Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA IMMUNE GLOBULIN 10 GRAM

Facility

$5,406.88

Service Code	HCPCS J1459
Hospital Charge Code	2509914
Hospital Revenue Code	636
Min. Negotiated Rate	$23.23
Max. Negotiated Rate	$4,595.85
Rate for Payer: BCBS BCN 65	$52.79
Rate for Payer: Blue Care Network Medicare Advantage	$52.79
Rate for Payer: Cash Price	$3,514.47
Rate for Payer: Cash Price	$3,514.47
Rate for Payer: Community Health Alliance Commercial	$4,595.85
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$52.79
Rate for Payer: Meridian Health Plan Medicare	$52.79
Rate for Payer: Priority Health Commercial	$3,784.82
Rate for Payer: Priority Health Medicaid	$52.79
Rate for Payer: Priority Health Medicare	$52.79
Rate for Payer: Priority Health PPO	$3,784.82
Rate for Payer: United Health Care Medicaid	$52.79
Rate for Payer: United Health Care Medicare Advantage	$23.23

PHA IMMUNE GLOBULIN 20 GM

Facility

$9,554.66

Service Code	HCPCS J1569
Hospital Charge Code	2505611
Hospital Revenue Code	636
Min. Negotiated Rate	$21.85
Max. Negotiated Rate	$8,121.46
Rate for Payer: BCBS BCN 65	$49.65
Rate for Payer: Blue Care Network Medicare Advantage	$49.65
Rate for Payer: Cash Price	$6,210.53
Rate for Payer: Cash Price	$6,210.53
Rate for Payer: Community Health Alliance Commercial	$8,121.46
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	$6,688.26
Rate for Payer: Priority Health Medicaid	$49.65
Rate for Payer: Priority Health Medicare	$49.65
Rate for Payer: Priority Health PPO	$6,688.26
Rate for Payer: United Health Care Medicaid	$49.65
Rate for Payer: United Health Care Medicare Advantage	$21.85

PHA IMMUNE GLOBULIN 20 GRAM

Facility

$10,813.77

Service Code	HCPCS J1459
Hospital Charge Code	2509915
Hospital Revenue Code	636
Min. Negotiated Rate	$23.23
Max. Negotiated Rate	$9,191.70
Rate for Payer: BCBS BCN 65	$52.79
Rate for Payer: Blue Care Network Medicare Advantage	$52.79
Rate for Payer: Cash Price	$7,028.95
Rate for Payer: Cash Price	$7,028.95
Rate for Payer: Community Health Alliance Commercial	$9,191.70
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$52.79
Rate for Payer: Meridian Health Plan Medicare	$52.79
Rate for Payer: Priority Health Commercial	$7,569.64
Rate for Payer: Priority Health Medicaid	$52.79
Rate for Payer: Priority Health Medicare	$52.79
Rate for Payer: Priority Health PPO	$7,569.64
Rate for Payer: United Health Care Medicaid	$52.79
Rate for Payer: United Health Care Medicare Advantage	$23.23

PHA IMMUNE GLOBULIN 30GM/300ML

Facility

$14,331.99

Service Code	HCPCS J1569
Hospital Charge Code	2500816
Hospital Revenue Code	636
Min. Negotiated Rate	$21.85
Max. Negotiated Rate	$12,182.19
Rate for Payer: BCBS BCN 65	$49.65
Rate for Payer: Blue Care Network Medicare Advantage	$49.65
Rate for Payer: Cash Price	$9,315.79
Rate for Payer: Cash Price	$9,315.79
Rate for Payer: Community Health Alliance Commercial	$12,182.19
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	$10,032.39
Rate for Payer: Priority Health Medicaid	$49.65
Rate for Payer: Priority Health Medicare	$49.65
Rate for Payer: Priority Health PPO	$10,032.39
Rate for Payer: United Health Care Medicaid	$49.65
Rate for Payer: United Health Care Medicare Advantage	$21.85

PHA IMMUNE GLOBULIN 5GM 0905

Facility

$2,388.66

Service Code	HCPCS J1569
Hospital Charge Code	2505620
Hospital Revenue Code	636
Min. Negotiated Rate	$21.85
Max. Negotiated Rate	$2,030.36
Rate for Payer: BCBS BCN 65	$49.65
Rate for Payer: Blue Care Network Medicare Advantage	$49.65
Rate for Payer: Cash Price	$1,552.63
Rate for Payer: Cash Price	$1,552.63
Rate for Payer: Community Health Alliance Commercial	$2,030.36
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	$1,672.06
Rate for Payer: Priority Health Medicaid	$49.65
Rate for Payer: Priority Health Medicare	$49.65
Rate for Payer: Priority Health PPO	$1,672.06
Rate for Payer: United Health Care Medicaid	$49.65
Rate for Payer: United Health Care Medicare Advantage	$21.85

PHA IMMUNE GLOBULIN 5 GRAM

Facility

$2,703.44

Service Code	HCPCS J1459
Hospital Charge Code	2509916
Hospital Revenue Code	636
Min. Negotiated Rate	$23.23
Max. Negotiated Rate	$2,297.92
Rate for Payer: BCBS BCN 65	$52.79
Rate for Payer: Blue Care Network Medicare Advantage	$52.79
Rate for Payer: Cash Price	$1,757.24
Rate for Payer: Cash Price	$1,757.24
Rate for Payer: Community Health Alliance Commercial	$2,297.92
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$52.79
Rate for Payer: Meridian Health Plan Medicare	$52.79
Rate for Payer: Priority Health Commercial	$1,892.41
Rate for Payer: Priority Health Medicaid	$52.79
Rate for Payer: Priority Health Medicare	$52.79
Rate for Payer: Priority Health PPO	$1,892.41
Rate for Payer: United Health Care Medicaid	$52.79
Rate for Payer: United Health Care Medicare Advantage	$23.23

PHA INDIGO CARMINE 5ML AMP

Facility

$45.01

Service Code	NDC 517037510
Hospital Charge Code	2506685
Hospital Revenue Code	250
Min. Negotiated Rate	$31.51
Max. Negotiated Rate	$38.26
Rate for Payer: Cash Price	$29.26
Rate for Payer: Community Health Alliance Commercial	$38.26
Rate for Payer: Priority Health Commercial	$31.51
Rate for Payer: Priority Health PPO	$31.51

PHA INDOMETHACIN 25MG CAP

Facility

$2.24

Service Code	HCPCS A9270 GY
Hospital Charge Code	2506690
Hospital Revenue Code	637
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$1.90
Rate for Payer: Cash Price	$1.46
Rate for Payer: Community Health Alliance Commercial	$1.90
Rate for Payer: Priority Health Commercial	$1.57
Rate for Payer: Priority Health PPO	$1.57

PHA INFLECTRA 100 MG VIAL

Facility

$2,589.03

Service Code	HCPCS Q5103
Hospital Charge Code	2510857
Hospital Revenue Code	636
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$2,200.68
Rate for Payer: BCBS BCN 65	$25.43
Rate for Payer: Blue Care Network Medicare Advantage	$25.43
Rate for Payer: Cash Price	$1,682.87
Rate for Payer: Cash Price	$1,682.87
Rate for Payer: Community Health Alliance Commercial	$2,200.68
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$25.43
Rate for Payer: Meridian Health Plan Medicare	$25.43
Rate for Payer: Priority Health Commercial	$1,812.32
Rate for Payer: Priority Health Medicaid	$25.43
Rate for Payer: Priority Health Medicare	$25.43
Rate for Payer: Priority Health PPO	$1,812.32
Rate for Payer: United Health Care Medicaid	$25.43
Rate for Payer: United Health Care Medicare Advantage	$11.19

PHA INFLU VIRUS VACC SPLIT 5ML

Facility

$143.16

Service Code	NDC 70461032303
Hospital Charge Code	2507700
Hospital Revenue Code	636
Min. Negotiated Rate	$100.21
Max. Negotiated Rate	$121.69
Rate for Payer: Cash Price	$93.05
Rate for Payer: Community Health Alliance Commercial	$121.69
Rate for Payer: Priority Health Commercial	$100.21
Rate for Payer: Priority Health PPO	$100.21

PHA INJECTAFER 50MG/ML 750 MG

Facility

$4,406.72

Service Code	HCPCS J1439
Hospital Charge Code	2501212
Hospital Revenue Code	636
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$3,745.71
Rate for Payer: BCBS BCN 65	$1.18
Rate for Payer: Blue Care Network Medicare Advantage	$1.18
Rate for Payer: Cash Price	$2,864.37
Rate for Payer: Cash Price	$2,864.37
Rate for Payer: Community Health Alliance Commercial	$3,745.71
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$1.18
Rate for Payer: Meridian Health Plan Medicare	$1.18
Rate for Payer: Priority Health Commercial	$3,084.70
Rate for Payer: Priority Health Medicaid	$1.18
Rate for Payer: Priority Health Medicare	$1.18
Rate for Payer: Priority Health PPO	$3,084.70
Rate for Payer: United Health Care Medicaid	$1.18
Rate for Payer: United Health Care Medicare Advantage	$0.52

PHA INSULIN ASPART 300U/3ML

Facility

$174.69

Service Code	HCPCS J1815 GY
Hospital Charge Code	2503454
Hospital Revenue Code	250
Min. Negotiated Rate	$122.28
Max. Negotiated Rate	$148.49
Rate for Payer: Cash Price	$113.55
Rate for Payer: Community Health Alliance Commercial	$148.49
Rate for Payer: Priority Health Commercial	$122.28
Rate for Payer: Priority Health PPO	$122.28

PHA INSULIN ASPART PROTAMINE

Facility

$174.69

Service Code	HCPCS J1815
Hospital Charge Code	2503455
Hospital Revenue Code	636
Min. Negotiated Rate	$122.28
Max. Negotiated Rate	$148.49
Rate for Payer: Cash Price	$113.55
Rate for Payer: Community Health Alliance Commercial	$148.49
Rate for Payer: Priority Health Commercial	$122.28
Rate for Payer: Priority Health PPO	$122.28

PHA INSULIN DETEMIR 300 U/3ML

Facility

$154.50

Service Code	HCPCS J1815 GY
Hospital Charge Code	2503456
Hospital Revenue Code	250
Min. Negotiated Rate	$108.15
Max. Negotiated Rate	$131.32
Rate for Payer: Cash Price	$100.43
Rate for Payer: Community Health Alliance Commercial	$131.32
Rate for Payer: Priority Health Commercial	$108.15
Rate for Payer: Priority Health PPO	$108.15

PHA INSULIN ISOPHANE & REG

Facility

$109.25

Service Code	HCPCS J1815 GY
Hospital Charge Code	2503452
Hospital Revenue Code	250
Min. Negotiated Rate	$76.47
Max. Negotiated Rate	$92.86
Rate for Payer: Cash Price	$71.01
Rate for Payer: Community Health Alliance Commercial	$92.86
Rate for Payer: Priority Health Commercial	$76.47
Rate for Payer: Priority Health PPO	$76.47

PHA INSULIN REG & ISOPH 1000U

Facility

$301.35

Service Code	HCPCS J1815 GY
Hospital Charge Code	2501171
Hospital Revenue Code	637
Min. Negotiated Rate	$210.94
Max. Negotiated Rate	$256.15
Rate for Payer: Cash Price	$195.88
Rate for Payer: Community Health Alliance Commercial	$256.15
Rate for Payer: Priority Health Commercial	$210.94
Rate for Payer: Priority Health PPO	$210.94

PHA INSULIN REGULAR 100 U/ML

Facility

$301.35

Service Code	HCPCS J1815 GY
Hospital Charge Code	2501200
Hospital Revenue Code	637
Min. Negotiated Rate	$210.94
Max. Negotiated Rate	$256.15
Rate for Payer: Cash Price	$195.88
Rate for Payer: Community Health Alliance Commercial	$256.15
Rate for Payer: Priority Health Commercial	$210.94
Rate for Payer: Priority Health PPO	$210.94

PHA INSULIN REGULAR 100 U/ML

Facility

$0.93

Service Code	HCPCS J1815 GY
Hospital Charge Code	2501201
Hospital Revenue Code	637
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.79
Rate for Payer: Cash Price	$0.60
Rate for Payer: Community Health Alliance Commercial	$0.79
Rate for Payer: Priority Health Commercial	$0.65
Rate for Payer: Priority Health PPO	$0.65

PHA INSULN ISOPH HUMAN 100U/ML

Facility

$301.35

Service Code	HCPCS J1815 GY
Hospital Charge Code	2501190
Hospital Revenue Code	637
Min. Negotiated Rate	$210.94
Max. Negotiated Rate	$256.15
Rate for Payer: Cash Price	$195.88
Rate for Payer: Community Health Alliance Commercial	$256.15
Rate for Payer: Priority Health Commercial	$210.94
Rate for Payer: Priority Health PPO	$210.94

PHA INTUNIV 2MG ER TAB

Facility

$53.40

Service Code	NDC 54092051502
Hospital Charge Code	2510789
Hospital Revenue Code	637
Min. Negotiated Rate	$37.38
Max. Negotiated Rate	$45.39
Rate for Payer: Cash Price	$34.71
Rate for Payer: Community Health Alliance Commercial	$45.39
Rate for Payer: Priority Health Commercial	$37.38
Rate for Payer: Priority Health PPO	$37.38

PHA IODINE 14 ML BTL

Facility

$177.75

Service Code	NDC 48433023015
Hospital Charge Code	2500628
Hospital Revenue Code	250
Min. Negotiated Rate	$124.42
Max. Negotiated Rate	$151.09
Rate for Payer: Cash Price	$115.54
Rate for Payer: Community Health Alliance Commercial	$151.09
Rate for Payer: Priority Health Commercial	$124.42
Rate for Payer: Priority Health PPO	$124.42

PHA IODIXANOL 32000MG/100ML VI

Facility

$368.60

Service Code	NDC 407222302
Hospital Charge Code	2503125
Hospital Revenue Code	250
Min. Negotiated Rate	$258.02
Max. Negotiated Rate	$313.31
Rate for Payer: Cash Price	$239.59
Rate for Payer: Community Health Alliance Commercial	$313.31
Rate for Payer: Priority Health Commercial	$258.02
Rate for Payer: Priority Health PPO	$258.02

PHA IPILUMUMAB 50MG/10ML VIAL

Facility

$25,269.24

Service Code	HCPCS J9228
Hospital Charge Code	2510835
Hospital Revenue Code	636
Min. Negotiated Rate	$86.35
Max. Negotiated Rate	$21,478.85
Rate for Payer: BCBS BCN 65	$196.26
Rate for Payer: Blue Care Network Medicare Advantage	$196.26
Rate for Payer: Cash Price	$16,425.01
Rate for Payer: Cash Price	$16,425.01
Rate for Payer: Community Health Alliance Commercial	$21,478.85
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$196.26
Rate for Payer: Meridian Health Plan Medicare	$196.26
Rate for Payer: Priority Health Commercial	$17,688.47
Rate for Payer: Priority Health Medicaid	$196.26
Rate for Payer: Priority Health Medicare	$196.26
Rate for Payer: Priority Health PPO	$17,688.47
Rate for Payer: United Health Care Medicaid	$196.26
Rate for Payer: United Health Care Medicare Advantage	$86.35

PHA IPRATROPIUM ALBUTEROL

Facility

$11.51

Service Code	NDC 487020101
Hospital Charge Code	2501404
Hospital Revenue Code	250
Min. Negotiated Rate	$8.06
Max. Negotiated Rate	$9.78
Rate for Payer: Cash Price	$7.48
Rate for Payer: Community Health Alliance Commercial	$9.78
Rate for Payer: Priority Health Commercial	$8.06
Rate for Payer: Priority Health PPO	$8.06

PHA IPRATROPIUM BROMIDE 200 PU

Facility

$113.59

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500905
Hospital Revenue Code	637
Min. Negotiated Rate	$79.51
Max. Negotiated Rate	$96.55
Rate for Payer: Cash Price	$73.83
Rate for Payer: Community Health Alliance Commercial	$96.55
Rate for Payer: Priority Health Commercial	$79.51
Rate for Payer: Priority Health PPO	$79.51

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges