Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA BUPIVACAINE LIPOSOME 1.3%

Facility

$1,235.78

Service Code	HCPCS C9290
Hospital Charge Code	2501223
Hospital Revenue Code	636
Min. Negotiated Rate	$865.05
Max. Negotiated Rate	$1,050.41
Rate for Payer: Cash Price	$803.26
Rate for Payer: Community Health Alliance Commercial	$1,050.41
Rate for Payer: Priority Health Commercial	$865.05
Rate for Payer: Priority Health PPO	$865.05

PHA BUPIVACAINE W/ EPINEPHRINE

Facility

$75.20

Service Code	HCPCS J3490
Hospital Charge Code	2508844
Hospital Revenue Code	636
Min. Negotiated Rate	$52.64
Max. Negotiated Rate	$63.92
Rate for Payer: Cash Price	$48.88
Rate for Payer: Community Health Alliance Commercial	$63.92
Rate for Payer: Priority Health Commercial	$52.64
Rate for Payer: Priority Health PPO	$52.64

PHA BUPROPION HCL 75MG TAB

Facility

$8.28

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502450
Hospital Revenue Code	637
Min. Negotiated Rate	$5.80
Max. Negotiated Rate	$7.04
Rate for Payer: Cash Price	$5.38
Rate for Payer: Community Health Alliance Commercial	$7.04
Rate for Payer: Priority Health Commercial	$5.80
Rate for Payer: Priority Health PPO	$5.80

PHA BUPROPION SR 150MG TAB

Facility

$3.65

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502456
Hospital Revenue Code	637
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$3.10
Rate for Payer: Cash Price	$2.37
Rate for Payer: Community Health Alliance Commercial	$3.10
Rate for Payer: Priority Health Commercial	$2.56
Rate for Payer: Priority Health PPO	$2.56

PHA BUSPIRONE HCL 5MG TAB

Facility

$4.01

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502460
Hospital Revenue Code	637
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$3.41
Rate for Payer: Cash Price	$2.61
Rate for Payer: Community Health Alliance Commercial	$3.41
Rate for Payer: Priority Health Commercial	$2.81
Rate for Payer: Priority Health PPO	$2.81

PHA BUTAMBEN-TETRA-BENZ 56GM

Facility

$1,750.07

Service Code	NDC 10223020103
Hospital Charge Code	2502470
Hospital Revenue Code	250
Min. Negotiated Rate	$1,225.05
Max. Negotiated Rate	$1,487.56
Rate for Payer: Cash Price	$1,137.55
Rate for Payer: Community Health Alliance Commercial	$1,487.56
Rate for Payer: Priority Health Commercial	$1,225.05
Rate for Payer: Priority Health PPO	$1,225.05

PHA BUTORPHANOL TARTRAT 2MG/ML

Facility

$29.18

Service Code	HCPCS J0595
Hospital Charge Code	2502480
Hospital Revenue Code	636
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$24.80
Rate for Payer: Cash Price	$18.97
Rate for Payer: Community Health Alliance Commercial	$24.80
Rate for Payer: Priority Health Commercial	$20.43
Rate for Payer: Priority Health PPO	$20.43

PHA BUTORPHANOL TARTRATE 1 MG

Facility

$92.88

Service Code	NDC 409162301
Hospital Charge Code	2502485
Hospital Revenue Code	250
Min. Negotiated Rate	$65.02
Max. Negotiated Rate	$78.95
Rate for Payer: Cash Price	$60.37
Rate for Payer: Community Health Alliance Commercial	$78.95
Rate for Payer: Priority Health Commercial	$65.02
Rate for Payer: Priority Health PPO	$65.02

PHA CABERGOLINE 0.5MG TAB NF

Facility

$145.91

Service Code	NDC 93542088
Hospital Charge Code	2510776
Hospital Revenue Code	637
Min. Negotiated Rate	$102.14
Max. Negotiated Rate	$124.02
Rate for Payer: Cash Price	$94.84
Rate for Payer: Community Health Alliance Commercial	$124.02
Rate for Payer: Priority Health Commercial	$102.14
Rate for Payer: Priority Health PPO	$102.14

PHA CAFFEINE/SOD BENZ 250MG/ML

Facility

$186.94

Service Code	HCPCS J0706
Hospital Charge Code	2502500
Hospital Revenue Code	636
Min. Negotiated Rate	$130.86
Max. Negotiated Rate	$158.90
Rate for Payer: Cash Price	$121.51
Rate for Payer: Community Health Alliance Commercial	$158.90
Rate for Payer: Priority Health Commercial	$130.86
Rate for Payer: Priority Health PPO	$130.86

PHA CALCITRIOL 0.25 MCG CAP NF

Facility

$6.67

Service Code	NDC 23155066203
Hospital Charge Code	2510777
Hospital Revenue Code	637
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$5.67
Rate for Payer: Cash Price	$4.34
Rate for Payer: Community Health Alliance Commercial	$5.67
Rate for Payer: Priority Health Commercial	$4.67
Rate for Payer: Priority Health PPO	$4.67

PHA CALCIUM CARBONATE 400MG TB

Facility

$0.52

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502550
Hospital Revenue Code	637
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.34
Rate for Payer: Community Health Alliance Commercial	$0.44
Rate for Payer: Priority Health Commercial	$0.36
Rate for Payer: Priority Health PPO	$0.36

PHA CALCIUM CHLORIDE 10% 10ML

Facility

$93.98

Service Code	NDC 409492834
Hospital Charge Code	2506123
Hospital Revenue Code	250
Min. Negotiated Rate	$65.79
Max. Negotiated Rate	$79.88
Rate for Payer: Cash Price	$61.09
Rate for Payer: Community Health Alliance Commercial	$79.88
Rate for Payer: Priority Health Commercial	$65.79
Rate for Payer: Priority Health PPO	$65.79

PHA CALC POLYCARB(FIBERCON)

Facility

$1.25

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501000
Hospital Revenue Code	637
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.81
Rate for Payer: Community Health Alliance Commercial	$1.06
Rate for Payer: Priority Health Commercial	$0.88
Rate for Payer: Priority Health PPO	$0.88

PHA CAL GLUCO 4.65MEQ/10ML INJ

Facility

$62.75

Service Code	HCPCS J0612
Hospital Charge Code	2502570
Hospital Revenue Code	636
Min. Negotiated Rate	$43.92
Max. Negotiated Rate	$53.34
Rate for Payer: Cash Price	$40.79
Rate for Payer: Community Health Alliance Commercial	$53.34
Rate for Payer: Priority Health Commercial	$43.92
Rate for Payer: Priority Health PPO	$43.92

PHA CARBACHOL 1.5 ML INJ

Facility

$186.24

Service Code	NDC 65002315
Hospital Charge Code	2507112
Hospital Revenue Code	250
Min. Negotiated Rate	$130.37
Max. Negotiated Rate	$158.30
Rate for Payer: Cash Price	$121.06
Rate for Payer: Community Health Alliance Commercial	$158.30
Rate for Payer: Priority Health Commercial	$130.37
Rate for Payer: Priority Health PPO	$130.37

PHA CARBAMAZEPINE 200MG TAB

Facility

$5.84

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502610
Hospital Revenue Code	637
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$4.96
Rate for Payer: Cash Price	$3.80
Rate for Payer: Community Health Alliance Commercial	$4.96
Rate for Payer: Priority Health Commercial	$4.09
Rate for Payer: Priority Health PPO	$4.09

PHA CARBAMIDE PEROXIDE 15ML BT

Facility

$10.32

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503550
Hospital Revenue Code	637
Min. Negotiated Rate	$7.22
Max. Negotiated Rate	$8.77
Rate for Payer: Cash Price	$6.71
Rate for Payer: Community Health Alliance Commercial	$8.77
Rate for Payer: Priority Health Commercial	$7.22
Rate for Payer: Priority Health PPO	$7.22

PHA CARBIDOPA W/LEVODOPA 10MG/

Facility

$5.99

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502600
Hospital Revenue Code	637
Min. Negotiated Rate	$4.19
Max. Negotiated Rate	$5.09
Rate for Payer: Cash Price	$3.89
Rate for Payer: Community Health Alliance Commercial	$5.09
Rate for Payer: Priority Health Commercial	$4.19
Rate for Payer: Priority Health PPO	$4.19

PHA CARBIDOPA W/LEVODOPA 25MG/

Facility

$3.13

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502620
Hospital Revenue Code	637
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$2.66
Rate for Payer: Cash Price	$2.03
Rate for Payer: Community Health Alliance Commercial	$2.66
Rate for Payer: Priority Health Commercial	$2.19
Rate for Payer: Priority Health PPO	$2.19

PHA CARBOPLATIN 150MG VIAL

Facility

$111.00

Service Code	HCPCS J9045
Hospital Charge Code	2502630
Hospital Revenue Code	636
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$94.35
Rate for Payer: Cash Price	$72.15
Rate for Payer: Community Health Alliance Commercial	$94.35
Rate for Payer: Priority Health Commercial	$77.70
Rate for Payer: Priority Health PPO	$77.70

PHA CARBOPLATIN 450MG VIAL

Facility

$260.52

Service Code	HCPCS J9045
Hospital Charge Code	2502640
Hospital Revenue Code	636
Min. Negotiated Rate	$182.36
Max. Negotiated Rate	$221.44
Rate for Payer: Cash Price	$169.34
Rate for Payer: Community Health Alliance Commercial	$221.44
Rate for Payer: Priority Health Commercial	$182.36
Rate for Payer: Priority Health PPO	$182.36

PHA CARBOPLATIN 50MG VIAL

Facility

$51.58

Service Code	HCPCS J9045
Hospital Charge Code	2502650
Hospital Revenue Code	636
Min. Negotiated Rate	$36.11
Max. Negotiated Rate	$43.84
Rate for Payer: Cash Price	$33.53
Rate for Payer: Community Health Alliance Commercial	$43.84
Rate for Payer: Priority Health Commercial	$36.11
Rate for Payer: Priority Health PPO	$36.11

PHA CARBOPLATIN 600 MG/60 ML

Facility

$246.93

Service Code	HCPCS J9045
Hospital Charge Code	2500802
Hospital Revenue Code	636
Min. Negotiated Rate	$172.85
Max. Negotiated Rate	$209.89
Rate for Payer: Cash Price	$160.50
Rate for Payer: Community Health Alliance Commercial	$209.89
Rate for Payer: Priority Health Commercial	$172.85
Rate for Payer: Priority Health PPO	$172.85

PHA CARBOPROST TRO 250 MCG/ML

Facility

$463.68

Service Code	NDC 9085608
Hospital Charge Code	2501100
Hospital Revenue Code	250
Min. Negotiated Rate	$324.58
Max. Negotiated Rate	$394.13
Rate for Payer: Cash Price	$301.39
Rate for Payer: Community Health Alliance Commercial	$394.13
Rate for Payer: Priority Health Commercial	$324.58
Rate for Payer: Priority Health PPO	$324.58

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges