Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

NEW PATIENT BRIEF PROF

Facility

$97.00

Hospital Charge Code	5150667
Hospital Revenue Code	960
Min. Negotiated Rate	$67.90
Max. Negotiated Rate	$82.45
Rate for Payer: Cash Price	$63.05
Rate for Payer: Community Health Alliance Commercial	$82.45
Rate for Payer: Priority Health Commercial	$67.90
Rate for Payer: Priority Health PPO	$67.90

NEW PATIENT COMPLEX

Facility

$508.00

Service Code	HCPCS G0463
Hospital Charge Code	5150565
Hospital Revenue Code	510
Min. Negotiated Rate	$62.84
Max. Negotiated Rate	$431.80
Rate for Payer: BCBS BCN 65	$142.82
Rate for Payer: Blue Care Network Medicare Advantage	$142.82
Rate for Payer: Cash Price	$330.20
Rate for Payer: Cash Price	$330.20
Rate for Payer: Community Health Alliance Commercial	$431.80
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$142.82
Rate for Payer: Meridian Health Plan Medicare	$142.82
Rate for Payer: Priority Health Commercial	$355.60
Rate for Payer: Priority Health Medicaid	$142.82
Rate for Payer: Priority Health Medicare	$142.82
Rate for Payer: Priority Health PPO	$355.60
Rate for Payer: United Health Care Medicaid	$142.82
Rate for Payer: United Health Care Medicare Advantage	$62.84

NEW PATIENT COMPLEX PROF

Facility

$194.00

Hospital Charge Code	5150665
Hospital Revenue Code	960
Min. Negotiated Rate	$135.80
Max. Negotiated Rate	$164.90
Rate for Payer: Cash Price	$126.10
Rate for Payer: Community Health Alliance Commercial	$164.90
Rate for Payer: Priority Health Commercial	$135.80
Rate for Payer: Priority Health PPO	$135.80

NEW PATIENT EXTENDED

Facility

$355.00

Service Code	HCPCS G0463
Hospital Charge Code	5150569
Hospital Revenue Code	510
Min. Negotiated Rate	$62.84
Max. Negotiated Rate	$301.75
Rate for Payer: BCBS BCN 65	$142.82
Rate for Payer: Blue Care Network Medicare Advantage	$142.82
Rate for Payer: Cash Price	$230.75
Rate for Payer: Cash Price	$230.75
Rate for Payer: Community Health Alliance Commercial	$301.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$142.82
Rate for Payer: Meridian Health Plan Medicare	$142.82
Rate for Payer: Priority Health Commercial	$248.50
Rate for Payer: Priority Health Medicaid	$142.82
Rate for Payer: Priority Health Medicare	$142.82
Rate for Payer: Priority Health PPO	$248.50
Rate for Payer: United Health Care Medicaid	$142.82
Rate for Payer: United Health Care Medicare Advantage	$62.84

NEW PATIENT EXTENDED PROF

Facility

$165.00

Hospital Charge Code	5150666
Hospital Revenue Code	960
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$140.25
Rate for Payer: Cash Price	$107.25
Rate for Payer: Community Health Alliance Commercial	$140.25
Rate for Payer: Priority Health Commercial	$115.50
Rate for Payer: Priority Health PPO	$115.50

NEW PATIENT INTERMEDIATE

Facility

$286.00

Service Code	HCPCS G0463
Hospital Charge Code	5150658
Hospital Revenue Code	510
Min. Negotiated Rate	$62.84
Max. Negotiated Rate	$243.10
Rate for Payer: BCBS BCN 65	$142.82
Rate for Payer: Blue Care Network Medicare Advantage	$142.82
Rate for Payer: Cash Price	$185.90
Rate for Payer: Cash Price	$185.90
Rate for Payer: Community Health Alliance Commercial	$243.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$142.82
Rate for Payer: Meridian Health Plan Medicare	$142.82
Rate for Payer: Priority Health Commercial	$200.20
Rate for Payer: Priority Health Medicaid	$142.82
Rate for Payer: Priority Health Medicare	$142.82
Rate for Payer: Priority Health PPO	$200.20
Rate for Payer: United Health Care Medicaid	$142.82
Rate for Payer: United Health Care Medicare Advantage	$62.84

NEW PATIENT INTERMEDIATE PROF

Facility

$148.00

Hospital Charge Code	5150669
Hospital Revenue Code	960
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$125.80
Rate for Payer: Cash Price	$96.20
Rate for Payer: Community Health Alliance Commercial	$125.80
Rate for Payer: Priority Health Commercial	$103.60
Rate for Payer: Priority Health PPO	$103.60

NEW PATIENT LIMITED

Facility

$219.00

Service Code	HCPCS G0463
Hospital Charge Code	5150657
Hospital Revenue Code	510
Min. Negotiated Rate	$62.84
Max. Negotiated Rate	$186.15
Rate for Payer: BCBS BCN 65	$142.82
Rate for Payer: Blue Care Network Medicare Advantage	$142.82
Rate for Payer: Cash Price	$142.35
Rate for Payer: Cash Price	$142.35
Rate for Payer: Community Health Alliance Commercial	$186.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$142.82
Rate for Payer: Meridian Health Plan Medicare	$142.82
Rate for Payer: Priority Health Commercial	$153.30
Rate for Payer: Priority Health Medicaid	$142.82
Rate for Payer: Priority Health Medicare	$142.82
Rate for Payer: Priority Health PPO	$153.30
Rate for Payer: United Health Care Medicaid	$142.82
Rate for Payer: United Health Care Medicare Advantage	$62.84

NEW PATIENT LIMITED PROF

Facility

$126.00

Hospital Charge Code	5150668
Hospital Revenue Code	960
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$107.10
Rate for Payer: Cash Price	$81.90
Rate for Payer: Community Health Alliance Commercial	$107.10
Rate for Payer: Priority Health Commercial	$88.20
Rate for Payer: Priority Health PPO	$88.20

NF-1

Facility

$62.50

Hospital Charge Code	3102172
Hospital Revenue Code	300
Min. Negotiated Rate	$43.75
Max. Negotiated Rate	$53.12
Rate for Payer: Cash Price	$40.63
Rate for Payer: Community Health Alliance Commercial	$53.12
Rate for Payer: Priority Health Commercial	$43.75
Rate for Payer: Priority Health PPO	$43.75

NF-2

Facility

$62.50

Hospital Charge Code	3102173
Hospital Revenue Code	300
Min. Negotiated Rate	$43.75
Max. Negotiated Rate	$53.12
Rate for Payer: Cash Price	$40.63
Rate for Payer: Community Health Alliance Commercial	$53.12
Rate for Payer: Priority Health Commercial	$43.75
Rate for Payer: Priority Health PPO	$43.75

NF-3

Facility

$62.50

Hospital Charge Code	3102174
Hospital Revenue Code	300
Min. Negotiated Rate	$43.75
Max. Negotiated Rate	$53.12
Rate for Payer: Cash Price	$40.63
Rate for Payer: Community Health Alliance Commercial	$53.12
Rate for Payer: Priority Health Commercial	$43.75
Rate for Payer: Priority Health PPO	$43.75

NF-4

Facility

$62.50

Hospital Charge Code	3102175
Hospital Revenue Code	300
Min. Negotiated Rate	$43.75
Max. Negotiated Rate	$53.12
Rate for Payer: Cash Price	$40.63
Rate for Payer: Community Health Alliance Commercial	$53.12
Rate for Payer: Priority Health Commercial	$43.75
Rate for Payer: Priority Health PPO	$43.75

NF CHLORTHALIDONE 25 MG TAB

Facility

$6.30

Service Code	NDC 66689034599
Hospital Charge Code	2510905
Hospital Revenue Code	637
Min. Negotiated Rate	$4.41
Max. Negotiated Rate	$5.36
Rate for Payer: Cash Price	$4.10
Rate for Payer: Community Health Alliance Commercial	$5.36
Rate for Payer: Priority Health Commercial	$4.41
Rate for Payer: Priority Health PPO	$4.41

NF HYDROCHLORATHIAZIDE 12.5

Facility

$2.19

Service Code	NDC 591034701
Hospital Charge Code	2510861
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.42
Rate for Payer: Community Health Alliance Commercial	$1.86
Rate for Payer: Priority Health Commercial	$1.53
Rate for Payer: Priority Health PPO	$1.53

NF LAMICTAL 200 MG TAB

Facility

$30.06

Service Code	NDC 29300011416
Hospital Charge Code	2510837
Hospital Revenue Code	637
Min. Negotiated Rate	$21.04
Max. Negotiated Rate	$25.55
Rate for Payer: Cash Price	$19.54
Rate for Payer: Community Health Alliance Commercial	$25.55
Rate for Payer: Priority Health Commercial	$21.04
Rate for Payer: Priority Health PPO	$21.04

NF LOVASTATIN 20 MG TAB

Facility

$12.35

Service Code	NDC 68180046801
Hospital Charge Code	2510877
Hospital Revenue Code	637
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$10.50
Rate for Payer: Cash Price	$8.03
Rate for Payer: Community Health Alliance Commercial	$10.50
Rate for Payer: Priority Health Commercial	$8.64
Rate for Payer: Priority Health PPO	$8.64

NF METOPROLOL XL 50MG TAB

Facility

$1.51

Service Code	NDC 24979003801
Hospital Charge Code	2510863
Hospital Revenue Code	637
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.28
Rate for Payer: Cash Price	$0.98
Rate for Payer: Community Health Alliance Commercial	$1.28
Rate for Payer: Priority Health Commercial	$1.06
Rate for Payer: Priority Health PPO	$1.06

NF PREVACID 30 MG CAP

Facility

$30.74

Service Code	NDC 378803077
Hospital Charge Code	2510873
Hospital Revenue Code	637
Min. Negotiated Rate	$21.52
Max. Negotiated Rate	$26.13
Rate for Payer: Cash Price	$19.98
Rate for Payer: Community Health Alliance Commercial	$26.13
Rate for Payer: Priority Health Commercial	$21.52
Rate for Payer: Priority Health PPO	$21.52

NF WELLBUTRIN SR 200 MG TAB

Facility

$80.33

Service Code	NDC 173072200
Hospital Charge Code	2510906
Hospital Revenue Code	637
Min. Negotiated Rate	$56.23
Max. Negotiated Rate	$68.28
Rate for Payer: Cash Price	$52.21
Rate for Payer: Community Health Alliance Commercial	$68.28
Rate for Payer: Priority Health Commercial	$56.23
Rate for Payer: Priority Health PPO	$56.23

NGS1

Facility

$448.00

Hospital Charge Code	3102696
Hospital Revenue Code	300
Min. Negotiated Rate	$313.60
Max. Negotiated Rate	$380.80
Rate for Payer: Cash Price	$291.20
Rate for Payer: Community Health Alliance Commercial	$380.80
Rate for Payer: Priority Health Commercial	$313.60
Rate for Payer: Priority Health PPO	$313.60

NGS2

Facility

$447.00

Hospital Charge Code	3102697
Hospital Revenue Code	300
Min. Negotiated Rate	$312.90
Max. Negotiated Rate	$379.95
Rate for Payer: Cash Price	$290.55
Rate for Payer: Community Health Alliance Commercial	$379.95
Rate for Payer: Priority Health Commercial	$312.90
Rate for Payer: Priority Health PPO	$312.90

NIACIN

Facility

$40.00

Service Code	HCPCS 84591
Hospital Charge Code	3006345
Hospital Revenue Code	301
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$34.00
Rate for Payer: BCBS BCN 65	$17.91
Rate for Payer: Blue Care Network Medicare Advantage	$17.91
Rate for Payer: Cash Price	$26.00
Rate for Payer: Cash Price	$26.00
Rate for Payer: Community Health Alliance Commercial	$34.00
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$17.91
Rate for Payer: Meridian Health Plan Medicare	$17.91
Rate for Payer: Priority Health Commercial	$28.00
Rate for Payer: Priority Health Medicaid	$17.91
Rate for Payer: Priority Health Medicare	$17.91
Rate for Payer: Priority Health PPO	$28.00
Rate for Payer: United Health Care Medicaid	$17.91
Rate for Payer: United Health Care Medicare Advantage	$7.88

NICKEL SERUM

Facility

$34.46

Hospital Charge Code	3101017
Hospital Revenue Code	301
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$29.29
Rate for Payer: Cash Price	$22.40
Rate for Payer: Community Health Alliance Commercial	$29.29
Rate for Payer: Priority Health Commercial	$24.12
Rate for Payer: Priority Health PPO	$24.12

NICOTINE AND MET QUANT BLOOD

Facility

$22.81

Service Code	HCPCS G0480
Hospital Charge Code	3016591
Hospital Revenue Code	301
Min. Negotiated Rate	$15.97
Max. Negotiated Rate	$120.15
Rate for Payer: BCBS BCN 65	$120.15
Rate for Payer: Blue Care Network Medicare Advantage	$120.15
Rate for Payer: Cash Price	$14.83
Rate for Payer: Cash Price	$14.83
Rate for Payer: Community Health Alliance Commercial	$19.39
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$120.15
Rate for Payer: Meridian Health Plan Medicare	$120.15
Rate for Payer: Priority Health Commercial	$15.97
Rate for Payer: Priority Health Medicaid	$120.15
Rate for Payer: Priority Health Medicare	$120.15
Rate for Payer: Priority Health PPO	$15.97
Rate for Payer: United Health Care Medicaid	$120.15
Rate for Payer: United Health Care Medicare Advantage	$52.87

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges