Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA LEVOFLOXACIN HEMIHYDRATE

Facility

$31.26

Service Code	NDC 36000004724
Hospital Charge Code	2509979
Hospital Revenue Code	250
Min. Negotiated Rate	$21.88
Max. Negotiated Rate	$26.57
Rate for Payer: Cash Price	$20.32
Rate for Payer: Community Health Alliance Commercial	$26.57
Rate for Payer: Priority Health Commercial	$21.88
Rate for Payer: Priority Health PPO	$21.88

PHA LEVOTHYROXINE SOD 0.05MG

Facility

$2.81

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509940
Hospital Revenue Code	637
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.39
Rate for Payer: Cash Price	$1.83
Rate for Payer: Community Health Alliance Commercial	$2.39
Rate for Payer: Priority Health Commercial	$1.97
Rate for Payer: Priority Health PPO	$1.97

PHA LEVOTHYROXINE SOD 0.1MG TB

Facility

$3.18

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509950
Hospital Revenue Code	637
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$2.70
Rate for Payer: Cash Price	$2.07
Rate for Payer: Community Health Alliance Commercial	$2.70
Rate for Payer: Priority Health Commercial	$2.23
Rate for Payer: Priority Health PPO	$2.23

PHA LEVOTHYROXINE SOD .088 TAB

Facility

$3.18

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509978
Hospital Revenue Code	637
Min. Negotiated Rate	$2.23
Max. Negotiated Rate	$2.70
Rate for Payer: Cash Price	$2.07
Rate for Payer: Community Health Alliance Commercial	$2.70
Rate for Payer: Priority Health Commercial	$2.23
Rate for Payer: Priority Health PPO	$2.23

PHA LEVOTHYROXINE SODIUM 100MC

Facility

$398.63

Service Code	HCPCS J3490
Hospital Charge Code	2500301
Hospital Revenue Code	636
Min. Negotiated Rate	$279.04
Max. Negotiated Rate	$338.84
Rate for Payer: Cash Price	$259.11
Rate for Payer: Community Health Alliance Commercial	$338.84
Rate for Payer: Priority Health Commercial	$279.04
Rate for Payer: Priority Health PPO	$279.04

PHA LEXISCAN 0.4 MG SYRINGE

Facility

$110.01

Service Code	HCPCS J2785
Hospital Charge Code	2501208
Hospital Revenue Code	636
Min. Negotiated Rate	$77.01
Max. Negotiated Rate	$93.51
Rate for Payer: Cash Price	$71.51
Rate for Payer: Community Health Alliance Commercial	$93.51
Rate for Payer: Priority Health Commercial	$77.01
Rate for Payer: Priority Health PPO	$77.01

PHA LIDOCAINE 1% 2 ML VIAL

Facility

$14.74

Service Code	NDC 63323049227
Hospital Charge Code	2510650
Hospital Revenue Code	250
Min. Negotiated Rate	$10.32
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$9.58
Rate for Payer: Community Health Alliance Commercial	$12.53
Rate for Payer: Priority Health Commercial	$10.32
Rate for Payer: Priority Health PPO	$10.32

PHA LIDOCAINE 1% W/EPINEPHRINE

Facility

$35.01

Service Code	NDC 63323048227
Hospital Charge Code	2510620
Hospital Revenue Code	250
Min. Negotiated Rate	$24.51
Max. Negotiated Rate	$29.76
Rate for Payer: Cash Price	$22.76
Rate for Payer: Community Health Alliance Commercial	$29.76
Rate for Payer: Priority Health Commercial	$24.51
Rate for Payer: Priority Health PPO	$24.51

PHA LIDOCAINE 2% 10ML AMP

Facility

$45.22

Service Code	NDC 409428202
Hospital Charge Code	2510675
Hospital Revenue Code	250
Min. Negotiated Rate	$31.65
Max. Negotiated Rate	$38.44
Rate for Payer: Cash Price	$29.39
Rate for Payer: Community Health Alliance Commercial	$38.44
Rate for Payer: Priority Health Commercial	$31.65
Rate for Payer: Priority Health PPO	$31.65

PHA LIDOCAINE 2% 20ML VIAL

Facility

$26.26

Service Code	NDC 55150025520
Hospital Charge Code	2510660
Hospital Revenue Code	250
Min. Negotiated Rate	$18.38
Max. Negotiated Rate	$22.32
Rate for Payer: Cash Price	$17.07
Rate for Payer: Community Health Alliance Commercial	$22.32
Rate for Payer: Priority Health Commercial	$18.38
Rate for Payer: Priority Health PPO	$18.38

PHA LIDOCAINE 2% 2 ML AMP

Facility

$18.50

Service Code	NDC 63323020202
Hospital Charge Code	2510690
Hospital Revenue Code	250
Min. Negotiated Rate	$12.95
Max. Negotiated Rate	$15.72
Rate for Payer: Cash Price	$12.03
Rate for Payer: Community Health Alliance Commercial	$15.72
Rate for Payer: Priority Health Commercial	$12.95
Rate for Payer: Priority Health PPO	$12.95

PHA LIDOCAINE 2% VISCOUS 20ML

Facility

$5.63

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501370
Hospital Revenue Code	637
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$4.79
Rate for Payer: Cash Price	$3.66
Rate for Payer: Community Health Alliance Commercial	$4.79
Rate for Payer: Priority Health Commercial	$3.94
Rate for Payer: Priority Health PPO	$3.94

PHA LIDOCAINE 2% W/WPINEPHRINE

Facility

$35.53

Service Code	NDC 63323048327
Hospital Charge Code	2510680
Hospital Revenue Code	250
Min. Negotiated Rate	$24.87
Max. Negotiated Rate	$30.20
Rate for Payer: Cash Price	$23.09
Rate for Payer: Community Health Alliance Commercial	$30.20
Rate for Payer: Priority Health Commercial	$24.87
Rate for Payer: Priority Health PPO	$24.87

PHA LIDOCAINE 4% TOPICAL 50ML

Facility

$215.90

Service Code	NDC 52565000950
Hospital Charge Code	2501340
Hospital Revenue Code	250
Min. Negotiated Rate	$151.13
Max. Negotiated Rate	$183.51
Rate for Payer: Cash Price	$140.34
Rate for Payer: Community Health Alliance Commercial	$183.51
Rate for Payer: Priority Health Commercial	$151.13
Rate for Payer: Priority Health PPO	$151.13

PHA LIDOCAINE 5% PATCH

Facility

$48.77

Service Code	NDC 591352530
Hospital Charge Code	2509355
Hospital Revenue Code	250
Min. Negotiated Rate	$34.14
Max. Negotiated Rate	$41.45
Rate for Payer: Cash Price	$31.70
Rate for Payer: Community Health Alliance Commercial	$41.45
Rate for Payer: Priority Health Commercial	$34.14
Rate for Payer: Priority Health PPO	$34.14

PHA LIDOCAINE HCL 100MG SYR

Facility

$45.43

Service Code	HCPCS J2001
Hospital Charge Code	2501310
Hospital Revenue Code	636
Min. Negotiated Rate	$31.80
Max. Negotiated Rate	$38.62
Rate for Payer: Cash Price	$29.53
Rate for Payer: Community Health Alliance Commercial	$38.62
Rate for Payer: Priority Health Commercial	$31.80
Rate for Payer: Priority Health PPO	$31.80

PHA LIDOCAINE HCL 10ML SYR

Facility

$44.02

Service Code	NDC 76329301305
Hospital Charge Code	2501320
Hospital Revenue Code	636
Min. Negotiated Rate	$30.81
Max. Negotiated Rate	$37.42
Rate for Payer: Cash Price	$28.61
Rate for Payer: Community Health Alliance Commercial	$37.42
Rate for Payer: Priority Health Commercial	$30.81
Rate for Payer: Priority Health PPO	$30.81

PHA LIDOCAINE HCL 1% 10ML VIAL

Facility

$18.96

Service Code	NDC 63323020110
Hospital Charge Code	2510625
Hospital Revenue Code	250
Min. Negotiated Rate	$13.27
Max. Negotiated Rate	$16.12
Rate for Payer: Cash Price	$12.32
Rate for Payer: Community Health Alliance Commercial	$16.12
Rate for Payer: Priority Health Commercial	$13.27
Rate for Payer: Priority Health PPO	$13.27

PHA LIDOCAINE HCL 1% MPF 5ML V

Facility

$11.25

Service Code	NDC 143959525
Hospital Charge Code	2510626
Hospital Revenue Code	250
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 LIDOCAINE HCL 2 GM/250 ML

Facility

$42.51

Service Code	NDC 338040903
Hospital Charge Code	2501321
Hospital Revenue Code	250
Min. Negotiated Rate	$29.76
Max. Negotiated Rate	$36.13
Rate for Payer: Cash Price	$27.63
Rate for Payer: Community Health Alliance Commercial	$36.13
Rate for Payer: Priority Health Commercial	$29.76
Rate for Payer: Priority Health PPO	$29.76

PHA LIDOCAINE HCL 5ML TUBE

Facility

$2.81

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501355
Hospital Revenue Code	637
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.39
Rate for Payer: Cash Price	$1.83
Rate for Payer: Community Health Alliance Commercial	$2.39
Rate for Payer: Priority Health Commercial	$1.97
Rate for Payer: Priority Health PPO	$1.97

PHA LIDOCAINE HCL 5ML VIAL

Facility

$13.81

Service Code	HCPCS J2003
Hospital Charge Code	2511005
Hospital Revenue Code	636
Min. Negotiated Rate	$9.67
Max. Negotiated Rate	$11.74
Rate for Payer: Cash Price	$8.98
Rate for Payer: Community Health Alliance Commercial	$11.74
Rate for Payer: Priority Health Commercial	$9.67
Rate for Payer: Priority Health PPO	$9.67

PHA LIDOCAINE HCL 5% OINTMENT

Facility

$630.83

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505167
Hospital Revenue Code	637
Min. Negotiated Rate	$441.58
Max. Negotiated Rate	$536.21
Rate for Payer: Cash Price	$410.04
Rate for Payer: Community Health Alliance Commercial	$536.21
Rate for Payer: Priority Health Commercial	$441.58
Rate for Payer: Priority Health PPO	$441.58

PHA LIDOCAINE-PRILOCAINE 5GM

Facility

$41.89

Service Code	NDC 115146860
Hospital Charge Code	2506030
Hospital Revenue Code	250
Min. Negotiated Rate	$29.32
Max. Negotiated Rate	$35.61
Rate for Payer: Cash Price	$27.23
Rate for Payer: Community Health Alliance Commercial	$35.61
Rate for Payer: Priority Health Commercial	$29.32
Rate for Payer: Priority Health PPO	$29.32

PHA LISONOPRIL 5MG TAB

Facility

$0.31

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501420
Hospital Revenue Code	637
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.20
Rate for Payer: Community Health Alliance Commercial	$0.26
Rate for Payer: Priority Health Commercial	$0.22
Rate for Payer: Priority Health PPO	$0.22

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges