Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA CLONIDINE HCL 0.3MG PTCH

Facility

$258.38

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510256
Hospital Revenue Code	637
Min. Negotiated Rate	$180.87
Max. Negotiated Rate	$219.62
Rate for Payer: Cash Price	$167.95
Rate for Payer: Community Health Alliance Commercial	$219.62
Rate for Payer: Priority Health Commercial	$180.87
Rate for Payer: Priority Health PPO	$180.87

PHA CLOPIDOGREL BISUL 75MG TAB

Facility

$22.72

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500049
Hospital Revenue Code	637
Min. Negotiated Rate	$15.90
Max. Negotiated Rate	$19.31
Rate for Payer: Cash Price	$14.77
Rate for Payer: Community Health Alliance Commercial	$19.31
Rate for Payer: Priority Health Commercial	$15.90
Rate for Payer: Priority Health PPO	$15.90

PHA CLOTRIMAZOLE 1% 15 GM TUBE

Facility

$29.18

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500108
Hospital Revenue Code	637
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 CLOTRIMAZOLE W/BETA 15GM

Facility

$92.65

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501540
Hospital Revenue Code	637
Min. Negotiated Rate	$64.86
Max. Negotiated Rate	$78.75
Rate for Payer: Cash Price	$60.22
Rate for Payer: Community Health Alliance Commercial	$78.75
Rate for Payer: Priority Health Commercial	$64.86
Rate for Payer: Priority Health PPO	$64.86

PHA COCAINE HCL 4% 4 ML

Facility

$615.81

Service Code	NDC 527172874
Hospital Charge Code	2503365
Hospital Revenue Code	250
Min. Negotiated Rate	$431.07
Max. Negotiated Rate	$523.44
Rate for Payer: Cash Price	$400.28
Rate for Payer: Community Health Alliance Commercial	$523.44
Rate for Payer: Priority Health Commercial	$431.07
Rate for Payer: Priority Health PPO	$431.07

PHA COLCHICINE 0.6 MG TAB

Facility

$51.07

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503390
Hospital Revenue Code	637
Min. Negotiated Rate	$35.75
Max. Negotiated Rate	$43.41
Rate for Payer: Cash Price	$33.20
Rate for Payer: Community Health Alliance Commercial	$43.41
Rate for Payer: Priority Health Commercial	$35.75
Rate for Payer: Priority Health PPO	$35.75

PHA COLLEGENASE 30 GM OINTMENT

Facility

$1,104.03

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501225
Hospital Revenue Code	637
Min. Negotiated Rate	$772.82
Max. Negotiated Rate	$938.43
Rate for Payer: Cash Price	$717.62
Rate for Payer: Community Health Alliance Commercial	$938.43
Rate for Payer: Priority Health Commercial	$772.82
Rate for Payer: Priority Health PPO	$772.82

PHA CONJUGATED ESTROGENS 25MG

Facility

$1,281.94

Service Code	HCPCS J1410
Hospital Charge Code	2508420
Hospital Revenue Code	636
Min. Negotiated Rate	$180.99
Max. Negotiated Rate	$1,089.65
Rate for Payer: BCBS BCN 65	$411.35
Rate for Payer: Blue Care Network Medicare Advantage	$411.35
Rate for Payer: Cash Price	$833.26
Rate for Payer: Cash Price	$833.26
Rate for Payer: Community Health Alliance Commercial	$1,089.65
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$411.35
Rate for Payer: Meridian Health Plan Medicare	$411.35
Rate for Payer: Priority Health Commercial	$897.36
Rate for Payer: Priority Health Medicaid	$411.35
Rate for Payer: Priority Health Medicare	$411.35
Rate for Payer: Priority Health PPO	$897.36
Rate for Payer: United Health Care Medicaid	$411.35
Rate for Payer: United Health Care Medicare Advantage	$180.99

PHA CORDARONE 200 MG TAB

Facility

$3.07

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500495
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

PHA CORICIDIN 4MG/30MG TAB NF

Facility

$1.72

Service Code	NDC 41100081138
Hospital Charge Code	2510778
Hospital Revenue Code	637
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.46
Rate for Payer: Cash Price	$1.12
Rate for Payer: Community Health Alliance Commercial	$1.46
Rate for Payer: Priority Health Commercial	$1.20
Rate for Payer: Priority Health PPO	$1.20

PHA CORTROSYN .25 MG INJ

Facility

$353.00

Service Code	HCPCS J0834
Hospital Charge Code	2507525
Hospital Revenue Code	636
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$300.05
Rate for Payer: Cash Price	$229.45
Rate for Payer: Community Health Alliance Commercial	$300.05
Rate for Payer: Priority Health Commercial	$247.10
Rate for Payer: Priority Health PPO	$247.10

PHA CUBICIN 500 MG/10 ML VIAL

Facility

$108.50

Service Code	HCPCS J0878
Hospital Charge Code	2507272
Hospital Revenue Code	636
Min. Negotiated Rate	$75.95
Max. Negotiated Rate	$92.22
Rate for Payer: Cash Price	$70.53
Rate for Payer: Community Health Alliance Commercial	$92.22
Rate for Payer: Priority Health Commercial	$75.95
Rate for Payer: Priority Health PPO	$75.95

PHA CYANIDE ANTIDOTE KIT 1EACH

Facility

$20.42

Service Code	NDC 60267081200
Hospital Charge Code	2503445
Hospital Revenue Code	250
Min. Negotiated Rate	$14.29
Max. Negotiated Rate	$17.36
Rate for Payer: Cash Price	$13.27
Rate for Payer: Community Health Alliance Commercial	$17.36
Rate for Payer: Priority Health Commercial	$14.29
Rate for Payer: Priority Health PPO	$14.29

PHA CYANOCOBALAMIN 1000MCG/ML

Facility

$45.54

Service Code	NDC 517003125
Hospital Charge Code	2503440
Hospital Revenue Code	250
Min. Negotiated Rate	$31.88
Max. Negotiated Rate	$38.71
Rate for Payer: Cash Price	$29.60
Rate for Payer: Community Health Alliance Commercial	$38.71
Rate for Payer: Priority Health Commercial	$31.88
Rate for Payer: Priority Health PPO	$31.88

PHA CYCLOBANZAPRINE 10MG TAB

Facility

$6.30

Service Code	NDC 904780961
Hospital Charge Code	2503481
Hospital Revenue Code	250
Min. Negotiated Rate	$4.41
Max. Negotiated Rate	$5.36
Rate for Payer: Cash Price	$4.10
Rate for Payer: Community Health Alliance Commercial	$5.36
Rate for Payer: Priority Health Commercial	$4.41
Rate for Payer: Priority Health PPO	$4.41

PHA CYCLOPEMTOLATE 15NL BOTTLE

Facility

$21.10

Service Code	NDC 65039515
Hospital Charge Code	2510912
Hospital Revenue Code	250
Min. Negotiated Rate	$14.77
Max. Negotiated Rate	$17.93
Rate for Payer: Cash Price	$13.72
Rate for Payer: Community Health Alliance Commercial	$17.93
Rate for Payer: Priority Health Commercial	$14.77
Rate for Payer: Priority Health PPO	$14.77

PHA CYCLOPENTOLATE 2% 2ML EYE

Facility

$117.45

Service Code	NDC 17478009702
Hospital Charge Code	2510842
Hospital Revenue Code	637
Min. Negotiated Rate	$82.22
Max. Negotiated Rate	$99.83
Rate for Payer: Cash Price	$76.34
Rate for Payer: Community Health Alliance Commercial	$99.83
Rate for Payer: Priority Health Commercial	$82.22
Rate for Payer: Priority Health PPO	$82.22

PHA CYCLOPENTOLATE HCL 1% 2ML

Facility

$67.65

Service Code	NDC 17478010002
Hospital Charge Code	2503470
Hospital Revenue Code	250
Min. Negotiated Rate	$47.35
Max. Negotiated Rate	$57.50
Rate for Payer: Cash Price	$43.97
Rate for Payer: Community Health Alliance Commercial	$57.50
Rate for Payer: Priority Health Commercial	$47.35
Rate for Payer: Priority Health PPO	$47.35

PHA CYCLOPENTOLATE W/ PHENLYEP

Facility

$176.79

Service Code	NDC 65035902
Hospital Charge Code	2500221
Hospital Revenue Code	250
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$150.27
Rate for Payer: Cash Price	$114.91
Rate for Payer: Community Health Alliance Commercial	$150.27
Rate for Payer: Priority Health Commercial	$123.75
Rate for Payer: Priority Health PPO	$123.75

PHA CYCLOPHOSPHAMIDE 1 MG

Facility

$1,385.91

Service Code	NDC 10019095601
Hospital Charge Code	2503480
Hospital Revenue Code	636
Min. Negotiated Rate	$970.14
Max. Negotiated Rate	$1,178.02
Rate for Payer: Cash Price	$900.84
Rate for Payer: Community Health Alliance Commercial	$1,178.02
Rate for Payer: Priority Health Commercial	$970.14
Rate for Payer: Priority Health PPO	$970.14

PHA CYCLOPHOSPHAMIDE 500 MG

Facility

$1,213.02

Service Code	HCPCS J9070
Hospital Charge Code	2503482
Hospital Revenue Code	636
Min. Negotiated Rate	$849.11
Max. Negotiated Rate	$1,031.07
Rate for Payer: Cash Price	$788.46
Rate for Payer: Community Health Alliance Commercial	$1,031.07
Rate for Payer: Priority Health Commercial	$849.11
Rate for Payer: Priority Health PPO	$849.11

PHA CYTARABINE 1GM VIAL

Facility

$61.26

Service Code	HCPCS J9100
Hospital Charge Code	2501135
Hospital Revenue Code	636
Min. Negotiated Rate	$42.88
Max. Negotiated Rate	$52.07
Rate for Payer: Cash Price	$39.82
Rate for Payer: Community Health Alliance Commercial	$52.07
Rate for Payer: Priority Health Commercial	$42.88
Rate for Payer: Priority Health PPO	$42.88

PHA CYTARBINE 100 MG/5ML VIAL

Facility

$47.35

Service Code	HCPCS J9100
Hospital Charge Code	2501136
Hospital Revenue Code	636
Min. Negotiated Rate	$33.15
Max. Negotiated Rate	$40.25
Rate for Payer: Cash Price	$30.78
Rate for Payer: Community Health Alliance Commercial	$40.25
Rate for Payer: Priority Health Commercial	$33.15
Rate for Payer: Priority Health PPO	$33.15

PHA CYTOTEC 50MCG TABLET

Facility

$5.11

Service Code	NDC 43386016006
Hospital Charge Code	2501112
Hospital Revenue Code	637
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$4.34
Rate for Payer: Cash Price	$3.32
Rate for Payer: Community Health Alliance Commercial	$4.34
Rate for Payer: Priority Health Commercial	$3.58
Rate for Payer: Priority Health PPO	$3.58

PHA DABIGATRAN ETEXILATE

Facility

$20.68

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500427
Hospital Revenue Code	637
Min. Negotiated Rate	$14.48
Max. Negotiated Rate	$17.58
Rate for Payer: Cash Price	$13.44
Rate for Payer: Community Health Alliance Commercial	$17.58
Rate for Payer: Priority Health Commercial	$14.48
Rate for Payer: Priority Health PPO	$14.48

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges