Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA FUROSEMIDE 20MG/2ML VIAL

Facility

$4.27

Service Code	HCPCS J1938
Hospital Charge Code	2505580
Hospital Revenue Code	636
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$3.63
Rate for Payer: Cash Price	$2.78
Rate for Payer: Community Health Alliance Commercial	$3.63
Rate for Payer: Priority Health Commercial	$2.99
Rate for Payer: Priority Health PPO	$2.99

PHA FUROSEMIDE 20MG TAB

Facility

$0.78

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505570
Hospital Revenue Code	637
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.66
Rate for Payer: Cash Price	$0.51
Rate for Payer: Community Health Alliance Commercial	$0.66
Rate for Payer: Priority Health Commercial	$0.55
Rate for Payer: Priority Health PPO	$0.55

PHA FUROSEMIDE 40MG/4ML VIAL

Facility

$6.93

Service Code	HCPCS J1938
Hospital Charge Code	2505600
Hospital Revenue Code	636
Min. Negotiated Rate	$4.85
Max. Negotiated Rate	$5.89
Rate for Payer: Cash Price	$4.50
Rate for Payer: Community Health Alliance Commercial	$5.89
Rate for Payer: Priority Health Commercial	$4.85
Rate for Payer: Priority Health PPO	$4.85

PHA FUROSEMIDE 40 MG TAB

Facility

$0.89

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505590
Hospital Revenue Code	637
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.76
Rate for Payer: Cash Price	$0.58
Rate for Payer: Community Health Alliance Commercial	$0.76
Rate for Payer: Priority Health Commercial	$0.62
Rate for Payer: Priority Health PPO	$0.62

PHA GABAPENTIN 100 MG CAP

Facility

$2.87

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502082
Hospital Revenue Code	637
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.44
Rate for Payer: Cash Price	$1.87
Rate for Payer: Community Health Alliance Commercial	$2.44
Rate for Payer: Priority Health Commercial	$2.01
Rate for Payer: Priority Health PPO	$2.01

PHA GABAPENTIN 300 MG TAB

Facility

$7.03

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500055
Hospital Revenue Code	637
Min. Negotiated Rate	$4.92
Max. Negotiated Rate	$5.98
Rate for Payer: Cash Price	$4.57
Rate for Payer: Community Health Alliance Commercial	$5.98
Rate for Payer: Priority Health Commercial	$4.92
Rate for Payer: Priority Health PPO	$4.92

PHA GADAVIST 10MM VIAL

Facility

$294.77

Service Code	HCPCS A9585
Hospital Charge Code	2500606
Hospital Revenue Code	636
Min. Negotiated Rate	$206.34
Max. Negotiated Rate	$250.55
Rate for Payer: Cash Price	$191.60
Rate for Payer: Community Health Alliance Commercial	$250.55
Rate for Payer: Priority Health Commercial	$206.34
Rate for Payer: Priority Health PPO	$206.34

PHA GADAVIST 7.5ML VIAL

Facility

$249.50

Service Code	HCPCS A9585
Hospital Charge Code	2500605
Hospital Revenue Code	636
Min. Negotiated Rate	$174.65
Max. Negotiated Rate	$212.07
Rate for Payer: Cash Price	$162.18
Rate for Payer: Community Health Alliance Commercial	$212.07
Rate for Payer: Priority Health Commercial	$174.65
Rate for Payer: Priority Health PPO	$174.65

PHA GADOXETATE DISODIUM 10 ML

Facility

$470.17

Service Code	HCPCS A9581
Hospital Charge Code	2500609
Hospital Revenue Code	636
Min. Negotiated Rate	$329.12
Max. Negotiated Rate	$399.64
Rate for Payer: Cash Price	$305.61
Rate for Payer: Community Health Alliance Commercial	$399.64
Rate for Payer: Priority Health Commercial	$329.12
Rate for Payer: Priority Health PPO	$329.12

PHA GEMCITABINE HYDROCHL 1 GM

Facility

$196.39

Service Code	HCPCS J9201
Hospital Charge Code	2505624
Hospital Revenue Code	636
Min. Negotiated Rate	$137.47
Max. Negotiated Rate	$166.93
Rate for Payer: Cash Price	$127.65
Rate for Payer: Community Health Alliance Commercial	$166.93
Rate for Payer: Priority Health Commercial	$137.47
Rate for Payer: Priority Health PPO	$137.47

PHA GEMFIBROZIL 600 MG TAB

Facility

$12.66

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505630
Hospital Revenue Code	637
Min. Negotiated Rate	$8.86
Max. Negotiated Rate	$10.76
Rate for Payer: Cash Price	$8.23
Rate for Payer: Community Health Alliance Commercial	$10.76
Rate for Payer: Priority Health Commercial	$8.86
Rate for Payer: Priority Health PPO	$8.86

PHA GENTAMICIN SULFATE 10MG/ML

Facility

$43.97

Service Code	NDC 63323017302
Hospital Charge Code	2505660
Hospital Revenue Code	250
Min. Negotiated Rate	$30.78
Max. Negotiated Rate	$37.37
Rate for Payer: Cash Price	$28.58
Rate for Payer: Community Health Alliance Commercial	$37.37
Rate for Payer: Priority Health Commercial	$30.78
Rate for Payer: Priority Health PPO	$30.78

PHA GENTAMICIN SULFATE 15GM TB

Facility

$18.76

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505680
Hospital Revenue Code	637
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

PHA GENTAMICIN SULFATE 3.5GM

Facility

$155.02

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505640
Hospital Revenue Code	637
Min. Negotiated Rate	$108.51
Max. Negotiated Rate	$131.77
Rate for Payer: Cash Price	$100.76
Rate for Payer: Community Health Alliance Commercial	$131.77
Rate for Payer: Priority Health Commercial	$108.51
Rate for Payer: Priority Health PPO	$108.51

PHA GENTAMICIN SULFATE 40MG

Facility

$181.33

Service Code	HCPCS J1580
Hospital Charge Code	2505675
Hospital Revenue Code	250
Min. Negotiated Rate	$126.93
Max. Negotiated Rate	$154.13
Rate for Payer: Cash Price	$117.86
Rate for Payer: Community Health Alliance Commercial	$154.13
Rate for Payer: Priority Health Commercial	$126.93
Rate for Payer: Priority Health PPO	$126.93

PHA GENTAMICIN SULFATE 40MG/ML

Facility

$33.03

Service Code	HCPCS J1580
Hospital Charge Code	2505670
Hospital Revenue Code	636
Min. Negotiated Rate	$23.12
Max. Negotiated Rate	$28.08
Rate for Payer: Cash Price	$21.47
Rate for Payer: Community Health Alliance Commercial	$28.08
Rate for Payer: Priority Health Commercial	$23.12
Rate for Payer: Priority Health PPO	$23.12

PHA GENTAMICIN SULFATE 5ML BTL

Facility

$99.39

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505650
Hospital Revenue Code	637
Min. Negotiated Rate	$69.57
Max. Negotiated Rate	$84.48
Rate for Payer: Cash Price	$64.60
Rate for Payer: Community Health Alliance Commercial	$84.48
Rate for Payer: Priority Health Commercial	$69.57
Rate for Payer: Priority Health PPO	$69.57

PHA GEODON 20MG/ML VIAL

Facility

$188.38

Service Code	NDC 43598084858
Hospital Charge Code	2510956
Hospital Revenue Code	250
Min. Negotiated Rate	$131.87
Max. Negotiated Rate	$160.12
Rate for Payer: Cash Price	$122.45
Rate for Payer: Community Health Alliance Commercial	$160.12
Rate for Payer: Priority Health Commercial	$131.87
Rate for Payer: Priority Health PPO	$131.87

PHA GLIMEPIRIDE 2 MG TAB

Facility

$6.41

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500178
Hospital Revenue Code	637
Min. Negotiated Rate	$4.49
Max. Negotiated Rate	$5.45
Rate for Payer: Cash Price	$4.17
Rate for Payer: Community Health Alliance Commercial	$5.45
Rate for Payer: Priority Health Commercial	$4.49
Rate for Payer: Priority Health PPO	$4.49

PHA GLIPIZIDE 5 MG TAB

Facility

$2.08

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505690
Hospital Revenue Code	637
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$1.77
Rate for Payer: Cash Price	$1.35
Rate for Payer: Community Health Alliance Commercial	$1.77
Rate for Payer: Priority Health Commercial	$1.46
Rate for Payer: Priority Health PPO	$1.46

PHA GLIPIZIDE EXT REL 5 MG TAB

Facility

$3.75

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505695
Hospital Revenue Code	637
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$3.19
Rate for Payer: Cash Price	$2.44
Rate for Payer: Community Health Alliance Commercial	$3.19
Rate for Payer: Priority Health Commercial	$2.62
Rate for Payer: Priority Health PPO	$2.62

PHA GLUCAGON 1 MG INJ

Facility

$568.34

Service Code	HCPCS J1610
Hospital Charge Code	2505700
Hospital Revenue Code	636
Min. Negotiated Rate	$76.17
Max. Negotiated Rate	$483.09
Rate for Payer: BCBS BCN 65	$173.10
Rate for Payer: Blue Care Network Medicare Advantage	$173.10
Rate for Payer: Cash Price	$369.42
Rate for Payer: Cash Price	$369.42
Rate for Payer: Community Health Alliance Commercial	$483.09
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$173.10
Rate for Payer: Meridian Health Plan Medicare	$173.10
Rate for Payer: Priority Health Commercial	$397.84
Rate for Payer: Priority Health Medicaid	$173.10
Rate for Payer: Priority Health Medicare	$173.10
Rate for Payer: Priority Health PPO	$397.84
Rate for Payer: United Health Care Medicaid	$173.10
Rate for Payer: United Health Care Medicare Advantage	$76.17

PHA GLYCERIN 1 EACH

Facility

$1.04

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505706
Hospital Revenue Code	637
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$0.88
Rate for Payer: Cash Price	$0.68
Rate for Payer: Community Health Alliance Commercial	$0.88
Rate for Payer: Priority Health Commercial	$0.73
Rate for Payer: Priority Health PPO	$0.73

PHA GLYCOPYROLATE 0.2 MG/ML VI

Facility

$18.24

Service Code	NDC 781382596
Hospital Charge Code	2500925
Hospital Revenue Code	250
Min. Negotiated Rate	$12.77
Max. Negotiated Rate	$15.50
Rate for Payer: Cash Price	$11.86
Rate for Payer: Community Health Alliance Commercial	$15.50
Rate for Payer: Priority Health Commercial	$12.77
Rate for Payer: Priority Health PPO	$12.77

PHA GOSERELIN ACETATE 10.8 SYR

Facility

$8,790.52

Service Code	HCPCS J9202
Hospital Charge Code	2509913
Hospital Revenue Code	636
Min. Negotiated Rate	$359.20
Max. Negotiated Rate	$7,471.94
Rate for Payer: BCBS BCN 65	$816.38
Rate for Payer: Blue Care Network Medicare Advantage	$816.38
Rate for Payer: Cash Price	$5,713.84
Rate for Payer: Cash Price	$5,713.84
Rate for Payer: Community Health Alliance Commercial	$7,471.94
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$816.38
Rate for Payer: Meridian Health Plan Medicare	$816.38
Rate for Payer: Priority Health Commercial	$6,153.36
Rate for Payer: Priority Health Medicaid	$816.38
Rate for Payer: Priority Health Medicare	$816.38
Rate for Payer: Priority Health PPO	$6,153.36
Rate for Payer: United Health Care Medicaid	$816.38
Rate for Payer: United Health Care Medicare Advantage	$359.20

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges