Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC COMP BURN GARM GLOVE-ELBOW

Facility

$160.00

Service Code	HCPCS A6505
Hospital Charge Code	98300030
Hospital Revenue Code	270
Min. Negotiated Rate	$64.00
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna Commercial	$144.00
Rate for Payer: ASR ASR	$155.20
Rate for Payer: BCBS Complete	$64.00
Rate for Payer: BCBS Trust/PPO	$124.05
Rate for Payer: BCN Commercial	$124.05
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cofinity Commercial	$150.40
Rate for Payer: Encore Health Key Benefits Commercial	$128.00
Rate for Payer: Healthscope Commercial	$160.00
Rate for Payer: Healthscope Whirlpool	$155.20
Rate for Payer: Mclaren Commercial	$144.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$136.00
Rate for Payer: Priority Health Cigna Priority Health	$112.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$145.60
Rate for Payer: Priority Health Narrow Network	$113.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$140.80

HC COMP BURN GARM GLOVE-ELBOW

Facility

$160.00

Service Code	HCPCS A6505
Hospital Charge Code	98300030
Hospital Revenue Code	270
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna Commercial	$144.00
Rate for Payer: ASR ASR	$155.20
Rate for Payer: BCBS Trust/PPO	$124.05
Rate for Payer: BCN Commercial	$124.05
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cofinity Commercial	$150.40
Rate for Payer: Encore Health Key Benefits Commercial	$128.00
Rate for Payer: Healthscope Commercial	$160.00
Rate for Payer: Healthscope Whirlpool	$155.20
Rate for Payer: Mclaren Commercial	$144.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$136.00
Rate for Payer: Priority Health Cigna Priority Health	$112.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$140.80

HC COMP BURN GARM GLOVE TO AXILLA

Facility

$176.00

Service Code	HCPCS A6506
Hospital Charge Code	98300029
Hospital Revenue Code	270
Min. Negotiated Rate	$70.40
Max. Negotiated Rate	$176.00
Rate for Payer: Aetna Commercial	$158.40
Rate for Payer: ASR ASR	$170.72
Rate for Payer: BCBS Complete	$70.40
Rate for Payer: BCBS Trust/PPO	$136.45
Rate for Payer: BCN Commercial	$136.45
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cofinity Commercial	$165.44
Rate for Payer: Encore Health Key Benefits Commercial	$140.80
Rate for Payer: Healthscope Commercial	$176.00
Rate for Payer: Healthscope Whirlpool	$170.72
Rate for Payer: Mclaren Commercial	$158.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$149.60
Rate for Payer: Priority Health Cigna Priority Health	$123.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$160.16
Rate for Payer: Priority Health Narrow Network	$124.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$154.88

HC COMP BURN GARM GLOVE TO AXILLA

Facility

$176.00

Service Code	HCPCS A6506
Hospital Charge Code	98300029
Hospital Revenue Code	270
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$176.00
Rate for Payer: Aetna Commercial	$158.40
Rate for Payer: ASR ASR	$170.72
Rate for Payer: BCBS Trust/PPO	$136.45
Rate for Payer: BCN Commercial	$136.45
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cofinity Commercial	$165.44
Rate for Payer: Encore Health Key Benefits Commercial	$140.80
Rate for Payer: Healthscope Commercial	$176.00
Rate for Payer: Healthscope Whirlpool	$170.72
Rate for Payer: Mclaren Commercial	$158.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$149.60
Rate for Payer: Priority Health Cigna Priority Health	$123.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$154.88

HC COMP BURN GARM GLOVE-WRIST

Facility

$110.00

Service Code	HCPCS A6504
Hospital Charge Code	98300031
Hospital Revenue Code	270
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$99.00
Rate for Payer: ASR ASR	$106.70
Rate for Payer: BCBS Complete	$44.00
Rate for Payer: BCBS Trust/PPO	$85.28
Rate for Payer: BCN Commercial	$85.28
Rate for Payer: Cash Price	$88.00
Rate for Payer: Cofinity Commercial	$103.40
Rate for Payer: Encore Health Key Benefits Commercial	$88.00
Rate for Payer: Healthscope Commercial	$110.00
Rate for Payer: Healthscope Whirlpool	$106.70
Rate for Payer: Mclaren Commercial	$99.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$93.50
Rate for Payer: Priority Health Cigna Priority Health	$77.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$100.10
Rate for Payer: Priority Health Narrow Network	$78.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$96.80

HC COMP BURN GARM GLOVE-WRIST

Facility

$110.00

Service Code	HCPCS A6504
Hospital Charge Code	98300031
Hospital Revenue Code	270
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$99.00
Rate for Payer: ASR ASR	$106.70
Rate for Payer: BCBS Trust/PPO	$85.28
Rate for Payer: BCN Commercial	$85.28
Rate for Payer: Cash Price	$88.00
Rate for Payer: Cofinity Commercial	$103.40
Rate for Payer: Encore Health Key Benefits Commercial	$88.00
Rate for Payer: Healthscope Commercial	$110.00
Rate for Payer: Healthscope Whirlpool	$106.70
Rate for Payer: Mclaren Commercial	$99.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$93.50
Rate for Payer: Priority Health Cigna Priority Health	$77.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$96.80

HC COMP BURN GARM HEAD BAND

Facility

$40.00

Service Code	HCPCS A6512
Hospital Charge Code	98300032
Hospital Revenue Code	270
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: ASR ASR	$38.80
Rate for Payer: BCBS Complete	$16.00
Rate for Payer: BCBS Trust/PPO	$31.01
Rate for Payer: BCN Commercial	$31.01
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cofinity Commercial	$37.60
Rate for Payer: Encore Health Key Benefits Commercial	$32.00
Rate for Payer: Healthscope Commercial	$40.00
Rate for Payer: Healthscope Whirlpool	$38.80
Rate for Payer: Mclaren Commercial	$36.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$34.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$36.40
Rate for Payer: Priority Health Narrow Network	$28.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$35.20

HC COMP BURN GARM HEAD BAND

Facility

$40.00

Service Code	HCPCS A6512
Hospital Charge Code	98300032
Hospital Revenue Code	270
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$36.00
Rate for Payer: ASR ASR	$38.80
Rate for Payer: BCBS Trust/PPO	$31.01
Rate for Payer: BCN Commercial	$31.01
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cofinity Commercial	$37.60
Rate for Payer: Encore Health Key Benefits Commercial	$32.00
Rate for Payer: Healthscope Commercial	$40.00
Rate for Payer: Healthscope Whirlpool	$38.80
Rate for Payer: Mclaren Commercial	$36.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$34.00
Rate for Payer: Priority Health Cigna Priority Health	$28.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$35.20

HC COMP BURN GARM HOOK&LOOP SNAP

Facility

$14.00

Service Code	HCPCS A6512
Hospital Charge Code	98300033
Hospital Revenue Code	270
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: ASR ASR	$13.58
Rate for Payer: BCBS Complete	$5.60
Rate for Payer: BCBS Trust/PPO	$10.85
Rate for Payer: BCN Commercial	$10.85
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cofinity Commercial	$13.16
Rate for Payer: Encore Health Key Benefits Commercial	$11.20
Rate for Payer: Healthscope Commercial	$14.00
Rate for Payer: Healthscope Whirlpool	$13.58
Rate for Payer: Mclaren Commercial	$12.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.90
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12.74
Rate for Payer: Priority Health Narrow Network	$9.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.32

HC COMP BURN GARM HOOK&LOOP SNAP

Facility

$14.00

Service Code	HCPCS A6512
Hospital Charge Code	98300033
Hospital Revenue Code	270
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: ASR ASR	$13.58
Rate for Payer: BCBS Trust/PPO	$10.85
Rate for Payer: BCN Commercial	$10.85
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cofinity Commercial	$13.16
Rate for Payer: Encore Health Key Benefits Commercial	$11.20
Rate for Payer: Healthscope Commercial	$14.00
Rate for Payer: Healthscope Whirlpool	$13.58
Rate for Payer: Mclaren Commercial	$12.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.90
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.32

HC COMP BURN GARM HOOK&LOOP TAB S

Facility

$8.00

Service Code	HCPCS A6512
Hospital Charge Code	98300034
Hospital Revenue Code	270
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.20
Rate for Payer: ASR ASR	$7.76
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: BCBS Trust/PPO	$6.20
Rate for Payer: BCN Commercial	$6.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cofinity Commercial	$7.52
Rate for Payer: Encore Health Key Benefits Commercial	$6.40
Rate for Payer: Healthscope Commercial	$8.00
Rate for Payer: Healthscope Whirlpool	$7.76
Rate for Payer: Mclaren Commercial	$7.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.80
Rate for Payer: Priority Health Cigna Priority Health	$5.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$7.28
Rate for Payer: Priority Health Narrow Network	$5.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$7.04

HC COMP BURN GARM HOOK&LOOP TAB S

Facility

$8.00

Service Code	HCPCS A6512
Hospital Charge Code	98300034
Hospital Revenue Code	270
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.20
Rate for Payer: ASR ASR	$7.76
Rate for Payer: BCBS Trust/PPO	$6.20
Rate for Payer: BCN Commercial	$6.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cofinity Commercial	$7.52
Rate for Payer: Encore Health Key Benefits Commercial	$6.40
Rate for Payer: Healthscope Commercial	$8.00
Rate for Payer: Healthscope Whirlpool	$7.76
Rate for Payer: Mclaren Commercial	$7.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$6.80
Rate for Payer: Priority Health Cigna Priority Health	$5.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$7.04

HC COMP BURN GARM LEG&CHAP TO WAI

Facility

$208.00

Service Code	HCPCS A6512
Hospital Charge Code	98300036
Hospital Revenue Code	270
Min. Negotiated Rate	$83.20
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: ASR ASR	$201.76
Rate for Payer: BCBS Complete	$83.20
Rate for Payer: BCBS Trust/PPO	$161.26
Rate for Payer: BCN Commercial	$161.26
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cofinity Commercial	$195.52
Rate for Payer: Encore Health Key Benefits Commercial	$166.40
Rate for Payer: Healthscope Commercial	$208.00
Rate for Payer: Healthscope Whirlpool	$201.76
Rate for Payer: Mclaren Commercial	$187.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$176.80
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$189.28
Rate for Payer: Priority Health Narrow Network	$147.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$183.04

HC COMP BURN GARM LEG&CHAP TO WAI

Facility

$208.00

Service Code	HCPCS A6512
Hospital Charge Code	98300036
Hospital Revenue Code	270
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$187.20
Rate for Payer: ASR ASR	$201.76
Rate for Payer: BCBS Trust/PPO	$161.26
Rate for Payer: BCN Commercial	$161.26
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cofinity Commercial	$195.52
Rate for Payer: Encore Health Key Benefits Commercial	$166.40
Rate for Payer: Healthscope Commercial	$208.00
Rate for Payer: Healthscope Whirlpool	$201.76
Rate for Payer: Mclaren Commercial	$187.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$176.80
Rate for Payer: Priority Health Cigna Priority Health	$145.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$183.04

HC COMP BURN GARM LEG & PANTY

Facility

$222.00

Service Code	HCPCS A6511
Hospital Charge Code	98300035
Hospital Revenue Code	270
Min. Negotiated Rate	$155.40
Max. Negotiated Rate	$222.00
Rate for Payer: Aetna Commercial	$199.80
Rate for Payer: ASR ASR	$215.34
Rate for Payer: BCBS Trust/PPO	$172.12
Rate for Payer: BCN Commercial	$172.12
Rate for Payer: Cash Price	$177.60
Rate for Payer: Cofinity Commercial	$208.68
Rate for Payer: Encore Health Key Benefits Commercial	$177.60
Rate for Payer: Healthscope Commercial	$222.00
Rate for Payer: Healthscope Whirlpool	$215.34
Rate for Payer: Mclaren Commercial	$199.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$188.70
Rate for Payer: Priority Health Cigna Priority Health	$155.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$195.36

HC COMP BURN GARM LEG & PANTY

Facility

$222.00

Service Code	HCPCS A6511
Hospital Charge Code	98300035
Hospital Revenue Code	270
Min. Negotiated Rate	$88.80
Max. Negotiated Rate	$222.00
Rate for Payer: Aetna Commercial	$199.80
Rate for Payer: ASR ASR	$215.34
Rate for Payer: BCBS Complete	$88.80
Rate for Payer: BCBS Trust/PPO	$172.12
Rate for Payer: BCN Commercial	$172.12
Rate for Payer: Cash Price	$177.60
Rate for Payer: Cofinity Commercial	$208.68
Rate for Payer: Encore Health Key Benefits Commercial	$177.60
Rate for Payer: Healthscope Commercial	$222.00
Rate for Payer: Healthscope Whirlpool	$215.34
Rate for Payer: Mclaren Commercial	$199.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$188.70
Rate for Payer: Priority Health Cigna Priority Health	$155.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$202.02
Rate for Payer: Priority Health Narrow Network	$157.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$195.36

HC COMP BURN GARM LINING,POCKET,F

Facility

$12.00

Service Code	HCPCS A6512
Hospital Charge Code	98300037
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$10.80
Rate for Payer: ASR ASR	$11.64
Rate for Payer: BCBS Trust/PPO	$9.30
Rate for Payer: BCN Commercial	$9.30
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cofinity Commercial	$11.28
Rate for Payer: Encore Health Key Benefits Commercial	$9.60
Rate for Payer: Healthscope Commercial	$12.00
Rate for Payer: Healthscope Whirlpool	$11.64
Rate for Payer: Mclaren Commercial	$10.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.20
Rate for Payer: Priority Health Cigna Priority Health	$8.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.56

HC COMP BURN GARM LINING,POCKET,F

Facility

$12.00

Service Code	HCPCS A6512
Hospital Charge Code	98300037
Hospital Revenue Code	270
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$10.80
Rate for Payer: ASR ASR	$11.64
Rate for Payer: BCBS Complete	$4.80
Rate for Payer: BCBS Trust/PPO	$9.30
Rate for Payer: BCN Commercial	$9.30
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cofinity Commercial	$11.28
Rate for Payer: Encore Health Key Benefits Commercial	$9.60
Rate for Payer: Healthscope Commercial	$12.00
Rate for Payer: Healthscope Whirlpool	$11.64
Rate for Payer: Mclaren Commercial	$10.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.20
Rate for Payer: Priority Health Cigna Priority Health	$8.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10.92
Rate for Payer: Priority Health Narrow Network	$8.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.56

HC COMP BURN GARM MITTEN TO WRIST

Facility

$68.00

Service Code	HCPCS A6512
Hospital Charge Code	98300038
Hospital Revenue Code	270
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$61.20
Rate for Payer: ASR ASR	$65.96
Rate for Payer: BCBS Complete	$27.20
Rate for Payer: BCBS Trust/PPO	$52.72
Rate for Payer: BCN Commercial	$52.72
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cofinity Commercial	$63.92
Rate for Payer: Encore Health Key Benefits Commercial	$54.40
Rate for Payer: Healthscope Commercial	$68.00
Rate for Payer: Healthscope Whirlpool	$65.96
Rate for Payer: Mclaren Commercial	$61.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.80
Rate for Payer: Priority Health Cigna Priority Health	$47.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$61.88
Rate for Payer: Priority Health Narrow Network	$48.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$59.84

HC COMP BURN GARM MITTEN TO WRIST

Facility

$68.00

Service Code	HCPCS A6512
Hospital Charge Code	98300038
Hospital Revenue Code	270
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$61.20
Rate for Payer: ASR ASR	$65.96
Rate for Payer: BCBS Trust/PPO	$52.72
Rate for Payer: BCN Commercial	$52.72
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cofinity Commercial	$63.92
Rate for Payer: Encore Health Key Benefits Commercial	$54.40
Rate for Payer: Healthscope Commercial	$68.00
Rate for Payer: Healthscope Whirlpool	$65.96
Rate for Payer: Mclaren Commercial	$61.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.80
Rate for Payer: Priority Health Cigna Priority Health	$47.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$59.84

HC COMP BURN GARM POCKET & PAD CO

Facility

$14.00

Service Code	HCPCS A6512
Hospital Charge Code	98300039
Hospital Revenue Code	270
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: ASR ASR	$13.58
Rate for Payer: BCBS Complete	$5.60
Rate for Payer: BCBS Trust/PPO	$10.85
Rate for Payer: BCN Commercial	$10.85
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cofinity Commercial	$13.16
Rate for Payer: Encore Health Key Benefits Commercial	$11.20
Rate for Payer: Healthscope Commercial	$14.00
Rate for Payer: Healthscope Whirlpool	$13.58
Rate for Payer: Mclaren Commercial	$12.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.90
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12.74
Rate for Payer: Priority Health Narrow Network	$9.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.32

HC COMP BURN GARM POCKET & PAD CO

Facility

$14.00

Service Code	HCPCS A6512
Hospital Charge Code	98300039
Hospital Revenue Code	270
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$12.60
Rate for Payer: ASR ASR	$13.58
Rate for Payer: BCBS Trust/PPO	$10.85
Rate for Payer: BCN Commercial	$10.85
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cofinity Commercial	$13.16
Rate for Payer: Encore Health Key Benefits Commercial	$11.20
Rate for Payer: Healthscope Commercial	$14.00
Rate for Payer: Healthscope Whirlpool	$13.58
Rate for Payer: Mclaren Commercial	$12.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.90
Rate for Payer: Priority Health Cigna Priority Health	$9.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$12.32

HC COMP BURN GARM REINFORCEMENTS

Facility

$12.00

Service Code	HCPCS A6512
Hospital Charge Code	98300041
Hospital Revenue Code	270
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$10.80
Rate for Payer: ASR ASR	$11.64
Rate for Payer: BCBS Complete	$4.80
Rate for Payer: BCBS Trust/PPO	$9.30
Rate for Payer: BCN Commercial	$9.30
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cofinity Commercial	$11.28
Rate for Payer: Encore Health Key Benefits Commercial	$9.60
Rate for Payer: Healthscope Commercial	$12.00
Rate for Payer: Healthscope Whirlpool	$11.64
Rate for Payer: Mclaren Commercial	$10.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.20
Rate for Payer: Priority Health Cigna Priority Health	$8.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10.92
Rate for Payer: Priority Health Narrow Network	$8.52
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.56

HC COMP BURN GARM REINFORCEMENTS

Facility

$12.00

Service Code	HCPCS A6512
Hospital Charge Code	98300041
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$10.80
Rate for Payer: ASR ASR	$11.64
Rate for Payer: BCBS Trust/PPO	$9.30
Rate for Payer: BCN Commercial	$9.30
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cofinity Commercial	$11.28
Rate for Payer: Encore Health Key Benefits Commercial	$9.60
Rate for Payer: Healthscope Commercial	$12.00
Rate for Payer: Healthscope Whirlpool	$11.64
Rate for Payer: Mclaren Commercial	$10.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.20
Rate for Payer: Priority Health Cigna Priority Health	$8.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.56

HC COMP BURN GARM REINF SET HK&LO

Facility

$10.00

Service Code	HCPCS A6512
Hospital Charge Code	98300040
Hospital Revenue Code	270
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: ASR ASR	$9.70
Rate for Payer: BCBS Trust/PPO	$7.75
Rate for Payer: BCN Commercial	$7.75
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cofinity Commercial	$9.40
Rate for Payer: Encore Health Key Benefits Commercial	$8.00
Rate for Payer: Healthscope Commercial	$10.00
Rate for Payer: Healthscope Whirlpool	$9.70
Rate for Payer: Mclaren Commercial	$9.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$8.50
Rate for Payer: Priority Health Cigna Priority Health	$7.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.80

Know your out-of-pocket cost for care.

All Charges