Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

N-METHYLHIST

Facility

$296.70

Hospital Charge Code	3101181
Hospital Revenue Code	301
Min. Negotiated Rate	$207.69
Max. Negotiated Rate	$252.19
Rate for Payer: Cash Price	$192.86
Rate for Payer: Community Health Alliance Commercial	$252.19
Rate for Payer: Priority Health Commercial	$207.69
Rate for Payer: Priority Health PPO	$207.69

NM GASTRIC EMPTYING STUDY

Facility

$675.00

Hospital Charge Code	3400035
Hospital Revenue Code	340
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$573.75
Rate for Payer: Cash Price	$438.75
Rate for Payer: Community Health Alliance Commercial	$573.75
Rate for Payer: Priority Health Commercial	$472.50
Rate for Payer: Priority Health PPO	$472.50

NM GASTRO ESOPHAGEAL REFLUX ST

Facility

$750.00

Hospital Charge Code	3400600
Hospital Revenue Code	340
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$637.50
Rate for Payer: Cash Price	$487.50
Rate for Payer: Community Health Alliance Commercial	$637.50
Rate for Payer: Priority Health Commercial	$525.00
Rate for Payer: Priority Health PPO	$525.00

NM GFR RENAL STUDY

Facility

$903.00

Service Code	HCPCS 78707
Hospital Charge Code	3400300
Hospital Revenue Code	340
Min. Negotiated Rate	$256.29
Max. Negotiated Rate	$767.55
Rate for Payer: BCBS BCN 65	$582.47
Rate for Payer: Blue Care Network Medicare Advantage	$582.47
Rate for Payer: Cash Price	$586.95
Rate for Payer: Cash Price	$586.95
Rate for Payer: Community Health Alliance Commercial	$767.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$582.47
Rate for Payer: Meridian Health Plan Medicare	$582.47
Rate for Payer: Priority Health Commercial	$632.10
Rate for Payer: Priority Health Medicaid	$582.47
Rate for Payer: Priority Health Medicare	$582.47
Rate for Payer: Priority Health PPO	$632.10
Rate for Payer: United Health Care Medicaid	$582.47
Rate for Payer: United Health Care Medicare Advantage	$256.29

NM I131 WHOLE BODY SCAN

Facility

$824.00

Service Code	HCPCS 78018
Hospital Charge Code	3400011
Hospital Revenue Code	340
Min. Negotiated Rate	$256.29
Max. Negotiated Rate	$700.40
Rate for Payer: BCBS BCN 65	$582.47
Rate for Payer: Blue Care Network Medicare Advantage	$582.47
Rate for Payer: Cash Price	$535.60
Rate for Payer: Cash Price	$535.60
Rate for Payer: Community Health Alliance Commercial	$700.40
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$582.47
Rate for Payer: Meridian Health Plan Medicare	$582.47
Rate for Payer: Priority Health Commercial	$576.80
Rate for Payer: Priority Health Medicaid	$582.47
Rate for Payer: Priority Health Medicare	$582.47
Rate for Payer: Priority Health PPO	$576.80
Rate for Payer: United Health Care Medicaid	$582.47
Rate for Payer: United Health Care Medicare Advantage	$256.29

NM INDIUM 111 ABSCESS LIMITED

Facility

$2,864.00

Service Code	HCPCS 78805
Hospital Charge Code	3400351
Hospital Revenue Code	340
Min. Negotiated Rate	$2,004.80
Max. Negotiated Rate	$2,434.40
Rate for Payer: Cash Price	$1,861.60
Rate for Payer: Community Health Alliance Commercial	$2,434.40
Rate for Payer: Priority Health Commercial	$2,004.80
Rate for Payer: Priority Health PPO	$2,004.80

NM INDIUM 111 WBC FOR ABCESS

Facility

$2,864.00

Service Code	HCPCS 78806
Hospital Charge Code	3400350
Hospital Revenue Code	340
Min. Negotiated Rate	$2,004.80
Max. Negotiated Rate	$2,434.40
Rate for Payer: Cash Price	$1,861.60
Rate for Payer: Community Health Alliance Commercial	$2,434.40
Rate for Payer: Priority Health Commercial	$2,004.80
Rate for Payer: Priority Health PPO	$2,004.80

NM INJECTION FOR CISTERNOGRAM

Facility

$1,512.00

Service Code	HCPCS 62270
Hospital Charge Code	3400309
Hospital Revenue Code	361
Min. Negotiated Rate	$333.18
Max. Negotiated Rate	$1,285.20
Rate for Payer: BCBS BCN 65	$757.23
Rate for Payer: Blue Care Network Medicare Advantage	$757.23
Rate for Payer: Cash Price	$982.80
Rate for Payer: Cash Price	$982.80
Rate for Payer: Community Health Alliance Commercial	$1,285.20
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$757.23
Rate for Payer: Meridian Health Plan Medicare	$757.23
Rate for Payer: Priority Health Commercial	$1,058.40
Rate for Payer: Priority Health Medicaid	$757.23
Rate for Payer: Priority Health Medicare	$757.23
Rate for Payer: Priority Health PPO	$1,058.40
Rate for Payer: United Health Care Medicaid	$757.23
Rate for Payer: United Health Care Medicare Advantage	$333.18

NM INTRA INJ SENTINEL NODE

Facility

$690.00

Hospital Charge Code	3400266
Hospital Revenue Code	361
Min. Negotiated Rate	$483.00
Max. Negotiated Rate	$586.50
Rate for Payer: Cash Price	$448.50
Rate for Payer: Community Health Alliance Commercial	$586.50
Rate for Payer: Priority Health Commercial	$483.00
Rate for Payer: Priority Health PPO	$483.00

NM KIDNEY IMAGING W VASC FLOW

Facility

$903.00

Service Code	HCPCS 78701
Hospital Charge Code	3400120
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$767.55
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$586.95
Rate for Payer: Cash Price	$586.95
Rate for Payer: Community Health Alliance Commercial	$767.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$428.85
Rate for Payer: Meridian Health Plan Medicare	$428.85
Rate for Payer: Priority Health Commercial	$632.10
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$632.10
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM LIVER/SPLEEN STATIC ONLY

Facility

$894.00

Service Code	HCPCS 78215
Hospital Charge Code	3400090
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$759.90
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$581.10
Rate for Payer: Cash Price	$581.10
Rate for Payer: Community Health Alliance Commercial	$759.90
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$428.85
Rate for Payer: Meridian Health Plan Medicare	$428.85
Rate for Payer: Priority Health Commercial	$625.80
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$625.80
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM LIVER/SPLEEN W VASC FLOW

Facility

$857.00

Service Code	HCPCS 78216
Hospital Charge Code	3400110
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$728.45
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$557.05
Rate for Payer: Cash Price	$557.05
Rate for Payer: Community Health Alliance Commercial	$728.45
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$428.85
Rate for Payer: Meridian Health Plan Medicare	$428.85
Rate for Payer: Priority Health Commercial	$599.90
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$599.90
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM LUNG VENTILATIO & PERFUSION

Facility

$623.00

Hospital Charge Code	3400161
Hospital Revenue Code	340
Min. Negotiated Rate	$436.10
Max. Negotiated Rate	$529.55
Rate for Payer: Cash Price	$404.95
Rate for Payer: Community Health Alliance Commercial	$529.55
Rate for Payer: Priority Health Commercial	$436.10
Rate for Payer: Priority Health PPO	$436.10

NM MAMMOGRAPHIC GUIDE NEEDLE

Facility

$1,243.00

Service Code	HCPCS 19281
Hospital Charge Code	3400268
Hospital Revenue Code	320
Min. Negotiated Rate	$779.56
Max. Negotiated Rate	$1,771.74
Rate for Payer: BCBS BCN 65	$1,771.74
Rate for Payer: Blue Care Network Medicare Advantage	$1,771.74
Rate for Payer: Cash Price	$807.95
Rate for Payer: Cash Price	$807.95
Rate for Payer: Community Health Alliance Commercial	$1,056.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$1,771.74
Rate for Payer: Meridian Health Plan Medicare	$1,771.74
Rate for Payer: Priority Health Commercial	$870.10
Rate for Payer: Priority Health Medicaid	$1,771.74
Rate for Payer: Priority Health Medicare	$1,771.74
Rate for Payer: Priority Health PPO	$870.10
Rate for Payer: United Health Care Medicaid	$1,771.74
Rate for Payer: United Health Care Medicare Advantage	$779.56

NM MECKELS DIVERTICULUM

Facility

$675.00

Service Code	HCPCS 78290
Hospital Charge Code	3400130
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$573.75
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$438.75
Rate for Payer: Cash Price	$438.75
Rate for Payer: Community Health Alliance Commercial	$573.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$428.85
Rate for Payer: Meridian Health Plan Medicare	$428.85
Rate for Payer: Priority Health Commercial	$472.50
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$472.50
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM MIRALUMA BREAST IMAGING

Facility

$824.00

Service Code	HCPCS 78800
Hospital Charge Code	3400061
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$700.40
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$535.60
Rate for Payer: Cash Price	$535.60
Rate for Payer: Community Health Alliance Commercial	$700.40
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$428.85
Rate for Payer: Meridian Health Plan Medicare	$428.85
Rate for Payer: Priority Health Commercial	$576.80
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$576.80
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM MUGA SCAN

Facility

$917.00

Service Code	HCPCS 78472
Hospital Charge Code	3400140
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$779.45
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$596.05
Rate for Payer: Cash Price	$596.05
Rate for Payer: Community Health Alliance Commercial	$779.45
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$428.85
Rate for Payer: Meridian Health Plan Medicare	$428.85
Rate for Payer: Priority Health Commercial	$641.90
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$641.90
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM MYOCARDIUM IMG CARD/STRESS

Facility

$2,864.00

Service Code	HCPCS 78451
Hospital Charge Code	3400200
Hospital Revenue Code	340
Min. Negotiated Rate	$611.08
Max. Negotiated Rate	$2,434.40
Rate for Payer: BCBS BCN 65	$1,388.82
Rate for Payer: Blue Care Network Medicare Advantage	$1,388.82
Rate for Payer: Cash Price	$1,861.60
Rate for Payer: Cash Price	$1,861.60
Rate for Payer: Community Health Alliance Commercial	$2,434.40
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$1,388.82
Rate for Payer: Meridian Health Plan Medicare	$1,388.82
Rate for Payer: Priority Health Commercial	$2,004.80
Rate for Payer: Priority Health Medicaid	$1,388.82
Rate for Payer: Priority Health Medicare	$1,388.82
Rate for Payer: Priority Health PPO	$2,004.80
Rate for Payer: United Health Care Medicaid	$1,388.82
Rate for Payer: United Health Care Medicare Advantage	$611.08

NM MYOCARDIUM IMG/REST

Facility

$2,864.00

Service Code	HCPCS 78451
Hospital Charge Code	3400210
Hospital Revenue Code	340
Min. Negotiated Rate	$611.08
Max. Negotiated Rate	$2,434.40
Rate for Payer: BCBS BCN 65	$1,388.82
Rate for Payer: Blue Care Network Medicare Advantage	$1,388.82
Rate for Payer: Cash Price	$1,861.60
Rate for Payer: Cash Price	$1,861.60
Rate for Payer: Community Health Alliance Commercial	$2,434.40
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$1,388.82
Rate for Payer: Meridian Health Plan Medicare	$1,388.82
Rate for Payer: Priority Health Commercial	$2,004.80
Rate for Payer: Priority Health Medicaid	$1,388.82
Rate for Payer: Priority Health Medicare	$1,388.82
Rate for Payer: Priority Health PPO	$2,004.80
Rate for Payer: United Health Care Medicaid	$1,388.82
Rate for Payer: United Health Care Medicare Advantage	$611.08

NM MYOCARDIUM IMG/REST

Facility

$1,117.00

Hospital Charge Code	3400211
Hospital Revenue Code	340
Min. Negotiated Rate	$781.90
Max. Negotiated Rate	$949.45
Rate for Payer: Cash Price	$726.05
Rate for Payer: Community Health Alliance Commercial	$949.45
Rate for Payer: Priority Health Commercial	$781.90
Rate for Payer: Priority Health PPO	$781.90

NM MYOCARD SPECT IMG STR/RST

Facility

$3,094.00

Service Code	HCPCS 78452
Hospital Charge Code	3400217
Hospital Revenue Code	340
Min. Negotiated Rate	$611.08
Max. Negotiated Rate	$2,629.90
Rate for Payer: BCBS BCN 65	$1,388.82
Rate for Payer: Blue Care Network Medicare Advantage	$1,388.82
Rate for Payer: Cash Price	$2,011.10
Rate for Payer: Cash Price	$2,011.10
Rate for Payer: Community Health Alliance Commercial	$2,629.90
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$1,388.82
Rate for Payer: Meridian Health Plan Medicare	$1,388.82
Rate for Payer: Priority Health Commercial	$2,165.80
Rate for Payer: Priority Health Medicaid	$1,388.82
Rate for Payer: Priority Health Medicare	$1,388.82
Rate for Payer: Priority Health PPO	$2,165.80
Rate for Payer: United Health Care Medicaid	$1,388.82
Rate for Payer: United Health Care Medicare Advantage	$611.08

NM OCTREOTIDE SCAN

Facility

$2,368.00

Hospital Charge Code	3400018
Hospital Revenue Code	340
Min. Negotiated Rate	$1,657.60
Max. Negotiated Rate	$2,012.80
Rate for Payer: Cash Price	$1,539.20
Rate for Payer: Community Health Alliance Commercial	$2,012.80
Rate for Payer: Priority Health Commercial	$1,657.60
Rate for Payer: Priority Health PPO	$1,657.60

NMO-IgG

Facility

$82.00

Hospital Charge Code	3100063
Hospital Revenue Code	300
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$69.70
Rate for Payer: Cash Price	$53.30
Rate for Payer: Community Health Alliance Commercial	$69.70
Rate for Payer: Priority Health Commercial	$57.40
Rate for Payer: Priority Health PPO	$57.40

NMP 22

Facility

$97.00

Hospital Charge Code	3006884
Hospital Revenue Code	302
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

NM PARATHYROID IMAGING

Facility

$1,094.00

Service Code	HCPCS 78070
Hospital Charge Code	3400240
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$929.90
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$711.10
Rate for Payer: Cash Price	$711.10
Rate for Payer: Community Health Alliance Commercial	$929.90
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$428.85
Rate for Payer: Meridian Health Plan Medicare	$428.85
Rate for Payer: Priority Health Commercial	$765.80
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$765.80
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges