate for Payer: ASR ASR	$5,594.36
Rate for Payer: BCBS Complete	$2,306.95
Rate for Payer: BCBS Trust/PPO	$4,471.45
Rate for Payer: BCN Commercial	$4,471.45
Rate for Payer: Cash Price	$4,613.90
Rate for Payer: Cofinity Commercial	$5,421.34
Rate for Payer: Encore Health Key Benefits Commercial	$4,613.90
Rate for Payer: Healthscope Commercial	$5,767.38
Rate for Payer: Healthscope Whirlpool	$5,594.36
Rate for Payer: Mclaren Commercial	$5,190.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4,902.27
Rate for Payer: Priority Health Cigna Priority Health	$4,037.17
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$5,248.32
Rate for Payer: Priority Health Narrow Network	$4,094.84
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$5,075.29

HC BRACE CTO

Facility

$1,453.00

Service Code	HCPCS L0200
Hospital Charge Code	27400029
Hospital Revenue Code	274
Min. Negotiated Rate	$581.20
Max. Negotiated Rate	$1,453.00
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: ASR ASR	$1,409.41
Rate for Payer: BCBS Complete	$581.20
Rate for Payer: BCBS Trust/PPO	$1,126.51
Rate for Payer: BCN Commercial	$1,126.51
Rate for Payer: Cash Price	$1,162.40
Rate for Payer: Cofinity Commercial	$1,365.82
Rate for Payer: Encore Health Key Benefits Commercial	$1,162.40
Rate for Payer: Healthscope Commercial	$1,453.00
Rate for Payer: Healthscope Whirlpool	$1,409.41
Rate for Payer: Mclaren Commercial	$1,307.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,235.05
Rate for Payer: Priority Health Cigna Priority Health	$1,017.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,322.23
Rate for Payer: Priority Health Narrow Network	$1,031.63
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,278.64

HC BRACE CTO

Facility

$1,453.00

Service Code	HCPCS L0200
Hospital Charge Code	27400029
Hospital Revenue Code	274
Min. Negotiated Rate	$1,017.10
Max. Negotiated Rate	$1,453.00
Rate for Payer: Aetna Commercial	$1,307.70
Rate for Payer: ASR ASR	$1,409.41
Rate for Payer: BCBS Trust/PPO	$1,126.51
Rate for Payer: BCN Commercial	$1,126.51
Rate for Payer: Cash Price	$1,162.40
Rate for Payer: Cofinity Commercial	$1,365.82
Rate for Payer: Encore Health Key Benefits Commercial	$1,162.40
Rate for Payer: Healthscope Commercial	$1,453.00
Rate for Payer: Healthscope Whirlpool	$1,409.41
Rate for Payer: Mclaren Commercial	$1,307.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,235.05
Rate for Payer: Priority Health Cigna Priority Health	$1,017.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,278.64

HC BRACE CTO REPLACEMENT PADS

Facility

$270.00

Service Code	HCPCS L1499
Hospital Charge Code	27400045
Hospital Revenue Code	274
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$243.00
Rate for Payer: ASR ASR	$261.90
Rate for Payer: BCBS Trust/PPO	$209.33
Rate for Payer: BCN Commercial	$209.33
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cofinity Commercial	$253.80
Rate for Payer: Encore Health Key Benefits Commercial	$216.00
Rate for Payer: Healthscope Commercial	$270.00
Rate for Payer: Healthscope Whirlpool	$261.90
Rate for Payer: Mclaren Commercial	$243.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$229.50
Rate for Payer: Priority Health Cigna Priority Health	$189.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$237.60

HC BRACE CTO REPLACEMENT PADS

Facility

$270.00

Service Code	HCPCS L1499
Hospital Charge Code	27400045
Hospital Revenue Code	274
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$243.00
Rate for Payer: ASR ASR	$261.90
Rate for Payer: BCBS Complete	$108.00
Rate for Payer: BCBS Trust/PPO	$209.33
Rate for Payer: BCN Commercial	$209.33
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cofinity Commercial	$253.80
Rate for Payer: Encore Health Key Benefits Commercial	$216.00
Rate for Payer: Healthscope Commercial	$270.00
Rate for Payer: Healthscope Whirlpool	$261.90
Rate for Payer: Mclaren Commercial	$243.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$229.50
Rate for Payer: Priority Health Cigna Priority Health	$189.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$245.70
Rate for Payer: Priority Health Narrow Network	$191.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$237.60

HC BRACE D RING SPLINT

Facility

$69.00

Service Code	HCPCS L3908
Hospital Charge Code	27400013
Hospital Revenue Code	274
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$62.10
Rate for Payer: ASR ASR	$66.93
Rate for Payer: BCBS Trust/PPO	$53.50
Rate for Payer: BCN Commercial	$53.50
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cofinity Commercial	$64.86
Rate for Payer: Encore Health Key Benefits Commercial	$55.20
Rate for Payer: Healthscope Commercial	$69.00
Rate for Payer: Healthscope Whirlpool	$66.93
Rate for Payer: Mclaren Commercial	$62.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$58.65
Rate for Payer: Priority Health Cigna Priority Health	$48.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$60.72

Know your out-of-pocket cost for care.

All Charges