Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

OBTURATOR W/SLEEVES #FPK02

Facility

$376.00

Hospital Charge Code	27265494
Hospital Revenue Code	272
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$319.60
Rate for Payer: Cash Price	$244.40
Rate for Payer: Community Health Alliance Commercial	$319.60
Rate for Payer: Priority Health Commercial	$263.20
Rate for Payer: Priority Health PPO	$263.20

OCC THERAPY EVAL HIGH COMPLEXI

Facility

$243.00

Service Code	HCPCS 97167 GO
Hospital Charge Code	4300033
Hospital Revenue Code	434
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$206.55
Rate for Payer: Cash Price	$157.95
Rate for Payer: Community Health Alliance Commercial	$206.55
Rate for Payer: Priority Health Commercial	$170.10
Rate for Payer: Priority Health PPO	$170.10

OCC THERAPY EVAL LOW COMPLEXIT

Facility

$243.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	4300031
Hospital Revenue Code	434
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$206.55
Rate for Payer: Cash Price	$157.95
Rate for Payer: Community Health Alliance Commercial	$206.55
Rate for Payer: Priority Health Commercial	$170.10
Rate for Payer: Priority Health PPO	$170.10

OCC THERAPY EVAL MOD COMPLEXIT

Facility

$243.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	4300032
Hospital Revenue Code	434
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$206.55
Rate for Payer: Cash Price	$157.95
Rate for Payer: Community Health Alliance Commercial	$206.55
Rate for Payer: Priority Health Commercial	$170.10
Rate for Payer: Priority Health PPO	$170.10

OCCULT BLOOD 3 SPECIMENS (DX)

Facility

$41.00

Service Code	HCPCS 82272
Hospital Charge Code	3006285
Hospital Revenue Code	301
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$34.85
Rate for Payer: BCBS BCN 65	$4.44
Rate for Payer: Blue Care Network Medicare Advantage	$4.44
Rate for Payer: Cash Price	$26.65
Rate for Payer: Cash Price	$26.65
Rate for Payer: Community Health Alliance Commercial	$34.85
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$4.44
Rate for Payer: Meridian Health Plan Medicare	$4.44
Rate for Payer: Priority Health Commercial	$28.70
Rate for Payer: Priority Health Medicaid	$4.44
Rate for Payer: Priority Health Medicare	$4.44
Rate for Payer: Priority Health PPO	$28.70
Rate for Payer: United Health Care Medicaid	$4.44
Rate for Payer: United Health Care Medicare Advantage	$1.95

OCCULT BLOOD 3 SPEC (SCREEN)

Facility

$41.00

Service Code	HCPCS 82270
Hospital Charge Code	3006280
Hospital Revenue Code	300
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$34.85
Rate for Payer: BCBS BCN 65	$4.60
Rate for Payer: Blue Care Network Medicare Advantage	$4.60
Rate for Payer: Cash Price	$26.65
Rate for Payer: Cash Price	$26.65
Rate for Payer: Community Health Alliance Commercial	$34.85
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$4.60
Rate for Payer: Meridian Health Plan Medicare	$4.60
Rate for Payer: Priority Health Commercial	$28.70
Rate for Payer: Priority Health Medicaid	$4.60
Rate for Payer: Priority Health Medicare	$4.60
Rate for Payer: Priority Health PPO	$28.70
Rate for Payer: United Health Care Medicaid	$4.60
Rate for Payer: United Health Care Medicare Advantage	$2.02

OCCULT BLOOD IMMUNO

Facility

$34.00

Service Code	HCPCS G0328
Hospital Charge Code	3007705
Hospital Revenue Code	300
Min. Negotiated Rate	$8.34
Max. Negotiated Rate	$28.90
Rate for Payer: BCBS BCN 65	$18.95
Rate for Payer: Blue Care Network Medicare Advantage	$18.95
Rate for Payer: Cash Price	$22.10
Rate for Payer: Cash Price	$22.10
Rate for Payer: Community Health Alliance Commercial	$28.90
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$18.95
Rate for Payer: Meridian Health Plan Medicare	$18.95
Rate for Payer: Priority Health Commercial	$23.80
Rate for Payer: Priority Health Medicaid	$18.95
Rate for Payer: Priority Health Medicare	$18.95
Rate for Payer: Priority Health PPO	$23.80
Rate for Payer: United Health Care Medicaid	$18.95
Rate for Payer: United Health Care Medicare Advantage	$8.34

OCCULT BLOOD IMMUNOASSAY DIAG

Facility

$63.00

Hospital Charge Code	3007718
Hospital Revenue Code	301
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$53.55
Rate for Payer: Cash Price	$40.95
Rate for Payer: Community Health Alliance Commercial	$53.55
Rate for Payer: Priority Health Commercial	$44.10
Rate for Payer: Priority Health PPO	$44.10

OCCULT BLOOD IMMUNOASSAY SCREE

Facility

$63.00

Service Code	HCPCS G0328
Hospital Charge Code	3007719
Hospital Revenue Code	301
Min. Negotiated Rate	$8.34
Max. Negotiated Rate	$53.55
Rate for Payer: BCBS BCN 65	$18.95
Rate for Payer: Blue Care Network Medicare Advantage	$18.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Cash Price	$40.95
Rate for Payer: Community Health Alliance Commercial	$53.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$18.95
Rate for Payer: Meridian Health Plan Medicare	$18.95
Rate for Payer: Priority Health Commercial	$44.10
Rate for Payer: Priority Health Medicaid	$18.95
Rate for Payer: Priority Health Medicare	$18.95
Rate for Payer: Priority Health PPO	$44.10
Rate for Payer: United Health Care Medicaid	$18.95
Rate for Payer: United Health Care Medicare Advantage	$8.34

OCCULT BLOOD-STOOL (DX)

Facility

$19.00

Service Code	HCPCS 82272
Hospital Charge Code	3007700
Hospital Revenue Code	300
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$16.15
Rate for Payer: BCBS BCN 65	$4.44
Rate for Payer: Blue Care Network Medicare Advantage	$4.44
Rate for Payer: Cash Price	$12.35
Rate for Payer: Cash Price	$12.35
Rate for Payer: Community Health Alliance Commercial	$16.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$4.44
Rate for Payer: Meridian Health Plan Medicare	$4.44
Rate for Payer: Priority Health Commercial	$13.30
Rate for Payer: Priority Health Medicaid	$4.44
Rate for Payer: Priority Health Medicare	$4.44
Rate for Payer: Priority Health PPO	$13.30
Rate for Payer: United Health Care Medicaid	$4.44
Rate for Payer: United Health Care Medicare Advantage	$1.95

OCCULT BLOOD-STOOL (SCREEN)

Facility

$18.00

Service Code	HCPCS 82270
Hospital Charge Code	3007710
Hospital Revenue Code	301
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$15.30
Rate for Payer: BCBS BCN 65	$4.60
Rate for Payer: Blue Care Network Medicare Advantage	$4.60
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cash Price	$11.70
Rate for Payer: Community Health Alliance Commercial	$15.30
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$4.60
Rate for Payer: Meridian Health Plan Medicare	$4.60
Rate for Payer: Priority Health Commercial	$12.60
Rate for Payer: Priority Health Medicaid	$4.60
Rate for Payer: Priority Health Medicare	$4.60
Rate for Payer: Priority Health PPO	$12.60
Rate for Payer: United Health Care Medicaid	$4.60
Rate for Payer: United Health Care Medicare Advantage	$2.02

OCCUP THERAPY,ORTHO FIT Q 15

Facility

$120.00

Service Code	HCPCS 97760 GO
Hospital Charge Code	4300040
Hospital Revenue Code	430
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$102.00
Rate for Payer: Cash Price	$78.00
Rate for Payer: Community Health Alliance Commercial	$102.00
Rate for Payer: Priority Health Commercial	$84.00
Rate for Payer: Priority Health PPO	$84.00

OLANZAPINE

Facility

$37.00

Hospital Charge Code	3006725
Hospital Revenue Code	301
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$31.45
Rate for Payer: Cash Price	$24.05
Rate for Payer: Community Health Alliance Commercial	$31.45
Rate for Payer: Priority Health Commercial	$25.90
Rate for Payer: Priority Health PPO	$25.90

OLIGOCLONAL BANDS CSF

Facility

$75.00

Hospital Charge Code	3007663
Hospital Revenue Code	301
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$63.75
Rate for Payer: Cash Price	$48.75
Rate for Payer: Community Health Alliance Commercial	$63.75
Rate for Payer: Priority Health Commercial	$52.50
Rate for Payer: Priority Health PPO	$52.50

OMALIZUMAB 150 MG VIAL

Facility

$4,251.08

Service Code	HCPCS J2357
Hospital Charge Code	2502323
Hospital Revenue Code	636
Min. Negotiated Rate	$21.02
Max. Negotiated Rate	$3,613.42
Rate for Payer: BCBS BCN 65	$47.77
Rate for Payer: Blue Care Network Medicare Advantage	$47.77
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Community Health Alliance Commercial	$3,613.42
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$47.77
Rate for Payer: Meridian Health Plan Medicare	$47.77
Rate for Payer: Priority Health Commercial	$2,975.76
Rate for Payer: Priority Health Medicaid	$47.77
Rate for Payer: Priority Health Medicare	$47.77
Rate for Payer: Priority Health PPO	$2,975.76
Rate for Payer: United Health Care Medicaid	$47.77
Rate for Payer: United Health Care Medicare Advantage	$21.02

OMEGA CHECK

Facility

$43.00

Hospital Charge Code	3102129
Hospital Revenue Code	300
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$36.55
Rate for Payer: Cash Price	$27.95
Rate for Payer: Community Health Alliance Commercial	$36.55
Rate for Payer: Priority Health Commercial	$30.10
Rate for Payer: Priority Health PPO	$30.10

OOC-1

Facility

$85.00

Hospital Charge Code	3101778
Hospital Revenue Code	300
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$72.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Community Health Alliance Commercial	$72.25
Rate for Payer: Priority Health Commercial	$59.50
Rate for Payer: Priority Health PPO	$59.50

OOC-2

Facility

$85.00

Hospital Charge Code	3101779
Hospital Revenue Code	300
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$72.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Community Health Alliance Commercial	$72.25
Rate for Payer: Priority Health Commercial	$59.50
Rate for Payer: Priority Health PPO	$59.50

OP-1

Facility

$2.45

Hospital Charge Code	3102680
Hospital Revenue Code	300
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.08
Rate for Payer: Cash Price	$1.59
Rate for Payer: Community Health Alliance Commercial	$2.08
Rate for Payer: Priority Health Commercial	$1.72
Rate for Payer: Priority Health PPO	$1.72

OP-2

Facility

$2.45

Hospital Charge Code	3102681
Hospital Revenue Code	300
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.08
Rate for Payer: Cash Price	$1.59
Rate for Payer: Community Health Alliance Commercial	$2.08
Rate for Payer: Priority Health Commercial	$1.72
Rate for Payer: Priority Health PPO	$1.72

OPEN BX/EXC ING NODES P/C

Facility

$983.00

Hospital Charge Code	5150687
Hospital Revenue Code	960
Min. Negotiated Rate	$688.10
Max. Negotiated Rate	$835.55
Rate for Payer: Cash Price	$638.95
Rate for Payer: Community Health Alliance Commercial	$835.55
Rate for Payer: Priority Health Commercial	$688.10
Rate for Payer: Priority Health PPO	$688.10

O&P EXAM FORMALIN ONLY

Facility

$6.56

Hospital Charge Code	3102119
Hospital Revenue Code	300
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$5.58
Rate for Payer: Cash Price	$4.26
Rate for Payer: Community Health Alliance Commercial	$5.58
Rate for Payer: Priority Health Commercial	$4.59
Rate for Payer: Priority Health PPO	$4.59

OPHTHALMIC IRRIGATION SOLUTION

Facility

$15.00

Hospital Charge Code	2508075
Hospital Revenue Code	250
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$12.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Community Health Alliance Commercial	$12.75
Rate for Payer: Priority Health Commercial	$10.50
Rate for Payer: Priority Health PPO	$10.50

OPIATE CONFIRMATION/QUANTITAT

Facility

$84.00

Service Code	HCPCS G0480
Hospital Charge Code	3005858
Hospital Revenue Code	301
Min. Negotiated Rate	$52.87
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	$54.60
Rate for Payer: Cash Price	$54.60
Rate for Payer: Community Health Alliance Commercial	$71.40
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	$58.80
Rate for Payer: Priority Health Medicaid	$120.15
Rate for Payer: Priority Health Medicare	$120.15
Rate for Payer: Priority Health PPO	$58.80
Rate for Payer: United Health Care Medicaid	$120.15
Rate for Payer: United Health Care Medicare Advantage	$52.87

OPIATE/OXY SCREEN W/CONF

Facility

$21.35

Hospital Charge Code	3102403
Hospital Revenue Code	300
Min. Negotiated Rate	$14.95
Max. Negotiated Rate	$18.15
Rate for Payer: Cash Price	$13.88
Rate for Payer: Community Health Alliance Commercial	$18.15
Rate for Payer: Priority Health Commercial	$14.95
Rate for Payer: Priority Health PPO	$14.95

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges