Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

MRI KNEE LEFT W CONTRAST

Facility

$1,703.00

Service Code	HCPCS 73722 LT
Hospital Charge Code	6100333
Hospital Revenue Code	614
Min. Negotiated Rate	$1,192.10
Max. Negotiated Rate	$1,447.55
Rate for Payer: Cash Price	$1,106.95
Rate for Payer: Community Health Alliance Commercial	$1,447.55
Rate for Payer: Priority Health Commercial	$1,192.10
Rate for Payer: Priority Health PPO	$1,192.10

MRI KNEE LEFT WO CONTRAST

Facility

$1,964.00

Service Code	HCPCS 73721 LT
Hospital Charge Code	6100331
Hospital Revenue Code	614
Min. Negotiated Rate	$1,374.80
Max. Negotiated Rate	$1,669.40
Rate for Payer: Cash Price	$1,276.60
Rate for Payer: Community Health Alliance Commercial	$1,669.40
Rate for Payer: Priority Health Commercial	$1,374.80
Rate for Payer: Priority Health PPO	$1,374.80

MRI KNEE LEFT W & WO CONTRAST

Facility

$2,256.00

Service Code	HCPCS 73723 LT
Hospital Charge Code	6100335
Hospital Revenue Code	614
Min. Negotiated Rate	$1,579.20
Max. Negotiated Rate	$1,917.60
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Community Health Alliance Commercial	$1,917.60
Rate for Payer: Priority Health Commercial	$1,579.20
Rate for Payer: Priority Health PPO	$1,579.20

MRI KNEE RIGHT W CONTRAST

Facility

$1,703.00

Service Code	HCPCS 73722 RT
Hospital Charge Code	6100332
Hospital Revenue Code	614
Min. Negotiated Rate	$1,192.10
Max. Negotiated Rate	$1,447.55
Rate for Payer: Cash Price	$1,106.95
Rate for Payer: Community Health Alliance Commercial	$1,447.55
Rate for Payer: Priority Health Commercial	$1,192.10
Rate for Payer: Priority Health PPO	$1,192.10

MRI KNEE RIGHT WO CONTRAST

Facility

$1,964.00

Service Code	HCPCS 73721 RT
Hospital Charge Code	6100330
Hospital Revenue Code	614
Min. Negotiated Rate	$1,374.80
Max. Negotiated Rate	$1,669.40
Rate for Payer: Cash Price	$1,276.60
Rate for Payer: Community Health Alliance Commercial	$1,669.40
Rate for Payer: Priority Health Commercial	$1,374.80
Rate for Payer: Priority Health PPO	$1,374.80

MRI KNEE RIGHT W & WO CONTRAST

Facility

$2,256.00

Service Code	HCPCS 73723 RT
Hospital Charge Code	6100334
Hospital Revenue Code	614
Min. Negotiated Rate	$1,579.20
Max. Negotiated Rate	$1,917.60
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Community Health Alliance Commercial	$1,917.60
Rate for Payer: Priority Health Commercial	$1,579.20
Rate for Payer: Priority Health PPO	$1,579.20

MRI LOWER EXT LEFT W CONTRAST

Facility

$1,703.00

Service Code	HCPCS 73722 LT
Hospital Charge Code	6100323
Hospital Revenue Code	614
Min. Negotiated Rate	$1,192.10
Max. Negotiated Rate	$1,447.55
Rate for Payer: Cash Price	$1,106.95
Rate for Payer: Community Health Alliance Commercial	$1,447.55
Rate for Payer: Priority Health Commercial	$1,192.10
Rate for Payer: Priority Health PPO	$1,192.10

MRI LUMBAR LMTD WO CONTRAST

Facility

$1,050.00

Service Code	HCPCS 72148 52
Hospital Charge Code	6100081
Hospital Revenue Code	612
Min. Negotiated Rate	$735.00
Max. Negotiated Rate	$892.50
Rate for Payer: Cash Price	$682.50
Rate for Payer: Community Health Alliance Commercial	$892.50
Rate for Payer: Priority Health Commercial	$735.00
Rate for Payer: Priority Health PPO	$735.00

MRI LUMBAR SPINE W CONTRAST

Facility

$2,115.00

Service Code	HCPCS 72149
Hospital Charge Code	6100090
Hospital Revenue Code	612
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$1,797.75
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$1,374.75
Rate for Payer: Cash Price	$1,374.75
Rate for Payer: Community Health Alliance Commercial	$1,797.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$374.25
Rate for Payer: Meridian Health Plan Medicare	$374.25
Rate for Payer: Priority Health Commercial	$1,480.50
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$1,480.50
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

MRI LUMBAR SPINE WO CONTRAST

Facility

$1,964.00

Service Code	HCPCS 72148
Hospital Charge Code	6100080
Hospital Revenue Code	612
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$1,669.40
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$1,276.60
Rate for Payer: Cash Price	$1,276.60
Rate for Payer: Community Health Alliance Commercial	$1,669.40
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$255.96
Rate for Payer: Meridian Health Plan Medicare	$255.96
Rate for Payer: Priority Health Commercial	$1,374.80
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$1,374.80
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

MRI LUMBAR SPINE W/WO CONTRAST

Facility

$2,805.00

Service Code	HCPCS 72158
Hospital Charge Code	6100100
Hospital Revenue Code	612
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$2,384.25
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$1,823.25
Rate for Payer: Cash Price	$1,823.25
Rate for Payer: Community Health Alliance Commercial	$2,384.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$374.25
Rate for Payer: Meridian Health Plan Medicare	$374.25
Rate for Payer: Priority Health Commercial	$1,963.50
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$1,963.50
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

MRI MEDIASTINUM W CONTRAST

Facility

$1,535.00

Service Code	HCPCS 71551
Hospital Charge Code	6100150
Hospital Revenue Code	614
Min. Negotiated Rate	$370.02
Max. Negotiated Rate	$1,304.75
Rate for Payer: BCBS BCN 65	$840.95
Rate for Payer: Blue Care Network Medicare Advantage	$840.95
Rate for Payer: Cash Price	$997.75
Rate for Payer: Cash Price	$997.75
Rate for Payer: Community Health Alliance Commercial	$1,304.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$840.95
Rate for Payer: Meridian Health Plan Medicare	$840.95
Rate for Payer: Priority Health Commercial	$1,074.50
Rate for Payer: Priority Health Medicaid	$840.95
Rate for Payer: Priority Health Medicare	$840.95
Rate for Payer: Priority Health PPO	$1,074.50
Rate for Payer: United Health Care Medicaid	$840.95
Rate for Payer: United Health Care Medicare Advantage	$370.02

MRI MEDIASTINUM W/O CONTRAST

Facility

$1,468.00

Service Code	HCPCS 71550
Hospital Charge Code	6100140
Hospital Revenue Code	614
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$1,247.80
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$954.20
Rate for Payer: Cash Price	$954.20
Rate for Payer: Community Health Alliance Commercial	$1,247.80
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$255.96
Rate for Payer: Meridian Health Plan Medicare	$255.96
Rate for Payer: Priority Health Commercial	$1,027.60
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$1,027.60
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

MRI MRCP

Facility

$1,616.00

Hospital Charge Code	6100209
Hospital Revenue Code	614
Min. Negotiated Rate	$1,131.20
Max. Negotiated Rate	$1,373.60
Rate for Payer: Cash Price	$1,050.40
Rate for Payer: Community Health Alliance Commercial	$1,373.60
Rate for Payer: Priority Health Commercial	$1,131.20
Rate for Payer: Priority Health PPO	$1,131.20

MRI ORBITS,NECK,PAROTID W

Facility

$1,703.00

Service Code	HCPCS 70542
Hospital Charge Code	6100182
Hospital Revenue Code	614
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$1,447.55
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$1,106.95
Rate for Payer: Cash Price	$1,106.95
Rate for Payer: Community Health Alliance Commercial	$1,447.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$374.25
Rate for Payer: Meridian Health Plan Medicare	$374.25
Rate for Payer: Priority Health Commercial	$1,192.10
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$1,192.10
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

MRI ORBITS,NECK,PAROTID WO

Facility

$1,616.00

Service Code	HCPCS 70540
Hospital Charge Code	6100180
Hospital Revenue Code	614
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$1,373.60
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$1,050.40
Rate for Payer: Cash Price	$1,050.40
Rate for Payer: Community Health Alliance Commercial	$1,373.60
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$255.96
Rate for Payer: Meridian Health Plan Medicare	$255.96
Rate for Payer: Priority Health Commercial	$1,131.20
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$1,131.20
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

MRI ORBITS,NECK,PAROTID W/WO

Facility

$2,256.00

Service Code	HCPCS 70543
Hospital Charge Code	6100181
Hospital Revenue Code	614
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$1,917.60
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Cash Price	$1,466.40
Rate for Payer: Community Health Alliance Commercial	$1,917.60
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$374.25
Rate for Payer: Meridian Health Plan Medicare	$374.25
Rate for Payer: Priority Health Commercial	$1,579.20
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$1,579.20
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

MRI PELVIS WITH CONTRAST

Facility

$1,873.00

Service Code	HCPCS 72196
Hospital Charge Code	6100230
Hospital Revenue Code	614
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$1,592.05
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$1,217.45
Rate for Payer: Cash Price	$1,217.45
Rate for Payer: Community Health Alliance Commercial	$1,592.05
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$374.25
Rate for Payer: Meridian Health Plan Medicare	$374.25
Rate for Payer: Priority Health Commercial	$1,311.10
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$1,311.10
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

MRI PELVIS W/O CONTRAST

Facility

$1,607.00

Service Code	HCPCS 72195
Hospital Charge Code	6100232
Hospital Revenue Code	614
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$1,365.95
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$1,044.55
Rate for Payer: Cash Price	$1,044.55
Rate for Payer: Community Health Alliance Commercial	$1,365.95
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$255.96
Rate for Payer: Meridian Health Plan Medicare	$255.96
Rate for Payer: Priority Health Commercial	$1,124.90
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$1,124.90
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

MRI PELVIS W & W/O CONTRAST

Facility

$2,805.00

Service Code	HCPCS 72197
Hospital Charge Code	6100235
Hospital Revenue Code	614
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$2,384.25
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$1,823.25
Rate for Payer: Cash Price	$1,823.25
Rate for Payer: Community Health Alliance Commercial	$2,384.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$374.25
Rate for Payer: Meridian Health Plan Medicare	$374.25
Rate for Payer: Priority Health Commercial	$1,963.50
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$1,963.50
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

MRI PORT

Facility

$2,176.00

Service Code	HCPCS C1788
Hospital Charge Code	27018093
Hospital Revenue Code	278
Min. Negotiated Rate	$1,523.20
Max. Negotiated Rate	$1,849.60
Rate for Payer: Cash Price	$1,414.40
Rate for Payer: Community Health Alliance Commercial	$1,849.60
Rate for Payer: Priority Health Commercial	$1,523.20
Rate for Payer: Priority Health PPO	$1,523.20

MRI SHOULDER LEFT W CONTRAST

Facility

$1,873.00

Service Code	HCPCS 73222 LT
Hospital Charge Code	6100343
Hospital Revenue Code	614
Min. Negotiated Rate	$1,311.10
Max. Negotiated Rate	$1,592.05
Rate for Payer: Cash Price	$1,217.45
Rate for Payer: Community Health Alliance Commercial	$1,592.05
Rate for Payer: Priority Health Commercial	$1,311.10
Rate for Payer: Priority Health PPO	$1,311.10

MRI SHOULDER LEFT WO CONTRAST

Facility

$1,964.00

Service Code	HCPCS 73221 LT
Hospital Charge Code	6100341
Hospital Revenue Code	614
Min. Negotiated Rate	$1,374.80
Max. Negotiated Rate	$1,669.40
Rate for Payer: Cash Price	$1,276.60
Rate for Payer: Community Health Alliance Commercial	$1,669.40
Rate for Payer: Priority Health Commercial	$1,374.80
Rate for Payer: Priority Health PPO	$1,374.80

MRI SHOULDER LEFT W & WO CONTR

Facility

$2,031.00

Service Code	HCPCS 73223 LT
Hospital Charge Code	6100345
Hospital Revenue Code	614
Min. Negotiated Rate	$1,421.70
Max. Negotiated Rate	$1,726.35
Rate for Payer: Cash Price	$1,320.15
Rate for Payer: Community Health Alliance Commercial	$1,726.35
Rate for Payer: Priority Health Commercial	$1,421.70
Rate for Payer: Priority Health PPO	$1,421.70

MRI SHOULDER RIGHT W CONTRAST

Facility

$1,873.00

Service Code	HCPCS 73222 RT
Hospital Charge Code	6100342
Hospital Revenue Code	614
Min. Negotiated Rate	$1,311.10
Max. Negotiated Rate	$1,592.05
Rate for Payer: Cash Price	$1,217.45
Rate for Payer: Community Health Alliance Commercial	$1,592.05
Rate for Payer: Priority Health Commercial	$1,311.10
Rate for Payer: Priority Health PPO	$1,311.10

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges