Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA LACTATED RINGERS 1000ML

Facility

$29.26

Service Code	HCPCS J7120
Hospital Charge Code	2510889
Hospital Revenue Code	636
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$24.87
Rate for Payer: Cash Price	$19.02
Rate for Payer: Community Health Alliance Commercial	$24.87
Rate for Payer: Priority Health Commercial	$20.48
Rate for Payer: Priority Health PPO	$20.48

PHA LACTATED RINGERS 1000ML BT

Facility

$61.49

Service Code	NDC 338011404
Hospital Charge Code	2507075
Hospital Revenue Code	250
Min. Negotiated Rate	$43.04
Max. Negotiated Rate	$52.27
Rate for Payer: Cash Price	$39.97
Rate for Payer: Community Health Alliance Commercial	$52.27
Rate for Payer: Priority Health Commercial	$43.04
Rate for Payer: Priority Health PPO	$43.04

PHA LACTOBACILLUS 5 BILL CELLS

Facility

$4.69

Service Code	NDC 49100040008
Hospital Charge Code	2500804
Hospital Revenue Code	250
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$3.99
Rate for Payer: Cash Price	$3.05
Rate for Payer: Community Health Alliance Commercial	$3.99
Rate for Payer: Priority Health Commercial	$3.28
Rate for Payer: Priority Health PPO	$3.28

PHA LACTULOSE 10 GM/15 ML ML

Facility

$11.83

Service Code	HCPCS A9270 GY
Hospital Charge Code	2508880
Hospital Revenue Code	637
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$10.06
Rate for Payer: Cash Price	$7.69
Rate for Payer: Community Health Alliance Commercial	$10.06
Rate for Payer: Priority Health Commercial	$8.28
Rate for Payer: Priority Health PPO	$8.28

PHALANGEAL COMPONENT

Facility

$1,264.00

Service Code	HCPCS C1713
Hospital Charge Code	27017608
Hospital Revenue Code	278
Min. Negotiated Rate	$884.80
Max. Negotiated Rate	$1,074.40
Rate for Payer: Cash Price	$821.60
Rate for Payer: Community Health Alliance Commercial	$1,074.40
Rate for Payer: Priority Health Commercial	$884.80
Rate for Payer: Priority Health PPO	$884.80

PHALANGEAL FIXATION

Facility

$1,696.00

Service Code	HCPCS C1713
Hospital Charge Code	27867086
Hospital Revenue Code	278
Min. Negotiated Rate	$1,187.20
Max. Negotiated Rate	$1,441.60
Rate for Payer: Cash Price	$1,102.40
Rate for Payer: Community Health Alliance Commercial	$1,441.60
Rate for Payer: Priority Health Commercial	$1,187.20
Rate for Payer: Priority Health PPO	$1,187.20

PHA LANOLIN 7 GM TUBE

Facility

$10.21

Service Code	NDC 92771059007
Hospital Charge Code	2507734
Hospital Revenue Code	250
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$8.68
Rate for Payer: Cash Price	$6.64
Rate for Payer: Community Health Alliance Commercial	$8.68
Rate for Payer: Priority Health Commercial	$7.15
Rate for Payer: Priority Health PPO	$7.15

PHA LANTUS 300 U/3 ML PEN

Facility

$120.51

Service Code	NDC 88221905
Hospital Charge Code	2503451
Hospital Revenue Code	250
Min. Negotiated Rate	$84.36
Max. Negotiated Rate	$102.43
Rate for Payer: Cash Price	$78.33
Rate for Payer: Community Health Alliance Commercial	$102.43
Rate for Payer: Priority Health Commercial	$84.36
Rate for Payer: Priority Health PPO	$84.36

PHA LATANOPROST 2.5 ML

Facility

$317.30

Service Code	NDC 61314054701
Hospital Charge Code	2509904
Hospital Revenue Code	250
Min. Negotiated Rate	$222.11
Max. Negotiated Rate	$269.70
Rate for Payer: Cash Price	$206.25
Rate for Payer: Community Health Alliance Commercial	$269.70
Rate for Payer: Priority Health Commercial	$222.11
Rate for Payer: Priority Health PPO	$222.11

PHA LESAPRO

Facility

$22.82

Service Code	HCPCS A9270 GY
Hospital Charge Code	2507315
Hospital Revenue Code	637
Min. Negotiated Rate	$15.97
Max. Negotiated Rate	$19.40
Rate for Payer: Cash Price	$14.83
Rate for Payer: Community Health Alliance Commercial	$19.40
Rate for Payer: Priority Health Commercial	$15.97
Rate for Payer: Priority Health PPO	$15.97

PHA LEUCOVORIN 500 MG INJ

Facility

$285.47

Service Code	HCPCS J0640
Hospital Charge Code	2509925
Hospital Revenue Code	250
Min. Negotiated Rate	$199.83
Max. Negotiated Rate	$242.65
Rate for Payer: Cash Price	$185.56
Rate for Payer: Community Health Alliance Commercial	$242.65
Rate for Payer: Priority Health Commercial	$199.83
Rate for Payer: Priority Health PPO	$199.83

PHA LEUCOVORIN CAL 350MG 0725

Facility

$104.15

Service Code	HCPCS J0640
Hospital Charge Code	2509910
Hospital Revenue Code	636
Min. Negotiated Rate	$72.91
Max. Negotiated Rate	$88.53
Rate for Payer: Cash Price	$67.70
Rate for Payer: Community Health Alliance Commercial	$88.53
Rate for Payer: Priority Health Commercial	$72.91
Rate for Payer: Priority Health PPO	$72.91

PHA LEUCOVORIN CALCIUM 100 MG

Facility

$109.92

Service Code	HCPCS J0640
Hospital Charge Code	2509922
Hospital Revenue Code	636
Min. Negotiated Rate	$76.94
Max. Negotiated Rate	$93.43
Rate for Payer: Cash Price	$71.45
Rate for Payer: Community Health Alliance Commercial	$93.43
Rate for Payer: Priority Health Commercial	$76.94
Rate for Payer: Priority Health PPO	$76.94

PHA LEUCOVORIN CALCIUM 200MG

Facility

$68.70

Service Code	HCPCS J0640
Hospital Charge Code	2509924
Hospital Revenue Code	636
Min. Negotiated Rate	$48.09
Max. Negotiated Rate	$58.40
Rate for Payer: Cash Price	$44.66
Rate for Payer: Community Health Alliance Commercial	$58.40
Rate for Payer: Priority Health Commercial	$48.09
Rate for Payer: Priority Health PPO	$48.09

PHA LEUCOVORIN CALCIUM 50 MG

Facility

$54.66

Service Code	HCPCS J0640
Hospital Charge Code	2509926
Hospital Revenue Code	636
Min. Negotiated Rate	$38.26
Max. Negotiated Rate	$46.46
Rate for Payer: Cash Price	$35.53
Rate for Payer: Community Health Alliance Commercial	$46.46
Rate for Payer: Priority Health Commercial	$38.26
Rate for Payer: Priority Health PPO	$38.26

PHA LEUPROLIDE 11.25 MG IM INJ

Facility

$15,522.81

Service Code	HCPCS J1950
Hospital Charge Code	2509927
Hospital Revenue Code	636
Min. Negotiated Rate	$814.91
Max. Negotiated Rate	$13,194.39
Rate for Payer: BCBS BCN 65	$1,852.06
Rate for Payer: Blue Care Network Medicare Advantage	$1,852.06
Rate for Payer: Cash Price	$10,089.83
Rate for Payer: Cash Price	$10,089.83
Rate for Payer: Community Health Alliance Commercial	$13,194.39
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$1,852.06
Rate for Payer: Meridian Health Plan Medicare	$1,852.06
Rate for Payer: Priority Health Commercial	$10,865.97
Rate for Payer: Priority Health Medicaid	$1,852.06
Rate for Payer: Priority Health Medicare	$1,852.06
Rate for Payer: Priority Health PPO	$10,865.97
Rate for Payer: United Health Care Medicaid	$1,852.06
Rate for Payer: United Health Care Medicare Advantage	$814.91

PHA LEUPROLIDE 22.5 MG

Facility

$18,497.59

Service Code	HCPCS J9217
Hospital Charge Code	2509932
Hospital Revenue Code	636
Min. Negotiated Rate	$78.90
Max. Negotiated Rate	$15,722.95
Rate for Payer: BCBS BCN 65	$179.32
Rate for Payer: Blue Care Network Medicare Advantage	$179.32
Rate for Payer: Cash Price	$12,023.43
Rate for Payer: Cash Price	$12,023.43
Rate for Payer: Community Health Alliance Commercial	$15,722.95
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$179.32
Rate for Payer: Meridian Health Plan Medicare	$179.32
Rate for Payer: Priority Health Commercial	$12,948.31
Rate for Payer: Priority Health Medicaid	$179.32
Rate for Payer: Priority Health Medicare	$179.32
Rate for Payer: Priority Health PPO	$12,948.31
Rate for Payer: United Health Care Medicaid	$179.32
Rate for Payer: United Health Care Medicare Advantage	$78.90

PHA LEUPROLIDE ACET 7.5MG 9217

Facility

$6,165.94

Service Code	HCPCS J9217
Hospital Charge Code	2509935
Hospital Revenue Code	636
Min. Negotiated Rate	$78.90
Max. Negotiated Rate	$5,241.05
Rate for Payer: BCBS BCN 65	$179.32
Rate for Payer: Blue Care Network Medicare Advantage	$179.32
Rate for Payer: Cash Price	$4,007.86
Rate for Payer: Cash Price	$4,007.86
Rate for Payer: Community Health Alliance Commercial	$5,241.05
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$179.32
Rate for Payer: Meridian Health Plan Medicare	$179.32
Rate for Payer: Priority Health Commercial	$4,316.16
Rate for Payer: Priority Health Medicaid	$179.32
Rate for Payer: Priority Health Medicare	$179.32
Rate for Payer: Priority Health PPO	$4,316.16
Rate for Payer: United Health Care Medicaid	$179.32
Rate for Payer: United Health Care Medicare Advantage	$78.90

PHA LEUPRON 30MG DEPOT INJ

Facility

$24,663.56

Service Code	HCPCS J9217
Hospital Charge Code	2509933
Hospital Revenue Code	636
Min. Negotiated Rate	$78.90
Max. Negotiated Rate	$20,964.03
Rate for Payer: BCBS BCN 65	$179.32
Rate for Payer: Blue Care Network Medicare Advantage	$179.32
Rate for Payer: Cash Price	$16,031.31
Rate for Payer: Cash Price	$16,031.31
Rate for Payer: Community Health Alliance Commercial	$20,964.03
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$179.32
Rate for Payer: Meridian Health Plan Medicare	$179.32
Rate for Payer: Priority Health Commercial	$17,264.49
Rate for Payer: Priority Health Medicaid	$179.32
Rate for Payer: Priority Health Medicare	$179.32
Rate for Payer: Priority Health PPO	$17,264.49
Rate for Payer: United Health Care Medicaid	$179.32
Rate for Payer: United Health Care Medicare Advantage	$78.90

PHA LEVALBUTEROL .63 MG INH

Facility

$10.42

Service Code	NDC 76204080025
Hospital Charge Code	2500237
Hospital Revenue Code	250
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$8.86
Rate for Payer: Cash Price	$6.77
Rate for Payer: Community Health Alliance Commercial	$8.86
Rate for Payer: Priority Health Commercial	$7.29
Rate for Payer: Priority Health PPO	$7.29

PHA LEVALBUTEROL HCL 1.25 NEB

Facility

$34.96

Service Code	NDC 93414856
Hospital Charge Code	2500238
Hospital Revenue Code	250
Min. Negotiated Rate	$24.47
Max. Negotiated Rate	$29.72
Rate for Payer: Cash Price	$22.72
Rate for Payer: Community Health Alliance Commercial	$29.72
Rate for Payer: Priority Health Commercial	$24.47
Rate for Payer: Priority Health PPO	$24.47

PHA LEVETIRACETAM 500MG TAB

Facility

$16.46

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500829
Hospital Revenue Code	637
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$13.99
Rate for Payer: Cash Price	$10.70
Rate for Payer: Community Health Alliance Commercial	$13.99
Rate for Payer: Priority Health Commercial	$11.52
Rate for Payer: Priority Health PPO	$11.52

PHA LEVOFLOXACIN HEM 500MG TAB

Facility

$77.04

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509941
Hospital Revenue Code	637
Min. Negotiated Rate	$53.93
Max. Negotiated Rate	$65.48
Rate for Payer: Cash Price	$50.08
Rate for Payer: Community Health Alliance Commercial	$65.48
Rate for Payer: Priority Health Commercial	$53.93
Rate for Payer: Priority Health PPO	$53.93

PHA LEVOFLOXACIN HEMIDYDRATE

Facility

$40.64

Service Code	HCPCS J1956
Hospital Charge Code	2509946
Hospital Revenue Code	636
Min. Negotiated Rate	$28.45
Max. Negotiated Rate	$34.54
Rate for Payer: Cash Price	$26.42
Rate for Payer: Community Health Alliance Commercial	$34.54
Rate for Payer: Priority Health Commercial	$28.45
Rate for Payer: Priority Health PPO	$28.45

PHA LEVOFLOXACIN HEMIHYD 250MG

Facility

$25.01

Service Code	NDC 36000004624
Hospital Charge Code	2509953
Hospital Revenue Code	250
Min. Negotiated Rate	$17.51
Max. Negotiated Rate	$21.26
Rate for Payer: Cash Price	$16.26
Rate for Payer: Community Health Alliance Commercial	$21.26
Rate for Payer: Priority Health Commercial	$17.51
Rate for Payer: Priority Health PPO	$17.51

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges