Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

ISOTOPE TC99 MDP

Facility

$150.00

Service Code	HCPCS A9503
Hospital Charge Code	3400021
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

ISOTOPE TC-99M MAA

Facility

$196.00

Service Code	HCPCS A9540
Hospital Charge Code	3400031
Hospital Revenue Code	343
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$166.60
Rate for Payer: Cash Price	$127.40
Rate for Payer: Community Health Alliance Commercial	$166.60
Rate for Payer: Priority Health Commercial	$137.20
Rate for Payer: Priority Health PPO	$137.20

ISOTOPE TC-99M MEBROFENIN

Facility

$150.00

Service Code	HCPCS A9537
Hospital Charge Code	3400071
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

ISOTOPE TC 99M PENTETATE

Facility

$196.00

Service Code	HCPCS A9539
Hospital Charge Code	3400029
Hospital Revenue Code	343
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$166.60
Rate for Payer: Cash Price	$127.40
Rate for Payer: Community Health Alliance Commercial	$166.60
Rate for Payer: Priority Health Commercial	$137.20
Rate for Payer: Priority Health PPO	$137.20

ISOTOPE TC99M SESTAMIBI -REST

Facility

$415.00

Service Code	HCPCS A9500
Hospital Charge Code	3400034
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 TC-99M SULFUR COLLOID

Facility

$176.00

Service Code	HCPCS A9541
Hospital Charge Code	3400077
Hospital Revenue Code	343
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$149.60
Rate for Payer: Cash Price	$114.40
Rate for Payer: Community Health Alliance Commercial	$149.60
Rate for Payer: Priority Health Commercial	$123.20
Rate for Payer: Priority Health PPO	$123.20

ISOTOPE TC99 - SENTINEL NODES

Facility

$324.00

Service Code	HCPCS A4641
Hospital Charge Code	3400269
Hospital Revenue Code	343
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$275.40
Rate for Payer: Cash Price	$210.60
Rate for Payer: Community Health Alliance Commercial	$275.40
Rate for Payer: Priority Health Commercial	$226.80
Rate for Payer: Priority Health PPO	$226.80

ISOVUE 300 200 ML VIAL

Facility

$314.31

Service Code	HCPCS Q9967
Hospital Charge Code	3500008
Hospital Revenue Code	250
Min. Negotiated Rate	$220.02
Max. Negotiated Rate	$267.16
Rate for Payer: Cash Price	$204.30
Rate for Payer: Community Health Alliance Commercial	$267.16
Rate for Payer: Priority Health Commercial	$220.02
Rate for Payer: Priority Health PPO	$220.02

ISOVUE 370 100 ML BOTTLE

Facility

$203.74

Service Code	HCPCS Q9967
Hospital Charge Code	3500007
Hospital Revenue Code	636
Min. Negotiated Rate	$142.62
Max. Negotiated Rate	$173.18
Rate for Payer: Cash Price	$132.43
Rate for Payer: Community Health Alliance Commercial	$173.18
Rate for Payer: Priority Health Commercial	$142.62
Rate for Payer: Priority Health PPO	$142.62

ISOVUE M 200 10ML VIAL

Facility

$259.02

Service Code	HCPCS Q9966
Hospital Charge Code	3500009
Hospital Revenue Code	636
Min. Negotiated Rate	$181.31
Max. Negotiated Rate	$220.17
Rate for Payer: Cash Price	$168.36
Rate for Payer: Community Health Alliance Commercial	$220.17
Rate for Payer: Priority Health Commercial	$181.31
Rate for Payer: Priority Health PPO	$181.31

ITRACONAZOLE LC

Facility

$65.00

Hospital Charge Code	3102724
Hospital Revenue Code	300
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$55.25
Rate for Payer: Cash Price	$42.25
Rate for Payer: Community Health Alliance Commercial	$55.25
Rate for Payer: Priority Health Commercial	$45.50
Rate for Payer: Priority Health PPO	$45.50

IU SENSITIVITY MIC

Facility

$15.00

Hospital Charge Code	3101328
Hospital Revenue Code	306
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$12.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Community Health Alliance Commercial	$12.75
Rate for Payer: Priority Health Commercial	$10.50
Rate for Payer: Priority Health PPO	$10.50

IVC FILTER PLACEMENT

Facility

$848.00

Service Code	HCPCS 75940
Hospital Charge Code	3201022
Hospital Revenue Code	320
Min. Negotiated Rate	$593.60
Max. Negotiated Rate	$720.80
Rate for Payer: Cash Price	$551.20
Rate for Payer: Community Health Alliance Commercial	$720.80
Rate for Payer: Priority Health Commercial	$593.60
Rate for Payer: Priority Health PPO	$593.60

I.V. CONCURRENT INFUSION ER

Facility

$55.00

Hospital Charge Code	4500852
Hospital Revenue Code	450
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$46.75
Rate for Payer: Cash Price	$35.75
Rate for Payer: Community Health Alliance Commercial	$46.75
Rate for Payer: Priority Health Commercial	$38.50
Rate for Payer: Priority Health PPO	$38.50

I.V. EA ADD'L PUSH/NEW SUB AMB

Facility

$108.00

Hospital Charge Code	9400401
Hospital Revenue Code	940
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$91.80
Rate for Payer: Cash Price	$70.20
Rate for Payer: Community Health Alliance Commercial	$91.80
Rate for Payer: Priority Health Commercial	$75.60
Rate for Payer: Priority Health PPO	$75.60

I.V. EA ADD'L PUSH/NEW SUB ER

Facility

$122.00

Hospital Charge Code	4500861
Hospital Revenue Code	450
Min. Negotiated Rate	$85.40
Max. Negotiated Rate	$103.70
Rate for Payer: Cash Price	$79.30
Rate for Payer: Community Health Alliance Commercial	$103.70
Rate for Payer: Priority Health Commercial	$85.40
Rate for Payer: Priority Health PPO	$85.40

I.V. EA ADD'L PUSH/NEW SUB M/S

Facility

$122.00

Hospital Charge Code	9400950
Hospital Revenue Code	940
Min. Negotiated Rate	$85.40
Max. Negotiated Rate	$103.70
Rate for Payer: Cash Price	$79.30
Rate for Payer: Community Health Alliance Commercial	$103.70
Rate for Payer: Priority Health Commercial	$85.40
Rate for Payer: Priority Health PPO	$85.40

I.V. EA ADD'L PUSH/SAME SUB-ER

Facility

$112.00

Hospital Charge Code	4500862
Hospital Revenue Code	450
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$95.20
Rate for Payer: Cash Price	$72.80
Rate for Payer: Community Health Alliance Commercial	$95.20
Rate for Payer: Priority Health Commercial	$78.40
Rate for Payer: Priority Health PPO	$78.40

I.V. EA ADD'L PUSH/SAME SUB-MS

Facility

$100.00

Hospital Charge Code	9400951
Hospital Revenue Code	940
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$85.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Community Health Alliance Commercial	$85.00
Rate for Payer: Priority Health Commercial	$70.00
Rate for Payer: Priority Health PPO	$70.00

I.V. INFUS HYDRATION EA ADD'L

Facility

$52.00

Hospital Charge Code	9400980
Hospital Revenue Code	940
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$44.20
Rate for Payer: Cash Price	$33.80
Rate for Payer: Community Health Alliance Commercial	$44.20
Rate for Payer: Priority Health Commercial	$36.40
Rate for Payer: Priority Health PPO	$36.40

I.V. PUSH THERA FOR CLINIC

Facility

$195.00

Service Code	HCPCS 96374
Hospital Charge Code	4501100
Hospital Revenue Code	260
Min. Negotiated Rate	$100.40
Max. Negotiated Rate	$228.18
Rate for Payer: BCBS BCN 65	$228.18
Rate for Payer: Blue Care Network Medicare Advantage	$228.18
Rate for Payer: Cash Price	$126.75
Rate for Payer: Cash Price	$126.75
Rate for Payer: Community Health Alliance Commercial	$165.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$228.18
Rate for Payer: Meridian Health Plan Medicare	$228.18
Rate for Payer: Priority Health Commercial	$136.50
Rate for Payer: Priority Health Medicaid	$228.18
Rate for Payer: Priority Health Medicare	$228.18
Rate for Payer: Priority Health PPO	$136.50
Rate for Payer: United Health Care Medicaid	$228.18
Rate for Payer: United Health Care Medicare Advantage	$100.40

I.V. PUSH THERAPEUTIC

Facility

$195.00

Service Code	HCPCS 96374
Hospital Charge Code	9400540
Hospital Revenue Code	260
Min. Negotiated Rate	$100.40
Max. Negotiated Rate	$228.18
Rate for Payer: BCBS BCN 65	$228.18
Rate for Payer: Blue Care Network Medicare Advantage	$228.18
Rate for Payer: Cash Price	$126.75
Rate for Payer: Cash Price	$126.75
Rate for Payer: Community Health Alliance Commercial	$165.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$228.18
Rate for Payer: Meridian Health Plan Medicare	$228.18
Rate for Payer: Priority Health Commercial	$136.50
Rate for Payer: Priority Health Medicaid	$228.18
Rate for Payer: Priority Health Medicare	$228.18
Rate for Payer: Priority Health PPO	$136.50
Rate for Payer: United Health Care Medicaid	$228.18
Rate for Payer: United Health Care Medicare Advantage	$100.40

I.V. PUSH THERAPUTIC AMBULATOR

Facility

$195.00

Service Code	HCPCS 96374
Hospital Charge Code	9400400
Hospital Revenue Code	940
Min. Negotiated Rate	$100.40
Max. Negotiated Rate	$228.18
Rate for Payer: BCBS BCN 65	$228.18
Rate for Payer: Blue Care Network Medicare Advantage	$228.18
Rate for Payer: Cash Price	$126.75
Rate for Payer: Cash Price	$126.75
Rate for Payer: Community Health Alliance Commercial	$165.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$228.18
Rate for Payer: Meridian Health Plan Medicare	$228.18
Rate for Payer: Priority Health Commercial	$136.50
Rate for Payer: Priority Health Medicaid	$228.18
Rate for Payer: Priority Health Medicare	$228.18
Rate for Payer: Priority Health PPO	$136.50
Rate for Payer: United Health Care Medicaid	$228.18
Rate for Payer: United Health Care Medicare Advantage	$100.40

IV SOLN SOD CHL

Facility

$70.00

Service Code	NDC 338004304
Hospital Charge Code	2510884
Hospital Revenue Code	250
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$59.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Community Health Alliance Commercial	$59.50
Rate for Payer: Priority Health Commercial	$49.00
Rate for Payer: Priority Health PPO	$49.00

IV SOLUTION

Facility

$44.00

Hospital Charge Code	2580010
Hospital Revenue Code	258
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$37.40
Rate for Payer: Cash Price	$28.60
Rate for Payer: Community Health Alliance Commercial	$37.40
Rate for Payer: Priority Health Commercial	$30.80
Rate for Payer: Priority Health PPO	$30.80

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges