Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

IV SOLUTION/D5W 5%

Facility

$44.00

Hospital Charge Code	27015917
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

IV SOLUT + START SOD CHL 1000M

Facility

$87.00

Hospital Charge Code	27018853
Hospital Revenue Code	636
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$73.95
Rate for Payer: Cash Price	$56.55
Rate for Payer: Community Health Alliance Commercial	$73.95
Rate for Payer: Priority Health Commercial	$60.90
Rate for Payer: Priority Health PPO	$60.90

I.V. THER ADD'L SEQ INFUS M/S

Facility

$87.00

Hospital Charge Code	9400960
Hospital Revenue Code	940
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$73.95
Rate for Payer: Cash Price	$56.55
Rate for Payer: Community Health Alliance Commercial	$73.95
Rate for Payer: Priority Health Commercial	$60.90
Rate for Payer: Priority Health PPO	$60.90

I.V. THERAPEUTIC ADD HR

Facility

$87.00

Service Code	HCPCS 96366
Hospital Charge Code	9400530
Hospital Revenue Code	260
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$73.95
Rate for Payer: BCBS BCN 65	$50.23
Rate for Payer: Blue Care Network Medicare Advantage	$50.23
Rate for Payer: Cash Price	$56.55
Rate for Payer: Cash Price	$56.55
Rate for Payer: Community Health Alliance Commercial	$73.95
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$50.23
Rate for Payer: Meridian Health Plan Medicare	$50.23
Rate for Payer: Priority Health Commercial	$60.90
Rate for Payer: Priority Health Medicaid	$50.23
Rate for Payer: Priority Health Medicare	$50.23
Rate for Payer: Priority Health PPO	$60.90
Rate for Payer: United Health Care Medicaid	$50.23
Rate for Payer: United Health Care Medicare Advantage	$22.10

I.V. THERAPUTIC ADD HR

Facility

$66.00

Service Code	HCPCS 96366
Hospital Charge Code	9400305
Hospital Revenue Code	260
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$56.10
Rate for Payer: BCBS BCN 65	$50.23
Rate for Payer: Blue Care Network Medicare Advantage	$50.23
Rate for Payer: Cash Price	$42.90
Rate for Payer: Cash Price	$42.90
Rate for Payer: Community Health Alliance Commercial	$56.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$50.23
Rate for Payer: Meridian Health Plan Medicare	$50.23
Rate for Payer: Priority Health Commercial	$46.20
Rate for Payer: Priority Health Medicaid	$50.23
Rate for Payer: Priority Health Medicare	$50.23
Rate for Payer: Priority Health PPO	$46.20
Rate for Payer: United Health Care Medicaid	$50.23
Rate for Payer: United Health Care Medicare Advantage	$22.10

I.V. THERAPY INFUSE 1ST HR

Facility

$310.00

Service Code	HCPCS 96365 59
Hospital Charge Code	9400521
Hospital Revenue Code	260
Min. Negotiated Rate	$217.00
Max. Negotiated Rate	$263.50
Rate for Payer: Cash Price	$201.50
Rate for Payer: Community Health Alliance Commercial	$263.50
Rate for Payer: Priority Health Commercial	$217.00
Rate for Payer: Priority Health PPO	$217.00

I.V. THERAPY INFUSE 1ST HR

Facility

$310.00

Service Code	HCPCS 96365
Hospital Charge Code	9400520
Hospital Revenue Code	260
Min. Negotiated Rate	$100.40
Max. Negotiated Rate	$263.50
Rate for Payer: BCBS BCN 65	$228.18
Rate for Payer: Blue Care Network Medicare Advantage	$228.18
Rate for Payer: Cash Price	$201.50
Rate for Payer: Cash Price	$201.50
Rate for Payer: Community Health Alliance Commercial	$263.50
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	$217.00
Rate for Payer: Priority Health Medicaid	$228.18
Rate for Payer: Priority Health Medicare	$228.18
Rate for Payer: Priority Health PPO	$217.00
Rate for Payer: United Health Care Medicaid	$228.18
Rate for Payer: United Health Care Medicare Advantage	$100.40

I.V. THERAPY INFUSE AMB 1ST HR

Facility

$259.00

Service Code	HCPCS 96365 59
Hospital Charge Code	9400301
Hospital Revenue Code	260
Min. Negotiated Rate	$181.30
Max. Negotiated Rate	$220.15
Rate for Payer: Cash Price	$168.35
Rate for Payer: Community Health Alliance Commercial	$220.15
Rate for Payer: Priority Health Commercial	$181.30
Rate for Payer: Priority Health PPO	$181.30

I.V. THERAPY INFUSE AMB 1ST HR

Facility

$292.00

Service Code	HCPCS 96365
Hospital Charge Code	9400300
Hospital Revenue Code	260
Min. Negotiated Rate	$100.40
Max. Negotiated Rate	$248.20
Rate for Payer: BCBS BCN 65	$228.18
Rate for Payer: Blue Care Network Medicare Advantage	$228.18
Rate for Payer: Cash Price	$189.80
Rate for Payer: Cash Price	$189.80
Rate for Payer: Community Health Alliance Commercial	$248.20
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	$204.40
Rate for Payer: Priority Health Medicaid	$228.18
Rate for Payer: Priority Health Medicare	$228.18
Rate for Payer: Priority Health PPO	$204.40
Rate for Payer: United Health Care Medicaid	$228.18
Rate for Payer: United Health Care Medicare Advantage	$100.40

I.V. THERAPY INFUSE FOR CLINIC

Facility

$292.00

Service Code	HCPCS 96365
Hospital Charge Code	4501050
Hospital Revenue Code	260
Min. Negotiated Rate	$100.40
Max. Negotiated Rate	$248.20
Rate for Payer: BCBS BCN 65	$228.18
Rate for Payer: Blue Care Network Medicare Advantage	$228.18
Rate for Payer: Cash Price	$189.80
Rate for Payer: Cash Price	$189.80
Rate for Payer: Community Health Alliance Commercial	$248.20
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	$204.40
Rate for Payer: Priority Health Medicaid	$228.18
Rate for Payer: Priority Health Medicare	$228.18
Rate for Payer: Priority Health PPO	$204.40
Rate for Payer: United Health Care Medicaid	$228.18
Rate for Payer: United Health Care Medicare Advantage	$100.40

J0 - 1 ANTIBODY

Facility

$14.66

Service Code	HCPCS 86235
Hospital Charge Code	3005485
Hospital Revenue Code	302
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$18.83
Rate for Payer: BCBS BCN 65	$18.83
Rate for Payer: Blue Care Network Medicare Advantage	$18.83
Rate for Payer: Cash Price	$9.53
Rate for Payer: Cash Price	$9.53
Rate for Payer: Community Health Alliance Commercial	$12.46
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$18.83
Rate for Payer: Meridian Health Plan Medicare	$18.83
Rate for Payer: Priority Health Commercial	$10.26
Rate for Payer: Priority Health Medicaid	$18.83
Rate for Payer: Priority Health Medicare	$18.83
Rate for Payer: Priority Health PPO	$10.26
Rate for Payer: United Health Care Medicaid	$18.83
Rate for Payer: United Health Care Medicare Advantage	$8.28

JACKSON PRATT

Facility

$56.00

Hospital Charge Code	27265866
Hospital Revenue Code	272
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$47.60
Rate for Payer: Cash Price	$36.40
Rate for Payer: Community Health Alliance Commercial	$47.60
Rate for Payer: Priority Health Commercial	$39.20
Rate for Payer: Priority Health PPO	$39.20

JACKSON PRATT HUBBUS 7MM

Facility

$27.00

Hospital Charge Code	27021295
Hospital Revenue Code	272
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$22.95
Rate for Payer: Cash Price	$17.55
Rate for Payer: Community Health Alliance Commercial	$22.95
Rate for Payer: Priority Health Commercial	$18.90
Rate for Payer: Priority Health PPO	$18.90

JACKSON-PRATT ROUND DRAIN 10FR

Facility

$26.00

Hospital Charge Code	27021469
Hospital Revenue Code	272
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$22.10
Rate for Payer: Cash Price	$16.90
Rate for Payer: Community Health Alliance Commercial	$22.10
Rate for Payer: Priority Health Commercial	$18.20
Rate for Payer: Priority Health PPO	$18.20

JACKSON-PRATT SUCT/DRAIN ASS'Y

Facility

$88.00

Hospital Charge Code	27011999
Hospital Revenue Code	272
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$74.80
Rate for Payer: Cash Price	$57.20
Rate for Payer: Community Health Alliance Commercial	$74.80
Rate for Payer: Priority Health Commercial	$61.60
Rate for Payer: Priority Health PPO	$61.60

JAK 2

Facility

$107.92

Hospital Charge Code	3001089
Hospital Revenue Code	301
Min. Negotiated Rate	$75.54
Max. Negotiated Rate	$91.73
Rate for Payer: Cash Price	$70.15
Rate for Payer: Community Health Alliance Commercial	$91.73
Rate for Payer: Priority Health Commercial	$75.54
Rate for Payer: Priority Health PPO	$75.54

JAK2 EXON 12 MUTATION ANALYSIS

Facility

$107.92

Hospital Charge Code	3101033
Hospital Revenue Code	310
Min. Negotiated Rate	$75.54
Max. Negotiated Rate	$91.73
Rate for Payer: Cash Price	$70.15
Rate for Payer: Community Health Alliance Commercial	$91.73
Rate for Payer: Priority Health Commercial	$75.54
Rate for Payer: Priority Health PPO	$75.54

JAK 2 EXON 12 & OTHER NON V617

Facility

$375.60

Hospital Charge Code	3101402
Hospital Revenue Code	310
Min. Negotiated Rate	$262.92
Max. Negotiated Rate	$319.26
Rate for Payer: Cash Price	$244.14
Rate for Payer: Community Health Alliance Commercial	$319.26
Rate for Payer: Priority Health Commercial	$262.92
Rate for Payer: Priority Health PPO	$262.92

JAK2 W REFLEX TO EXON 12-15

Facility

$107.92

Hospital Charge Code	3102539
Hospital Revenue Code	300
Min. Negotiated Rate	$75.54
Max. Negotiated Rate	$91.73
Rate for Payer: Cash Price	$70.15
Rate for Payer: Community Health Alliance Commercial	$91.73
Rate for Payer: Priority Health Commercial	$75.54
Rate for Payer: Priority Health PPO	$75.54

JEJUNAL FEEDING TUBE

Facility

$249.00

Hospital Charge Code	27263469
Hospital Revenue Code	272
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$211.65
Rate for Payer: Cash Price	$161.85
Rate for Payer: Community Health Alliance Commercial	$211.65
Rate for Payer: Priority Health Commercial	$174.30
Rate for Payer: Priority Health PPO	$174.30

JEJUNAL PEG - 24

Facility

$334.00

Hospital Charge Code	27262834
Hospital Revenue Code	272
Min. Negotiated Rate	$233.80
Max. Negotiated Rate	$283.90
Rate for Payer: Cash Price	$217.10
Rate for Payer: Community Health Alliance Commercial	$283.90
Rate for Payer: Priority Health Commercial	$233.80
Rate for Payer: Priority Health PPO	$233.80

JHU ADDITIONAL/IHC STAINS

Facility

$135.00

Hospital Charge Code	3101103
Hospital Revenue Code	310
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$114.75
Rate for Payer: Cash Price	$87.75
Rate for Payer: Community Health Alliance Commercial	$114.75
Rate for Payer: Priority Health Commercial	$94.50
Rate for Payer: Priority Health PPO	$94.50

JOHNSON WIRE SET

Facility

$101.00

Hospital Charge Code	27262052
Hospital Revenue Code	272
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$85.85
Rate for Payer: Cash Price	$65.65
Rate for Payer: Community Health Alliance Commercial	$85.85
Rate for Payer: Priority Health Commercial	$70.70
Rate for Payer: Priority Health PPO	$70.70

JOINT,DOUBLE BALL

Facility

$885.00

Service Code	HCPCS C1776
Hospital Charge Code	27018747
Hospital Revenue Code	278
Min. Negotiated Rate	$619.50
Max. Negotiated Rate	$752.25
Rate for Payer: Cash Price	$575.25
Rate for Payer: Community Health Alliance Commercial	$752.25
Rate for Payer: Priority Health Commercial	$619.50
Rate for Payer: Priority Health PPO	$619.50

JOINT,DOUBLE PARALLEL BALL

Facility

$1,020.00

Service Code	HCPCS C1776
Hospital Charge Code	27018754
Hospital Revenue Code	278
Min. Negotiated Rate	$714.00
Max. Negotiated Rate	$867.00
Rate for Payer: Cash Price	$663.00
Rate for Payer: Community Health Alliance Commercial	$867.00
Rate for Payer: Priority Health Commercial	$714.00
Rate for Payer: Priority Health PPO	$714.00

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges