Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA ALPRAZOLAM 0.25 MG TAB

Facility

$7.92

Service Code	HCPCS A9270 GY
Hospital Charge Code	2506363
Hospital Revenue Code	637
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$6.73
Rate for Payer: Cash Price	$5.15
Rate for Payer: Community Health Alliance Commercial	$6.73
Rate for Payer: Priority Health Commercial	$5.54
Rate for Payer: Priority Health PPO	$5.54

PHA ALPRAZOLAM .25 MG TAB

Facility

$3.33

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500365
Hospital Revenue Code	637
Min. Negotiated Rate	$2.33
Max. Negotiated Rate	$2.83
Rate for Payer: Cash Price	$2.16
Rate for Payer: Community Health Alliance Commercial	$2.83
Rate for Payer: Priority Health Commercial	$2.33
Rate for Payer: Priority Health PPO	$2.33

PHA ALTEPLASE,RECOMBNANT 0915

Facility

$24,077.78

Service Code	HCPCS J2997
Hospital Charge Code	2500370
Hospital Revenue Code	636
Min. Negotiated Rate	$43.35
Max. Negotiated Rate	$20,466.11
Rate for Payer: BCBS BCN 65	$98.52
Rate for Payer: Blue Care Network Medicare Advantage	$98.52
Rate for Payer: Cash Price	$15,650.56
Rate for Payer: Cash Price	$15,650.56
Rate for Payer: Community Health Alliance Commercial	$20,466.11
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$98.52
Rate for Payer: Meridian Health Plan Medicare	$98.52
Rate for Payer: Priority Health Commercial	$16,854.45
Rate for Payer: Priority Health Medicaid	$98.52
Rate for Payer: Priority Health Medicare	$98.52
Rate for Payer: Priority Health PPO	$16,854.45
Rate for Payer: United Health Care Medicaid	$98.52
Rate for Payer: United Health Care Medicare Advantage	$43.35

PHA ALUM & MAG HYDROX-SIMETHIC

Facility

$19.75

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501551
Hospital Revenue Code	637
Min. Negotiated Rate	$13.82
Max. Negotiated Rate	$16.79
Rate for Payer: Cash Price	$12.84
Rate for Payer: Community Health Alliance Commercial	$16.79
Rate for Payer: Priority Health Commercial	$13.82
Rate for Payer: Priority Health PPO	$13.82

PHA AMANTADINE HCL 100 MG CAP

Facility

$11.20

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500420
Hospital Revenue Code	637
Min. Negotiated Rate	$7.84
Max. Negotiated Rate	$9.52
Rate for Payer: Cash Price	$7.28
Rate for Payer: Community Health Alliance Commercial	$9.52
Rate for Payer: Priority Health Commercial	$7.84
Rate for Payer: Priority Health PPO	$7.84

PHA AMIDODARONE 360MG/200ML

Facility

$184.94

Service Code	HCPCS J0282
Hospital Charge Code	2507782
Hospital Revenue Code	636
Min. Negotiated Rate	$129.46
Max. Negotiated Rate	$157.20
Rate for Payer: Cash Price	$120.21
Rate for Payer: Community Health Alliance Commercial	$157.20
Rate for Payer: Priority Health Commercial	$129.46
Rate for Payer: Priority Health PPO	$129.46

PHA AMINOPHYLLINE 25 MG/ML V

Facility

$77.81

Service Code	HCPCS J0280
Hospital Charge Code	2500470
Hospital Revenue Code	636
Min. Negotiated Rate	$54.47
Max. Negotiated Rate	$66.14
Rate for Payer: Cash Price	$50.58
Rate for Payer: Community Health Alliance Commercial	$66.14
Rate for Payer: Priority Health Commercial	$54.47
Rate for Payer: Priority Health PPO	$54.47

PHA AMIODARONE HCL 50 MG

Facility

$12.50

Service Code	HCPCS J0282
Hospital Charge Code	2500496
Hospital Revenue Code	636
Min. Negotiated Rate	$8.75
Max. Negotiated Rate	$10.62
Rate for Payer: Cash Price	$8.13
Rate for Payer: Community Health Alliance Commercial	$10.62
Rate for Payer: Priority Health Commercial	$8.75
Rate for Payer: Priority Health PPO	$8.75

PHA AMITRIPTYLINE 50MG TAB

Facility

$6.62

Service Code	NDC 378265001
Hospital Charge Code	2510769
Hospital Revenue Code	637
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$5.63
Rate for Payer: Cash Price	$4.30
Rate for Payer: Community Health Alliance Commercial	$5.63
Rate for Payer: Priority Health Commercial	$4.63
Rate for Payer: Priority Health PPO	$4.63

PHA AMITRIPTYLINE HCL 10 MG TB

Facility

$1.67

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500500
Hospital Revenue Code	637
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.42
Rate for Payer: Cash Price	$1.09
Rate for Payer: Community Health Alliance Commercial	$1.42
Rate for Payer: Priority Health Commercial	$1.17
Rate for Payer: Priority Health PPO	$1.17

PHA AMITRIPTYLINE HCL 25 MG TB

Facility

$3.33

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500510
Hospital Revenue Code	637
Min. Negotiated Rate	$2.33
Max. Negotiated Rate	$2.83
Rate for Payer: Cash Price	$2.16
Rate for Payer: Community Health Alliance Commercial	$2.83
Rate for Payer: Priority Health Commercial	$2.33
Rate for Payer: Priority Health PPO	$2.33

PHA AMMONIA 1 EACH INH

Facility

$2.87

Service Code	NDC 39822990002
Hospital Charge Code	2500530
Hospital Revenue Code	250
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.44
Rate for Payer: Cash Price	$1.87
Rate for Payer: Community Health Alliance Commercial	$2.44
Rate for Payer: Priority Health Commercial	$2.01
Rate for Payer: Priority Health PPO	$2.01

PHA AMOLDIPINE BESYLATE 5MG TB

Facility

$8.54

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500520
Hospital Revenue Code	637
Min. Negotiated Rate	$5.98
Max. Negotiated Rate	$7.26
Rate for Payer: Cash Price	$5.55
Rate for Payer: Community Health Alliance Commercial	$7.26
Rate for Payer: Priority Health Commercial	$5.98
Rate for Payer: Priority Health PPO	$5.98

PHA AMOXICILLIN & POT CLAVULAN

Facility

$84.50

Service Code	NDC 65862053350
Hospital Charge Code	2505477
Hospital Revenue Code	250
Min. Negotiated Rate	$59.15
Max. Negotiated Rate	$71.83
Rate for Payer: Cash Price	$54.93
Rate for Payer: Community Health Alliance Commercial	$71.83
Rate for Payer: Priority Health Commercial	$59.15
Rate for Payer: Priority Health PPO	$59.15

PHA AMOXICILLIN & POT CLAVULAN

Facility

$26.31

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500975
Hospital Revenue Code	637
Min. Negotiated Rate	$18.42
Max. Negotiated Rate	$22.36
Rate for Payer: Cash Price	$17.10
Rate for Payer: Community Health Alliance Commercial	$22.36
Rate for Payer: Priority Health Commercial	$18.42
Rate for Payer: Priority Health PPO	$18.42

PHA AMOXICILLIN TRIHYDRATE 100

Facility

$31.94

Service Code	NDC 93415573
Hospital Charge Code	2500561
Hospital Revenue Code	250
Min. Negotiated Rate	$22.36
Max. Negotiated Rate	$27.15
Rate for Payer: Cash Price	$20.76
Rate for Payer: Community Health Alliance Commercial	$27.15
Rate for Payer: Priority Health Commercial	$22.36
Rate for Payer: Priority Health PPO	$22.36

PHA AMOX&POT CLAV 500MG TAB

Facility

$19.69

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500970
Hospital Revenue Code	637
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$16.74
Rate for Payer: Cash Price	$12.80
Rate for Payer: Community Health Alliance Commercial	$16.74
Rate for Payer: Priority Health Commercial	$13.78
Rate for Payer: Priority Health PPO	$13.78

PHA AMOX&POT CLAVUL 250MG TAB

Facility

$30.84

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500940
Hospital Revenue Code	637
Min. Negotiated Rate	$21.59
Max. Negotiated Rate	$26.21
Rate for Payer: Cash Price	$20.05
Rate for Payer: Community Health Alliance Commercial	$26.21
Rate for Payer: Priority Health Commercial	$21.59
Rate for Payer: Priority Health PPO	$21.59

PHA AMOX TRIHYDRATE 500 MG CAP

Facility

$2.45

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500580
Hospital Revenue Code	637
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

PHA AMPHOTERICIN B 50 MG 7001

Facility

$1,085.87

Service Code	HCPCS J0285
Hospital Charge Code	2500590
Hospital Revenue Code	636
Min. Negotiated Rate	$760.11
Max. Negotiated Rate	$922.99
Rate for Payer: Cash Price	$705.82
Rate for Payer: Community Health Alliance Commercial	$922.99
Rate for Payer: Priority Health Commercial	$760.11
Rate for Payer: Priority Health PPO	$760.11

PHA AMPICILLIN 500 MG/16.6ML

Facility

$42.77

Service Code	HCPCS J0290
Hospital Charge Code	2500623
Hospital Revenue Code	636
Min. Negotiated Rate	$29.94
Max. Negotiated Rate	$36.35
Rate for Payer: Cash Price	$27.80
Rate for Payer: Community Health Alliance Commercial	$36.35
Rate for Payer: Priority Health Commercial	$29.94
Rate for Payer: Priority Health PPO	$29.94

PHA AMPICILLIN SOD 250 MG INJ

Facility

$20.74

Service Code	HCPCS J0290
Hospital Charge Code	2500622
Hospital Revenue Code	636
Min. Negotiated Rate	$14.52
Max. Negotiated Rate	$17.63
Rate for Payer: Cash Price	$13.48
Rate for Payer: Community Health Alliance Commercial	$17.63
Rate for Payer: Priority Health Commercial	$14.52
Rate for Payer: Priority Health PPO	$14.52

PHA AMPICILLIN SODIUM 1 GM INJ

Facility

$42.77

Service Code	HCPCS J0290
Hospital Charge Code	2500620
Hospital Revenue Code	636
Min. Negotiated Rate	$29.94
Max. Negotiated Rate	$36.35
Rate for Payer: Cash Price	$27.80
Rate for Payer: Community Health Alliance Commercial	$36.35
Rate for Payer: Priority Health Commercial	$29.94
Rate for Payer: Priority Health PPO	$29.94

PHA AMPICILLIN SODIUM 2 GM

Facility

$72.91

Service Code	HCPCS J0290
Hospital Charge Code	2500621
Hospital Revenue Code	636
Min. Negotiated Rate	$51.04
Max. Negotiated Rate	$61.97
Rate for Payer: Cash Price	$47.39
Rate for Payer: Community Health Alliance Commercial	$61.97
Rate for Payer: Priority Health Commercial	$51.04
Rate for Payer: Priority Health PPO	$51.04

PHA AMPICILLIN &SUBACTAM SOD

Facility

$43.76

Service Code	HCPCS J0295
Hospital Charge Code	2510320
Hospital Revenue Code	636
Min. Negotiated Rate	$30.63
Max. Negotiated Rate	$37.20
Rate for Payer: Cash Price	$28.44
Rate for Payer: Community Health Alliance Commercial	$37.20
Rate for Payer: Priority Health Commercial	$30.63
Rate for Payer: Priority Health PPO	$30.63

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges