Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC BRACE KNEE HINGED CUSTOM

Facility

$1,385.37

Service Code	HCPCS L1832
Hospital Charge Code	27400004
Hospital Revenue Code	274
Min. Negotiated Rate	$900.49
Max. Negotiated Rate	$1,385.37
Rate for Payer: Aetna Commercial	$1,246.83
Rate for Payer: ASR ASR	$1,343.81
Rate for Payer: ASR Commercial	$1,343.81
Rate for Payer: BCBS Trust/PPO	$1,128.94
Rate for Payer: BCN Commercial	$1,074.08
Rate for Payer: Cash Price	$1,108.30
Rate for Payer: Cofinity Commercial	$1,302.25
Rate for Payer: Encore Health Key Benefits Commercial	$1,108.30
Rate for Payer: Healthscope Commercial	$1,385.37
Rate for Payer: Healthscope Whirlpool	$1,343.81
Rate for Payer: Mclaren Commercial	$1,246.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,177.56
Rate for Payer: Nomi Health Commercial	$1,136.00
Rate for Payer: Priority Health Cigna Priority Health	$900.49
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,219.13

HC BRACE KNEE HINGED OTS

Facility

$1,629.86

Service Code	HCPCS L1833
Hospital Charge Code	27400021
Hospital Revenue Code	274
Min. Negotiated Rate	$1,059.41
Max. Negotiated Rate	$1,629.86
Rate for Payer: Aetna Commercial	$1,466.87
Rate for Payer: ASR ASR	$1,580.96
Rate for Payer: ASR Commercial	$1,580.96
Rate for Payer: BCBS Trust/PPO	$1,328.17
Rate for Payer: BCN Commercial	$1,263.63
Rate for Payer: Cash Price	$1,303.89
Rate for Payer: Cofinity Commercial	$1,532.07
Rate for Payer: Encore Health Key Benefits Commercial	$1,303.89
Rate for Payer: Healthscope Commercial	$1,629.86
Rate for Payer: Healthscope Whirlpool	$1,580.96
Rate for Payer: Mclaren Commercial	$1,466.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,385.38
Rate for Payer: Nomi Health Commercial	$1,336.49
Rate for Payer: Priority Health Cigna Priority Health	$1,059.41
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,434.28

HC BRACE KNEE HINGED OTS

Facility

$1,629.86

Service Code	HCPCS L1833
Hospital Charge Code	27400021
Hospital Revenue Code	274
Min. Negotiated Rate	$651.94
Max. Negotiated Rate	$1,629.86
Rate for Payer: Aetna Commercial	$1,466.87
Rate for Payer: Aetna Medicare	$814.93
Rate for Payer: ASR ASR	$1,580.96
Rate for Payer: ASR Commercial	$1,580.96
Rate for Payer: BCBS Complete	$651.94
Rate for Payer: BCBS Trust/PPO	$1,334.69
Rate for Payer: BCN Commercial	$1,263.63
Rate for Payer: Cash Price	$1,303.89
Rate for Payer: Cofinity Commercial	$1,532.07
Rate for Payer: Encore Health Key Benefits Commercial	$1,303.89
Rate for Payer: Healthscope Commercial	$1,629.86
Rate for Payer: Healthscope Whirlpool	$1,580.96
Rate for Payer: Mclaren Commercial	$1,466.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,385.38
Rate for Payer: Nomi Health Commercial	$1,336.49
Rate for Payer: Priority Health Cigna Priority Health	$1,059.41
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,428.08
Rate for Payer: Priority Health Narrow Network	$1,142.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,434.28

HC BRACE KNEE IMMOBILIZER

Facility

$202.83

Service Code	HCPCS L1830
Hospital Charge Code	27400008
Hospital Revenue Code	274
Min. Negotiated Rate	$81.13
Max. Negotiated Rate	$202.83
Rate for Payer: Aetna Commercial	$182.55
Rate for Payer: Aetna Medicare	$101.42
Rate for Payer: ASR ASR	$196.75
Rate for Payer: ASR Commercial	$196.75
Rate for Payer: BCBS Complete	$81.13
Rate for Payer: BCBS Trust/PPO	$166.10
Rate for Payer: BCN Commercial	$157.25
Rate for Payer: Cash Price	$162.26
Rate for Payer: Cofinity Commercial	$190.66
Rate for Payer: Encore Health Key Benefits Commercial	$162.26
Rate for Payer: Healthscope Commercial	$202.83
Rate for Payer: Healthscope Whirlpool	$196.75
Rate for Payer: Mclaren Commercial	$182.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$172.41
Rate for Payer: Nomi Health Commercial	$166.32
Rate for Payer: Priority Health Cigna Priority Health	$131.84
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$177.72
Rate for Payer: Priority Health Narrow Network	$142.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$178.49

HC BRACE KNEE IMMOBILIZER

Facility

$202.83

Service Code	HCPCS L1830
Hospital Charge Code	27400008
Hospital Revenue Code	274
Min. Negotiated Rate	$131.84
Max. Negotiated Rate	$202.83
Rate for Payer: Aetna Commercial	$182.55
Rate for Payer: ASR ASR	$196.75
Rate for Payer: ASR Commercial	$196.75
Rate for Payer: BCBS Trust/PPO	$165.29
Rate for Payer: BCN Commercial	$157.25
Rate for Payer: Cash Price	$162.26
Rate for Payer: Cofinity Commercial	$190.66
Rate for Payer: Encore Health Key Benefits Commercial	$162.26
Rate for Payer: Healthscope Commercial	$202.83
Rate for Payer: Healthscope Whirlpool	$196.75
Rate for Payer: Mclaren Commercial	$182.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$172.41
Rate for Payer: Nomi Health Commercial	$166.32
Rate for Payer: Priority Health Cigna Priority Health	$131.84
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$178.49

HC BRACE LO SAG RGD A&P L1-L5 PREFAB

Facility

$651.78

Service Code	HCPCS L0627
Hospital Charge Code	27400025
Hospital Revenue Code	274
Min. Negotiated Rate	$423.66
Max. Negotiated Rate	$651.78
Rate for Payer: Aetna Commercial	$586.60
Rate for Payer: ASR ASR	$632.23
Rate for Payer: ASR Commercial	$632.23
Rate for Payer: BCBS Trust/PPO	$531.14
Rate for Payer: BCN Commercial	$505.33
Rate for Payer: Cash Price	$521.42
Rate for Payer: Cofinity Commercial	$612.67
Rate for Payer: Encore Health Key Benefits Commercial	$521.42
Rate for Payer: Healthscope Commercial	$651.78
Rate for Payer: Healthscope Whirlpool	$632.23
Rate for Payer: Mclaren Commercial	$586.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$554.01
Rate for Payer: Nomi Health Commercial	$534.46
Rate for Payer: Priority Health Cigna Priority Health	$423.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$573.57

HC BRACE LO SAG RGD A&P L1-L5 PREFAB

Facility

$651.78

Service Code	HCPCS L0627
Hospital Charge Code	27400025
Hospital Revenue Code	274
Min. Negotiated Rate	$260.71
Max. Negotiated Rate	$651.78
Rate for Payer: Aetna Commercial	$586.60
Rate for Payer: Aetna Medicare	$325.89
Rate for Payer: ASR ASR	$632.23
Rate for Payer: ASR Commercial	$632.23
Rate for Payer: BCBS Complete	$260.71
Rate for Payer: BCBS Trust/PPO	$533.74
Rate for Payer: BCN Commercial	$505.33
Rate for Payer: Cash Price	$521.42
Rate for Payer: Cofinity Commercial	$612.67
Rate for Payer: Encore Health Key Benefits Commercial	$521.42
Rate for Payer: Healthscope Commercial	$651.78
Rate for Payer: Healthscope Whirlpool	$632.23
Rate for Payer: Mclaren Commercial	$586.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$554.01
Rate for Payer: Nomi Health Commercial	$534.46
Rate for Payer: Priority Health Cigna Priority Health	$423.66
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$571.09
Rate for Payer: Priority Health Narrow Network	$456.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$573.57

HC BRACE LS CORSET CUSTOM

Facility

$185.64

Service Code	HCPCS L0626
Hospital Charge Code	27400005
Hospital Revenue Code	274
Min. Negotiated Rate	$120.67
Max. Negotiated Rate	$185.64
Rate for Payer: Aetna Commercial	$167.08
Rate for Payer: ASR ASR	$180.07
Rate for Payer: ASR Commercial	$180.07
Rate for Payer: BCBS Trust/PPO	$151.28
Rate for Payer: BCN Commercial	$143.93
Rate for Payer: Cash Price	$148.51
Rate for Payer: Cofinity Commercial	$174.50
Rate for Payer: Encore Health Key Benefits Commercial	$148.51
Rate for Payer: Healthscope Commercial	$185.64
Rate for Payer: Healthscope Whirlpool	$180.07
Rate for Payer: Mclaren Commercial	$167.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$157.79
Rate for Payer: Nomi Health Commercial	$152.22
Rate for Payer: Priority Health Cigna Priority Health	$120.67
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$163.36

HC BRACE LS CORSET CUSTOM

Facility

$185.64

Service Code	HCPCS L0626
Hospital Charge Code	27400005
Hospital Revenue Code	274
Min. Negotiated Rate	$74.26
Max. Negotiated Rate	$185.64
Rate for Payer: Aetna Commercial	$167.08
Rate for Payer: Aetna Medicare	$92.82
Rate for Payer: ASR ASR	$180.07
Rate for Payer: ASR Commercial	$180.07
Rate for Payer: BCBS Complete	$74.26
Rate for Payer: BCBS Trust/PPO	$152.02
Rate for Payer: BCN Commercial	$143.93
Rate for Payer: Cash Price	$148.51
Rate for Payer: Cofinity Commercial	$174.50
Rate for Payer: Encore Health Key Benefits Commercial	$148.51
Rate for Payer: Healthscope Commercial	$185.64
Rate for Payer: Healthscope Whirlpool	$180.07
Rate for Payer: Mclaren Commercial	$167.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$157.79
Rate for Payer: Nomi Health Commercial	$152.22
Rate for Payer: Priority Health Cigna Priority Health	$120.67
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$162.66
Rate for Payer: Priority Health Narrow Network	$130.13
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$163.36

HC BRACE LS CORSET OTS

Facility

$194.92

Service Code	HCPCS L0641
Hospital Charge Code	27400019
Hospital Revenue Code	274
Min. Negotiated Rate	$77.97
Max. Negotiated Rate	$194.92
Rate for Payer: Aetna Commercial	$175.43
Rate for Payer: Aetna Medicare	$97.46
Rate for Payer: ASR ASR	$189.07
Rate for Payer: ASR Commercial	$189.07
Rate for Payer: BCBS Complete	$77.97
Rate for Payer: BCBS Trust/PPO	$159.62
Rate for Payer: BCN Commercial	$151.12
Rate for Payer: Cash Price	$155.94
Rate for Payer: Cofinity Commercial	$183.22
Rate for Payer: Encore Health Key Benefits Commercial	$155.94
Rate for Payer: Healthscope Commercial	$194.92
Rate for Payer: Healthscope Whirlpool	$189.07
Rate for Payer: Mclaren Commercial	$175.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$165.68
Rate for Payer: Nomi Health Commercial	$159.83
Rate for Payer: Priority Health Cigna Priority Health	$126.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$170.79
Rate for Payer: Priority Health Narrow Network	$136.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$171.53

HC BRACE LS CORSET OTS

Facility

$194.92

Service Code	HCPCS L0641
Hospital Charge Code	27400019
Hospital Revenue Code	274
Min. Negotiated Rate	$126.70
Max. Negotiated Rate	$194.92
Rate for Payer: Aetna Commercial	$175.43
Rate for Payer: ASR ASR	$189.07
Rate for Payer: ASR Commercial	$189.07
Rate for Payer: BCBS Trust/PPO	$158.84
Rate for Payer: BCN Commercial	$151.12
Rate for Payer: Cash Price	$155.94
Rate for Payer: Cofinity Commercial	$183.22
Rate for Payer: Encore Health Key Benefits Commercial	$155.94
Rate for Payer: Healthscope Commercial	$194.92
Rate for Payer: Healthscope Whirlpool	$189.07
Rate for Payer: Mclaren Commercial	$175.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$165.68
Rate for Payer: Nomi Health Commercial	$159.83
Rate for Payer: Priority Health Cigna Priority Health	$126.70
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$171.53

HC BRACE LSO CUSTOM

Facility

$2,554.51

Hospital Charge Code	27400006
Hospital Revenue Code	274
Min. Negotiated Rate	$1,660.43
Max. Negotiated Rate	$2,554.51
Rate for Payer: Aetna Commercial	$2,299.06
Rate for Payer: ASR ASR	$2,477.87
Rate for Payer: ASR Commercial	$2,477.87
Rate for Payer: BCBS Trust/PPO	$2,081.67
Rate for Payer: BCN Commercial	$1,980.51
Rate for Payer: Cash Price	$2,043.61
Rate for Payer: Cofinity Commercial	$2,401.24
Rate for Payer: Encore Health Key Benefits Commercial	$2,043.61
Rate for Payer: Healthscope Commercial	$2,554.51
Rate for Payer: Healthscope Whirlpool	$2,477.87
Rate for Payer: Mclaren Commercial	$2,299.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,171.33
Rate for Payer: Nomi Health Commercial	$2,094.70
Rate for Payer: Priority Health Cigna Priority Health	$1,660.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,247.97

HC BRACE LSO CUSTOM

Facility

$2,554.51

Hospital Charge Code	27400006
Hospital Revenue Code	274
Min. Negotiated Rate	$1,021.80
Max. Negotiated Rate	$2,554.51
Rate for Payer: Aetna Commercial	$2,299.06
Rate for Payer: Aetna Medicare	$1,277.26
Rate for Payer: ASR ASR	$2,477.87
Rate for Payer: ASR Commercial	$2,477.87
Rate for Payer: BCBS Complete	$1,021.80
Rate for Payer: BCBS Trust/PPO	$2,091.89
Rate for Payer: BCN Commercial	$1,980.51
Rate for Payer: Cash Price	$2,043.61
Rate for Payer: Cofinity Commercial	$2,401.24
Rate for Payer: Encore Health Key Benefits Commercial	$2,043.61
Rate for Payer: Healthscope Commercial	$2,554.51
Rate for Payer: Healthscope Whirlpool	$2,477.87
Rate for Payer: Mclaren Commercial	$2,299.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,171.33
Rate for Payer: Nomi Health Commercial	$2,094.70
Rate for Payer: Priority Health Cigna Priority Health	$1,660.43
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,238.26
Rate for Payer: Priority Health Narrow Network	$1,790.71
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,247.97

HC BRACE LSO SC CTRL RIGID AP PNL CSTM

Facility

$2,719.28

Service Code	HCPCS L0637
Hospital Charge Code	27400046
Hospital Revenue Code	274
Min. Negotiated Rate	$1,767.53
Max. Negotiated Rate	$2,719.28
Rate for Payer: Aetna Commercial	$2,447.35
Rate for Payer: ASR ASR	$2,637.70
Rate for Payer: ASR Commercial	$2,637.70
Rate for Payer: BCBS Trust/PPO	$2,215.94
Rate for Payer: BCN Commercial	$2,108.26
Rate for Payer: Cash Price	$2,175.42
Rate for Payer: Cofinity Commercial	$2,556.12
Rate for Payer: Encore Health Key Benefits Commercial	$2,175.42
Rate for Payer: Healthscope Commercial	$2,719.28
Rate for Payer: Healthscope Whirlpool	$2,637.70
Rate for Payer: Mclaren Commercial	$2,447.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,311.39
Rate for Payer: Nomi Health Commercial	$2,229.81
Rate for Payer: Priority Health Cigna Priority Health	$1,767.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,392.97

HC BRACE LSO SC CTRL RIGID AP PNL CSTM

Facility

$2,719.28

Service Code	HCPCS L0637
Hospital Charge Code	27400046
Hospital Revenue Code	274
Min. Negotiated Rate	$1,087.71
Max. Negotiated Rate	$2,719.28
Rate for Payer: Aetna Commercial	$2,447.35
Rate for Payer: Aetna Medicare	$1,359.64
Rate for Payer: ASR ASR	$2,637.70
Rate for Payer: ASR Commercial	$2,637.70
Rate for Payer: BCBS Complete	$1,087.71
Rate for Payer: BCBS Trust/PPO	$2,226.82
Rate for Payer: BCN Commercial	$2,108.26
Rate for Payer: Cash Price	$2,175.42
Rate for Payer: Cofinity Commercial	$2,556.12
Rate for Payer: Encore Health Key Benefits Commercial	$2,175.42
Rate for Payer: Healthscope Commercial	$2,719.28
Rate for Payer: Healthscope Whirlpool	$2,637.70
Rate for Payer: Mclaren Commercial	$2,447.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,311.39
Rate for Payer: Nomi Health Commercial	$2,229.81
Rate for Payer: Priority Health Cigna Priority Health	$1,767.53
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,382.63
Rate for Payer: Priority Health Narrow Network	$1,906.22
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,392.97

HC BRACE PAVLIK HARNESS CUSTOM

Facility

$371.81

Service Code	HCPCS L1620
Hospital Charge Code	27000010
Hospital Revenue Code	274
Min. Negotiated Rate	$148.72
Max. Negotiated Rate	$371.81
Rate for Payer: Aetna Commercial	$334.63
Rate for Payer: Aetna Medicare	$185.91
Rate for Payer: ASR ASR	$360.66
Rate for Payer: ASR Commercial	$360.66
Rate for Payer: BCBS Complete	$148.72
Rate for Payer: BCBS Trust/PPO	$304.48
Rate for Payer: BCN Commercial	$288.26
Rate for Payer: Cash Price	$297.45
Rate for Payer: Cofinity Commercial	$349.50
Rate for Payer: Encore Health Key Benefits Commercial	$297.45
Rate for Payer: Healthscope Commercial	$371.81
Rate for Payer: Healthscope Whirlpool	$360.66
Rate for Payer: Mclaren Commercial	$334.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$316.04
Rate for Payer: Nomi Health Commercial	$304.88
Rate for Payer: Priority Health Cigna Priority Health	$241.68
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$325.78
Rate for Payer: Priority Health Narrow Network	$260.64
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$327.19

HC BRACE PAVLIK HARNESS CUSTOM

Facility

$371.81

Service Code	HCPCS L1620
Hospital Charge Code	27000010
Hospital Revenue Code	274
Min. Negotiated Rate	$241.68
Max. Negotiated Rate	$371.81
Rate for Payer: Aetna Commercial	$334.63
Rate for Payer: ASR ASR	$360.66
Rate for Payer: ASR Commercial	$360.66
Rate for Payer: BCBS Trust/PPO	$302.99
Rate for Payer: BCN Commercial	$288.26
Rate for Payer: Cash Price	$297.45
Rate for Payer: Cofinity Commercial	$349.50
Rate for Payer: Encore Health Key Benefits Commercial	$297.45
Rate for Payer: Healthscope Commercial	$371.81
Rate for Payer: Healthscope Whirlpool	$360.66
Rate for Payer: Mclaren Commercial	$334.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$316.04
Rate for Payer: Nomi Health Commercial	$304.88
Rate for Payer: Priority Health Cigna Priority Health	$241.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$327.19

HC BRACE PRAFO CUSTOM

Facility

$397.09

Service Code	HCPCS L4396
Hospital Charge Code	27000012
Hospital Revenue Code	274
Min. Negotiated Rate	$258.11
Max. Negotiated Rate	$397.09
Rate for Payer: Aetna Commercial	$357.38
Rate for Payer: ASR ASR	$385.18
Rate for Payer: ASR Commercial	$385.18
Rate for Payer: BCBS Trust/PPO	$323.59
Rate for Payer: BCN Commercial	$307.86
Rate for Payer: Cash Price	$317.67
Rate for Payer: Cofinity Commercial	$373.26
Rate for Payer: Encore Health Key Benefits Commercial	$317.67
Rate for Payer: Healthscope Commercial	$397.09
Rate for Payer: Healthscope Whirlpool	$385.18
Rate for Payer: Mclaren Commercial	$357.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$337.53
Rate for Payer: Nomi Health Commercial	$325.61
Rate for Payer: Priority Health Cigna Priority Health	$258.11
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$349.44

HC BRACE PRAFO CUSTOM

Facility

$397.09

Service Code	HCPCS L4396
Hospital Charge Code	27000012
Hospital Revenue Code	274
Min. Negotiated Rate	$158.84
Max. Negotiated Rate	$397.09
Rate for Payer: Aetna Commercial	$357.38
Rate for Payer: Aetna Medicare	$198.54
Rate for Payer: ASR ASR	$385.18
Rate for Payer: ASR Commercial	$385.18
Rate for Payer: BCBS Complete	$158.84
Rate for Payer: BCBS Trust/PPO	$325.18
Rate for Payer: BCN Commercial	$307.86
Rate for Payer: Cash Price	$317.67
Rate for Payer: Cofinity Commercial	$373.26
Rate for Payer: Encore Health Key Benefits Commercial	$317.67
Rate for Payer: Healthscope Commercial	$397.09
Rate for Payer: Healthscope Whirlpool	$385.18
Rate for Payer: Mclaren Commercial	$357.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$337.53
Rate for Payer: Nomi Health Commercial	$325.61
Rate for Payer: Priority Health Cigna Priority Health	$258.11
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$347.93
Rate for Payer: Priority Health Narrow Network	$278.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$349.44

HC BRACE PRAFO OTS

Facility

$436.79

Service Code	HCPCS L4397
Hospital Charge Code	27000456
Hospital Revenue Code	274
Min. Negotiated Rate	$174.72
Max. Negotiated Rate	$436.79
Rate for Payer: Aetna Commercial	$393.11
Rate for Payer: Aetna Medicare	$218.40
Rate for Payer: ASR ASR	$423.69
Rate for Payer: ASR Commercial	$423.69
Rate for Payer: BCBS Complete	$174.72
Rate for Payer: BCBS Trust/PPO	$357.69
Rate for Payer: BCN Commercial	$338.64
Rate for Payer: Cash Price	$349.43
Rate for Payer: Cofinity Commercial	$410.58
Rate for Payer: Encore Health Key Benefits Commercial	$349.43
Rate for Payer: Healthscope Commercial	$436.79
Rate for Payer: Healthscope Whirlpool	$423.69
Rate for Payer: Mclaren Commercial	$393.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$371.27
Rate for Payer: Nomi Health Commercial	$358.17
Rate for Payer: Priority Health Cigna Priority Health	$283.91
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$382.72
Rate for Payer: Priority Health Narrow Network	$306.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$384.38

HC BRACE PRAFO OTS

Facility

$436.79

Service Code	HCPCS L4397
Hospital Charge Code	27000456
Hospital Revenue Code	274
Min. Negotiated Rate	$283.91
Max. Negotiated Rate	$436.79
Rate for Payer: Aetna Commercial	$393.11
Rate for Payer: ASR ASR	$423.69
Rate for Payer: ASR Commercial	$423.69
Rate for Payer: BCBS Trust/PPO	$355.94
Rate for Payer: BCN Commercial	$338.64
Rate for Payer: Cash Price	$349.43
Rate for Payer: Cofinity Commercial	$410.58
Rate for Payer: Encore Health Key Benefits Commercial	$349.43
Rate for Payer: Healthscope Commercial	$436.79
Rate for Payer: Healthscope Whirlpool	$423.69
Rate for Payer: Mclaren Commercial	$393.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$371.27
Rate for Payer: Nomi Health Commercial	$358.17
Rate for Payer: Priority Health Cigna Priority Health	$283.91
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$384.38

HC BRACE RESTING NIGHTSPLINT CUSTOM

Facility

$538.45

Service Code	HCPCS L3807
Hospital Charge Code	27000200
Hospital Revenue Code	274
Min. Negotiated Rate	$349.99
Max. Negotiated Rate	$538.45
Rate for Payer: Aetna Commercial	$484.61
Rate for Payer: ASR ASR	$522.30
Rate for Payer: ASR Commercial	$522.30
Rate for Payer: BCBS Trust/PPO	$438.78
Rate for Payer: BCN Commercial	$417.46
Rate for Payer: Cash Price	$430.76
Rate for Payer: Cofinity Commercial	$506.14
Rate for Payer: Encore Health Key Benefits Commercial	$430.76
Rate for Payer: Healthscope Commercial	$538.45
Rate for Payer: Healthscope Whirlpool	$522.30
Rate for Payer: Mclaren Commercial	$484.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$457.68
Rate for Payer: Nomi Health Commercial	$441.53
Rate for Payer: Priority Health Cigna Priority Health	$349.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$473.84

HC BRACE RESTING NIGHTSPLINT CUSTOM

Facility

$538.45

Service Code	HCPCS L3807
Hospital Charge Code	27000200
Hospital Revenue Code	274
Min. Negotiated Rate	$215.38
Max. Negotiated Rate	$538.45
Rate for Payer: Aetna Commercial	$484.61
Rate for Payer: Aetna Medicare	$269.23
Rate for Payer: ASR ASR	$522.30
Rate for Payer: ASR Commercial	$522.30
Rate for Payer: BCBS Complete	$215.38
Rate for Payer: BCBS Trust/PPO	$440.94
Rate for Payer: BCN Commercial	$417.46
Rate for Payer: Cash Price	$430.76
Rate for Payer: Cofinity Commercial	$506.14
Rate for Payer: Encore Health Key Benefits Commercial	$430.76
Rate for Payer: Healthscope Commercial	$538.45
Rate for Payer: Healthscope Whirlpool	$522.30
Rate for Payer: Mclaren Commercial	$484.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$457.68
Rate for Payer: Nomi Health Commercial	$441.53
Rate for Payer: Priority Health Cigna Priority Health	$349.99
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$471.79
Rate for Payer: Priority Health Narrow Network	$377.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$473.84

HC BRACE RIGID NECK

Facility

$185.06

Service Code	HCPCS L0140
Hospital Charge Code	27400009
Hospital Revenue Code	274
Min. Negotiated Rate	$74.02
Max. Negotiated Rate	$185.06
Rate for Payer: Aetna Commercial	$166.55
Rate for Payer: Aetna Medicare	$92.53
Rate for Payer: ASR ASR	$179.51
Rate for Payer: ASR Commercial	$179.51
Rate for Payer: BCBS Complete	$74.02
Rate for Payer: BCBS Trust/PPO	$151.55
Rate for Payer: BCN Commercial	$143.48
Rate for Payer: Cash Price	$148.05
Rate for Payer: Cofinity Commercial	$173.96
Rate for Payer: Encore Health Key Benefits Commercial	$148.05
Rate for Payer: Healthscope Commercial	$185.06
Rate for Payer: Healthscope Whirlpool	$179.51
Rate for Payer: Mclaren Commercial	$166.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$157.30
Rate for Payer: Nomi Health Commercial	$151.75
Rate for Payer: Priority Health Cigna Priority Health	$120.29
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$162.15
Rate for Payer: Priority Health Narrow Network	$129.73
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$162.85

HC BRACE RIGID NECK

Facility

$185.06

Service Code	HCPCS L0140
Hospital Charge Code	27400009
Hospital Revenue Code	274
Min. Negotiated Rate	$120.29
Max. Negotiated Rate	$185.06
Rate for Payer: Aetna Commercial	$166.55
Rate for Payer: ASR ASR	$179.51
Rate for Payer: ASR Commercial	$179.51
Rate for Payer: BCBS Trust/PPO	$150.81
Rate for Payer: BCN Commercial	$143.48
Rate for Payer: Cash Price	$148.05
Rate for Payer: Cofinity Commercial	$173.96
Rate for Payer: Encore Health Key Benefits Commercial	$148.05
Rate for Payer: Healthscope Commercial	$185.06
Rate for Payer: Healthscope Whirlpool	$179.51
Rate for Payer: Mclaren Commercial	$166.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$157.30
Rate for Payer: Nomi Health Commercial	$151.75
Rate for Payer: Priority Health Cigna Priority Health	$120.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$162.85

Know your out-of-pocket cost for care.

All Charges