Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA LITHIUM CARBONATE 150 MG

Facility

$0.99

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502424
Hospital Revenue Code	637
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$0.84
Rate for Payer: Cash Price	$0.64
Rate for Payer: Community Health Alliance Commercial	$0.84
Rate for Payer: Priority Health Commercial	$0.69
Rate for Payer: Priority Health PPO	$0.69

PHA LOPERAMIDE HCL 2MG CAP

Facility

$5.31

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501450
Hospital Revenue Code	637
Min. Negotiated Rate	$3.72
Max. Negotiated Rate	$4.51
Rate for Payer: Cash Price	$3.45
Rate for Payer: Community Health Alliance Commercial	$4.51
Rate for Payer: Priority Health Commercial	$3.72
Rate for Payer: Priority Health PPO	$3.72

PHA LORATADINE 10 MG TAB

Facility

$4.17

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500223
Hospital Revenue Code	637
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$3.54
Rate for Payer: Cash Price	$2.71
Rate for Payer: Community Health Alliance Commercial	$3.54
Rate for Payer: Priority Health Commercial	$2.92
Rate for Payer: Priority Health PPO	$2.92

PHA LORAZEPAM 2MG INJ

Facility

$15.00

Service Code	HCPCS J2060
Hospital Charge Code	2501510
Hospital Revenue Code	636
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$12.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Community Health Alliance Commercial	$12.75
Rate for Payer: Priority Health Commercial	$10.50
Rate for Payer: Priority Health PPO	$10.50

PHA LORAZEPAM 2MG/ML 1ML CARPU

Facility

$87.94

Service Code	NDC 409198530
Hospital Charge Code	2510952
Hospital Revenue Code	250
Min. Negotiated Rate	$61.56
Max. Negotiated Rate	$74.75
Rate for Payer: Cash Price	$57.16
Rate for Payer: Community Health Alliance Commercial	$74.75
Rate for Payer: Priority Health Commercial	$61.56
Rate for Payer: Priority Health PPO	$61.56

PHA LORZAEPAM 0.5MG TAB

Facility

$0.52

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501480
Hospital Revenue Code	637
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.34
Rate for Payer: Community Health Alliance Commercial	$0.44
Rate for Payer: Priority Health Commercial	$0.36
Rate for Payer: Priority Health PPO	$0.36

PHA LOSARTAN POTASSIUM 50MGTAB

Facility

$4.22

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500822
Hospital Revenue Code	637
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$3.59
Rate for Payer: Cash Price	$2.74
Rate for Payer: Community Health Alliance Commercial	$3.59
Rate for Payer: Priority Health Commercial	$2.95
Rate for Payer: Priority Health PPO	$2.95

PHA LYMPHAZURIN 10MG/5ML VIAL

Facility

$676.20

Service Code	HCPCS Q9968
Hospital Charge Code	2501002
Hospital Revenue Code	636
Min. Negotiated Rate	$4.53
Max. Negotiated Rate	$574.77
Rate for Payer: BCBS BCN 65	$10.30
Rate for Payer: Blue Care Network Medicare Advantage	$10.30
Rate for Payer: Cash Price	$439.53
Rate for Payer: Cash Price	$439.53
Rate for Payer: Community Health Alliance Commercial	$574.77
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$10.30
Rate for Payer: Meridian Health Plan Medicare	$10.30
Rate for Payer: Priority Health Commercial	$473.34
Rate for Payer: Priority Health Medicaid	$10.30
Rate for Payer: Priority Health Medicare	$10.30
Rate for Payer: Priority Health PPO	$473.34
Rate for Payer: United Health Care Medicaid	$10.30
Rate for Payer: United Health Care Medicare Advantage	$4.53

PHA MAGNESIUM CHLORIDE 64MG TA

Facility

$0.57

Service Code	HCPCS A9270 GY
Hospital Charge Code	2508505
Hospital Revenue Code	637
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.37
Rate for Payer: Community Health Alliance Commercial	$0.48
Rate for Payer: Priority Health Commercial	$0.40
Rate for Payer: Priority Health PPO	$0.40

PHA MAGNESIUM CITRATE 300ML ML

Facility

$13.23

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501570
Hospital Revenue Code	637
Min. Negotiated Rate	$9.26
Max. Negotiated Rate	$11.25
Rate for Payer: Cash Price	$8.60
Rate for Payer: Community Health Alliance Commercial	$11.25
Rate for Payer: Priority Health Commercial	$9.26
Rate for Payer: Priority Health PPO	$9.26

PHA MAGNESIUM HYDROXIDE 30ML

Facility

$24.28

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501810
Hospital Revenue Code	637
Min. Negotiated Rate	$17.00
Max. Negotiated Rate	$20.64
Rate for Payer: Cash Price	$15.78
Rate for Payer: Community Health Alliance Commercial	$20.64
Rate for Payer: Priority Health Commercial	$17.00
Rate for Payer: Priority Health PPO	$17.00

PHA MAGNESIUM OXIDE 400 MG TAB

Facility

$0.94

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503773
Hospital Revenue Code	637
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.61
Rate for Payer: Community Health Alliance Commercial	$0.80
Rate for Payer: Priority Health Commercial	$0.66
Rate for Payer: Priority Health PPO	$0.66

PHA MAGNESIUM SULFATE 1GM 100M

Facility

$51.42

Service Code	HCPCS J3475
Hospital Charge Code	2507708
Hospital Revenue Code	636
Min. Negotiated Rate	$35.99
Max. Negotiated Rate	$43.71
Rate for Payer: Cash Price	$33.42
Rate for Payer: Community Health Alliance Commercial	$43.71
Rate for Payer: Priority Health Commercial	$35.99
Rate for Payer: Priority Health PPO	$35.99

PHA MAGNESIUM SULFATE 2G/50ML

Facility

$42.41

Service Code	HCPCS J3475
Hospital Charge Code	2507709
Hospital Revenue Code	636
Min. Negotiated Rate	$29.69
Max. Negotiated Rate	$36.05
Rate for Payer: Cash Price	$27.57
Rate for Payer: Community Health Alliance Commercial	$36.05
Rate for Payer: Priority Health Commercial	$29.69
Rate for Payer: Priority Health PPO	$29.69

PHA MAGNESIUM SULFATE 40GM

Facility

$46.30

Service Code	HCPCS J3475
Hospital Charge Code	2500913
Hospital Revenue Code	636
Min. Negotiated Rate	$32.41
Max. Negotiated Rate	$39.35
Rate for Payer: Cash Price	$30.10
Rate for Payer: Community Health Alliance Commercial	$39.35
Rate for Payer: Priority Health Commercial	$32.41
Rate for Payer: Priority Health PPO	$32.41

PHA MAGNEVIST 20 ML

Facility

$332.66

Service Code	HCPCS A9579
Hospital Charge Code	3500002
Hospital Revenue Code	636
Min. Negotiated Rate	$232.86
Max. Negotiated Rate	$282.76
Rate for Payer: Cash Price	$216.23
Rate for Payer: Community Health Alliance Commercial	$282.76
Rate for Payer: Priority Health Commercial	$232.86
Rate for Payer: Priority Health PPO	$232.86

PHA MAG SULF INJ 5GM/10ML VIAL

Facility

$49.74

Service Code	HCPCS J3475
Hospital Charge Code	2501580
Hospital Revenue Code	636
Min. Negotiated Rate	$34.82
Max. Negotiated Rate	$42.28
Rate for Payer: Cash Price	$32.33
Rate for Payer: Community Health Alliance Commercial	$42.28
Rate for Payer: Priority Health Commercial	$34.82
Rate for Payer: Priority Health PPO	$34.82

PHA MANNITOL 12.5GM/50ML VIAL

Facility

$49.78

Service Code	HCPCS J2150
Hospital Charge Code	2501610
Hospital Revenue Code	636
Min. Negotiated Rate	$34.85
Max. Negotiated Rate	$42.31
Rate for Payer: Cash Price	$32.36
Rate for Payer: Community Health Alliance Commercial	$42.31
Rate for Payer: Priority Health Commercial	$34.85
Rate for Payer: Priority Health PPO	$34.85

PHA MARCAINE W/EPI 0.25%

Facility

$66.50

Service Code	HCPCS J3490
Hospital Charge Code	2500624
Hospital Revenue Code	636
Min. Negotiated Rate	$46.55
Max. Negotiated Rate	$56.52
Rate for Payer: Cash Price	$43.23
Rate for Payer: Community Health Alliance Commercial	$56.52
Rate for Payer: Priority Health Commercial	$46.55
Rate for Payer: Priority Health PPO	$46.55

PHA MECLIZINE HCL 12.5MG TAB

Facility

$4.38

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501640
Hospital Revenue Code	637
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$3.72
Rate for Payer: Cash Price	$2.85
Rate for Payer: Community Health Alliance Commercial	$3.72
Rate for Payer: Priority Health Commercial	$3.07
Rate for Payer: Priority Health PPO	$3.07

PHA MEDROXYPROGESTERONE ACETAT

Facility

$1.62

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501655
Hospital Revenue Code	637
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$1.05
Rate for Payer: Community Health Alliance Commercial	$1.38
Rate for Payer: Priority Health Commercial	$1.13
Rate for Payer: Priority Health PPO	$1.13

PHA MEDROXYPROGESTERONE ACETAT

Facility

$326.82

Service Code	NDC 59762453701
Hospital Charge Code	2507001
Hospital Revenue Code	250
Min. Negotiated Rate	$228.77
Max. Negotiated Rate	$277.80
Rate for Payer: Cash Price	$212.43
Rate for Payer: Community Health Alliance Commercial	$277.80
Rate for Payer: Priority Health Commercial	$228.77
Rate for Payer: Priority Health PPO	$228.77

PHA MEGESTROL ACETATE 400 MG

Facility

$23.60

Service Code	NDC 121477610
Hospital Charge Code	2510013
Hospital Revenue Code	250
Min. Negotiated Rate	$16.52
Max. Negotiated Rate	$20.06
Rate for Payer: Cash Price	$15.34
Rate for Payer: Community Health Alliance Commercial	$20.06
Rate for Payer: Priority Health Commercial	$16.52
Rate for Payer: Priority Health PPO	$16.52

PHA MEGESTROL ACETATE 40MG TAB

Facility

$2.91

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510012
Hospital Revenue Code	637
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$2.47
Rate for Payer: Cash Price	$1.89
Rate for Payer: Community Health Alliance Commercial	$2.47
Rate for Payer: Priority Health Commercial	$2.04
Rate for Payer: Priority Health PPO	$2.04

PHA MELOXICAM 7.5 MG TAB

Facility

$16.15

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500401
Hospital Revenue Code	637
Min. Negotiated Rate	$11.30
Max. Negotiated Rate	$13.73
Rate for Payer: Cash Price	$10.50
Rate for Payer: Community Health Alliance Commercial	$13.73
Rate for Payer: Priority Health Commercial	$11.30
Rate for Payer: Priority Health PPO	$11.30

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges