Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC OT Z GAUNTLET EA $175

Facility

$175.00

Service Code	HCPCS A6549
Hospital Charge Code	98300077
Hospital Revenue Code	270
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$157.50
Rate for Payer: ASR ASR	$169.75
Rate for Payer: BCBS Complete	$70.00
Rate for Payer: BCBS Trust/PPO	$135.68
Rate for Payer: BCN Commercial	$135.68
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cofinity Commercial	$164.50
Rate for Payer: Encore Health Key Benefits Commercial	$140.00
Rate for Payer: Healthscope Commercial	$175.00
Rate for Payer: Healthscope Whirlpool	$169.75
Rate for Payer: Mclaren Commercial	$157.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$148.75
Rate for Payer: Priority Health Cigna Priority Health	$122.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$159.25
Rate for Payer: Priority Health Narrow Network	$124.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$154.00

HC OT Z GAUNTLET EA $175

Facility

$175.00

Service Code	HCPCS A6549
Hospital Charge Code	98300077
Hospital Revenue Code	270
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$157.50
Rate for Payer: ASR ASR	$169.75
Rate for Payer: BCBS Trust/PPO	$135.68
Rate for Payer: BCN Commercial	$135.68
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cofinity Commercial	$164.50
Rate for Payer: Encore Health Key Benefits Commercial	$140.00
Rate for Payer: Healthscope Commercial	$175.00
Rate for Payer: Healthscope Whirlpool	$169.75
Rate for Payer: Mclaren Commercial	$157.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$148.75
Rate for Payer: Priority Health Cigna Priority Health	$122.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$154.00

HC OT Z GAUNTLET EA $20

Facility

$20.00

Service Code	HCPCS A6549
Hospital Charge Code	98300078
Hospital Revenue Code	270
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: ASR ASR	$19.40
Rate for Payer: BCBS Trust/PPO	$15.51
Rate for Payer: BCN Commercial	$15.51
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Commercial	$18.80
Rate for Payer: Encore Health Key Benefits Commercial	$16.00
Rate for Payer: Healthscope Commercial	$20.00
Rate for Payer: Healthscope Whirlpool	$19.40
Rate for Payer: Mclaren Commercial	$18.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.00
Rate for Payer: Priority Health Cigna Priority Health	$14.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.60

HC OT Z GAUNTLET EA $20

Facility

$20.00

Service Code	HCPCS A6549
Hospital Charge Code	98300078
Hospital Revenue Code	270
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$18.00
Rate for Payer: ASR ASR	$19.40
Rate for Payer: BCBS Complete	$8.00
Rate for Payer: BCBS Trust/PPO	$15.51
Rate for Payer: BCN Commercial	$15.51
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cofinity Commercial	$18.80
Rate for Payer: Encore Health Key Benefits Commercial	$16.00
Rate for Payer: Healthscope Commercial	$20.00
Rate for Payer: Healthscope Whirlpool	$19.40
Rate for Payer: Mclaren Commercial	$18.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.00
Rate for Payer: Priority Health Cigna Priority Health	$14.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$18.20
Rate for Payer: Priority Health Narrow Network	$14.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.60

HC OT Z GAUNTLET EA $200

Facility

$200.00

Service Code	HCPCS A6549
Hospital Charge Code	98300079
Hospital Revenue Code	270
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$180.00
Rate for Payer: ASR ASR	$194.00
Rate for Payer: BCBS Complete	$80.00
Rate for Payer: BCBS Trust/PPO	$155.06
Rate for Payer: BCN Commercial	$155.06
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cofinity Commercial	$188.00
Rate for Payer: Encore Health Key Benefits Commercial	$160.00
Rate for Payer: Healthscope Commercial	$200.00
Rate for Payer: Healthscope Whirlpool	$194.00
Rate for Payer: Mclaren Commercial	$180.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$170.00
Rate for Payer: Priority Health Cigna Priority Health	$140.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$182.00
Rate for Payer: Priority Health Narrow Network	$142.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$176.00

HC OT Z GAUNTLET EA $200

Facility

$200.00

Service Code	HCPCS A6549
Hospital Charge Code	98300079
Hospital Revenue Code	270
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$180.00
Rate for Payer: ASR ASR	$194.00
Rate for Payer: BCBS Trust/PPO	$155.06
Rate for Payer: BCN Commercial	$155.06
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cofinity Commercial	$188.00
Rate for Payer: Encore Health Key Benefits Commercial	$160.00
Rate for Payer: Healthscope Commercial	$200.00
Rate for Payer: Healthscope Whirlpool	$194.00
Rate for Payer: Mclaren Commercial	$180.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$170.00
Rate for Payer: Priority Health Cigna Priority Health	$140.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$176.00

HC OT Z GAUNTLET EA $225

Facility

$225.00

Service Code	HCPCS A6549
Hospital Charge Code	98300080
Hospital Revenue Code	270
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna Commercial	$202.50
Rate for Payer: ASR ASR	$218.25
Rate for Payer: BCBS Trust/PPO	$174.44
Rate for Payer: BCN Commercial	$174.44
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cofinity Commercial	$211.50
Rate for Payer: Encore Health Key Benefits Commercial	$180.00
Rate for Payer: Healthscope Commercial	$225.00
Rate for Payer: Healthscope Whirlpool	$218.25
Rate for Payer: Mclaren Commercial	$202.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$191.25
Rate for Payer: Priority Health Cigna Priority Health	$157.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$198.00

HC OT Z GAUNTLET EA $225

Facility

$225.00

Service Code	HCPCS A6549
Hospital Charge Code	98300080
Hospital Revenue Code	270
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna Commercial	$202.50
Rate for Payer: ASR ASR	$218.25
Rate for Payer: BCBS Complete	$90.00
Rate for Payer: BCBS Trust/PPO	$174.44
Rate for Payer: BCN Commercial	$174.44
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cofinity Commercial	$211.50
Rate for Payer: Encore Health Key Benefits Commercial	$180.00
Rate for Payer: Healthscope Commercial	$225.00
Rate for Payer: Healthscope Whirlpool	$218.25
Rate for Payer: Mclaren Commercial	$202.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$191.25
Rate for Payer: Priority Health Cigna Priority Health	$157.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$204.75
Rate for Payer: Priority Health Narrow Network	$159.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$198.00

HC OT Z GAUNTLET EA $250

Facility

$250.00

Service Code	HCPCS A6549
Hospital Charge Code	98300081
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 OT Z GAUNTLET EA $250

Facility

$250.00

Service Code	HCPCS A6549
Hospital Charge Code	98300081
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 OT Z GAUNTLET EA $275

Facility

$275.00

Service Code	HCPCS A6549
Hospital Charge Code	98300082
Hospital Revenue Code	270
Min. Negotiated Rate	$110.00
Max. Negotiated Rate	$275.00
Rate for Payer: Aetna Commercial	$247.50
Rate for Payer: ASR ASR	$266.75
Rate for Payer: BCBS Complete	$110.00
Rate for Payer: BCBS Trust/PPO	$213.21
Rate for Payer: BCN Commercial	$213.21
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cofinity Commercial	$258.50
Rate for Payer: Encore Health Key Benefits Commercial	$220.00
Rate for Payer: Healthscope Commercial	$275.00
Rate for Payer: Healthscope Whirlpool	$266.75
Rate for Payer: Mclaren Commercial	$247.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$233.75
Rate for Payer: Priority Health Cigna Priority Health	$192.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$250.25
Rate for Payer: Priority Health Narrow Network	$195.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$242.00

HC OT Z GAUNTLET EA $275

Facility

$275.00

Service Code	HCPCS A6549
Hospital Charge Code	98300082
Hospital Revenue Code	270
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$275.00
Rate for Payer: Aetna Commercial	$247.50
Rate for Payer: ASR ASR	$266.75
Rate for Payer: BCBS Trust/PPO	$213.21
Rate for Payer: BCN Commercial	$213.21
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cofinity Commercial	$258.50
Rate for Payer: Encore Health Key Benefits Commercial	$220.00
Rate for Payer: Healthscope Commercial	$275.00
Rate for Payer: Healthscope Whirlpool	$266.75
Rate for Payer: Mclaren Commercial	$247.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$233.75
Rate for Payer: Priority Health Cigna Priority Health	$192.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$242.00

HC OT Z GAUNTLET EA $300

Facility

$300.00

Service Code	HCPCS A6549
Hospital Charge Code	98300083
Hospital Revenue Code	270
Min. Negotiated Rate	$120.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$270.00
Rate for Payer: ASR ASR	$291.00
Rate for Payer: BCBS Complete	$120.00
Rate for Payer: BCBS Trust/PPO	$232.59
Rate for Payer: BCN Commercial	$232.59
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cofinity Commercial	$282.00
Rate for Payer: Encore Health Key Benefits Commercial	$240.00
Rate for Payer: Healthscope Commercial	$300.00
Rate for Payer: Healthscope Whirlpool	$291.00
Rate for Payer: Mclaren Commercial	$270.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$255.00
Rate for Payer: Priority Health Cigna Priority Health	$210.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$273.00
Rate for Payer: Priority Health Narrow Network	$213.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$264.00

HC OT Z GAUNTLET EA $300

Facility

$300.00

Service Code	HCPCS A6549
Hospital Charge Code	98300083
Hospital Revenue Code	270
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$270.00
Rate for Payer: ASR ASR	$291.00
Rate for Payer: BCBS Trust/PPO	$232.59
Rate for Payer: BCN Commercial	$232.59
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cofinity Commercial	$282.00
Rate for Payer: Encore Health Key Benefits Commercial	$240.00
Rate for Payer: Healthscope Commercial	$300.00
Rate for Payer: Healthscope Whirlpool	$291.00
Rate for Payer: Mclaren Commercial	$270.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$255.00
Rate for Payer: Priority Health Cigna Priority Health	$210.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$264.00

HC OT Z GAUNTLET EA $325

Facility

$325.00

Service Code	HCPCS A6549
Hospital Charge Code	98300084
Hospital Revenue Code	270
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$292.50
Rate for Payer: ASR ASR	$315.25
Rate for Payer: BCBS Trust/PPO	$251.97
Rate for Payer: BCN Commercial	$251.97
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cofinity Commercial	$305.50
Rate for Payer: Encore Health Key Benefits Commercial	$260.00
Rate for Payer: Healthscope Commercial	$325.00
Rate for Payer: Healthscope Whirlpool	$315.25
Rate for Payer: Mclaren Commercial	$292.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$276.25
Rate for Payer: Priority Health Cigna Priority Health	$227.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$286.00

HC OT Z GAUNTLET EA $325

Facility

$325.00

Service Code	HCPCS A6549
Hospital Charge Code	98300084
Hospital Revenue Code	270
Min. Negotiated Rate	$130.00
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$292.50
Rate for Payer: ASR ASR	$315.25
Rate for Payer: BCBS Complete	$130.00
Rate for Payer: BCBS Trust/PPO	$251.97
Rate for Payer: BCN Commercial	$251.97
Rate for Payer: Cash Price	$260.00
Rate for Payer: Cofinity Commercial	$305.50
Rate for Payer: Encore Health Key Benefits Commercial	$260.00
Rate for Payer: Healthscope Commercial	$325.00
Rate for Payer: Healthscope Whirlpool	$315.25
Rate for Payer: Mclaren Commercial	$292.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$276.25
Rate for Payer: Priority Health Cigna Priority Health	$227.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$295.75
Rate for Payer: Priority Health Narrow Network	$230.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$286.00

HC OT Z GAUNTLET EA $350

Facility

$350.00

Service Code	HCPCS A6549
Hospital Charge Code	98300085
Hospital Revenue Code	270
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$315.00
Rate for Payer: ASR ASR	$339.50
Rate for Payer: BCBS Complete	$140.00
Rate for Payer: BCBS Trust/PPO	$271.36
Rate for Payer: BCN Commercial	$271.36
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cofinity Commercial	$329.00
Rate for Payer: Encore Health Key Benefits Commercial	$280.00
Rate for Payer: Healthscope Commercial	$350.00
Rate for Payer: Healthscope Whirlpool	$339.50
Rate for Payer: Mclaren Commercial	$315.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$297.50
Rate for Payer: Priority Health Cigna Priority Health	$245.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$318.50
Rate for Payer: Priority Health Narrow Network	$248.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$308.00

HC OT Z GAUNTLET EA $350

Facility

$350.00

Service Code	HCPCS A6549
Hospital Charge Code	98300085
Hospital Revenue Code	270
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$315.00
Rate for Payer: ASR ASR	$339.50
Rate for Payer: BCBS Trust/PPO	$271.36
Rate for Payer: BCN Commercial	$271.36
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cofinity Commercial	$329.00
Rate for Payer: Encore Health Key Benefits Commercial	$280.00
Rate for Payer: Healthscope Commercial	$350.00
Rate for Payer: Healthscope Whirlpool	$339.50
Rate for Payer: Mclaren Commercial	$315.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$297.50
Rate for Payer: Priority Health Cigna Priority Health	$245.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$308.00

HC OT Z GAUNTLET EA $375

Facility

$375.00

Service Code	HCPCS A6549
Hospital Charge Code	98300086
Hospital Revenue Code	270
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$337.50
Rate for Payer: ASR ASR	$363.75
Rate for Payer: BCBS Trust/PPO	$290.74
Rate for Payer: BCN Commercial	$290.74
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cofinity Commercial	$352.50
Rate for Payer: Encore Health Key Benefits Commercial	$300.00
Rate for Payer: Healthscope Commercial	$375.00
Rate for Payer: Healthscope Whirlpool	$363.75
Rate for Payer: Mclaren Commercial	$337.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$318.75
Rate for Payer: Priority Health Cigna Priority Health	$262.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$330.00

HC OT Z GAUNTLET EA $375

Facility

$375.00

Service Code	HCPCS A6549
Hospital Charge Code	98300086
Hospital Revenue Code	270
Min. Negotiated Rate	$150.00
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$337.50
Rate for Payer: ASR ASR	$363.75
Rate for Payer: BCBS Complete	$150.00
Rate for Payer: BCBS Trust/PPO	$290.74
Rate for Payer: BCN Commercial	$290.74
Rate for Payer: Cash Price	$300.00
Rate for Payer: Cofinity Commercial	$352.50
Rate for Payer: Encore Health Key Benefits Commercial	$300.00
Rate for Payer: Healthscope Commercial	$375.00
Rate for Payer: Healthscope Whirlpool	$363.75
Rate for Payer: Mclaren Commercial	$337.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$318.75
Rate for Payer: Priority Health Cigna Priority Health	$262.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$341.25
Rate for Payer: Priority Health Narrow Network	$266.25
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$330.00

HC OT Z GAUNTLET EA $400

Facility

$400.00

Service Code	HCPCS A6549
Hospital Charge Code	98300087
Hospital Revenue Code	270
Min. Negotiated Rate	$160.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$360.00
Rate for Payer: ASR ASR	$388.00
Rate for Payer: BCBS Complete	$160.00
Rate for Payer: BCBS Trust/PPO	$310.12
Rate for Payer: BCN Commercial	$310.12
Rate for Payer: Cash Price	$320.00
Rate for Payer: Cofinity Commercial	$376.00
Rate for Payer: Encore Health Key Benefits Commercial	$320.00
Rate for Payer: Healthscope Commercial	$400.00
Rate for Payer: Healthscope Whirlpool	$388.00
Rate for Payer: Mclaren Commercial	$360.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$340.00
Rate for Payer: Priority Health Cigna Priority Health	$280.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$364.00
Rate for Payer: Priority Health Narrow Network	$284.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$352.00

HC OT Z GAUNTLET EA $400

Facility

$400.00

Service Code	HCPCS A6549
Hospital Charge Code	98300087
Hospital Revenue Code	270
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$360.00
Rate for Payer: ASR ASR	$388.00
Rate for Payer: BCBS Trust/PPO	$310.12
Rate for Payer: BCN Commercial	$310.12
Rate for Payer: Cash Price	$320.00
Rate for Payer: Cofinity Commercial	$376.00
Rate for Payer: Encore Health Key Benefits Commercial	$320.00
Rate for Payer: Healthscope Commercial	$400.00
Rate for Payer: Healthscope Whirlpool	$388.00
Rate for Payer: Mclaren Commercial	$360.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$340.00
Rate for Payer: Priority Health Cigna Priority Health	$280.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$352.00

HC OT Z GAUNTLET EA $425

Facility

$425.00

Service Code	HCPCS A6549
Hospital Charge Code	98300088
Hospital Revenue Code	270
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$425.00
Rate for Payer: Aetna Commercial	$382.50
Rate for Payer: ASR ASR	$412.25
Rate for Payer: BCBS Trust/PPO	$329.50
Rate for Payer: BCN Commercial	$329.50
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cofinity Commercial	$399.50
Rate for Payer: Encore Health Key Benefits Commercial	$340.00
Rate for Payer: Healthscope Commercial	$425.00
Rate for Payer: Healthscope Whirlpool	$412.25
Rate for Payer: Mclaren Commercial	$382.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$361.25
Rate for Payer: Priority Health Cigna Priority Health	$297.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$374.00

HC OT Z GAUNTLET EA $425

Facility

$425.00

Service Code	HCPCS A6549
Hospital Charge Code	98300088
Hospital Revenue Code	270
Min. Negotiated Rate	$170.00
Max. Negotiated Rate	$425.00
Rate for Payer: Aetna Commercial	$382.50
Rate for Payer: ASR ASR	$412.25
Rate for Payer: BCBS Complete	$170.00
Rate for Payer: BCBS Trust/PPO	$329.50
Rate for Payer: BCN Commercial	$329.50
Rate for Payer: Cash Price	$340.00
Rate for Payer: Cofinity Commercial	$399.50
Rate for Payer: Encore Health Key Benefits Commercial	$340.00
Rate for Payer: Healthscope Commercial	$425.00
Rate for Payer: Healthscope Whirlpool	$412.25
Rate for Payer: Mclaren Commercial	$382.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$361.25
Rate for Payer: Priority Health Cigna Priority Health	$297.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$386.75
Rate for Payer: Priority Health Narrow Network	$301.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$374.00

HC OT Z GAUNTLET EA $450

Facility

$450.00

Service Code	HCPCS A6549
Hospital Charge Code	98300089
Hospital Revenue Code	270
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna Commercial	$405.00
Rate for Payer: ASR ASR	$436.50
Rate for Payer: BCBS Complete	$180.00
Rate for Payer: BCBS Trust/PPO	$348.88
Rate for Payer: BCN Commercial	$348.88
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cofinity Commercial	$423.00
Rate for Payer: Encore Health Key Benefits Commercial	$360.00
Rate for Payer: Healthscope Commercial	$450.00
Rate for Payer: Healthscope Whirlpool	$436.50
Rate for Payer: Mclaren Commercial	$405.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$382.50
Rate for Payer: Priority Health Cigna Priority Health	$315.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$409.50
Rate for Payer: Priority Health Narrow Network	$319.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$396.00

Know your out-of-pocket cost for care.

All Charges