Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

OT E-STIMULATION UNATTENDED

Facility

$142.00

Service Code	HCPCS G0283 GO
Hospital Charge Code	4300097
Hospital Revenue Code	430
Min. Negotiated Rate	$99.40
Max. Negotiated Rate	$120.70
Rate for Payer: Cash Price	$92.30
Rate for Payer: Community Health Alliance Commercial	$120.70
Rate for Payer: Priority Health Commercial	$99.40
Rate for Payer: Priority Health PPO	$99.40

OT ICE MASSAGE

Facility

$42.00

Hospital Charge Code	4300098
Hospital Revenue Code	430
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$35.70
Rate for Payer: Cash Price	$27.30
Rate for Payer: Community Health Alliance Commercial	$35.70
Rate for Payer: Priority Health Commercial	$29.40
Rate for Payer: Priority Health PPO	$29.40

OT MANUAL THERAPY

Facility

$86.00

Hospital Charge Code	4300085
Hospital Revenue Code	430
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$73.10
Rate for Payer: Cash Price	$55.90
Rate for Payer: Community Health Alliance Commercial	$73.10
Rate for Payer: Priority Health Commercial	$60.20
Rate for Payer: Priority Health PPO	$60.20

OT MASSAGE

Facility

$89.00

Hospital Charge Code	4300075
Hospital Revenue Code	430
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$75.65
Rate for Payer: Cash Price	$57.85
Rate for Payer: Community Health Alliance Commercial	$75.65
Rate for Payer: Priority Health Commercial	$62.30
Rate for Payer: Priority Health PPO	$62.30

OT PARAFFIN BATH

Facility

$56.00

Hospital Charge Code	4300055
Hospital Revenue Code	430
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$47.60
Rate for Payer: Cash Price	$36.40
Rate for Payer: Community Health Alliance Commercial	$47.60
Rate for Payer: Priority Health Commercial	$39.20
Rate for Payer: Priority Health PPO	$39.20

OT RE-EVALUATION

Facility

$200.00

Service Code	HCPCS 97168 GO
Hospital Charge Code	4320010
Hospital Revenue Code	434
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$170.00
Rate for Payer: Cash Price	$130.00
Rate for Payer: Community Health Alliance Commercial	$170.00
Rate for Payer: Priority Health Commercial	$140.00
Rate for Payer: Priority Health PPO	$140.00

OT SELF CARE/HOME MANAGEMENT

Facility

$91.00

Service Code	HCPCS 97535 GO
Hospital Charge Code	4300030
Hospital Revenue Code	430
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$77.35
Rate for Payer: Cash Price	$59.15
Rate for Payer: Community Health Alliance Commercial	$77.35
Rate for Payer: Priority Health Commercial	$63.70
Rate for Payer: Priority Health PPO	$63.70

OT THEREPEUTIC ACTIVITIES

Facility

$104.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	4300020
Hospital Revenue Code	430
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$88.40
Rate for Payer: Cash Price	$67.60
Rate for Payer: Community Health Alliance Commercial	$88.40
Rate for Payer: Priority Health Commercial	$72.80
Rate for Payer: Priority Health PPO	$72.80

OT ULTRASOUND

Facility

$115.00

Hospital Charge Code	4300025
Hospital Revenue Code	430
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$97.75
Rate for Payer: Cash Price	$74.75
Rate for Payer: Community Health Alliance Commercial	$97.75
Rate for Payer: Priority Health Commercial	$80.50
Rate for Payer: Priority Health PPO	$80.50

OVA1

Facility

$675.00

Hospital Charge Code	3100828
Hospital Revenue Code	309
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

OVA AND PARASITE

Facility

$53.00

Service Code	HCPCS 87177
Hospital Charge Code	3006400
Hospital Revenue Code	306
Min. Negotiated Rate	$4.11
Max. Negotiated Rate	$45.05
Rate for Payer: BCBS BCN 65	$9.35
Rate for Payer: Blue Care Network Medicare Advantage	$9.35
Rate for Payer: Cash Price	$34.45
Rate for Payer: Cash Price	$34.45
Rate for Payer: Community Health Alliance Commercial	$45.05
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$9.35
Rate for Payer: Meridian Health Plan Medicare	$9.35
Rate for Payer: Priority Health Commercial	$37.10
Rate for Payer: Priority Health Medicaid	$9.35
Rate for Payer: Priority Health Medicare	$9.35
Rate for Payer: Priority Health PPO	$37.10
Rate for Payer: United Health Care Medicaid	$9.35
Rate for Payer: United Health Care Medicare Advantage	$4.11

OVA AND PARASITE BF-1

Facility

$9.75

Hospital Charge Code	3101265
Hospital Revenue Code	306
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$8.29
Rate for Payer: Cash Price	$6.34
Rate for Payer: Community Health Alliance Commercial	$8.29
Rate for Payer: Priority Health Commercial	$6.83
Rate for Payer: Priority Health PPO	$6.83

OVA AND PARASITE BF-2

Facility

$9.75

Hospital Charge Code	3101266
Hospital Revenue Code	306
Min. Negotiated Rate	$6.83
Max. Negotiated Rate	$8.29
Rate for Payer: Cash Price	$6.34
Rate for Payer: Community Health Alliance Commercial	$8.29
Rate for Payer: Priority Health Commercial	$6.83
Rate for Payer: Priority Health PPO	$6.83

OVAL BUR,MEDIUM #5091-238

Facility

$86.00

Hospital Charge Code	27020735
Hospital Revenue Code	270
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$73.10
Rate for Payer: Cash Price	$55.90
Rate for Payer: Community Health Alliance Commercial	$73.10
Rate for Payer: Priority Health Commercial	$60.20
Rate for Payer: Priority Health PPO	$60.20

OXALATE

Facility

$218.50

Hospital Charge Code	3000822
Hospital Revenue Code	301
Min. Negotiated Rate	$152.95
Max. Negotiated Rate	$185.72
Rate for Payer: Cash Price	$142.03
Rate for Payer: Community Health Alliance Commercial	$185.72
Rate for Payer: Priority Health Commercial	$152.95
Rate for Payer: Priority Health PPO	$152.95

OXALATE,24 HR URINE

Facility

$9.00

Service Code	HCPCS 83945
Hospital Charge Code	3000821
Hospital Revenue Code	301
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$15.17
Rate for Payer: BCBS BCN 65	$15.17
Rate for Payer: Blue Care Network Medicare Advantage	$15.17
Rate for Payer: Cash Price	$5.85
Rate for Payer: Cash Price	$5.85
Rate for Payer: Community Health Alliance Commercial	$7.65
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$15.17
Rate for Payer: Meridian Health Plan Medicare	$15.17
Rate for Payer: Priority Health Commercial	$6.30
Rate for Payer: Priority Health Medicaid	$15.17
Rate for Payer: Priority Health Medicare	$15.17
Rate for Payer: Priority Health PPO	$6.30
Rate for Payer: United Health Care Medicaid	$15.17
Rate for Payer: United Health Care Medicare Advantage	$6.68

OXALATE URINE

Facility

$11.00

Hospital Charge Code	3102528
Hospital Revenue Code	300
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$9.35
Rate for Payer: Cash Price	$7.15
Rate for Payer: Community Health Alliance Commercial	$9.35
Rate for Payer: Priority Health Commercial	$7.70
Rate for Payer: Priority Health PPO	$7.70

OXIDANT SCREEN

Facility

$54.00

Hospital Charge Code	3100627
Hospital Revenue Code	300
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$45.90
Rate for Payer: Cash Price	$35.10
Rate for Payer: Community Health Alliance Commercial	$45.90
Rate for Payer: Priority Health Commercial	$37.80
Rate for Payer: Priority Health PPO	$37.80

OXIMETRY CONTINUOS OVERNIGHT

Facility

$335.00

Service Code	HCPCS 94762
Hospital Charge Code	4600060
Hospital Revenue Code	410
Min. Negotiated Rate	$60.73
Max. Negotiated Rate	$284.75
Rate for Payer: BCBS BCN 65	$138.03
Rate for Payer: Blue Care Network Medicare Advantage	$138.03
Rate for Payer: Cash Price	$217.75
Rate for Payer: Cash Price	$217.75
Rate for Payer: Community Health Alliance Commercial	$284.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$138.03
Rate for Payer: Meridian Health Plan Medicare	$138.03
Rate for Payer: Priority Health Commercial	$234.50
Rate for Payer: Priority Health Medicaid	$138.03
Rate for Payer: Priority Health Medicare	$138.03
Rate for Payer: Priority Health PPO	$234.50
Rate for Payer: United Health Care Medicaid	$138.03
Rate for Payer: United Health Care Medicare Advantage	$60.73

OXIMETRY MULTI DETERMINATIONS

Facility

$328.00

Service Code	HCPCS 94761
Hospital Charge Code	4600050
Hospital Revenue Code	410
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$278.80
Rate for Payer: Cash Price	$213.20
Rate for Payer: Community Health Alliance Commercial	$278.80
Rate for Payer: Priority Health Commercial	$229.60
Rate for Payer: Priority Health PPO	$229.60

OXIMETRY SINGLE DETERMINATION

Facility

$80.00

Service Code	HCPCS 94760
Hospital Charge Code	4600065
Hospital Revenue Code	410
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$68.00
Rate for Payer: Cash Price	$52.00
Rate for Payer: Community Health Alliance Commercial	$68.00
Rate for Payer: Priority Health Commercial	$56.00
Rate for Payer: Priority Health PPO	$56.00

OXLDL

Facility

$23.00

Hospital Charge Code	3102573
Hospital Revenue Code	300
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$19.55
Rate for Payer: Cash Price	$14.95
Rate for Payer: Community Health Alliance Commercial	$19.55
Rate for Payer: Priority Health Commercial	$16.10
Rate for Payer: Priority Health PPO	$16.10

OXYGEN USAGE

Facility

$12.00

Hospital Charge Code	27094987
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$10.20
Rate for Payer: Cash Price	$7.80
Rate for Payer: Community Health Alliance Commercial	$10.20
Rate for Payer: Priority Health Commercial	$8.40
Rate for Payer: Priority Health PPO	$8.40

PA-1

Facility

$1.66

Hospital Charge Code	31027624
Hospital Revenue Code	300
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.41
Rate for Payer: Cash Price	$1.08
Rate for Payer: Community Health Alliance Commercial	$1.41
Rate for Payer: Priority Health Commercial	$1.16
Rate for Payer: Priority Health PPO	$1.16

PA-10

Facility

$1.66

Hospital Charge Code	31027633
Hospital Revenue Code	300
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.41
Rate for Payer: Cash Price	$1.08
Rate for Payer: Community Health Alliance Commercial	$1.41
Rate for Payer: Priority Health Commercial	$1.16
Rate for Payer: Priority Health PPO	$1.16

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges