Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

NM PULMONARY PERFUSION IMAGING

Facility

$553.00

Service Code	HCPCS 78580
Hospital Charge Code	3400150
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$470.05
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$359.45
Rate for Payer: Cash Price	$359.45
Rate for Payer: Community Health Alliance Commercial	$470.05
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	$387.10
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$387.10
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM PULMONARY VENTILATION IMAGI

Facility

$553.00

Service Code	HCPCS 78579
Hospital Charge Code	3400170
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$470.05
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$359.45
Rate for Payer: Cash Price	$359.45
Rate for Payer: Community Health Alliance Commercial	$470.05
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	$387.10
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$387.10
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NMR #1

Facility

$16.30

Hospital Charge Code	3101487
Hospital Revenue Code	300
Min. Negotiated Rate	$11.41
Max. Negotiated Rate	$13.86
Rate for Payer: Cash Price	$10.60
Rate for Payer: Community Health Alliance Commercial	$13.86
Rate for Payer: Priority Health Commercial	$11.41
Rate for Payer: Priority Health PPO	$11.41

NMR #2

Facility

$16.31

Hospital Charge Code	3101488
Hospital Revenue Code	300
Min. Negotiated Rate	$11.42
Max. Negotiated Rate	$13.86
Rate for Payer: Cash Price	$10.60
Rate for Payer: Community Health Alliance Commercial	$13.86
Rate for Payer: Priority Health Commercial	$11.42
Rate for Payer: Priority Health PPO	$11.42

NM RADIONUCLIDE THERAPY HYPERT

Facility

$958.00

Service Code	HCPCS 79005
Hospital Charge Code	3400180
Hospital Revenue Code	342
Min. Negotiated Rate	$110.14
Max. Negotiated Rate	$814.30
Rate for Payer: BCBS BCN 65	$250.31
Rate for Payer: Blue Care Network Medicare Advantage	$250.31
Rate for Payer: Cash Price	$622.70
Rate for Payer: Cash Price	$622.70
Rate for Payer: Community Health Alliance Commercial	$814.30
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$250.31
Rate for Payer: Meridian Health Plan Medicare	$250.31
Rate for Payer: Priority Health Commercial	$670.60
Rate for Payer: Priority Health Medicaid	$250.31
Rate for Payer: Priority Health Medicare	$250.31
Rate for Payer: Priority Health PPO	$670.60
Rate for Payer: United Health Care Medicaid	$250.31
Rate for Payer: United Health Care Medicare Advantage	$110.14

NM RENAL DMSA-SPECT

Facility

$827.00

Hospital Charge Code	3400328
Hospital Revenue Code	340
Min. Negotiated Rate	$578.90
Max. Negotiated Rate	$702.95
Rate for Payer: Cash Price	$537.55
Rate for Payer: Community Health Alliance Commercial	$702.95
Rate for Payer: Priority Health Commercial	$578.90
Rate for Payer: Priority Health PPO	$578.90

NM RENAL DMSA-SPECT

Facility

$889.00

Hospital Charge Code	3400327
Hospital Revenue Code	340
Min. Negotiated Rate	$622.30
Max. Negotiated Rate	$755.65
Rate for Payer: Cash Price	$577.85
Rate for Payer: Community Health Alliance Commercial	$755.65
Rate for Payer: Priority Health Commercial	$622.30
Rate for Payer: Priority Health PPO	$622.30

NM SENTINEL NODE IMAGING

Facility

$654.00

Service Code	HCPCS 78195
Hospital Charge Code	3400267
Hospital Revenue Code	340
Min. Negotiated Rate	$256.29
Max. Negotiated Rate	$582.47
Rate for Payer: BCBS BCN 65	$582.47
Rate for Payer: Blue Care Network Medicare Advantage	$582.47
Rate for Payer: Cash Price	$425.10
Rate for Payer: Cash Price	$425.10
Rate for Payer: Community Health Alliance Commercial	$555.90
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	$457.80
Rate for Payer: Priority Health Medicaid	$582.47
Rate for Payer: Priority Health Medicare	$582.47
Rate for Payer: Priority Health PPO	$457.80
Rate for Payer: United Health Care Medicaid	$582.47
Rate for Payer: United Health Care Medicare Advantage	$256.29

NM SPECT BONE

Facility

$986.00

Service Code	HCPCS 78803
Hospital Charge Code	3400060
Hospital Revenue Code	340
Min. Negotiated Rate	$256.29
Max. Negotiated Rate	$838.10
Rate for Payer: BCBS BCN 65	$582.47
Rate for Payer: Blue Care Network Medicare Advantage	$582.47
Rate for Payer: Cash Price	$640.90
Rate for Payer: Cash Price	$640.90
Rate for Payer: Community Health Alliance Commercial	$838.10
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	$690.20
Rate for Payer: Priority Health Medicaid	$582.47
Rate for Payer: Priority Health Medicare	$582.47
Rate for Payer: Priority Health PPO	$690.20
Rate for Payer: United Health Care Medicaid	$582.47
Rate for Payer: United Health Care Medicare Advantage	$256.29

NMT-1

Facility

$74.25

Hospital Charge Code	3102394
Hospital Revenue Code	300
Min. Negotiated Rate	$51.98
Max. Negotiated Rate	$63.11
Rate for Payer: Cash Price	$48.26
Rate for Payer: Community Health Alliance Commercial	$63.11
Rate for Payer: Priority Health Commercial	$51.98
Rate for Payer: Priority Health PPO	$51.98

NMT-2

Facility

$74.25

Hospital Charge Code	3102395
Hospital Revenue Code	300
Min. Negotiated Rate	$51.98
Max. Negotiated Rate	$63.11
Rate for Payer: Cash Price	$48.26
Rate for Payer: Community Health Alliance Commercial	$63.11
Rate for Payer: Priority Health Commercial	$51.98
Rate for Payer: Priority Health PPO	$51.98

NMT-3

Facility

$74.25

Hospital Charge Code	3102396
Hospital Revenue Code	300
Min. Negotiated Rate	$51.98
Max. Negotiated Rate	$63.11
Rate for Payer: Cash Price	$48.26
Rate for Payer: Community Health Alliance Commercial	$63.11
Rate for Payer: Priority Health Commercial	$51.98
Rate for Payer: Priority Health PPO	$51.98

NMT-4

Facility

$74.25

Hospital Charge Code	3102397
Hospital Revenue Code	300
Min. Negotiated Rate	$51.98
Max. Negotiated Rate	$63.11
Rate for Payer: Cash Price	$48.26
Rate for Payer: Community Health Alliance Commercial	$63.11
Rate for Payer: Priority Health Commercial	$51.98
Rate for Payer: Priority Health PPO	$51.98

NM TESTICULAR IMAGING/VASCULAR

Facility

$727.00

Service Code	HCPCS 78761
Hospital Charge Code	3400280
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$617.95
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$472.55
Rate for Payer: Cash Price	$472.55
Rate for Payer: Community Health Alliance Commercial	$617.95
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	$508.90
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$508.90
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM THYROID IMAGING

Facility

$613.00

Service Code	HCPCS 78013
Hospital Charge Code	3400290
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$521.05
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$398.45
Rate for Payer: Cash Price	$398.45
Rate for Payer: Community Health Alliance Commercial	$521.05
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	$429.10
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$429.10
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM THYROID IMAG W UPTAKE I123

Facility

$613.00

Service Code	HCPCS 78014
Hospital Charge Code	3400316
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$521.05
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$398.45
Rate for Payer: Cash Price	$398.45
Rate for Payer: Community Health Alliance Commercial	$521.05
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	$429.10
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$429.10
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM THYROID UPTAKE STUDY I-131

Facility

$859.00

Service Code	HCPCS 78012
Hospital Charge Code	3400332
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$730.15
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$558.35
Rate for Payer: Cash Price	$558.35
Rate for Payer: Community Health Alliance Commercial	$730.15
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	$601.30
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$601.30
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM TUMOR/GA OR ONCOSCI

Facility

$1,155.00

Service Code	HCPCS 78801
Hospital Charge Code	3400020
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$981.75
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$750.75
Rate for Payer: Cash Price	$750.75
Rate for Payer: Community Health Alliance Commercial	$981.75
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	$808.50
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$808.50
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NM URETERAL REFLUX STUDY

Facility

$727.00

Service Code	HCPCS 78740
Hospital Charge Code	3400336
Hospital Revenue Code	340
Min. Negotiated Rate	$188.69
Max. Negotiated Rate	$617.95
Rate for Payer: BCBS BCN 65	$428.85
Rate for Payer: Blue Care Network Medicare Advantage	$428.85
Rate for Payer: Cash Price	$472.55
Rate for Payer: Cash Price	$472.55
Rate for Payer: Community Health Alliance Commercial	$617.95
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	$508.90
Rate for Payer: Priority Health Medicaid	$428.85
Rate for Payer: Priority Health Medicare	$428.85
Rate for Payer: Priority Health PPO	$508.90
Rate for Payer: United Health Care Medicaid	$428.85
Rate for Payer: United Health Care Medicare Advantage	$188.69

NON GYN FLUID, CELL BLOCK

Facility

$95.00

Service Code	HCPCS 88305
Hospital Charge Code	3100395
Hospital Revenue Code	312
Min. Negotiated Rate	$24.60
Max. Negotiated Rate	$80.75
Rate for Payer: BCBS BCN 65	$55.90
Rate for Payer: Blue Care Network Medicare Advantage	$55.90
Rate for Payer: Cash Price	$61.75
Rate for Payer: Cash Price	$61.75
Rate for Payer: Community Health Alliance Commercial	$80.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$55.90
Rate for Payer: Meridian Health Plan Medicare	$55.90
Rate for Payer: Priority Health Commercial	$66.50
Rate for Payer: Priority Health Medicaid	$55.90
Rate for Payer: Priority Health Medicare	$55.90
Rate for Payer: Priority Health PPO	$66.50
Rate for Payer: United Health Care Medicaid	$55.90
Rate for Payer: United Health Care Medicare Advantage	$24.60

NON GYN STAIN TECH

Facility

$45.00

Service Code	HCPCS 88161
Hospital Charge Code	3100400
Hospital Revenue Code	311
Min. Negotiated Rate	$13.65
Max. Negotiated Rate	$38.25
Rate for Payer: BCBS BCN 65	$31.03
Rate for Payer: Blue Care Network Medicare Advantage	$31.03
Rate for Payer: Cash Price	$29.25
Rate for Payer: Cash Price	$29.25
Rate for Payer: Community Health Alliance Commercial	$38.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$31.03
Rate for Payer: Meridian Health Plan Medicare	$31.03
Rate for Payer: Priority Health Commercial	$31.50
Rate for Payer: Priority Health Medicaid	$31.03
Rate for Payer: Priority Health Medicare	$31.03
Rate for Payer: Priority Health PPO	$31.50
Rate for Payer: United Health Care Medicaid	$31.03
Rate for Payer: United Health Care Medicare Advantage	$13.65

NORCLOMIPRAMINE URINE

Facility

$79.00

Hospital Charge Code	3100784
Hospital Revenue Code	300
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$67.15
Rate for Payer: Cash Price	$51.35
Rate for Payer: Community Health Alliance Commercial	$67.15
Rate for Payer: Priority Health Commercial	$55.30
Rate for Payer: Priority Health PPO	$55.30

NORDOXEPIN

Facility

$41.00

Hospital Charge Code	3100702
Hospital Revenue Code	301
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$34.85
Rate for Payer: Cash Price	$26.65
Rate for Payer: Community Health Alliance Commercial	$34.85
Rate for Payer: Priority Health Commercial	$28.70
Rate for Payer: Priority Health PPO	$28.70

NORDOXEPIN URINE

Facility

$79.00

Hospital Charge Code	3100781
Hospital Revenue Code	300
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$67.15
Rate for Payer: Cash Price	$51.35
Rate for Payer: Community Health Alliance Commercial	$67.15
Rate for Payer: Priority Health Commercial	$55.30
Rate for Payer: Priority Health PPO	$55.30

NORMETANEPHERINE URINE 24' 1

Facility

$128.00

Service Code	HCPCS 82383
Hospital Charge Code	3006335
Hospital Revenue Code	301
Min. Negotiated Rate	$13.43
Max. Negotiated Rate	$108.80
Rate for Payer: BCBS BCN 65	$30.53
Rate for Payer: Blue Care Network Medicare Advantage	$30.53
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Community Health Alliance Commercial	$108.80
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$30.53
Rate for Payer: Meridian Health Plan Medicare	$30.53
Rate for Payer: Priority Health Commercial	$89.60
Rate for Payer: Priority Health Medicaid	$30.53
Rate for Payer: Priority Health Medicare	$30.53
Rate for Payer: Priority Health PPO	$89.60
Rate for Payer: United Health Care Medicaid	$30.53
Rate for Payer: United Health Care Medicare Advantage	$13.43

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges