Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

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	$4.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.00
Rate for Payer: ASR ASR	$9.70
Rate for Payer: BCBS Complete	$4.00
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: Priority Health HMO/PPO/Tiered Network	$9.10
Rate for Payer: Priority Health Narrow Network	$7.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.80

HC COMP BURN GARM SHOULD FLAP REG

Facility

$34.00

Service Code	HCPCS A6512
Hospital Charge Code	98300042
Hospital Revenue Code	270
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$30.60
Rate for Payer: ASR ASR	$32.98
Rate for Payer: BCBS Trust/PPO	$26.36
Rate for Payer: BCN Commercial	$26.36
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cofinity Commercial	$31.96
Rate for Payer: Encore Health Key Benefits Commercial	$27.20
Rate for Payer: Healthscope Commercial	$34.00
Rate for Payer: Healthscope Whirlpool	$32.98
Rate for Payer: Mclaren Commercial	$30.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$28.90
Rate for Payer: Priority Health Cigna Priority Health	$23.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$29.92

HC COMP BURN GARM SHOULD FLAP REG

Facility

$34.00

Service Code	HCPCS A6512
Hospital Charge Code	98300042
Hospital Revenue Code	270
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$30.60
Rate for Payer: ASR ASR	$32.98
Rate for Payer: BCBS Complete	$13.60
Rate for Payer: BCBS Trust/PPO	$26.36
Rate for Payer: BCN Commercial	$26.36
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cofinity Commercial	$31.96
Rate for Payer: Encore Health Key Benefits Commercial	$27.20
Rate for Payer: Healthscope Commercial	$34.00
Rate for Payer: Healthscope Whirlpool	$32.98
Rate for Payer: Mclaren Commercial	$30.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$28.90
Rate for Payer: Priority Health Cigna Priority Health	$23.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$30.94
Rate for Payer: Priority Health Narrow Network	$24.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$29.92

HC COMP BURN GARM SILON-TEX P/D-G

Facility

$60.00

Service Code	HCPCS A6512
Hospital Charge Code	98300044
Hospital Revenue Code	270
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: ASR ASR	$58.20
Rate for Payer: BCBS Complete	$24.00
Rate for Payer: BCBS Trust/PPO	$46.52
Rate for Payer: BCN Commercial	$46.52
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cofinity Commercial	$56.40
Rate for Payer: Encore Health Key Benefits Commercial	$48.00
Rate for Payer: Healthscope Commercial	$60.00
Rate for Payer: Healthscope Whirlpool	$58.20
Rate for Payer: Mclaren Commercial	$54.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$51.00
Rate for Payer: Priority Health Cigna Priority Health	$42.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$54.60
Rate for Payer: Priority Health Narrow Network	$42.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$52.80

HC COMP BURN GARM SILON-TEX P/D-G

Facility

$60.00

Service Code	HCPCS A6512
Hospital Charge Code	98300044
Hospital Revenue Code	270
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: ASR ASR	$58.20
Rate for Payer: BCBS Trust/PPO	$46.52
Rate for Payer: BCN Commercial	$46.52
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cofinity Commercial	$56.40
Rate for Payer: Encore Health Key Benefits Commercial	$48.00
Rate for Payer: Healthscope Commercial	$60.00
Rate for Payer: Healthscope Whirlpool	$58.20
Rate for Payer: Mclaren Commercial	$54.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$51.00
Rate for Payer: Priority Health Cigna Priority Health	$42.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$52.80

HC COMP BURN GARM SILON-TEX UP TO

Facility

$36.00

Service Code	HCPCS A6512
Hospital Charge Code	98300045
Hospital Revenue Code	270
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$32.40
Rate for Payer: ASR ASR	$34.92
Rate for Payer: BCBS Complete	$14.40
Rate for Payer: BCBS Trust/PPO	$27.91
Rate for Payer: BCN Commercial	$27.91
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cofinity Commercial	$33.84
Rate for Payer: Encore Health Key Benefits Commercial	$28.80
Rate for Payer: Healthscope Commercial	$36.00
Rate for Payer: Healthscope Whirlpool	$34.92
Rate for Payer: Mclaren Commercial	$32.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$30.60
Rate for Payer: Priority Health Cigna Priority Health	$25.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$32.76
Rate for Payer: Priority Health Narrow Network	$25.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$31.68

HC COMP BURN GARM SILON-TEX UP TO

Facility

$36.00

Service Code	HCPCS A6512
Hospital Charge Code	98300045
Hospital Revenue Code	270
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$32.40
Rate for Payer: ASR ASR	$34.92
Rate for Payer: BCBS Trust/PPO	$27.91
Rate for Payer: BCN Commercial	$27.91
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cofinity Commercial	$33.84
Rate for Payer: Encore Health Key Benefits Commercial	$28.80
Rate for Payer: Healthscope Commercial	$36.00
Rate for Payer: Healthscope Whirlpool	$34.92
Rate for Payer: Mclaren Commercial	$32.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$30.60
Rate for Payer: Priority Health Cigna Priority Health	$25.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$31.68

HC COMP BURN GARM SILON-TEX WHOL

Facility

$84.00

Service Code	HCPCS A6512
Hospital Charge Code	98300046
Hospital Revenue Code	270
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$75.60
Rate for Payer: ASR ASR	$81.48
Rate for Payer: BCBS Trust/PPO	$65.13
Rate for Payer: BCN Commercial	$65.13
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cofinity Commercial	$78.96
Rate for Payer: Encore Health Key Benefits Commercial	$67.20
Rate for Payer: Healthscope Commercial	$84.00
Rate for Payer: Healthscope Whirlpool	$81.48
Rate for Payer: Mclaren Commercial	$75.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$71.40
Rate for Payer: Priority Health Cigna Priority Health	$58.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$73.92

HC COMP BURN GARM SILON-TEX WHOL

Facility

$84.00

Service Code	HCPCS A6512
Hospital Charge Code	98300046
Hospital Revenue Code	270
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$75.60
Rate for Payer: ASR ASR	$81.48
Rate for Payer: BCBS Complete	$33.60
Rate for Payer: BCBS Trust/PPO	$65.13
Rate for Payer: BCN Commercial	$65.13
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cofinity Commercial	$78.96
Rate for Payer: Encore Health Key Benefits Commercial	$67.20
Rate for Payer: Healthscope Commercial	$84.00
Rate for Payer: Healthscope Whirlpool	$81.48
Rate for Payer: Mclaren Commercial	$75.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$71.40
Rate for Payer: Priority Health Cigna Priority Health	$58.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$76.44
Rate for Payer: Priority Health Narrow Network	$59.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$73.92

HC COMP BURN GARM SLEEVE WRIST/AX

Facility

$70.00

Service Code	HCPCS A6512
Hospital Charge Code	98300047
Hospital Revenue Code	270
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: ASR ASR	$67.90
Rate for Payer: BCBS Complete	$28.00
Rate for Payer: BCBS Trust/PPO	$54.27
Rate for Payer: BCN Commercial	$54.27
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$65.80
Rate for Payer: Encore Health Key Benefits Commercial	$56.00
Rate for Payer: Healthscope Commercial	$70.00
Rate for Payer: Healthscope Whirlpool	$67.90
Rate for Payer: Mclaren Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$49.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$63.70
Rate for Payer: Priority Health Narrow Network	$49.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.60

HC COMP BURN GARM SLEEVE WRIST/AX

Facility

$70.00

Service Code	HCPCS A6512
Hospital Charge Code	98300047
Hospital Revenue Code	270
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: ASR ASR	$67.90
Rate for Payer: BCBS Trust/PPO	$54.27
Rate for Payer: BCN Commercial	$54.27
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$65.80
Rate for Payer: Encore Health Key Benefits Commercial	$56.00
Rate for Payer: Healthscope Commercial	$70.00
Rate for Payer: Healthscope Whirlpool	$67.90
Rate for Payer: Mclaren Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$49.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.60

HC COMP BURN GARM SLV WRST-ELB/EL

Facility

$60.00

Service Code	HCPCS A6512
Hospital Charge Code	98300048
Hospital Revenue Code	270
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: ASR ASR	$58.20
Rate for Payer: BCBS Trust/PPO	$46.52
Rate for Payer: BCN Commercial	$46.52
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cofinity Commercial	$56.40
Rate for Payer: Encore Health Key Benefits Commercial	$48.00
Rate for Payer: Healthscope Commercial	$60.00
Rate for Payer: Healthscope Whirlpool	$58.20
Rate for Payer: Mclaren Commercial	$54.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$51.00
Rate for Payer: Priority Health Cigna Priority Health	$42.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$52.80

HC COMP BURN GARM SLV WRST-ELB/EL

Facility

$60.00

Service Code	HCPCS A6512
Hospital Charge Code	98300048
Hospital Revenue Code	270
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$54.00
Rate for Payer: ASR ASR	$58.20
Rate for Payer: BCBS Complete	$24.00
Rate for Payer: BCBS Trust/PPO	$46.52
Rate for Payer: BCN Commercial	$46.52
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cofinity Commercial	$56.40
Rate for Payer: Encore Health Key Benefits Commercial	$48.00
Rate for Payer: Healthscope Commercial	$60.00
Rate for Payer: Healthscope Whirlpool	$58.20
Rate for Payer: Mclaren Commercial	$54.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$51.00
Rate for Payer: Priority Health Cigna Priority Health	$42.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$54.60
Rate for Payer: Priority Health Narrow Network	$42.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$52.80

HC COMP BURN GARM STERNAL STRAP

Facility

$68.00

Service Code	HCPCS A6512
Hospital Charge Code	98300049
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 STERNAL STRAP

Facility

$68.00

Service Code	HCPCS A6512
Hospital Charge Code	98300049
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 STKNG KNEE TO T

Facility

$70.40

Service Code	HCPCS A6512
Hospital Charge Code	98300050
Hospital Revenue Code	270
Min. Negotiated Rate	$28.16
Max. Negotiated Rate	$70.40
Rate for Payer: Aetna Commercial	$63.36
Rate for Payer: ASR ASR	$68.29
Rate for Payer: BCBS Complete	$28.16
Rate for Payer: BCBS Trust/PPO	$54.58
Rate for Payer: BCN Commercial	$54.58
Rate for Payer: Cash Price	$56.32
Rate for Payer: Cofinity Commercial	$66.18
Rate for Payer: Encore Health Key Benefits Commercial	$56.32
Rate for Payer: Healthscope Commercial	$70.40
Rate for Payer: Healthscope Whirlpool	$68.29
Rate for Payer: Mclaren Commercial	$63.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.84
Rate for Payer: Priority Health Cigna Priority Health	$49.28
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$64.06
Rate for Payer: Priority Health Narrow Network	$49.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.95

HC COMP BURN GARM STKNG KNEE TO T

Facility

$70.40

Service Code	HCPCS A6512
Hospital Charge Code	98300050
Hospital Revenue Code	270
Min. Negotiated Rate	$49.28
Max. Negotiated Rate	$70.40
Rate for Payer: Aetna Commercial	$63.36
Rate for Payer: ASR ASR	$68.29
Rate for Payer: BCBS Trust/PPO	$54.58
Rate for Payer: BCN Commercial	$54.58
Rate for Payer: Cash Price	$56.32
Rate for Payer: Cofinity Commercial	$66.18
Rate for Payer: Encore Health Key Benefits Commercial	$56.32
Rate for Payer: Healthscope Commercial	$70.40
Rate for Payer: Healthscope Whirlpool	$68.29
Rate for Payer: Mclaren Commercial	$63.36
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.84
Rate for Payer: Priority Health Cigna Priority Health	$49.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.95

HC COMP BURN GARM STKNG TO THI NO

Facility

$78.00

Service Code	HCPCS A6512
Hospital Charge Code	98300051
Hospital Revenue Code	270
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: ASR ASR	$75.66
Rate for Payer: BCBS Trust/PPO	$60.47
Rate for Payer: BCN Commercial	$60.47
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cofinity Commercial	$73.32
Rate for Payer: Encore Health Key Benefits Commercial	$62.40
Rate for Payer: Healthscope Commercial	$78.00
Rate for Payer: Healthscope Whirlpool	$75.66
Rate for Payer: Mclaren Commercial	$70.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$66.30
Rate for Payer: Priority Health Cigna Priority Health	$54.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$68.64

HC COMP BURN GARM STKNG TO THI NO

Facility

$78.00

Service Code	HCPCS A6512
Hospital Charge Code	98300051
Hospital Revenue Code	270
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$70.20
Rate for Payer: ASR ASR	$75.66
Rate for Payer: BCBS Complete	$31.20
Rate for Payer: BCBS Trust/PPO	$60.47
Rate for Payer: BCN Commercial	$60.47
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cofinity Commercial	$73.32
Rate for Payer: Encore Health Key Benefits Commercial	$62.40
Rate for Payer: Healthscope Commercial	$78.00
Rate for Payer: Healthscope Whirlpool	$75.66
Rate for Payer: Mclaren Commercial	$70.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$66.30
Rate for Payer: Priority Health Cigna Priority Health	$54.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$70.98
Rate for Payer: Priority Health Narrow Network	$55.38
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$68.64

HC COMP BURN GARM STMP CLS ORNG P

Facility

$12.24

Service Code	HCPCS A4649
Hospital Charge Code	98300052
Hospital Revenue Code	270
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$12.24
Rate for Payer: Aetna Commercial	$11.02
Rate for Payer: ASR ASR	$11.87
Rate for Payer: BCBS Complete	$4.90
Rate for Payer: BCBS Trust/PPO	$9.49
Rate for Payer: BCN Commercial	$9.49
Rate for Payer: Cash Price	$9.79
Rate for Payer: Cofinity Commercial	$11.51
Rate for Payer: Encore Health Key Benefits Commercial	$9.79
Rate for Payer: Healthscope Commercial	$12.24
Rate for Payer: Healthscope Whirlpool	$11.87
Rate for Payer: Mclaren Commercial	$11.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.40
Rate for Payer: Priority Health Cigna Priority Health	$8.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11.14
Rate for Payer: Priority Health Narrow Network	$8.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.77

HC COMP BURN GARM STMP CLS ORNG P

Facility

$12.24

Service Code	HCPCS A4649
Hospital Charge Code	98300052
Hospital Revenue Code	270
Min. Negotiated Rate	$8.57
Max. Negotiated Rate	$12.24
Rate for Payer: Aetna Commercial	$11.02
Rate for Payer: ASR ASR	$11.87
Rate for Payer: BCBS Trust/PPO	$9.49
Rate for Payer: BCN Commercial	$9.49
Rate for Payer: Cash Price	$9.79
Rate for Payer: Cofinity Commercial	$11.51
Rate for Payer: Encore Health Key Benefits Commercial	$9.79
Rate for Payer: Healthscope Commercial	$12.24
Rate for Payer: Healthscope Whirlpool	$11.87
Rate for Payer: Mclaren Commercial	$11.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.40
Rate for Payer: Priority Health Cigna Priority Health	$8.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.77

HC COMP BURN GARM STMP CLS STRCH

Facility

$12.24

Service Code	HCPCS A4649
Hospital Charge Code	98300053
Hospital Revenue Code	270
Min. Negotiated Rate	$8.57
Max. Negotiated Rate	$12.24
Rate for Payer: Aetna Commercial	$11.02
Rate for Payer: ASR ASR	$11.87
Rate for Payer: BCBS Trust/PPO	$9.49
Rate for Payer: BCN Commercial	$9.49
Rate for Payer: Cash Price	$9.79
Rate for Payer: Cofinity Commercial	$11.51
Rate for Payer: Encore Health Key Benefits Commercial	$9.79
Rate for Payer: Healthscope Commercial	$12.24
Rate for Payer: Healthscope Whirlpool	$11.87
Rate for Payer: Mclaren Commercial	$11.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.40
Rate for Payer: Priority Health Cigna Priority Health	$8.57
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.77

HC COMP BURN GARM STMP CLS STRCH

Facility

$12.24

Service Code	HCPCS A4649
Hospital Charge Code	98300053
Hospital Revenue Code	270
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$12.24
Rate for Payer: Aetna Commercial	$11.02
Rate for Payer: ASR ASR	$11.87
Rate for Payer: BCBS Complete	$4.90
Rate for Payer: BCBS Trust/PPO	$9.49
Rate for Payer: BCN Commercial	$9.49
Rate for Payer: Cash Price	$9.79
Rate for Payer: Cofinity Commercial	$11.51
Rate for Payer: Encore Health Key Benefits Commercial	$9.79
Rate for Payer: Healthscope Commercial	$12.24
Rate for Payer: Healthscope Whirlpool	$11.87
Rate for Payer: Mclaren Commercial	$11.02
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.40
Rate for Payer: Priority Health Cigna Priority Health	$8.57
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$11.14
Rate for Payer: Priority Health Narrow Network	$8.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.77

HC COMP BURN GARM STOCKING TO KNE

Facility

$70.00

Service Code	HCPCS A6507
Hospital Charge Code	98300054
Hospital Revenue Code	270
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: ASR ASR	$67.90
Rate for Payer: BCBS Complete	$28.00
Rate for Payer: BCBS Trust/PPO	$54.27
Rate for Payer: BCN Commercial	$54.27
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$65.80
Rate for Payer: Encore Health Key Benefits Commercial	$56.00
Rate for Payer: Healthscope Commercial	$70.00
Rate for Payer: Healthscope Whirlpool	$67.90
Rate for Payer: Mclaren Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$49.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$63.70
Rate for Payer: Priority Health Narrow Network	$49.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.60

HC COMP BURN GARM STOCKING TO KNE

Facility

$70.00

Service Code	HCPCS A6507
Hospital Charge Code	98300054
Hospital Revenue Code	270
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$63.00
Rate for Payer: ASR ASR	$67.90
Rate for Payer: BCBS Trust/PPO	$54.27
Rate for Payer: BCN Commercial	$54.27
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cofinity Commercial	$65.80
Rate for Payer: Encore Health Key Benefits Commercial	$56.00
Rate for Payer: Healthscope Commercial	$70.00
Rate for Payer: Healthscope Whirlpool	$67.90
Rate for Payer: Mclaren Commercial	$63.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$59.50
Rate for Payer: Priority Health Cigna Priority Health	$49.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$61.60

Know your out-of-pocket cost for care.

All Charges