Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA GOSERELIN ACETATE 3.6 MG

Facility

$3,225.79

Service Code	HCPCS J9202
Hospital Charge Code	2503838
Hospital Revenue Code	636
Min. Negotiated Rate	$359.20
Max. Negotiated Rate	$2,741.92
Rate for Payer: BCBS BCN 65	$816.38
Rate for Payer: Blue Care Network Medicare Advantage	$816.38
Rate for Payer: Cash Price	$2,096.76
Rate for Payer: Cash Price	$2,096.76
Rate for Payer: Community Health Alliance Commercial	$2,741.92
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	$2,258.05
Rate for Payer: Priority Health Medicaid	$816.38
Rate for Payer: Priority Health Medicare	$816.38
Rate for Payer: Priority Health PPO	$2,258.05
Rate for Payer: United Health Care Medicaid	$816.38
Rate for Payer: United Health Care Medicare Advantage	$359.20

PHA GRANIX 300MCG/0.ML SYRINGE

Facility

$827.53

Service Code	HCPCS J1447
Hospital Charge Code	2500128
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$703.40
Rate for Payer: BCBS BCN 65	$0.26
Rate for Payer: Blue Care Network Medicare Advantage	$0.26
Rate for Payer: Cash Price	$537.89
Rate for Payer: Cash Price	$537.89
Rate for Payer: Community Health Alliance Commercial	$703.40
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$0.26
Rate for Payer: Meridian Health Plan Medicare	$0.26
Rate for Payer: Priority Health Commercial	$579.27
Rate for Payer: Priority Health Medicaid	$0.26
Rate for Payer: Priority Health Medicare	$0.26
Rate for Payer: Priority Health PPO	$579.27
Rate for Payer: United Health Care Medicaid	$0.26
Rate for Payer: United Health Care Medicare Advantage	$0.12

PHA GRANIX 480MCG/O.8ML SYRING

Facility

$1,324.44

Service Code	HCPCS J1447
Hospital Charge Code	2500129
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$1,125.77
Rate for Payer: BCBS BCN 65	$0.26
Rate for Payer: Blue Care Network Medicare Advantage	$0.26
Rate for Payer: Cash Price	$860.89
Rate for Payer: Cash Price	$860.89
Rate for Payer: Community Health Alliance Commercial	$1,125.77
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$0.26
Rate for Payer: Meridian Health Plan Medicare	$0.26
Rate for Payer: Priority Health Commercial	$927.11
Rate for Payer: Priority Health Medicaid	$0.26
Rate for Payer: Priority Health Medicare	$0.26
Rate for Payer: Priority Health PPO	$927.11
Rate for Payer: United Health Care Medicaid	$0.26
Rate for Payer: United Health Care Medicare Advantage	$0.12

PHA GUAIFENESIN 100MG/5 ML

Facility

$11.36

Service Code	NDC 121223200
Hospital Charge Code	2509145
Hospital Revenue Code	250
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$9.66
Rate for Payer: Cash Price	$7.38
Rate for Payer: Community Health Alliance Commercial	$9.66
Rate for Payer: Priority Health Commercial	$7.95
Rate for Payer: Priority Health PPO	$7.95

PHA GUAIFENISIN/DEXTROM 120ML

Facility

$14.43

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509130
Hospital Revenue Code	637
Min. Negotiated Rate	$10.10
Max. Negotiated Rate	$12.27
Rate for Payer: Cash Price	$9.38
Rate for Payer: Community Health Alliance Commercial	$12.27
Rate for Payer: Priority Health Commercial	$10.10
Rate for Payer: Priority Health PPO	$10.10

PHA GUAIFENSIN 600 MG TAB

Facility

$2.66

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500005
Hospital Revenue Code	637
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$2.26
Rate for Payer: Cash Price	$1.73
Rate for Payer: Community Health Alliance Commercial	$2.26
Rate for Payer: Priority Health Commercial	$1.86
Rate for Payer: Priority Health PPO	$1.86

PHA HALAVEN 1MG/2ML VIAL

Facility

$3,857.76

Service Code	HCPCS J9179
Hospital Charge Code	2502005
Hospital Revenue Code	636
Min. Negotiated Rate	$33.55
Max. Negotiated Rate	$3,279.10
Rate for Payer: BCBS BCN 65	$76.24
Rate for Payer: Blue Care Network Medicare Advantage	$76.24
Rate for Payer: Cash Price	$2,507.54
Rate for Payer: Cash Price	$2,507.54
Rate for Payer: Community Health Alliance Commercial	$3,279.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$76.24
Rate for Payer: Meridian Health Plan Medicare	$76.24
Rate for Payer: Priority Health Commercial	$2,700.43
Rate for Payer: Priority Health Medicaid	$76.24
Rate for Payer: Priority Health Medicare	$76.24
Rate for Payer: Priority Health PPO	$2,700.43
Rate for Payer: United Health Care Medicaid	$76.24
Rate for Payer: United Health Care Medicare Advantage	$33.55

PHA HALOPERIDOL 0.5 MG TAB

Facility

$1.82

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505760
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 HALOPERIDOL LACTAT 5 MG/ML

Facility

$10.00

Service Code	NDC 143950125
Hospital Charge Code	2505780
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$8.50
Rate for Payer: Cash Price	$6.50
Rate for Payer: Community Health Alliance Commercial	$8.50
Rate for Payer: Priority Health Commercial	$7.00
Rate for Payer: Priority Health PPO	$7.00

PHA HEPARIN SOD 100 UN/5ML SYR

Facility

$19.33

Service Code	HCPCS J1642
Hospital Charge Code	2504334
Hospital Revenue Code	636
Min. Negotiated Rate	$13.53
Max. Negotiated Rate	$16.43
Rate for Payer: Cash Price	$12.56
Rate for Payer: Community Health Alliance Commercial	$16.43
Rate for Payer: Priority Health Commercial	$13.53
Rate for Payer: Priority Health PPO	$13.53

PHA HEPATITIS B IMM GLOB 5 ML

Facility

$2,492.50

Service Code	HCPCS 90371
Hospital Charge Code	2501155
Hospital Revenue Code	636
Min. Negotiated Rate	$63.68
Max. Negotiated Rate	$2,118.62
Rate for Payer: BCBS BCN 65	$144.72
Rate for Payer: Blue Care Network Medicare Advantage	$144.72
Rate for Payer: Cash Price	$1,620.13
Rate for Payer: Cash Price	$1,620.13
Rate for Payer: Community Health Alliance Commercial	$2,118.62
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$144.72
Rate for Payer: Meridian Health Plan Medicare	$144.72
Rate for Payer: Priority Health Commercial	$1,744.75
Rate for Payer: Priority Health Medicaid	$144.72
Rate for Payer: Priority Health Medicare	$144.72
Rate for Payer: Priority Health PPO	$1,744.75
Rate for Payer: United Health Care Medicaid	$144.72
Rate for Payer: United Health Care Medicare Advantage	$63.68

PHA HEPATITIS B IMMUNE GLOBULI

Facility

$301.72

Service Code	NDC 13533063603
Hospital Charge Code	2501156
Hospital Revenue Code	250
Min. Negotiated Rate	$211.20
Max. Negotiated Rate	$256.46
Rate for Payer: Cash Price	$196.12
Rate for Payer: Community Health Alliance Commercial	$256.46
Rate for Payer: Priority Health Commercial	$211.20
Rate for Payer: Priority Health PPO	$211.20

PHA HEPATITIS B VIRUS VACCINE

Facility

$139.18

Service Code	NDC 6498100
Hospital Charge Code	2505658
Hospital Revenue Code	250
Min. Negotiated Rate	$97.43
Max. Negotiated Rate	$118.30
Rate for Payer: Cash Price	$90.47
Rate for Payer: Community Health Alliance Commercial	$118.30
Rate for Payer: Priority Health Commercial	$97.43
Rate for Payer: Priority Health PPO	$97.43

PHA HEP B VAC RCO 10MCG/ML 1ML

Facility

$264.19

Service Code	HCPCS 90746
Hospital Charge Code	2501130
Hospital Revenue Code	636
Min. Negotiated Rate	$184.93
Max. Negotiated Rate	$224.56
Rate for Payer: Cash Price	$171.72
Rate for Payer: Community Health Alliance Commercial	$224.56
Rate for Payer: Priority Health Commercial	$184.93
Rate for Payer: Priority Health PPO	$184.93

PHA HEP SODIUM 25000 U/500 ML

Facility

$90.27

Service Code	HCPCS J1644
Hospital Charge Code	2501115
Hospital Revenue Code	636
Min. Negotiated Rate	$63.19
Max. Negotiated Rate	$76.73
Rate for Payer: Cash Price	$58.68
Rate for Payer: Community Health Alliance Commercial	$76.73
Rate for Payer: Priority Health Commercial	$63.19
Rate for Payer: Priority Health PPO	$63.19

PHA HEP SOD(PORCINE) 1000 U/ML

Facility

$15.68

Service Code	NDC 63739092025
Hospital Charge Code	2501140
Hospital Revenue Code	250
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$13.33
Rate for Payer: Cash Price	$10.19
Rate for Payer: Community Health Alliance Commercial	$13.33
Rate for Payer: Priority Health Commercial	$10.98
Rate for Payer: Priority Health PPO	$10.98

PHA HEP SOD(PORCINE) 5000 U/ML

Facility

$27.09

Service Code	HCPCS J1644
Hospital Charge Code	2501150
Hospital Revenue Code	636
Min. Negotiated Rate	$18.96
Max. Negotiated Rate	$23.03
Rate for Payer: Cash Price	$17.61
Rate for Payer: Community Health Alliance Commercial	$23.03
Rate for Payer: Priority Health Commercial	$18.96
Rate for Payer: Priority Health PPO	$18.96

PHA HYALURONIDASE 150U/ML VIAL

Facility

$118.21

Service Code	HCPCS J3470
Hospital Charge Code	2501220
Hospital Revenue Code	636
Min. Negotiated Rate	$82.75
Max. Negotiated Rate	$100.48
Rate for Payer: Cash Price	$76.84
Rate for Payer: Community Health Alliance Commercial	$100.48
Rate for Payer: Priority Health Commercial	$82.75
Rate for Payer: Priority Health PPO	$82.75

PHA HYALURONIDASE OVINE 240 UN

Facility

$400.17

Service Code	HCPCS J3471
Hospital Charge Code	2500308
Hospital Revenue Code	636
Min. Negotiated Rate	$280.12
Max. Negotiated Rate	$340.14
Rate for Payer: Cash Price	$260.11
Rate for Payer: Community Health Alliance Commercial	$340.14
Rate for Payer: Priority Health Commercial	$280.12
Rate for Payer: Priority Health PPO	$280.12

PHA HYCAMTIN 4MG VIAL

Facility

$3,166.92

Service Code	HCPCS J9351
Hospital Charge Code	2502525
Hospital Revenue Code	636
Min. Negotiated Rate	$2,216.84
Max. Negotiated Rate	$2,691.88
Rate for Payer: Cash Price	$2,058.50
Rate for Payer: Community Health Alliance Commercial	$2,691.88
Rate for Payer: Priority Health Commercial	$2,216.84
Rate for Payer: Priority Health PPO	$2,216.84

PHA HYDRALAZINE HCL 10MG TAB

Facility

$0.63

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501240
Hospital Revenue Code	637
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.41
Rate for Payer: Community Health Alliance Commercial	$0.54
Rate for Payer: Priority Health Commercial	$0.44
Rate for Payer: Priority Health PPO	$0.44

PHA HYDRALAZINE HCL 20MG/ML VL

Facility

$51.53

Service Code	HCPCS J0360
Hospital Charge Code	2504420
Hospital Revenue Code	636
Min. Negotiated Rate	$36.07
Max. Negotiated Rate	$43.80
Rate for Payer: Cash Price	$33.49
Rate for Payer: Community Health Alliance Commercial	$43.80
Rate for Payer: Priority Health Commercial	$36.07
Rate for Payer: Priority Health PPO	$36.07

PHA HYDRALAZINE HCL 25MG TAB

Facility

$0.78

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501260
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 HYDROCHLOROTHIAZIDE 25MG

Facility

$0.68

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501270
Hospital Revenue Code	637
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 HYDROCHLOROTHIAZIDE W/TRIA

Facility

$1.98

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505090
Hospital Revenue Code	637
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$1.68
Rate for Payer: Cash Price	$1.29
Rate for Payer: Community Health Alliance Commercial	$1.68
Rate for Payer: Priority Health Commercial	$1.39
Rate for Payer: Priority Health PPO	$1.39

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges