Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC COMP BURN GARM STOCKING TO THI

Facility

$92.00

Service Code	HCPCS A6508
Hospital Charge Code	98300055
Hospital Revenue Code	270
Min. Negotiated Rate	$36.80
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: ASR ASR	$89.24
Rate for Payer: BCBS Complete	$36.80
Rate for Payer: BCBS Trust/PPO	$71.33
Rate for Payer: BCN Commercial	$71.33
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cofinity Commercial	$86.48
Rate for Payer: Encore Health Key Benefits Commercial	$73.60
Rate for Payer: Healthscope Commercial	$92.00
Rate for Payer: Healthscope Whirlpool	$89.24
Rate for Payer: Mclaren Commercial	$82.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$78.20
Rate for Payer: Priority Health Cigna Priority Health	$64.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$83.72
Rate for Payer: Priority Health Narrow Network	$65.32
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$80.96

HC COMP BURN GARM STOCKING TO THI

Facility

$92.00

Service Code	HCPCS A6508
Hospital Charge Code	98300055
Hospital Revenue Code	270
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$82.80
Rate for Payer: ASR ASR	$89.24
Rate for Payer: BCBS Trust/PPO	$71.33
Rate for Payer: BCN Commercial	$71.33
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cofinity Commercial	$86.48
Rate for Payer: Encore Health Key Benefits Commercial	$73.60
Rate for Payer: Healthscope Commercial	$92.00
Rate for Payer: Healthscope Whirlpool	$89.24
Rate for Payer: Mclaren Commercial	$82.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$78.20
Rate for Payer: Priority Health Cigna Priority Health	$64.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$80.96

HC COMP BURN GARM STOCK-KNEE/NO F

Facility

$62.00

Service Code	HCPCS A6512
Hospital Charge Code	98300056
Hospital Revenue Code	270
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$55.80
Rate for Payer: ASR ASR	$60.14
Rate for Payer: BCBS Trust/PPO	$48.07
Rate for Payer: BCN Commercial	$48.07
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cofinity Commercial	$58.28
Rate for Payer: Encore Health Key Benefits Commercial	$49.60
Rate for Payer: Healthscope Commercial	$62.00
Rate for Payer: Healthscope Whirlpool	$60.14
Rate for Payer: Mclaren Commercial	$55.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$52.70
Rate for Payer: Priority Health Cigna Priority Health	$43.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$54.56

HC COMP BURN GARM STOCK-KNEE/NO F

Facility

$62.00

Service Code	HCPCS A6512
Hospital Charge Code	98300056
Hospital Revenue Code	270
Min. Negotiated Rate	$24.80
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$55.80
Rate for Payer: ASR ASR	$60.14
Rate for Payer: BCBS Complete	$24.80
Rate for Payer: BCBS Trust/PPO	$48.07
Rate for Payer: BCN Commercial	$48.07
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cofinity Commercial	$58.28
Rate for Payer: Encore Health Key Benefits Commercial	$49.60
Rate for Payer: Healthscope Commercial	$62.00
Rate for Payer: Healthscope Whirlpool	$60.14
Rate for Payer: Mclaren Commercial	$55.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$52.70
Rate for Payer: Priority Health Cigna Priority Health	$43.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$56.42
Rate for Payer: Priority Health Narrow Network	$44.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$54.56

HC COMP BURN GARM STRETCH INSERT

Facility

$12.24

Service Code	HCPCS A4649
Hospital Charge Code	98300057
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 STRETCH INSERT

Facility

$12.24

Service Code	HCPCS A4649
Hospital Charge Code	98300057
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 SUEDE/LEATHER G

Facility

$45.00

Service Code	HCPCS A9900
Hospital Charge Code	98300058
Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: ASR ASR	$43.65
Rate for Payer: BCBS Complete	$18.00
Rate for Payer: BCBS Trust/PPO	$34.89
Rate for Payer: BCN Commercial	$34.89
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cofinity Commercial	$42.30
Rate for Payer: Encore Health Key Benefits Commercial	$36.00
Rate for Payer: Healthscope Commercial	$45.00
Rate for Payer: Healthscope Whirlpool	$43.65
Rate for Payer: Mclaren Commercial	$40.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.25
Rate for Payer: Priority Health Cigna Priority Health	$31.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$40.95
Rate for Payer: Priority Health Narrow Network	$31.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.60

HC COMP BURN GARM SUEDE/LEATHER G

Facility

$45.00

Service Code	HCPCS A9900
Hospital Charge Code	98300058
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: ASR ASR	$43.65
Rate for Payer: BCBS Trust/PPO	$34.89
Rate for Payer: BCN Commercial	$34.89
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cofinity Commercial	$42.30
Rate for Payer: Encore Health Key Benefits Commercial	$36.00
Rate for Payer: Healthscope Commercial	$45.00
Rate for Payer: Healthscope Whirlpool	$43.65
Rate for Payer: Mclaren Commercial	$40.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.25
Rate for Payer: Priority Health Cigna Priority Health	$31.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.60

HC COMP BURN GARM SUIT SLVD ABV K

Facility

$380.00

Service Code	HCPCS A6512
Hospital Charge Code	98300059
Hospital Revenue Code	270
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: ASR ASR	$368.60
Rate for Payer: BCBS Trust/PPO	$294.61
Rate for Payer: BCN Commercial	$294.61
Rate for Payer: Cash Price	$304.00
Rate for Payer: Cofinity Commercial	$357.20
Rate for Payer: Encore Health Key Benefits Commercial	$304.00
Rate for Payer: Healthscope Commercial	$380.00
Rate for Payer: Healthscope Whirlpool	$368.60
Rate for Payer: Mclaren Commercial	$342.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$323.00
Rate for Payer: Priority Health Cigna Priority Health	$266.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$334.40

HC COMP BURN GARM SUIT SLVD ABV K

Facility

$380.00

Service Code	HCPCS A6512
Hospital Charge Code	98300059
Hospital Revenue Code	270
Min. Negotiated Rate	$152.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: ASR ASR	$368.60
Rate for Payer: BCBS Complete	$152.00
Rate for Payer: BCBS Trust/PPO	$294.61
Rate for Payer: BCN Commercial	$294.61
Rate for Payer: Cash Price	$304.00
Rate for Payer: Cofinity Commercial	$357.20
Rate for Payer: Encore Health Key Benefits Commercial	$304.00
Rate for Payer: Healthscope Commercial	$380.00
Rate for Payer: Healthscope Whirlpool	$368.60
Rate for Payer: Mclaren Commercial	$342.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$323.00
Rate for Payer: Priority Health Cigna Priority Health	$266.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$345.80
Rate for Payer: Priority Health Narrow Network	$269.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$334.40

HC COMP BURN GARM SUIT SLVD TWO LEGS

Facility

$482.00

Service Code	HCPCS A6501
Hospital Charge Code	98300060
Hospital Revenue Code	270
Min. Negotiated Rate	$192.80
Max. Negotiated Rate	$482.00
Rate for Payer: Aetna Commercial	$433.80
Rate for Payer: ASR ASR	$467.54
Rate for Payer: BCBS Complete	$192.80
Rate for Payer: BCBS Trust/PPO	$373.69
Rate for Payer: BCN Commercial	$373.69
Rate for Payer: Cash Price	$385.60
Rate for Payer: Cofinity Commercial	$453.08
Rate for Payer: Encore Health Key Benefits Commercial	$385.60
Rate for Payer: Healthscope Commercial	$482.00
Rate for Payer: Healthscope Whirlpool	$467.54
Rate for Payer: Mclaren Commercial	$433.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$409.70
Rate for Payer: Priority Health Cigna Priority Health	$337.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$438.62
Rate for Payer: Priority Health Narrow Network	$342.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$424.16

HC COMP BURN GARM SUIT SLVD TWO LEGS

Facility

$482.00

Service Code	HCPCS A6501
Hospital Charge Code	98300060
Hospital Revenue Code	270
Min. Negotiated Rate	$337.40
Max. Negotiated Rate	$482.00
Rate for Payer: Aetna Commercial	$433.80
Rate for Payer: ASR ASR	$467.54
Rate for Payer: BCBS Trust/PPO	$373.69
Rate for Payer: BCN Commercial	$373.69
Rate for Payer: Cash Price	$385.60
Rate for Payer: Cofinity Commercial	$453.08
Rate for Payer: Encore Health Key Benefits Commercial	$385.60
Rate for Payer: Healthscope Commercial	$482.00
Rate for Payer: Healthscope Whirlpool	$467.54
Rate for Payer: Mclaren Commercial	$433.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$409.70
Rate for Payer: Priority Health Cigna Priority Health	$337.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$424.16

HC COMP BURN GARM SUIT SLVLS ABV

Facility

$314.00

Service Code	HCPCS A6512
Hospital Charge Code	98300061
Hospital Revenue Code	270
Min. Negotiated Rate	$219.80
Max. Negotiated Rate	$314.00
Rate for Payer: Aetna Commercial	$282.60
Rate for Payer: ASR ASR	$304.58
Rate for Payer: BCBS Trust/PPO	$243.44
Rate for Payer: BCN Commercial	$243.44
Rate for Payer: Cash Price	$251.20
Rate for Payer: Cofinity Commercial	$295.16
Rate for Payer: Encore Health Key Benefits Commercial	$251.20
Rate for Payer: Healthscope Commercial	$314.00
Rate for Payer: Healthscope Whirlpool	$304.58
Rate for Payer: Mclaren Commercial	$282.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$266.90
Rate for Payer: Priority Health Cigna Priority Health	$219.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$276.32

HC COMP BURN GARM SUIT SLVLS ABV

Facility

$314.00

Service Code	HCPCS A6512
Hospital Charge Code	98300061
Hospital Revenue Code	270
Min. Negotiated Rate	$125.60
Max. Negotiated Rate	$314.00
Rate for Payer: Aetna Commercial	$282.60
Rate for Payer: ASR ASR	$304.58
Rate for Payer: BCBS Complete	$125.60
Rate for Payer: BCBS Trust/PPO	$243.44
Rate for Payer: BCN Commercial	$243.44
Rate for Payer: Cash Price	$251.20
Rate for Payer: Cofinity Commercial	$295.16
Rate for Payer: Encore Health Key Benefits Commercial	$251.20
Rate for Payer: Healthscope Commercial	$314.00
Rate for Payer: Healthscope Whirlpool	$304.58
Rate for Payer: Mclaren Commercial	$282.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$266.90
Rate for Payer: Priority Health Cigna Priority Health	$219.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$285.74
Rate for Payer: Priority Health Narrow Network	$222.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$276.32

HC COMP BURN GARM SUIT SLVLS-TWO LEGS

Facility

$368.00

Service Code	HCPCS A6512
Hospital Charge Code	98300062
Hospital Revenue Code	270
Min. Negotiated Rate	$147.20
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$331.20
Rate for Payer: ASR ASR	$356.96
Rate for Payer: BCBS Complete	$147.20
Rate for Payer: BCBS Trust/PPO	$285.31
Rate for Payer: BCN Commercial	$285.31
Rate for Payer: Cash Price	$294.40
Rate for Payer: Cofinity Commercial	$345.92
Rate for Payer: Encore Health Key Benefits Commercial	$294.40
Rate for Payer: Healthscope Commercial	$368.00
Rate for Payer: Healthscope Whirlpool	$356.96
Rate for Payer: Mclaren Commercial	$331.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$312.80
Rate for Payer: Priority Health Cigna Priority Health	$257.60
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$334.88
Rate for Payer: Priority Health Narrow Network	$261.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$323.84

HC COMP BURN GARM SUIT SLVLS-TWO LEGS

Facility

$368.00

Service Code	HCPCS A6512
Hospital Charge Code	98300062
Hospital Revenue Code	270
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$331.20
Rate for Payer: ASR ASR	$356.96
Rate for Payer: BCBS Trust/PPO	$285.31
Rate for Payer: BCN Commercial	$285.31
Rate for Payer: Cash Price	$294.40
Rate for Payer: Cofinity Commercial	$345.92
Rate for Payer: Encore Health Key Benefits Commercial	$294.40
Rate for Payer: Healthscope Commercial	$368.00
Rate for Payer: Healthscope Whirlpool	$356.96
Rate for Payer: Mclaren Commercial	$331.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$312.80
Rate for Payer: Priority Health Cigna Priority Health	$257.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$323.84

HC COMP BURN GARM SUSPENDERS ATTA

Facility

$45.00

Service Code	HCPCS A9900
Hospital Charge Code	98300063
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: ASR ASR	$43.65
Rate for Payer: BCBS Trust/PPO	$34.89
Rate for Payer: BCN Commercial	$34.89
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cofinity Commercial	$42.30
Rate for Payer: Encore Health Key Benefits Commercial	$36.00
Rate for Payer: Healthscope Commercial	$45.00
Rate for Payer: Healthscope Whirlpool	$43.65
Rate for Payer: Mclaren Commercial	$40.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.25
Rate for Payer: Priority Health Cigna Priority Health	$31.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.60

HC COMP BURN GARM SUSPENDERS ATTA

Facility

$45.00

Service Code	HCPCS A9900
Hospital Charge Code	98300063
Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$40.50
Rate for Payer: ASR ASR	$43.65
Rate for Payer: BCBS Complete	$18.00
Rate for Payer: BCBS Trust/PPO	$34.89
Rate for Payer: BCN Commercial	$34.89
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cofinity Commercial	$42.30
Rate for Payer: Encore Health Key Benefits Commercial	$36.00
Rate for Payer: Healthscope Commercial	$45.00
Rate for Payer: Healthscope Whirlpool	$43.65
Rate for Payer: Mclaren Commercial	$40.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.25
Rate for Payer: Priority Health Cigna Priority Health	$31.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$40.95
Rate for Payer: Priority Health Narrow Network	$31.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$39.60

HC COMP BURN GARM SUSPENDERS REMO

Facility

$12.00

Service Code	HCPCS A9900
Hospital Charge Code	98300064
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 SUSPENDERS REMO

Facility

$12.00

Service Code	HCPCS A9900
Hospital Charge Code	98300064
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 TWO LEGS PREGNA

Facility

$250.00

Service Code	HCPCS A6512
Hospital Charge Code	98300065
Hospital Revenue Code	270
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: ASR ASR	$242.50
Rate for Payer: BCBS Complete	$100.00
Rate for Payer: BCBS Trust/PPO	$193.82
Rate for Payer: BCN Commercial	$193.82
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cofinity Commercial	$235.00
Rate for Payer: Encore Health Key Benefits Commercial	$200.00
Rate for Payer: Healthscope Commercial	$250.00
Rate for Payer: Healthscope Whirlpool	$242.50
Rate for Payer: Mclaren Commercial	$225.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$212.50
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$227.50
Rate for Payer: Priority Health Narrow Network	$177.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$220.00

HC COMP BURN GARM TWO LEGS PREGNA

Facility

$250.00

Service Code	HCPCS A6512
Hospital Charge Code	98300065
Hospital Revenue Code	270
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: ASR ASR	$242.50
Rate for Payer: BCBS Trust/PPO	$193.82
Rate for Payer: BCN Commercial	$193.82
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cofinity Commercial	$235.00
Rate for Payer: Encore Health Key Benefits Commercial	$200.00
Rate for Payer: Healthscope Commercial	$250.00
Rate for Payer: Healthscope Whirlpool	$242.50
Rate for Payer: Mclaren Commercial	$225.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$212.50
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$220.00

HC COMP BURN GARM VEST SLEEVED

Facility

$250.00

Service Code	HCPCS A6509
Hospital Charge Code	98300066
Hospital Revenue Code	270
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: ASR ASR	$242.50
Rate for Payer: BCBS Complete	$100.00
Rate for Payer: BCBS Trust/PPO	$193.82
Rate for Payer: BCN Commercial	$193.82
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cofinity Commercial	$235.00
Rate for Payer: Encore Health Key Benefits Commercial	$200.00
Rate for Payer: Healthscope Commercial	$250.00
Rate for Payer: Healthscope Whirlpool	$242.50
Rate for Payer: Mclaren Commercial	$225.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$212.50
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$227.50
Rate for Payer: Priority Health Narrow Network	$177.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$220.00

HC COMP BURN GARM VEST SLEEVED

Facility

$250.00

Service Code	HCPCS A6509
Hospital Charge Code	98300066
Hospital Revenue Code	270
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: ASR ASR	$242.50
Rate for Payer: BCBS Trust/PPO	$193.82
Rate for Payer: BCN Commercial	$193.82
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cofinity Commercial	$235.00
Rate for Payer: Encore Health Key Benefits Commercial	$200.00
Rate for Payer: Healthscope Commercial	$250.00
Rate for Payer: Healthscope Whirlpool	$242.50
Rate for Payer: Mclaren Commercial	$225.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$212.50
Rate for Payer: Priority Health Cigna Priority Health	$175.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$220.00

HC COMP BURN GARM VEST SLEEVELESS

Facility

$132.00

Service Code	HCPCS A6509
Hospital Charge Code	98300067
Hospital Revenue Code	270
Min. Negotiated Rate	$92.40
Max. Negotiated Rate	$132.00
Rate for Payer: Aetna Commercial	$118.80
Rate for Payer: ASR ASR	$128.04
Rate for Payer: BCBS Trust/PPO	$102.34
Rate for Payer: BCN Commercial	$102.34
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cofinity Commercial	$124.08
Rate for Payer: Encore Health Key Benefits Commercial	$105.60
Rate for Payer: Healthscope Commercial	$132.00
Rate for Payer: Healthscope Whirlpool	$128.04
Rate for Payer: Mclaren Commercial	$118.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$112.20
Rate for Payer: Priority Health Cigna Priority Health	$92.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$116.16

Know your out-of-pocket cost for care.

All Charges