Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

IRON LIVER TISSUE

Facility

$49.00

Hospital Charge Code	3100735
Hospital Revenue Code	301
Min. Negotiated Rate	$34.30
Max. Negotiated Rate	$41.65
Rate for Payer: Cash Price	$31.85
Rate for Payer: Community Health Alliance Commercial	$41.65
Rate for Payer: Priority Health Commercial	$34.30
Rate for Payer: Priority Health PPO	$34.30

IRON, SERUM

Facility

$39.00

Service Code	HCPCS 83540
Hospital Charge Code	3005480
Hospital Revenue Code	301
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$33.15
Rate for Payer: BCBS BCN 65	$6.79
Rate for Payer: Blue Care Network Medicare Advantage	$6.79
Rate for Payer: Cash Price	$25.35
Rate for Payer: Cash Price	$25.35
Rate for Payer: Community Health Alliance Commercial	$33.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$6.79
Rate for Payer: Meridian Health Plan Medicare	$6.79
Rate for Payer: Priority Health Commercial	$27.30
Rate for Payer: Priority Health Medicaid	$6.79
Rate for Payer: Priority Health Medicare	$6.79
Rate for Payer: Priority Health PPO	$27.30
Rate for Payer: United Health Care Medicaid	$6.79
Rate for Payer: United Health Care Medicare Advantage	$2.99

IRON STAIN TECH

Facility

$53.00

Service Code	HCPCS 88313
Hospital Charge Code	3100310
Hospital Revenue Code	310
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$142.73
Rate for Payer: BCBS BCN 65	$142.73
Rate for Payer: Blue Care Network Medicare Advantage	$142.73
Rate for Payer: Cash Price	$34.45
Rate for Payer: Cash Price	$34.45
Rate for Payer: Community Health Alliance Commercial	$45.05
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$142.73
Rate for Payer: Meridian Health Plan Medicare	$142.73
Rate for Payer: Priority Health Commercial	$37.10
Rate for Payer: Priority Health Medicaid	$142.73
Rate for Payer: Priority Health Medicare	$142.73
Rate for Payer: Priority Health PPO	$37.10
Rate for Payer: United Health Care Medicaid	$142.73
Rate for Payer: United Health Care Medicare Advantage	$62.80

IRRADIATION CHARGE

Facility

$18.00

Service Code	HCPCS 86945
Hospital Charge Code	3910070
Hospital Revenue Code	300
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$40.07
Rate for Payer: BCBS BCN 65	$40.07
Rate for Payer: Blue Care Network Medicare Advantage	$40.07
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cash Price	$11.70
Rate for Payer: Community Health Alliance Commercial	$15.30
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$40.07
Rate for Payer: Meridian Health Plan Medicare	$40.07
Rate for Payer: Priority Health Commercial	$12.60
Rate for Payer: Priority Health Medicaid	$40.07
Rate for Payer: Priority Health Medicare	$40.07
Rate for Payer: Priority Health PPO	$12.60
Rate for Payer: United Health Care Medicaid	$40.07
Rate for Payer: United Health Care Medicare Advantage	$17.63

ISH ea addl AB

Facility

$126.96

Hospital Charge Code	31027474
Hospital Revenue Code	300
Min. Negotiated Rate	$88.87
Max. Negotiated Rate	$107.92
Rate for Payer: Cash Price	$82.52
Rate for Payer: Community Health Alliance Commercial	$107.92
Rate for Payer: Priority Health Commercial	$88.87
Rate for Payer: Priority Health PPO	$88.87

ISLET CELL AB

Facility

$10.52

Hospital Charge Code	3004330
Hospital Revenue Code	302
Min. Negotiated Rate	$7.36
Max. Negotiated Rate	$8.94
Rate for Payer: Cash Price	$6.84
Rate for Payer: Community Health Alliance Commercial	$8.94
Rate for Payer: Priority Health Commercial	$7.36
Rate for Payer: Priority Health PPO	$7.36

ISOSPORA I

Facility

$62.00

Service Code	HCPCS 88312
Hospital Charge Code	3004640
Hospital Revenue Code	310
Min. Negotiated Rate	$24.60
Max. Negotiated Rate	$55.90
Rate for Payer: BCBS BCN 65	$55.90
Rate for Payer: Blue Care Network Medicare Advantage	$55.90
Rate for Payer: Cash Price	$40.30
Rate for Payer: Cash Price	$40.30
Rate for Payer: Community Health Alliance Commercial	$52.70
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$55.90
Rate for Payer: Meridian Health Plan Medicare	$55.90
Rate for Payer: Priority Health Commercial	$43.40
Rate for Payer: Priority Health Medicaid	$55.90
Rate for Payer: Priority Health Medicare	$55.90
Rate for Payer: Priority Health PPO	$43.40
Rate for Payer: United Health Care Medicaid	$55.90
Rate for Payer: United Health Care Medicare Advantage	$24.60

ISOSPORA II

Facility

$62.00

Service Code	HCPCS 87015
Hospital Charge Code	3004660
Hospital Revenue Code	306
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$52.70
Rate for Payer: BCBS BCN 65	$7.01
Rate for Payer: Blue Care Network Medicare Advantage	$7.01
Rate for Payer: Cash Price	$40.30
Rate for Payer: Cash Price	$40.30
Rate for Payer: Community Health Alliance Commercial	$52.70
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$7.01
Rate for Payer: Meridian Health Plan Medicare	$7.01
Rate for Payer: Priority Health Commercial	$43.40
Rate for Payer: Priority Health Medicaid	$7.01
Rate for Payer: Priority Health Medicare	$7.01
Rate for Payer: Priority Health PPO	$43.40
Rate for Payer: United Health Care Medicaid	$7.01
Rate for Payer: United Health Care Medicare Advantage	$3.09

ISOTOPE ACUTECT (DVT)

Facility

$1,019.00

Service Code	HCPCS A9504
Hospital Charge Code	3400347
Hospital Revenue Code	343
Min. Negotiated Rate	$713.30
Max. Negotiated Rate	$866.15
Rate for Payer: Cash Price	$662.35
Rate for Payer: Community Health Alliance Commercial	$866.15
Rate for Payer: Priority Health Commercial	$713.30
Rate for Payer: Priority Health PPO	$713.30

ISOTOPE CARDIOLITE STRESS

Facility

$415.00

Service Code	HCPCS A9500
Hospital Charge Code	3400033
Hospital Revenue Code	343
Min. Negotiated Rate	$290.50
Max. Negotiated Rate	$352.75
Rate for Payer: Cash Price	$269.75
Rate for Payer: Community Health Alliance Commercial	$352.75
Rate for Payer: Priority Health Commercial	$290.50
Rate for Payer: Priority Health PPO	$290.50

ISOTOPE CEA

Facility

$2,156.00

Service Code	HCPCS A9568
Hospital Charge Code	3400052
Hospital Revenue Code	343
Min. Negotiated Rate	$1,509.20
Max. Negotiated Rate	$1,832.60
Rate for Payer: Cash Price	$1,401.40
Rate for Payer: Community Health Alliance Commercial	$1,832.60
Rate for Payer: Priority Health Commercial	$1,509.20
Rate for Payer: Priority Health PPO	$1,509.20

ISOTOPE DMSA

Facility

$1,043.00

Service Code	HCPCS A9551
Hospital Charge Code	3400329
Hospital Revenue Code	343
Min. Negotiated Rate	$304.89
Max. Negotiated Rate	$886.55
Rate for Payer: BCBS BCN 65	$692.93
Rate for Payer: Blue Care Network Medicare Advantage	$692.93
Rate for Payer: Cash Price	$677.95
Rate for Payer: Cash Price	$677.95
Rate for Payer: Community Health Alliance Commercial	$886.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$692.93
Rate for Payer: Meridian Health Plan Medicare	$692.93
Rate for Payer: Priority Health Commercial	$730.10
Rate for Payer: Priority Health Medicaid	$692.93
Rate for Payer: Priority Health Medicare	$692.93
Rate for Payer: Priority Health PPO	$730.10
Rate for Payer: United Health Care Medicaid	$692.93
Rate for Payer: United Health Care Medicare Advantage	$304.89

ISOTOPE GALLIUM 1 mCi

Facility

$343.00

Service Code	HCPCS A9556
Hospital Charge Code	3400026
Hospital Revenue Code	343
Min. Negotiated Rate	$240.10
Max. Negotiated Rate	$291.55
Rate for Payer: Cash Price	$222.95
Rate for Payer: Community Health Alliance Commercial	$291.55
Rate for Payer: Priority Health Commercial	$240.10
Rate for Payer: Priority Health PPO	$240.10

ISOTOPE I111 DTPA 1.5 mCi

Facility

$1,224.00

Service Code	HCPCS A9539
Hospital Charge Code	3400024
Hospital Revenue Code	343
Min. Negotiated Rate	$856.80
Max. Negotiated Rate	$1,040.40
Rate for Payer: Cash Price	$795.60
Rate for Payer: Community Health Alliance Commercial	$1,040.40
Rate for Payer: Priority Health Commercial	$856.80
Rate for Payer: Priority Health PPO	$856.80

ISOTOPE I123

Facility

$288.00

Service Code	HCPCS A9516
Hospital Charge Code	3400022
Hospital Revenue Code	343
Min. Negotiated Rate	$201.60
Max. Negotiated Rate	$244.80
Rate for Payer: Cash Price	$187.20
Rate for Payer: Community Health Alliance Commercial	$244.80
Rate for Payer: Priority Health Commercial	$201.60
Rate for Payer: Priority Health PPO	$201.60

ISOTOPE I131 (PARATHYROID)

Facility

$454.00

Service Code	HCPCS 78990
Hospital Charge Code	3400027
Hospital Revenue Code	343
Min. Negotiated Rate	$317.80
Max. Negotiated Rate	$385.90
Rate for Payer: Cash Price	$295.10
Rate for Payer: Community Health Alliance Commercial	$385.90
Rate for Payer: Priority Health Commercial	$317.80
Rate for Payer: Priority Health PPO	$317.80

ISOTOPE I131 THERAPY 10 mCi

Facility

$1,384.00

Service Code	HCPCS A9517
Hospital Charge Code	3400032
Hospital Revenue Code	344
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$1,176.40
Rate for Payer: BCBS BCN 65	$25.27
Rate for Payer: Blue Care Network Medicare Advantage	$25.27
Rate for Payer: Cash Price	$899.60
Rate for Payer: Cash Price	$899.60
Rate for Payer: Community Health Alliance Commercial	$1,176.40
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$25.27
Rate for Payer: Meridian Health Plan Medicare	$25.27
Rate for Payer: Priority Health Commercial	$968.80
Rate for Payer: Priority Health Medicaid	$25.27
Rate for Payer: Priority Health Medicare	$25.27
Rate for Payer: Priority Health PPO	$968.80
Rate for Payer: United Health Care Medicaid	$25.27
Rate for Payer: United Health Care Medicare Advantage	$11.12

ISOTOPE I131 THERAPY 15mCI

Facility

$825.00

Service Code	HCPCS A9517
Hospital Charge Code	3400046
Hospital Revenue Code	255
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$701.25
Rate for Payer: BCBS BCN 65	$25.27
Rate for Payer: Blue Care Network Medicare Advantage	$25.27
Rate for Payer: Cash Price	$536.25
Rate for Payer: Cash Price	$536.25
Rate for Payer: Community Health Alliance Commercial	$701.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$25.27
Rate for Payer: Meridian Health Plan Medicare	$25.27
Rate for Payer: Priority Health Commercial	$577.50
Rate for Payer: Priority Health Medicaid	$25.27
Rate for Payer: Priority Health Medicare	$25.27
Rate for Payer: Priority Health PPO	$577.50
Rate for Payer: United Health Care Medicaid	$25.27
Rate for Payer: United Health Care Medicare Advantage	$11.12

ISOTOPE I131 THERAPY 20mCI

Facility

$1,100.00

Service Code	HCPCS A9517
Hospital Charge Code	3400047
Hospital Revenue Code	344
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$935.00
Rate for Payer: BCBS BCN 65	$25.27
Rate for Payer: Blue Care Network Medicare Advantage	$25.27
Rate for Payer: Cash Price	$715.00
Rate for Payer: Cash Price	$715.00
Rate for Payer: Community Health Alliance Commercial	$935.00
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$25.27
Rate for Payer: Meridian Health Plan Medicare	$25.27
Rate for Payer: Priority Health Commercial	$770.00
Rate for Payer: Priority Health Medicaid	$25.27
Rate for Payer: Priority Health Medicare	$25.27
Rate for Payer: Priority Health PPO	$770.00
Rate for Payer: United Health Care Medicaid	$25.27
Rate for Payer: United Health Care Medicare Advantage	$11.12

ISOTOPE I131 THERAPY 25mCI

Facility

$1,375.00

Service Code	HCPCS A9517
Hospital Charge Code	3400048
Hospital Revenue Code	255
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$1,168.75
Rate for Payer: BCBS BCN 65	$25.27
Rate for Payer: Blue Care Network Medicare Advantage	$25.27
Rate for Payer: Cash Price	$893.75
Rate for Payer: Cash Price	$893.75
Rate for Payer: Community Health Alliance Commercial	$1,168.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$25.27
Rate for Payer: Meridian Health Plan Medicare	$25.27
Rate for Payer: Priority Health Commercial	$962.50
Rate for Payer: Priority Health Medicaid	$25.27
Rate for Payer: Priority Health Medicare	$25.27
Rate for Payer: Priority Health PPO	$962.50
Rate for Payer: United Health Care Medicaid	$25.27
Rate for Payer: United Health Care Medicare Advantage	$11.12

ISOTOPE I131 THERAPY 30 mCi

Facility

$1,336.00

Service Code	HCPCS A9517
Hospital Charge Code	3400042
Hospital Revenue Code	344
Min. Negotiated Rate	$11.12
Max. Negotiated Rate	$1,135.60
Rate for Payer: BCBS BCN 65	$25.27
Rate for Payer: Blue Care Network Medicare Advantage	$25.27
Rate for Payer: Cash Price	$868.40
Rate for Payer: Cash Price	$868.40
Rate for Payer: Community Health Alliance Commercial	$1,135.60
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$25.27
Rate for Payer: Meridian Health Plan Medicare	$25.27
Rate for Payer: Priority Health Commercial	$935.20
Rate for Payer: Priority Health Medicaid	$25.27
Rate for Payer: Priority Health Medicare	$25.27
Rate for Payer: Priority Health PPO	$935.20
Rate for Payer: United Health Care Medicaid	$25.27
Rate for Payer: United Health Care Medicare Advantage	$11.12

ISOTOPE INDIUM 111

Facility

$12,567.00

Service Code	HCPCS A9572
Hospital Charge Code	3400017
Hospital Revenue Code	343
Min. Negotiated Rate	$924.43
Max. Negotiated Rate	$10,681.95
Rate for Payer: BCBS BCN 65	$2,100.99
Rate for Payer: Blue Care Network Medicare Advantage	$2,100.99
Rate for Payer: Cash Price	$8,168.55
Rate for Payer: Cash Price	$8,168.55
Rate for Payer: Community Health Alliance Commercial	$10,681.95
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$2,100.99
Rate for Payer: Meridian Health Plan Medicare	$2,100.99
Rate for Payer: Priority Health Commercial	$8,796.90
Rate for Payer: Priority Health Medicaid	$2,100.99
Rate for Payer: Priority Health Medicare	$2,100.99
Rate for Payer: Priority Health PPO	$8,796.90
Rate for Payer: United Health Care Medicaid	$2,100.99
Rate for Payer: United Health Care Medicare Advantage	$924.43

ISOTOPE INDIUM 1.5 mCi

Facility

$2,097.00

Service Code	HCPCS A9548
Hospital Charge Code	3400023
Hospital Revenue Code	343
Min. Negotiated Rate	$344.48
Max. Negotiated Rate	$1,782.45
Rate for Payer: BCBS BCN 65	$782.90
Rate for Payer: Blue Care Network Medicare Advantage	$782.90
Rate for Payer: Cash Price	$1,363.05
Rate for Payer: Cash Price	$1,363.05
Rate for Payer: Community Health Alliance Commercial	$1,782.45
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$782.90
Rate for Payer: Meridian Health Plan Medicare	$782.90
Rate for Payer: Priority Health Commercial	$1,467.90
Rate for Payer: Priority Health Medicaid	$782.90
Rate for Payer: Priority Health Medicare	$782.90
Rate for Payer: Priority Health PPO	$1,467.90
Rate for Payer: United Health Care Medicaid	$782.90
Rate for Payer: United Health Care Medicare Advantage	$344.48

ISOTOPE ONCOSCINT

Facility

$2,924.00

Service Code	HCPCS A4642
Hospital Charge Code	3400028
Hospital Revenue Code	343
Min. Negotiated Rate	$2,046.80
Max. Negotiated Rate	$2,485.40
Rate for Payer: Cash Price	$1,900.60
Rate for Payer: Community Health Alliance Commercial	$2,485.40
Rate for Payer: Priority Health Commercial	$2,046.80
Rate for Payer: Priority Health PPO	$2,046.80

ISOTOPE TC-99M AEROSOL

Facility

$150.00

Service Code	HCPCS A9567
Hospital Charge Code	3400079
Hospital Revenue Code	343
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$127.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Community Health Alliance Commercial	$127.50
Rate for Payer: Priority Health Commercial	$105.00
Rate for Payer: Priority Health PPO	$105.00

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges