Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA IPRATROPIUM BROMIDE 2.5 ML

Facility

$1.88

Service Code	NDC 487980101
Hospital Charge Code	2507775
Hospital Revenue Code	250
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.60
Rate for Payer: Cash Price	$1.22
Rate for Payer: Community Health Alliance Commercial	$1.60
Rate for Payer: Priority Health Commercial	$1.32
Rate for Payer: Priority Health PPO	$1.32

PHA IRINOTECAN HYDROCHLORIDE

Facility

$107.46

Service Code	HCPCS J9206
Hospital Charge Code	2507773
Hospital Revenue Code	636
Min. Negotiated Rate	$75.22
Max. Negotiated Rate	$91.34
Rate for Payer: Cash Price	$69.85
Rate for Payer: Community Health Alliance Commercial	$91.34
Rate for Payer: Priority Health Commercial	$75.22
Rate for Payer: Priority Health PPO	$75.22

PHA IRINOTECAN HYDROCLOR 0830

Facility

$168.59

Service Code	HCPCS J9206
Hospital Charge Code	2507774
Hospital Revenue Code	636
Min. Negotiated Rate	$118.01
Max. Negotiated Rate	$143.30
Rate for Payer: Cash Price	$109.58
Rate for Payer: Community Health Alliance Commercial	$143.30
Rate for Payer: Priority Health Commercial	$118.01
Rate for Payer: Priority Health PPO	$118.01

PHA IRON DEXTRAN 50MG/ML VIAL

Facility

$186.98

Service Code	HCPCS J1750
Hospital Charge Code	2507780
Hospital Revenue Code	636
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$158.93
Rate for Payer: BCBS BCN 65	$18.98
Rate for Payer: Blue Care Network Medicare Advantage	$18.98
Rate for Payer: Cash Price	$121.54
Rate for Payer: Cash Price	$121.54
Rate for Payer: Community Health Alliance Commercial	$158.93
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$18.98
Rate for Payer: Meridian Health Plan Medicare	$18.98
Rate for Payer: Priority Health Commercial	$130.89
Rate for Payer: Priority Health Medicaid	$18.98
Rate for Payer: Priority Health Medicare	$18.98
Rate for Payer: Priority Health PPO	$130.89
Rate for Payer: United Health Care Medicaid	$18.98
Rate for Payer: United Health Care Medicare Advantage	$8.35

PHA IRON SUCROSE COMPLEX INJ

Facility

$260.32

Service Code	HCPCS J1756
Hospital Charge Code	2507785
Hospital Revenue Code	636
Min. Negotiated Rate	$182.22
Max. Negotiated Rate	$221.27
Rate for Payer: Cash Price	$169.21
Rate for Payer: Community Health Alliance Commercial	$221.27
Rate for Payer: Priority Health Commercial	$182.22
Rate for Payer: Priority Health PPO	$182.22

PHA ISENTRESS 400MG TAB NF

Facility

$169.63

Service Code	NDC 6022761
Hospital Charge Code	2510812
Hospital Revenue Code	637
Min. Negotiated Rate	$118.74
Max. Negotiated Rate	$144.19
Rate for Payer: Cash Price	$110.26
Rate for Payer: Community Health Alliance Commercial	$144.19
Rate for Payer: Priority Health Commercial	$118.74
Rate for Payer: Priority Health PPO	$118.74

PHA ISOPROTERENOL HCL 0.2MG/ML

Facility

$229.97

Service Code	NDC 409141005
Hospital Charge Code	2507770
Hospital Revenue Code	250
Min. Negotiated Rate	$160.98
Max. Negotiated Rate	$195.47
Rate for Payer: Cash Price	$149.48
Rate for Payer: Community Health Alliance Commercial	$195.47
Rate for Payer: Priority Health Commercial	$160.98
Rate for Payer: Priority Health PPO	$160.98

PHA ISOSORBIDE MONONITRATE TAB

Facility

$8.65

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510735
Hospital Revenue Code	637
Min. Negotiated Rate	$6.05
Max. Negotiated Rate	$7.35
Rate for Payer: Cash Price	$5.62
Rate for Payer: Community Health Alliance Commercial	$7.35
Rate for Payer: Priority Health Commercial	$6.05
Rate for Payer: Priority Health PPO	$6.05

PHA ISOVUE 30 ML VIAL

Facility

$105.27

Service Code	NDC 270131525
Hospital Charge Code	3500003
Hospital Revenue Code	250
Min. Negotiated Rate	$73.69
Max. Negotiated Rate	$89.48
Rate for Payer: Cash Price	$68.43
Rate for Payer: Community Health Alliance Commercial	$89.48
Rate for Payer: Priority Health Commercial	$73.69
Rate for Payer: Priority Health PPO	$73.69

PHA ISTALOL 0.5% ML EYE DRP[

Facility

$988.41

Service Code	NDC 24208000403
Hospital Charge Code	2510817
Hospital Revenue Code	637
Min. Negotiated Rate	$691.89
Max. Negotiated Rate	$840.15
Rate for Payer: Cash Price	$642.47
Rate for Payer: Community Health Alliance Commercial	$840.15
Rate for Payer: Priority Health Commercial	$691.89
Rate for Payer: Priority Health PPO	$691.89

PHA IV SOLN 5% & 45 SOD CHL

Facility

$70.00

Service Code	NDC 338008503
Hospital Charge Code	2510891
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 IXEMPRA 15 MG INJECTION

Facility

$3,142.62

Service Code	HCPCS J9207
Hospital Charge Code	2504554
Hospital Revenue Code	636
Min. Negotiated Rate	$64.67
Max. Negotiated Rate	$2,671.23
Rate for Payer: BCBS BCN 65	$146.98
Rate for Payer: Blue Care Network Medicare Advantage	$146.98
Rate for Payer: Cash Price	$2,042.70
Rate for Payer: Cash Price	$2,042.70
Rate for Payer: Community Health Alliance Commercial	$2,671.23
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$146.98
Rate for Payer: Meridian Health Plan Medicare	$146.98
Rate for Payer: Priority Health Commercial	$2,199.83
Rate for Payer: Priority Health Medicaid	$146.98
Rate for Payer: Priority Health Medicare	$146.98
Rate for Payer: Priority Health PPO	$2,199.83
Rate for Payer: United Health Care Medicaid	$146.98
Rate for Payer: United Health Care Medicare Advantage	$64.67

PHA IXEMPRA 45 MG INJECTION

Facility

$9,415.27

Service Code	HCPCS J9207
Hospital Charge Code	2504553
Hospital Revenue Code	636
Min. Negotiated Rate	$64.67
Max. Negotiated Rate	$8,002.98
Rate for Payer: BCBS BCN 65	$146.98
Rate for Payer: Blue Care Network Medicare Advantage	$146.98
Rate for Payer: Cash Price	$6,119.93
Rate for Payer: Cash Price	$6,119.93
Rate for Payer: Community Health Alliance Commercial	$8,002.98
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$146.98
Rate for Payer: Meridian Health Plan Medicare	$146.98
Rate for Payer: Priority Health Commercial	$6,590.69
Rate for Payer: Priority Health Medicaid	$146.98
Rate for Payer: Priority Health Medicare	$146.98
Rate for Payer: Priority Health PPO	$6,590.69
Rate for Payer: United Health Care Medicaid	$146.98
Rate for Payer: United Health Care Medicare Advantage	$64.67

PHA KAOLIN-PECTIN 240ML ML

Facility

$16.57

Service Code	HCPCS A9270 GY
Hospital Charge Code	2508820
Hospital Revenue Code	637
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$14.08
Rate for Payer: Cash Price	$10.77
Rate for Payer: Community Health Alliance Commercial	$14.08
Rate for Payer: Priority Health Commercial	$11.60
Rate for Payer: Priority Health PPO	$11.60

PHA KEPPRA 100MG/ML 5 ML VIAL

Facility

$18.76

Service Code	NDC 55150017705
Hospital Charge Code	2510847
Hospital Revenue Code	250
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 KETAMINE 100MG/5ML VIAL

Facility

$52.00

Service Code	HCPCS J3490
Hospital Charge Code	2507158
Hospital Revenue Code	636
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$44.20
Rate for Payer: Cash Price	$33.80
Rate for Payer: Community Health Alliance Commercial	$44.20
Rate for Payer: Priority Health Commercial	$36.40
Rate for Payer: Priority Health PPO	$36.40

PHA KETOCONAZOLE 60 MG TUBE

Facility

$764.41

Service Code	HCPCS A9270 GY
Hospital Charge Code	2507161
Hospital Revenue Code	637
Min. Negotiated Rate	$535.09
Max. Negotiated Rate	$649.75
Rate for Payer: Cash Price	$496.87
Rate for Payer: Community Health Alliance Commercial	$649.75
Rate for Payer: Priority Health Commercial	$535.09
Rate for Payer: Priority Health PPO	$535.09

PHA KETOROLAC TROMETH 60MG/2ML

Facility

$61.23

Service Code	HCPCS J1885
Hospital Charge Code	2510100
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$52.05
Rate for Payer: BCBS BCN 65	$0.35
Rate for Payer: Blue Care Network Medicare Advantage	$0.35
Rate for Payer: Cash Price	$39.80
Rate for Payer: Cash Price	$39.80
Rate for Payer: Community Health Alliance Commercial	$52.05
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$0.35
Rate for Payer: Meridian Health Plan Medicare	$0.35
Rate for Payer: Priority Health Commercial	$42.86
Rate for Payer: Priority Health Medicaid	$0.35
Rate for Payer: Priority Health Medicare	$0.35
Rate for Payer: Priority Health PPO	$42.86
Rate for Payer: United Health Care Medicaid	$0.35
Rate for Payer: United Health Care Medicare Advantage	$0.15

PHA KETOROLAC TROMETHA 30MG/ML

Facility

$35.64

Service Code	HCPCS J1885
Hospital Charge Code	2510090
Hospital Revenue Code	636
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$30.29
Rate for Payer: BCBS BCN 65	$0.35
Rate for Payer: Blue Care Network Medicare Advantage	$0.35
Rate for Payer: Cash Price	$23.17
Rate for Payer: Cash Price	$23.17
Rate for Payer: Community Health Alliance Commercial	$30.29
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$0.35
Rate for Payer: Meridian Health Plan Medicare	$0.35
Rate for Payer: Priority Health Commercial	$24.95
Rate for Payer: Priority Health Medicaid	$0.35
Rate for Payer: Priority Health Medicare	$0.35
Rate for Payer: Priority Health PPO	$24.95
Rate for Payer: United Health Care Medicaid	$0.35
Rate for Payer: United Health Care Medicare Advantage	$0.15

PHA KETOROLAC TROMETHAM 10MG

Facility

$11.25

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510080
Hospital Revenue Code	637
Min. Negotiated Rate	$7.88
Max. Negotiated Rate	$9.56
Rate for Payer: Cash Price	$7.31
Rate for Payer: Community Health Alliance Commercial	$9.56
Rate for Payer: Priority Health Commercial	$7.88
Rate for Payer: Priority Health PPO	$7.88

PHA KETOROLAC TROMETHAMINE

Facility

$61.23

Service Code	HCPCS A9270 GY
Hospital Charge Code	2508228
Hospital Revenue Code	637
Min. Negotiated Rate	$42.86
Max. Negotiated Rate	$52.05
Rate for Payer: Cash Price	$39.80
Rate for Payer: Community Health Alliance Commercial	$52.05
Rate for Payer: Priority Health Commercial	$42.86
Rate for Payer: Priority Health PPO	$42.86

PHA KETOROLAC TROMETHAMINE 5ML

Facility

$105.91

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500195
Hospital Revenue Code	637
Min. Negotiated Rate	$74.14
Max. Negotiated Rate	$90.02
Rate for Payer: Cash Price	$68.84
Rate for Payer: Community Health Alliance Commercial	$90.02
Rate for Payer: Priority Health Commercial	$74.14
Rate for Payer: Priority Health PPO	$74.14

PHA KEYTRUDA 25MG/ML 4 ML VIAL

Facility

$16,458.91

Service Code	HCPCS J9271
Hospital Charge Code	2507599
Hospital Revenue Code	636
Min. Negotiated Rate	$27.60
Max. Negotiated Rate	$13,990.07
Rate for Payer: BCBS BCN 65	$62.72
Rate for Payer: Blue Care Network Medicare Advantage	$62.72
Rate for Payer: Cash Price	$10,698.29
Rate for Payer: Cash Price	$10,698.29
Rate for Payer: Community Health Alliance Commercial	$13,990.07
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$62.72
Rate for Payer: Meridian Health Plan Medicare	$62.72
Rate for Payer: Priority Health Commercial	$11,521.24
Rate for Payer: Priority Health Medicaid	$62.72
Rate for Payer: Priority Health Medicare	$62.72
Rate for Payer: Priority Health PPO	$11,521.24
Rate for Payer: United Health Care Medicaid	$62.72
Rate for Payer: United Health Care Medicare Advantage	$27.60

PHA LABETALOL HCL 200 MG TAB

Facility

$11.88

Service Code	HCPCS A9270 GY
Hospital Charge Code	2508860
Hospital Revenue Code	637
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$10.10
Rate for Payer: Cash Price	$7.72
Rate for Payer: Community Health Alliance Commercial	$10.10
Rate for Payer: Priority Health Commercial	$8.32
Rate for Payer: Priority Health PPO	$8.32

PHA LABETALOL HCL 5MG/ML VIAL

Facility

$43.76

Service Code	NDC 143962201
Hospital Charge Code	2510750
Hospital Revenue Code	250
Min. Negotiated Rate	$30.63
Max. Negotiated Rate	$37.20
Rate for Payer: Cash Price	$28.44
Rate for Payer: Community Health Alliance Commercial	$37.20
Rate for Payer: Priority Health Commercial	$30.63
Rate for Payer: Priority Health PPO	$30.63

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges