Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA HYDROCODONE ACET 5/325 TAB

Facility

$5.78

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501017
Hospital Revenue Code	637
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$4.91
Rate for Payer: Cash Price	$3.76
Rate for Payer: Community Health Alliance Commercial	$4.91
Rate for Payer: Priority Health Commercial	$4.05
Rate for Payer: Priority Health PPO	$4.05

PHA HYDROCODONE-ACET 7.5/325M

Facility

$3.28

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501059
Hospital Revenue Code	637
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$2.79
Rate for Payer: Cash Price	$2.13
Rate for Payer: Community Health Alliance Commercial	$2.79
Rate for Payer: Priority Health Commercial	$2.30
Rate for Payer: Priority Health PPO	$2.30

PHA HYDROCORT CRM 1% 30GM TB

Facility

$22.30

Service Code	HCPCS A9270 GY
Hospital Charge Code	2504450
Hospital Revenue Code	637
Min. Negotiated Rate	$15.61
Max. Negotiated Rate	$18.95
Rate for Payer: Cash Price	$14.50
Rate for Payer: Community Health Alliance Commercial	$18.95
Rate for Payer: Priority Health Commercial	$15.61
Rate for Payer: Priority Health PPO	$15.61

PHA HYDROCORTISONE 2.5% 30GM

Facility

$50.38

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501250
Hospital Revenue Code	637
Min. Negotiated Rate	$35.27
Max. Negotiated Rate	$42.82
Rate for Payer: Cash Price	$32.75
Rate for Payer: Community Health Alliance Commercial	$42.82
Rate for Payer: Priority Health Commercial	$35.27
Rate for Payer: Priority Health PPO	$35.27

PHA HYDROCORTISONE ACETAT 25MG

Facility

$75.18

Service Code	HCPCS J1700
Hospital Charge Code	2500680
Hospital Revenue Code	636
Min. Negotiated Rate	$52.63
Max. Negotiated Rate	$63.90
Rate for Payer: Cash Price	$48.87
Rate for Payer: Community Health Alliance Commercial	$63.90
Rate for Payer: Priority Health Commercial	$52.63
Rate for Payer: Priority Health PPO	$52.63

PHA HYDROCORT SOD SUCC 100MG

Facility

$118.48

Service Code	HCPCS J1720
Hospital Charge Code	2504430
Hospital Revenue Code	636
Min. Negotiated Rate	$82.94
Max. Negotiated Rate	$100.71
Rate for Payer: Cash Price	$77.01
Rate for Payer: Community Health Alliance Commercial	$100.71
Rate for Payer: Priority Health Commercial	$82.94
Rate for Payer: Priority Health PPO	$82.94

PHA HYDROCORT SOD SUCC 500MG

Facility

$333.05

Service Code	HCPCS J1720
Hospital Charge Code	2501295
Hospital Revenue Code	636
Min. Negotiated Rate	$233.13
Max. Negotiated Rate	$283.09
Rate for Payer: Cash Price	$216.48
Rate for Payer: Community Health Alliance Commercial	$283.09
Rate for Payer: Priority Health Commercial	$233.13
Rate for Payer: Priority Health PPO	$233.13

PHA HYDROMORPHONE 2MG/ML

Facility

$9.01

Service Code	HCPCS J1171
Hospital Charge Code	2501285
Hospital Revenue Code	636
Min. Negotiated Rate	$6.31
Max. Negotiated Rate	$7.66
Rate for Payer: Cash Price	$5.86
Rate for Payer: Community Health Alliance Commercial	$7.66
Rate for Payer: Priority Health Commercial	$6.31
Rate for Payer: Priority Health PPO	$6.31

PHA HYDROMORPHONE HCL 2MG TAB

Facility

$1.04

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501290
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 HYDROMORPHONE HCL IMG

Facility

$60.46

Service Code	HCPCS J1171
Hospital Charge Code	2501281
Hospital Revenue Code	636
Min. Negotiated Rate	$42.32
Max. Negotiated Rate	$51.39
Rate for Payer: Cash Price	$39.30
Rate for Payer: Community Health Alliance Commercial	$51.39
Rate for Payer: Priority Health Commercial	$42.32
Rate for Payer: Priority Health PPO	$42.32

PHA HYDROXYLCHLOROQUINE 200 MG

Facility

$21.31

Service Code	NDC 57664076188
Hospital Charge Code	2510867
Hospital Revenue Code	637
Min. Negotiated Rate	$14.92
Max. Negotiated Rate	$18.11
Rate for Payer: Cash Price	$13.85
Rate for Payer: Community Health Alliance Commercial	$18.11
Rate for Payer: Priority Health Commercial	$14.92
Rate for Payer: Priority Health PPO	$14.92

PHA HYDROXYPROGESTERONE CAPRO

Facility

$2,370.46

Service Code	HCPCS J1726
Hospital Charge Code	2501202
Hospital Revenue Code	636
Min. Negotiated Rate	$1,659.32
Max. Negotiated Rate	$2,014.89
Rate for Payer: Cash Price	$1,540.80
Rate for Payer: Community Health Alliance Commercial	$2,014.89
Rate for Payer: Priority Health Commercial	$1,659.32
Rate for Payer: Priority Health PPO	$1,659.32

PHA HYDROXYPROPYL METHYLCELLUL

Facility

$132.25

Service Code	NDC 59390018213
Hospital Charge Code	2507796
Hospital Revenue Code	250
Min. Negotiated Rate	$92.58
Max. Negotiated Rate	$112.41
Rate for Payer: Cash Price	$85.96
Rate for Payer: Community Health Alliance Commercial	$112.41
Rate for Payer: Priority Health Commercial	$92.58
Rate for Payer: Priority Health PPO	$92.58

PHA HYDROXYZINE HCL 10MG/5ML

Facility

$14.48

Service Code	HCPCS A9270 GY
Hospital Charge Code	2506600
Hospital Revenue Code	637
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$12.31
Rate for Payer: Cash Price	$9.41
Rate for Payer: Community Health Alliance Commercial	$12.31
Rate for Payer: Priority Health Commercial	$10.14
Rate for Payer: Priority Health PPO	$10.14

PHA HYDROXYZINE HCL 10MG TAB

Facility

$1.46

Service Code	HCPCS A9270 GY
Hospital Charge Code	2504480
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.24
Rate for Payer: Cash Price	$0.95
Rate for Payer: Community Health Alliance Commercial	$1.24
Rate for Payer: Priority Health Commercial	$1.02
Rate for Payer: Priority Health PPO	$1.02

PHA HYDROXYZINE HCL 50MG/ML

Facility

$160.99

Service Code	HCPCS J3410
Hospital Charge Code	2504400
Hospital Revenue Code	636
Min. Negotiated Rate	$112.69
Max. Negotiated Rate	$136.84
Rate for Payer: Cash Price	$104.64
Rate for Payer: Community Health Alliance Commercial	$136.84
Rate for Payer: Priority Health Commercial	$112.69
Rate for Payer: Priority Health PPO	$112.69

PHA HYDROXYZINE PAMOATE 25MG

Facility

$1.56

Service Code	HCPCS Q0177
Hospital Charge Code	2504490
Hospital Revenue Code	636
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.33
Rate for Payer: Cash Price	$1.01
Rate for Payer: Community Health Alliance Commercial	$1.33
Rate for Payer: Priority Health Commercial	$1.09
Rate for Payer: Priority Health PPO	$1.09

PHA HYOSCYAMINE SL 0.125MG TAB

Facility

$4.43

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500004
Hospital Revenue Code	637
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$3.77
Rate for Payer: Cash Price	$2.88
Rate for Payer: Community Health Alliance Commercial	$3.77
Rate for Payer: Priority Health Commercial	$3.10
Rate for Payer: Priority Health PPO	$3.10

PHA HYOSCYAMINE SULFATE 0.125

Facility

$158.36

Service Code	NDC 39328004715
Hospital Charge Code	2507806
Hospital Revenue Code	250
Min. Negotiated Rate	$110.85
Max. Negotiated Rate	$134.61
Rate for Payer: Cash Price	$102.93
Rate for Payer: Community Health Alliance Commercial	$134.61
Rate for Payer: Priority Health Commercial	$110.85
Rate for Payer: Priority Health PPO	$110.85

PHA IBUPROFEN 100 MG/5 ML BTL

Facility

$5.84

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500155
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 IBUPROFEN 400 MG TAB

Facility

$1.15

Service Code	HCPCS A9270 GY
Hospital Charge Code	2506620
Hospital Revenue Code	637
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.75
Rate for Payer: Community Health Alliance Commercial	$0.98
Rate for Payer: Priority Health Commercial	$0.81
Rate for Payer: Priority Health PPO	$0.81

PHA IBUPROFEN 600 MG TAB

Facility

$1.56

Service Code	HCPCS A9270 GY
Hospital Charge Code	2506630
Hospital Revenue Code	637
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.33
Rate for Payer: Cash Price	$1.01
Rate for Payer: Community Health Alliance Commercial	$1.33
Rate for Payer: Priority Health Commercial	$1.09
Rate for Payer: Priority Health PPO	$1.09

PHA IBUPROFEN 800MG TAB

Facility

$0.63

Service Code	HCPCS A9270 GY
Hospital Charge Code	2506640
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 IBUTILIDE FUMARATE .01 MG

Facility

$1,652.63

Service Code	HCPCS J1742
Hospital Charge Code	2506655
Hospital Revenue Code	636
Min. Negotiated Rate	$91.71
Max. Negotiated Rate	$1,404.74
Rate for Payer: BCBS BCN 65	$208.44
Rate for Payer: Blue Care Network Medicare Advantage	$208.44
Rate for Payer: Cash Price	$1,074.21
Rate for Payer: Cash Price	$1,074.21
Rate for Payer: Community Health Alliance Commercial	$1,404.74
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$208.44
Rate for Payer: Meridian Health Plan Medicare	$208.44
Rate for Payer: Priority Health Commercial	$1,156.84
Rate for Payer: Priority Health Medicaid	$208.44
Rate for Payer: Priority Health Medicare	$208.44
Rate for Payer: Priority Health PPO	$1,156.84
Rate for Payer: United Health Care Medicaid	$208.44
Rate for Payer: United Health Care Medicare Advantage	$91.71

PHA IMMUNE GLOBULIN 10GM

Facility

$4,777.33

Service Code	HCPCS J1569
Hospital Charge Code	2505610
Hospital Revenue Code	636
Min. Negotiated Rate	$21.85
Max. Negotiated Rate	$4,060.73
Rate for Payer: BCBS BCN 65	$49.65
Rate for Payer: Blue Care Network Medicare Advantage	$49.65
Rate for Payer: Cash Price	$3,105.26
Rate for Payer: Cash Price	$3,105.26
Rate for Payer: Community Health Alliance Commercial	$4,060.73
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$49.65
Rate for Payer: Meridian Health Plan Medicare	$49.65
Rate for Payer: Priority Health Commercial	$3,344.13
Rate for Payer: Priority Health Medicaid	$49.65
Rate for Payer: Priority Health Medicare	$49.65
Rate for Payer: Priority Health PPO	$3,344.13
Rate for Payer: United Health Care Medicaid	$49.65
Rate for Payer: United Health Care Medicare Advantage	$21.85

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges