Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA BETAMETH ACETAT&SOD 6MG/ML

Facility

$60.50

Service Code	HCPCS J0702
Hospital Charge Code	2502210
Hospital Revenue Code	636
Min. Negotiated Rate	$42.35
Max. Negotiated Rate	$51.42
Rate for Payer: Cash Price	$39.33
Rate for Payer: Community Health Alliance Commercial	$51.42
Rate for Payer: Priority Health Commercial	$42.35
Rate for Payer: Priority Health PPO	$42.35

PHA BISACODYL 10MG SUP

Facility

$1.82

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502290
Hospital Revenue Code	637
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$1.55
Rate for Payer: Cash Price	$1.18
Rate for Payer: Community Health Alliance Commercial	$1.55
Rate for Payer: Priority Health Commercial	$1.27
Rate for Payer: Priority Health PPO	$1.27

PHA BISACODYL 5MG TAB

Facility

$0.36

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502280
Hospital Revenue Code	637
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.31
Rate for Payer: Cash Price	$0.23
Rate for Payer: Community Health Alliance Commercial	$0.31
Rate for Payer: Priority Health Commercial	$0.25
Rate for Payer: Priority Health PPO	$0.25

PHA BLEOMYCIN 30 UNITS/20ML

Facility

$316.36

Service Code	HCPCS J9040
Hospital Charge Code	2503374
Hospital Revenue Code	636
Min. Negotiated Rate	$221.45
Max. Negotiated Rate	$268.91
Rate for Payer: Cash Price	$205.63
Rate for Payer: Community Health Alliance Commercial	$268.91
Rate for Payer: Priority Health Commercial	$221.45
Rate for Payer: Priority Health PPO	$221.45

PHA BLEOMYCIN SULFATE 15 U INJ

Facility

$202.24

Service Code	HCPCS J9040
Hospital Charge Code	2502300
Hospital Revenue Code	636
Min. Negotiated Rate	$141.57
Max. Negotiated Rate	$171.90
Rate for Payer: Cash Price	$131.46
Rate for Payer: Community Health Alliance Commercial	$171.90
Rate for Payer: Priority Health Commercial	$141.57
Rate for Payer: Priority Health PPO	$141.57

PHA BONIVA 3MG/3ML SYRINGE

Facility

$1,556.88

Service Code	HCPCS J1740
Hospital Charge Code	2506611
Hospital Revenue Code	636
Min. Negotiated Rate	$1,089.82
Max. Negotiated Rate	$1,323.35
Rate for Payer: Cash Price	$1,011.97
Rate for Payer: Community Health Alliance Commercial	$1,323.35
Rate for Payer: Priority Health Commercial	$1,089.82
Rate for Payer: Priority Health PPO	$1,089.82

PHA BORTEZOMIB 3.5MG VIAL

Facility

$4,385.81

Service Code	HCPCS J9041
Hospital Charge Code	2506789
Hospital Revenue Code	636
Min. Negotiated Rate	$3,070.07
Max. Negotiated Rate	$3,727.94
Rate for Payer: Cash Price	$2,850.78
Rate for Payer: Community Health Alliance Commercial	$3,727.94
Rate for Payer: Priority Health Commercial	$3,070.07
Rate for Payer: Priority Health PPO	$3,070.07

PHA BOT TOXIN TYPE A APC 0902

Facility

$1,921.75

Service Code	HCPCS J0585
Hospital Charge Code	2502305
Hospital Revenue Code	636
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$1,633.49
Rate for Payer: BCBS BCN 65	$6.84
Rate for Payer: Blue Care Network Medicare Advantage	$6.84
Rate for Payer: Cash Price	$1,249.14
Rate for Payer: Cash Price	$1,249.14
Rate for Payer: Community Health Alliance Commercial	$1,633.49
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$6.84
Rate for Payer: Meridian Health Plan Medicare	$6.84
Rate for Payer: Priority Health Commercial	$1,345.22
Rate for Payer: Priority Health Medicaid	$6.84
Rate for Payer: Priority Health Medicare	$6.84
Rate for Payer: Priority Health PPO	$1,345.22
Rate for Payer: United Health Care Medicaid	$6.84
Rate for Payer: United Health Care Medicare Advantage	$3.01

PHA BREVIBLOC 2,500.000MCG/250

Facility

$1,241.17

Service Code	NDC 67457065725
Hospital Charge Code	2510935
Hospital Revenue Code	250
Min. Negotiated Rate	$868.82
Max. Negotiated Rate	$1,054.99
Rate for Payer: Cash Price	$806.76
Rate for Payer: Community Health Alliance Commercial	$1,054.99
Rate for Payer: Priority Health Commercial	$868.82
Rate for Payer: Priority Health PPO	$868.82

PHA BRIMONIDINE TARTRATE 100GT

Facility

$529.04

Service Code	NDC 61314014405
Hospital Charge Code	2506788
Hospital Revenue Code	250
Min. Negotiated Rate	$370.33
Max. Negotiated Rate	$449.68
Rate for Payer: Cash Price	$343.88
Rate for Payer: Community Health Alliance Commercial	$449.68
Rate for Payer: Priority Health Commercial	$370.33
Rate for Payer: Priority Health PPO	$370.33

PHA BRINTELLIX 5MG TAB NF

Facility

$58.26

Service Code	NDC 64764072030
Hospital Charge Code	2510823
Hospital Revenue Code	637
Min. Negotiated Rate	$40.78
Max. Negotiated Rate	$49.52
Rate for Payer: Cash Price	$37.87
Rate for Payer: Community Health Alliance Commercial	$49.52
Rate for Payer: Priority Health Commercial	$40.78
Rate for Payer: Priority Health PPO	$40.78

PHA BUDESONIDE 10 ML

Facility

$49.03

Service Code	NDC 93681555
Hospital Charge Code	2506001
Hospital Revenue Code	250
Min. Negotiated Rate	$34.32
Max. Negotiated Rate	$41.68
Rate for Payer: Cash Price	$31.87
Rate for Payer: Community Health Alliance Commercial	$41.68
Rate for Payer: Priority Health Commercial	$34.32
Rate for Payer: Priority Health PPO	$34.32

PHA BUDESONIDE 3MG CAPSULE NF

Facility

$86.33

Service Code	NDC 49884050101
Hospital Charge Code	2510773
Hospital Revenue Code	637
Min. Negotiated Rate	$60.43
Max. Negotiated Rate	$73.38
Rate for Payer: Cash Price	$56.11
Rate for Payer: Community Health Alliance Commercial	$73.38
Rate for Payer: Priority Health Commercial	$60.43
Rate for Payer: Priority Health PPO	$60.43

PHA BUDESONIDE RESPULES .25INH

Facility

$50.75

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500245
Hospital Revenue Code	637
Min. Negotiated Rate	$35.52
Max. Negotiated Rate	$43.14
Rate for Payer: Cash Price	$32.99
Rate for Payer: Community Health Alliance Commercial	$43.14
Rate for Payer: Priority Health Commercial	$35.52
Rate for Payer: Priority Health PPO	$35.52

PHA BUMETANIDE 0.25MG/ML VIAL

Facility

$18.86

Service Code	NDC 641600810
Hospital Charge Code	2502380
Hospital Revenue Code	250
Min. Negotiated Rate	$13.20
Max. Negotiated Rate	$16.03
Rate for Payer: Cash Price	$12.26
Rate for Payer: Community Health Alliance Commercial	$16.03
Rate for Payer: Priority Health Commercial	$13.20
Rate for Payer: Priority Health PPO	$13.20

PHA BUMETANIDE 1MG TAB

Facility

$7.82

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502370
Hospital Revenue Code	637
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$6.65
Rate for Payer: Cash Price	$5.08
Rate for Payer: Community Health Alliance Commercial	$6.65
Rate for Payer: Priority Health Commercial	$5.47
Rate for Payer: Priority Health PPO	$5.47

PHA BUPIVACAINE 0.25% 50 ML IN

Facility

$57.71

Service Code	NDC 409175250
Hospital Charge Code	2502405
Hospital Revenue Code	250
Min. Negotiated Rate	$40.40
Max. Negotiated Rate	$49.05
Rate for Payer: Cash Price	$37.51
Rate for Payer: Community Health Alliance Commercial	$49.05
Rate for Payer: Priority Health Commercial	$40.40
Rate for Payer: Priority Health PPO	$40.40

PHA BUPIVACAINE 0.5% 30 ML

Facility

$18.44

Service Code	NDC 55150017030
Hospital Charge Code	2502421
Hospital Revenue Code	250
Min. Negotiated Rate	$12.91
Max. Negotiated Rate	$15.67
Rate for Payer: Cash Price	$11.99
Rate for Payer: Community Health Alliance Commercial	$15.67
Rate for Payer: Priority Health Commercial	$12.91
Rate for Payer: Priority Health PPO	$12.91

PHA BUPIVACAINE 0.75% 2 ML INJ

Facility

$30.63

Service Code	NDC 36000009210
Hospital Charge Code	2502441
Hospital Revenue Code	250
Min. Negotiated Rate	$21.44
Max. Negotiated Rate	$26.04
Rate for Payer: Cash Price	$19.91
Rate for Payer: Community Health Alliance Commercial	$26.04
Rate for Payer: Priority Health Commercial	$21.44
Rate for Payer: Priority Health PPO	$21.44

PHA BUPIVACAINE 0.75% 30 ML VI

Facility

$30.06

Service Code	HCPCS S0020
Hospital Charge Code	2503209
Hospital Revenue Code	250
Min. Negotiated Rate	$21.04
Max. Negotiated Rate	$25.55
Rate for Payer: Cash Price	$19.54
Rate for Payer: Community Health Alliance Commercial	$25.55
Rate for Payer: Priority Health Commercial	$21.04
Rate for Payer: Priority Health PPO	$21.04

PHA BUPIVACAINE .25% 30ML VIAL

Facility

$16.67

Service Code	NDC 55150016830
Hospital Charge Code	2502410
Hospital Revenue Code	250
Min. Negotiated Rate	$11.67
Max. Negotiated Rate	$14.17
Rate for Payer: Cash Price	$10.84
Rate for Payer: Community Health Alliance Commercial	$14.17
Rate for Payer: Priority Health Commercial	$11.67
Rate for Payer: Priority Health PPO	$11.67

PHA BUPIVACAINE .25% 50ML VIAL

Facility

$25.74

Service Code	NDC 55150024950
Hospital Charge Code	2502400
Hospital Revenue Code	250
Min. Negotiated Rate	$18.02
Max. Negotiated Rate	$21.88
Rate for Payer: Cash Price	$16.73
Rate for Payer: Community Health Alliance Commercial	$21.88
Rate for Payer: Priority Health Commercial	$18.02
Rate for Payer: Priority Health PPO	$18.02

PHA BUPIVACAINE/DEXTROSE

Facility

$28.34

Service Code	HCPCS J3490
Hospital Charge Code	2503212
Hospital Revenue Code	636
Min. Negotiated Rate	$19.84
Max. Negotiated Rate	$24.09
Rate for Payer: Cash Price	$18.42
Rate for Payer: Community Health Alliance Commercial	$24.09
Rate for Payer: Priority Health Commercial	$19.84
Rate for Payer: Priority Health PPO	$19.84

PHA BUPIVACAINE HCL 0.25%

Facility

$14.80

Service Code	NDC 409115901
Hospital Charge Code	2502415
Hospital Revenue Code	250
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$12.58
Rate for Payer: Cash Price	$9.62
Rate for Payer: Community Health Alliance Commercial	$12.58
Rate for Payer: Priority Health Commercial	$10.36
Rate for Payer: Priority Health PPO	$10.36

PHA BUPIVACAINE HCL .5% 10ML V

Facility

$18.76

Service Code	NDC 55150016910
Hospital Charge Code	2502813
Hospital Revenue Code	250
Min. Negotiated Rate	$13.13
Max. Negotiated Rate	$15.95
Rate for Payer: Cash Price	$12.19
Rate for Payer: Community Health Alliance Commercial	$15.95
Rate for Payer: Priority Health Commercial	$13.13
Rate for Payer: Priority Health PPO	$13.13

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges