Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

HC OT Z SLEEVE OR GLOVE EA $80

Facility

$80.00

Service Code	HCPCS L3999
Hospital Charge Code	96000046
Hospital Revenue Code	270
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$72.00
Rate for Payer: ASR ASR	$77.60
Rate for Payer: BCBS Complete	$32.00
Rate for Payer: BCBS Trust/PPO	$62.02
Rate for Payer: BCN Commercial	$62.02
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cofinity Commercial	$75.20
Rate for Payer: Encore Health Key Benefits Commercial	$64.00
Rate for Payer: Healthscope Commercial	$80.00
Rate for Payer: Healthscope Whirlpool	$77.60
Rate for Payer: Mclaren Commercial	$72.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$68.00
Rate for Payer: Priority Health Cigna Priority Health	$56.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$72.80
Rate for Payer: Priority Health Narrow Network	$56.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$70.40

HC OT Z SLEEVE OR GLOVE EA $90

Facility

$90.00

Service Code	HCPCS L3999
Hospital Charge Code	96000047
Hospital Revenue Code	270
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$81.00
Rate for Payer: ASR ASR	$87.30
Rate for Payer: BCBS Complete	$36.00
Rate for Payer: BCBS Trust/PPO	$69.78
Rate for Payer: BCN Commercial	$69.78
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cofinity Commercial	$84.60
Rate for Payer: Encore Health Key Benefits Commercial	$72.00
Rate for Payer: Healthscope Commercial	$90.00
Rate for Payer: Healthscope Whirlpool	$87.30
Rate for Payer: Mclaren Commercial	$81.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$76.50
Rate for Payer: Priority Health Cigna Priority Health	$63.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$81.90
Rate for Payer: Priority Health Narrow Network	$63.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$79.20

HC OT Z SLEEVE OR GLOVE EA $90

Facility

$90.00

Service Code	HCPCS L3999
Hospital Charge Code	96000047
Hospital Revenue Code	270
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$81.00
Rate for Payer: ASR ASR	$87.30
Rate for Payer: BCBS Trust/PPO	$69.78
Rate for Payer: BCN Commercial	$69.78
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cofinity Commercial	$84.60
Rate for Payer: Encore Health Key Benefits Commercial	$72.00
Rate for Payer: Healthscope Commercial	$90.00
Rate for Payer: Healthscope Whirlpool	$87.30
Rate for Payer: Mclaren Commercial	$81.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$76.50
Rate for Payer: Priority Health Cigna Priority Health	$63.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$79.20

HC OT Z STOCKINGS CUSTOM EA $100

Facility

$100.00

Service Code	HCPCS A6549
Hospital Charge Code	98300094
Hospital Revenue Code	270
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$90.00
Rate for Payer: ASR ASR	$97.00
Rate for Payer: BCBS Complete	$40.00
Rate for Payer: BCBS Trust/PPO	$77.53
Rate for Payer: BCN Commercial	$77.53
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cofinity Commercial	$94.00
Rate for Payer: Encore Health Key Benefits Commercial	$80.00
Rate for Payer: Healthscope Commercial	$100.00
Rate for Payer: Healthscope Whirlpool	$97.00
Rate for Payer: Mclaren Commercial	$90.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$85.00
Rate for Payer: Priority Health Cigna Priority Health	$70.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$91.00
Rate for Payer: Priority Health Narrow Network	$71.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$88.00

HC OT Z STOCKINGS CUSTOM EA $100

Facility

$100.00

Service Code	HCPCS A6549
Hospital Charge Code	98300094
Hospital Revenue Code	270
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$90.00
Rate for Payer: ASR ASR	$97.00
Rate for Payer: BCBS Trust/PPO	$77.53
Rate for Payer: BCN Commercial	$77.53
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cofinity Commercial	$94.00
Rate for Payer: Encore Health Key Benefits Commercial	$80.00
Rate for Payer: Healthscope Commercial	$100.00
Rate for Payer: Healthscope Whirlpool	$97.00
Rate for Payer: Mclaren Commercial	$90.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$85.00
Rate for Payer: Priority Health Cigna Priority Health	$70.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$88.00

HC OT Z STOCKINGS CUSTOM EA $125

Facility

$125.00

Service Code	HCPCS A6549
Hospital Charge Code	98300095
Hospital Revenue Code	270
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$112.50
Rate for Payer: ASR ASR	$121.25
Rate for Payer: BCBS Trust/PPO	$96.91
Rate for Payer: BCN Commercial	$96.91
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cofinity Commercial	$117.50
Rate for Payer: Encore Health Key Benefits Commercial	$100.00
Rate for Payer: Healthscope Commercial	$125.00
Rate for Payer: Healthscope Whirlpool	$121.25
Rate for Payer: Mclaren Commercial	$112.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$106.25
Rate for Payer: Priority Health Cigna Priority Health	$87.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$110.00

HC OT Z STOCKINGS CUSTOM EA $125

Facility

$125.00

Service Code	HCPCS A6549
Hospital Charge Code	98300095
Hospital Revenue Code	270
Min. Negotiated Rate	$50.00
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$112.50
Rate for Payer: ASR ASR	$121.25
Rate for Payer: BCBS Complete	$50.00
Rate for Payer: BCBS Trust/PPO	$96.91
Rate for Payer: BCN Commercial	$96.91
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cofinity Commercial	$117.50
Rate for Payer: Encore Health Key Benefits Commercial	$100.00
Rate for Payer: Healthscope Commercial	$125.00
Rate for Payer: Healthscope Whirlpool	$121.25
Rate for Payer: Mclaren Commercial	$112.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$106.25
Rate for Payer: Priority Health Cigna Priority Health	$87.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$113.75
Rate for Payer: Priority Health Narrow Network	$88.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$110.00

HC OT Z STOCKINGS CUSTOM EA $150

Facility

$150.00

Service Code	HCPCS A6549
Hospital Charge Code	98300096
Hospital Revenue Code	270
Min. Negotiated Rate	$60.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$135.00
Rate for Payer: ASR ASR	$145.50
Rate for Payer: BCBS Complete	$60.00
Rate for Payer: BCBS Trust/PPO	$116.30
Rate for Payer: BCN Commercial	$116.30
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cofinity Commercial	$141.00
Rate for Payer: Encore Health Key Benefits Commercial	$120.00
Rate for Payer: Healthscope Commercial	$150.00
Rate for Payer: Healthscope Whirlpool	$145.50
Rate for Payer: Mclaren Commercial	$135.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$127.50
Rate for Payer: Priority Health Cigna Priority Health	$105.00
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$136.50
Rate for Payer: Priority Health Narrow Network	$106.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$132.00

HC OT Z STOCKINGS CUSTOM EA $150

Facility

$150.00

Service Code	HCPCS A6549
Hospital Charge Code	98300096
Hospital Revenue Code	270
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$135.00
Rate for Payer: ASR ASR	$145.50
Rate for Payer: BCBS Trust/PPO	$116.30
Rate for Payer: BCN Commercial	$116.30
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cofinity Commercial	$141.00
Rate for Payer: Encore Health Key Benefits Commercial	$120.00
Rate for Payer: Healthscope Commercial	$150.00
Rate for Payer: Healthscope Whirlpool	$145.50
Rate for Payer: Mclaren Commercial	$135.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$127.50
Rate for Payer: Priority Health Cigna Priority Health	$105.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$132.00

HC OT Z STOCKINGS CUSTOM EA $175

Facility

$175.00

Service Code	HCPCS A6549
Hospital Charge Code	98300097
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 STOCKINGS CUSTOM EA $175

Facility

$175.00

Service Code	HCPCS A6549
Hospital Charge Code	98300097
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 STOCKINGS CUSTOM EA $200

Facility

$200.00

Service Code	HCPCS A6549
Hospital Charge Code	98300098
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 STOCKINGS CUSTOM EA $200

Facility

$200.00

Service Code	HCPCS A6549
Hospital Charge Code	98300098
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 STOCKINGS CUSTOM EA $225

Facility

$225.00

Service Code	HCPCS A6549
Hospital Charge Code	98300099
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 STOCKINGS CUSTOM EA $225

Facility

$225.00

Service Code	HCPCS A6549
Hospital Charge Code	98300099
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 STOCKINGS CUSTOM EA $250

Facility

$250.00

Service Code	HCPCS A6549
Hospital Charge Code	98300100
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 STOCKINGS CUSTOM EA $250

Facility

$250.00

Service Code	HCPCS A6549
Hospital Charge Code	98300100
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 STOCKINGS CUSTOM EA $275

Facility

$275.00

Service Code	HCPCS A6549
Hospital Charge Code	98300101
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 STOCKINGS CUSTOM EA $275

Facility

$275.00

Service Code	HCPCS A6549
Hospital Charge Code	98300101
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 STOCKINGS CUSTOM EA $300

Facility

$300.00

Service Code	HCPCS A6549
Hospital Charge Code	98300102
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 STOCKINGS CUSTOM EA $300

Facility

$300.00

Service Code	HCPCS A6549
Hospital Charge Code	98300102
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 STOCKINGS CUSTOM EA $325

Facility

$325.00

Service Code	HCPCS A6549
Hospital Charge Code	98300103
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 STOCKINGS CUSTOM EA $325

Facility

$325.00

Service Code	HCPCS A6549
Hospital Charge Code	98300103
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 STOCKINGS CUSTOM EA $350

Facility

$350.00

Service Code	HCPCS A6549
Hospital Charge Code	98300104
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 STOCKINGS CUSTOM EA $350

Facility

$350.00

Service Code	HCPCS A6549
Hospital Charge Code	98300104
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

Know your out-of-pocket cost for care.

All Charges