Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA ATROPINE SULF 1MG/ML INJ

Facility

$69.02

Service Code	HCPCS J0461
Hospital Charge Code	2500890
Hospital Revenue Code	636
Min. Negotiated Rate	$48.31
Max. Negotiated Rate	$58.67
Rate for Payer: Cash Price	$44.86
Rate for Payer: Community Health Alliance Commercial	$58.67
Rate for Payer: Priority Health Commercial	$48.31
Rate for Payer: Priority Health PPO	$48.31

PHA ATROPINE SULF .4MG/ML INJ

Facility

$50.02

Service Code	HCPCS J0461
Hospital Charge Code	2500860
Hospital Revenue Code	636
Min. Negotiated Rate	$35.01
Max. Negotiated Rate	$42.52
Rate for Payer: Cash Price	$32.51
Rate for Payer: Community Health Alliance Commercial	$42.52
Rate for Payer: Priority Health Commercial	$35.01
Rate for Payer: Priority Health PPO	$35.01

PHA AVASTIN 100 MG/4ML VIAL

Facility

$2,352.57

Service Code	HCPCS J9035
Hospital Charge Code	2509996
Hospital Revenue Code	636
Min. Negotiated Rate	$34.02
Max. Negotiated Rate	$1,999.68
Rate for Payer: BCBS BCN 65	$77.31
Rate for Payer: Blue Care Network Medicare Advantage	$77.31
Rate for Payer: Cash Price	$1,529.17
Rate for Payer: Cash Price	$1,529.17
Rate for Payer: Community Health Alliance Commercial	$1,999.68
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$77.31
Rate for Payer: Meridian Health Plan Medicare	$77.31
Rate for Payer: Priority Health Commercial	$1,646.80
Rate for Payer: Priority Health Medicaid	$77.31
Rate for Payer: Priority Health Medicare	$77.31
Rate for Payer: Priority Health PPO	$1,646.80
Rate for Payer: United Health Care Medicaid	$77.31
Rate for Payer: United Health Care Medicare Advantage	$34.02

PHA AVASTIN 400MG/16MO VIAL

Facility

$8,721.71

Service Code	HCPCS J9035
Hospital Charge Code	2509995
Hospital Revenue Code	636
Min. Negotiated Rate	$34.02
Max. Negotiated Rate	$7,413.45
Rate for Payer: BCBS BCN 65	$77.31
Rate for Payer: Blue Care Network Medicare Advantage	$77.31
Rate for Payer: Cash Price	$5,669.11
Rate for Payer: Cash Price	$5,669.11
Rate for Payer: Community Health Alliance Commercial	$7,413.45
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$77.31
Rate for Payer: Meridian Health Plan Medicare	$77.31
Rate for Payer: Priority Health Commercial	$6,105.20
Rate for Payer: Priority Health Medicaid	$77.31
Rate for Payer: Priority Health Medicare	$77.31
Rate for Payer: Priority Health PPO	$6,105.20
Rate for Payer: United Health Care Medicaid	$77.31
Rate for Payer: United Health Care Medicare Advantage	$34.02

PHA AZACTAM 2G VIAL

Facility

$229.26

Service Code	HCPCS J3490
Hospital Charge Code	2510838
Hospital Revenue Code	636
Min. Negotiated Rate	$160.48
Max. Negotiated Rate	$194.87
Rate for Payer: Cash Price	$149.02
Rate for Payer: Community Health Alliance Commercial	$194.87
Rate for Payer: Priority Health Commercial	$160.48
Rate for Payer: Priority Health PPO	$160.48

PHA AZITHROMYCIN 200MG/5ML 30M

Facility

$138.82

Service Code	NDC 42806015134
Hospital Charge Code	2510775
Hospital Revenue Code	250
Min. Negotiated Rate	$97.17
Max. Negotiated Rate	$118.00
Rate for Payer: Cash Price	$90.23
Rate for Payer: Community Health Alliance Commercial	$118.00
Rate for Payer: Priority Health Commercial	$97.17
Rate for Payer: Priority Health PPO	$97.17

PHA AZITHROMYCIN 200MG/5ML SUS

Facility

$165.49

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500565
Hospital Revenue Code	637
Min. Negotiated Rate	$115.84
Max. Negotiated Rate	$140.67
Rate for Payer: Cash Price	$107.57
Rate for Payer: Community Health Alliance Commercial	$140.67
Rate for Payer: Priority Health Commercial	$115.84
Rate for Payer: Priority Health PPO	$115.84

PHA AZITHROMYCIN 250MG CAP

Facility

$7.71

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510720
Hospital Revenue Code	637
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$6.55
Rate for Payer: Cash Price	$5.01
Rate for Payer: Community Health Alliance Commercial	$6.55
Rate for Payer: Priority Health Commercial	$5.40
Rate for Payer: Priority Health PPO	$5.40

PHA AZITHROMYCIN 500 MG

Facility

$79.23

Service Code	HCPCS J0456
Hospital Charge Code	2510725
Hospital Revenue Code	636
Min. Negotiated Rate	$55.46
Max. Negotiated Rate	$67.35
Rate for Payer: Cash Price	$51.50
Rate for Payer: Community Health Alliance Commercial	$67.35
Rate for Payer: Priority Health Commercial	$55.46
Rate for Payer: Priority Health PPO	$55.46

PHA AZTREONAM 1 GM VIAL

Facility

$141.97

Service Code	HCPCS S0073
Hospital Charge Code	2504413
Hospital Revenue Code	250
Min. Negotiated Rate	$99.38
Max. Negotiated Rate	$120.67
Rate for Payer: Cash Price	$92.28
Rate for Payer: Community Health Alliance Commercial	$120.67
Rate for Payer: Priority Health Commercial	$99.38
Rate for Payer: Priority Health PPO	$99.38

PHA BACITRACIN 30 GM TUBE

Facility

$0.57

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502040
Hospital Revenue Code	637
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.37
Rate for Payer: Community Health Alliance Commercial	$0.48
Rate for Payer: Priority Health Commercial	$0.40
Rate for Payer: Priority Health PPO	$0.40

PHA BACITRACIN 50000 U INJ

Facility

$54.96

Service Code	NDC 70594002602
Hospital Charge Code	2502030
Hospital Revenue Code	250
Min. Negotiated Rate	$38.47
Max. Negotiated Rate	$46.72
Rate for Payer: Cash Price	$35.72
Rate for Payer: Community Health Alliance Commercial	$46.72
Rate for Payer: Priority Health Commercial	$38.47
Rate for Payer: Priority Health PPO	$38.47

PHA BACITRACIN OINTMENT 3.5 GM

Facility

$357.94

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501633
Hospital Revenue Code	637
Min. Negotiated Rate	$250.56
Max. Negotiated Rate	$304.25
Rate for Payer: Cash Price	$232.66
Rate for Payer: Community Health Alliance Commercial	$304.25
Rate for Payer: Priority Health Commercial	$250.56
Rate for Payer: Priority Health PPO	$250.56

PHA BACLOFEN 10 MG TAB

Facility

$2.61

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502709
Hospital Revenue Code	637
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.22
Rate for Payer: Cash Price	$1.70
Rate for Payer: Community Health Alliance Commercial	$2.22
Rate for Payer: Priority Health Commercial	$1.83
Rate for Payer: Priority Health PPO	$1.83

PHA BCG 50 MG LIVE VAC

Facility

$602.67

Service Code	HCPCS J9030
Hospital Charge Code	2502055
Hospital Revenue Code	636
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$512.27
Rate for Payer: BCBS BCN 65	$3.44
Rate for Payer: Blue Care Network Medicare Advantage	$3.44
Rate for Payer: Cash Price	$391.74
Rate for Payer: Cash Price	$391.74
Rate for Payer: Community Health Alliance Commercial	$512.27
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3.44
Rate for Payer: Meridian Health Plan Medicare	$3.44
Rate for Payer: Priority Health Commercial	$421.87
Rate for Payer: Priority Health Medicaid	$3.44
Rate for Payer: Priority Health Medicare	$3.44
Rate for Payer: Priority Health PPO	$421.87
Rate for Payer: United Health Care Medicaid	$3.44
Rate for Payer: United Health Care Medicare Advantage	$1.52

PHA BELLADONNA AKLA&OPIUM 60MG

Facility

$174.27

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502020
Hospital Revenue Code	637
Min. Negotiated Rate	$121.99
Max. Negotiated Rate	$148.13
Rate for Payer: Cash Price	$113.28
Rate for Payer: Community Health Alliance Commercial	$148.13
Rate for Payer: Priority Health Commercial	$121.99
Rate for Payer: Priority Health PPO	$121.99

PHA BENDAMUSTINE 1MG

Facility

$8,137.14

Service Code	HCPCS J9033
Hospital Charge Code	2500323
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$6,916.57
Rate for Payer: BCBS BCN 65	$2.15
Rate for Payer: Blue Care Network Medicare Advantage	$2.15
Rate for Payer: Cash Price	$5,289.14
Rate for Payer: Cash Price	$5,289.14
Rate for Payer: Community Health Alliance Commercial	$6,916.57
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$2.15
Rate for Payer: Meridian Health Plan Medicare	$2.15
Rate for Payer: Priority Health Commercial	$5,696.00
Rate for Payer: Priority Health Medicaid	$2.15
Rate for Payer: Priority Health Medicare	$2.15
Rate for Payer: Priority Health PPO	$5,696.00
Rate for Payer: United Health Care Medicaid	$2.15
Rate for Payer: United Health Care Medicare Advantage	$0.95

PHA BENDAMUSTINE HYDROCHLORIDE

Facility

$2,199.49

Service Code	HCPCS J9033
Hospital Charge Code	2500121
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1,869.57
Rate for Payer: BCBS BCN 65	$2.15
Rate for Payer: Blue Care Network Medicare Advantage	$2.15
Rate for Payer: Cash Price	$1,429.67
Rate for Payer: Cash Price	$1,429.67
Rate for Payer: Community Health Alliance Commercial	$1,869.57
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$2.15
Rate for Payer: Meridian Health Plan Medicare	$2.15
Rate for Payer: Priority Health Commercial	$1,539.64
Rate for Payer: Priority Health Medicaid	$2.15
Rate for Payer: Priority Health Medicare	$2.15
Rate for Payer: Priority Health PPO	$1,539.64
Rate for Payer: United Health Care Medicaid	$2.15
Rate for Payer: United Health Care Medicare Advantage	$0.95

PHA BENDEKA 25 MG

Facility

$6,768.32

Service Code	HCPCS J9034
Hospital Charge Code	2500119
Hospital Revenue Code	636
Min. Negotiated Rate	$5.93
Max. Negotiated Rate	$5,753.07
Rate for Payer: BCBS BCN 65	$13.47
Rate for Payer: Blue Care Network Medicare Advantage	$13.47
Rate for Payer: Cash Price	$4,399.41
Rate for Payer: Cash Price	$4,399.41
Rate for Payer: Community Health Alliance Commercial	$5,753.07
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$13.47
Rate for Payer: Meridian Health Plan Medicare	$13.47
Rate for Payer: Priority Health Commercial	$4,737.82
Rate for Payer: Priority Health Medicaid	$13.47
Rate for Payer: Priority Health Medicare	$13.47
Rate for Payer: Priority Health PPO	$4,737.82
Rate for Payer: United Health Care Medicaid	$13.47
Rate for Payer: United Health Care Medicare Advantage	$5.93

PHA BENRALIZUMAB 30MG/ML 1ML

Facility

$16,477.47

Service Code	HCPCS J0517
Hospital Charge Code	2510846
Hospital Revenue Code	636
Min. Negotiated Rate	$75.75
Max. Negotiated Rate	$14,005.85
Rate for Payer: BCBS BCN 65	$172.17
Rate for Payer: Blue Care Network Medicare Advantage	$172.17
Rate for Payer: Cash Price	$10,710.36
Rate for Payer: Cash Price	$10,710.36
Rate for Payer: Community Health Alliance Commercial	$14,005.85
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$172.17
Rate for Payer: Meridian Health Plan Medicare	$172.17
Rate for Payer: Priority Health Commercial	$11,534.23
Rate for Payer: Priority Health Medicaid	$172.17
Rate for Payer: Priority Health Medicare	$172.17
Rate for Payer: Priority Health PPO	$11,534.23
Rate for Payer: United Health Care Medicaid	$172.17
Rate for Payer: United Health Care Medicare Advantage	$75.75

PHA BENZOCAINE 20% DENTAL GEL

Facility

$37.98

Service Code	NDC 31031028340
Hospital Charge Code	2502509
Hospital Revenue Code	250
Min. Negotiated Rate	$26.59
Max. Negotiated Rate	$32.28
Rate for Payer: Cash Price	$24.69
Rate for Payer: Community Health Alliance Commercial	$32.28
Rate for Payer: Priority Health Commercial	$26.59
Rate for Payer: Priority Health PPO	$26.59

PHA BENZOCAINE&ANTIPYRINE 15ML

Facility

$68.97

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502200
Hospital Revenue Code	637
Min. Negotiated Rate	$48.28
Max. Negotiated Rate	$58.62
Rate for Payer: Cash Price	$44.83
Rate for Payer: Community Health Alliance Commercial	$58.62
Rate for Payer: Priority Health Commercial	$48.28
Rate for Payer: Priority Health PPO	$48.28

PHA BENZOIN COMPOUND 3.5 OZ

Facility

$1.56

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500235
Hospital Revenue Code	637
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.33
Rate for Payer: Cash Price	$1.01
Rate for Payer: Community Health Alliance Commercial	$1.33
Rate for Payer: Priority Health Commercial	$1.09
Rate for Payer: Priority Health PPO	$1.09

PHA BENZONATATE 100 MG CAPSULE

Facility

$3.80

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505025
Hospital Revenue Code	637
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$3.23
Rate for Payer: Cash Price	$2.47
Rate for Payer: Community Health Alliance Commercial	$3.23
Rate for Payer: Priority Health Commercial	$2.66
Rate for Payer: Priority Health PPO	$2.66

PHA BENZTROPINE MESYLATE 1 MG

Facility

$3.07

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502081
Hospital Revenue Code	637
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$2.61
Rate for Payer: Cash Price	$2.00
Rate for Payer: Community Health Alliance Commercial	$2.61
Rate for Payer: Priority Health Commercial	$2.15
Rate for Payer: Priority Health PPO	$2.15

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges