Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA DEXAMETHASONE 1 MG TAB

Facility

$1.93

Service Code	HCPCS J8540
Hospital Charge Code	2503630
Hospital Revenue Code	636
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.64
Rate for Payer: Cash Price	$1.25
Rate for Payer: Community Health Alliance Commercial	$1.64
Rate for Payer: Priority Health Commercial	$1.35
Rate for Payer: Priority Health PPO	$1.35

PHA DEXAMETHASONE 4MG/ML VIAL

Facility

$43.19

Service Code	HCPCS J1100
Hospital Charge Code	2503645
Hospital Revenue Code	250
Min. Negotiated Rate	$30.23
Max. Negotiated Rate	$36.71
Rate for Payer: Cash Price	$28.07
Rate for Payer: Community Health Alliance Commercial	$36.71
Rate for Payer: Priority Health Commercial	$30.23
Rate for Payer: Priority Health PPO	$30.23

PHA DEXAMETHASONE SOD PHOS 4MG

Facility

$18.03

Service Code	HCPCS J1100
Hospital Charge Code	2503640
Hospital Revenue Code	636
Min. Negotiated Rate	$12.62
Max. Negotiated Rate	$15.33
Rate for Payer: Cash Price	$11.72
Rate for Payer: Community Health Alliance Commercial	$15.33
Rate for Payer: Priority Health Commercial	$12.62
Rate for Payer: Priority Health PPO	$12.62

PHA DEXTR 5%/NACL 0.45% 1000ML

Facility

$69.43

Hospital Charge Code	2503710
Hospital Revenue Code	258
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$59.02
Rate for Payer: Cash Price	$45.13
Rate for Payer: Community Health Alliance Commercial	$59.02
Rate for Payer: Priority Health Commercial	$48.60
Rate for Payer: Priority Health PPO	$48.60

PHA DEXTROSE 10% 1000ML BAG

Facility

$70.00

Service Code	NDC 338002304
Hospital Charge Code	2510882
Hospital Revenue Code	250
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$59.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Community Health Alliance Commercial	$59.50
Rate for Payer: Priority Health Commercial	$49.00
Rate for Payer: Priority Health PPO	$49.00

PHA DEXTROSE 10% 250ML BAG

Facility

$70.00

Service Code	NDC 338002302
Hospital Charge Code	2510881
Hospital Revenue Code	250
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$59.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Community Health Alliance Commercial	$59.50
Rate for Payer: Priority Health Commercial	$49.00
Rate for Payer: Priority Health PPO	$49.00

PHA DEXTROSE 20% 500 ML

Facility

$78.00

Hospital Charge Code	2503745
Hospital Revenue Code	258
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$66.30
Rate for Payer: Cash Price	$50.70
Rate for Payer: Community Health Alliance Commercial	$66.30
Rate for Payer: Priority Health Commercial	$54.60
Rate for Payer: Priority Health PPO	$54.60

PHA DEXTROSE 25% 10ML SYR

Facility

$108.14

Service Code	NDC 409177510
Hospital Charge Code	2503760
Hospital Revenue Code	250
Min. Negotiated Rate	$75.70
Max. Negotiated Rate	$91.92
Rate for Payer: Cash Price	$70.29
Rate for Payer: Community Health Alliance Commercial	$91.92
Rate for Payer: Priority Health Commercial	$75.70
Rate for Payer: Priority Health PPO	$75.70

PHA DEXTROSE 5%

Facility

$233.80

Service Code	HCPCS J7042
Hospital Charge Code	2510899
Hospital Revenue Code	636
Min. Negotiated Rate	$163.66
Max. Negotiated Rate	$198.73
Rate for Payer: Cash Price	$151.97
Rate for Payer: Community Health Alliance Commercial	$198.73
Rate for Payer: Priority Health Commercial	$163.66
Rate for Payer: Priority Health PPO	$163.66

PHA DEXTROSE 50% 50 ML SYR

Facility

$45.21

Service Code	NDC 338001704
Hospital Charge Code	2503806
Hospital Revenue Code	250
Min. Negotiated Rate	$31.65
Max. Negotiated Rate	$38.43
Rate for Payer: Cash Price	$29.39
Rate for Payer: Community Health Alliance Commercial	$38.43
Rate for Payer: Priority Health Commercial	$31.65
Rate for Payer: Priority Health PPO	$31.65

PHA DEXTROSE 5% 1000 ML BAG

Facility

$69.43

Hospital Charge Code	2503730
Hospital Revenue Code	258
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$59.02
Rate for Payer: Cash Price	$45.13
Rate for Payer: Community Health Alliance Commercial	$59.02
Rate for Payer: Priority Health Commercial	$48.60
Rate for Payer: Priority Health PPO	$48.60

PHA DEXTROSE 5% 100ML

Facility

$70.00

Service Code	NDC 338055118
Hospital Charge Code	2510886
Hospital Revenue Code	250
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$59.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Community Health Alliance Commercial	$59.50
Rate for Payer: Priority Health Commercial	$49.00
Rate for Payer: Priority Health PPO	$49.00

PHA DEXTROSE 5% 250ML BAG

Facility

$70.00

Service Code	NDC 338001702
Hospital Charge Code	2510887
Hospital Revenue Code	250
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$59.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Community Health Alliance Commercial	$59.50
Rate for Payer: Priority Health Commercial	$49.00
Rate for Payer: Priority Health PPO	$49.00

PHA DEXTROSE 5% -WATER 1000ML

Facility

$70.00

Service Code	HCPCS J7060
Hospital Charge Code	2510902
Hospital Revenue Code	636
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$59.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Community Health Alliance Commercial	$59.50
Rate for Payer: Priority Health Commercial	$49.00
Rate for Payer: Priority Health PPO	$49.00

PHA DEXTROSE N LACTATED RINGRS

Facility

$69.57

Hospital Charge Code	2503820
Hospital Revenue Code	258
Min. Negotiated Rate	$48.70
Max. Negotiated Rate	$59.13
Rate for Payer: Cash Price	$45.22
Rate for Payer: Community Health Alliance Commercial	$59.13
Rate for Payer: Priority Health Commercial	$48.70
Rate for Payer: Priority Health PPO	$48.70

PHA DIATRIZOATE MEGLUMINE 300M

Facility

$0.68

Service Code	NDC 270141030
Hospital Charge Code	2503115
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.44
Rate for Payer: Community Health Alliance Commercial	$0.58
Rate for Payer: Priority Health Commercial	$0.48
Rate for Payer: Priority Health PPO	$0.48

PHA DIAZEPAM 5MG/ML VIAL

Facility

$191.04

Service Code	HCPCS J3360
Hospital Charge Code	2503860
Hospital Revenue Code	636
Min. Negotiated Rate	$133.73
Max. Negotiated Rate	$162.38
Rate for Payer: Cash Price	$124.18
Rate for Payer: Community Health Alliance Commercial	$162.38
Rate for Payer: Priority Health Commercial	$133.73
Rate for Payer: Priority Health PPO	$133.73

PHA DIAZEPAM 5 MG TAB

Facility

$1.67

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503845
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 DICYCLOMINE HCL 10MG CAP

Facility

$3.13

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503900
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 DIGOXIN 0.125 MG TAB

Facility

$8.75

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503930
Hospital Revenue Code	637
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$7.44
Rate for Payer: Cash Price	$5.69
Rate for Payer: Community Health Alliance Commercial	$7.44
Rate for Payer: Priority Health Commercial	$6.12
Rate for Payer: Priority Health PPO	$6.12

PHA DIGOXIN 0.25 MG/ML AMP

Facility

$34.39

Service Code	NDC 641141035
Hospital Charge Code	2503940
Hospital Revenue Code	250
Min. Negotiated Rate	$24.07
Max. Negotiated Rate	$29.23
Rate for Payer: Cash Price	$22.35
Rate for Payer: Community Health Alliance Commercial	$29.23
Rate for Payer: Priority Health Commercial	$24.07
Rate for Payer: Priority Health PPO	$24.07

PHA DIGOXIN IMMUNE FAB 7025

Facility

$13,608.86

Service Code	HCPCS J1162
Hospital Charge Code	2503915
Hospital Revenue Code	636
Min. Negotiated Rate	$2,387.15
Max. Negotiated Rate	$11,567.53
Rate for Payer: BCBS BCN 65	$5,425.34
Rate for Payer: Blue Care Network Medicare Advantage	$5,425.34
Rate for Payer: Cash Price	$8,845.76
Rate for Payer: Cash Price	$8,845.76
Rate for Payer: Community Health Alliance Commercial	$11,567.53
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$5,425.34
Rate for Payer: Meridian Health Plan Medicare	$5,425.34
Rate for Payer: Priority Health Commercial	$9,526.20
Rate for Payer: Priority Health Medicaid	$5,425.34
Rate for Payer: Priority Health Medicare	$5,425.34
Rate for Payer: Priority Health PPO	$9,526.20
Rate for Payer: United Health Care Medicaid	$5,425.34
Rate for Payer: United Health Care Medicare Advantage	$2,387.15

PHA DILTIAZEM HCL 120MG CAP

Facility

$2.03

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502690
Hospital Revenue Code	637
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$1.73
Rate for Payer: Cash Price	$1.32
Rate for Payer: Community Health Alliance Commercial	$1.73
Rate for Payer: Priority Health Commercial	$1.42
Rate for Payer: Priority Health PPO	$1.42

PHA DILTIAZEM HCL 180MG CAP

Facility

$2.19

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502700
Hospital Revenue Code	637
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.42
Rate for Payer: Community Health Alliance Commercial	$1.86
Rate for Payer: Priority Health Commercial	$1.53
Rate for Payer: Priority Health PPO	$1.53

PHA DILTIAZEM HCL 30MG TAB

Facility

$2.34

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503960
Hospital Revenue Code	637
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.99
Rate for Payer: Cash Price	$1.52
Rate for Payer: Community Health Alliance Commercial	$1.99
Rate for Payer: Priority Health Commercial	$1.64
Rate for Payer: Priority Health PPO	$1.64

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges