Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA METOPROLOL SUCCINATE 25MG

Facility

$6.46

Service Code	HCPCS A9270 GY
Hospital Charge Code	2501727
Hospital Revenue Code	637
Min. Negotiated Rate	$4.52
Max. Negotiated Rate	$5.49
Rate for Payer: Cash Price	$4.20
Rate for Payer: Community Health Alliance Commercial	$5.49
Rate for Payer: Priority Health Commercial	$4.52
Rate for Payer: Priority Health PPO	$4.52

PHA METOPROLOL TARTRATE 1MG/ML

Facility

$6.25

Service Code	NDC 36000003310
Hospital Charge Code	2502160
Hospital Revenue Code	250
Min. Negotiated Rate	$4.38
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$4.06
Rate for Payer: Community Health Alliance Commercial	$5.31
Rate for Payer: Priority Health Commercial	$4.38
Rate for Payer: Priority Health PPO	$4.38

PHA METOPROLOL TARTRATE 50MG

Facility

$0.68

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502170
Hospital Revenue Code	637
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.44
Rate for Payer: Community Health Alliance Commercial	$0.58
Rate for Payer: Priority Health Commercial	$0.48
Rate for Payer: Priority Health PPO	$0.48

PHA METRONIDAZOLE 250MG TAB

Facility

$3.02

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502180
Hospital Revenue Code	637
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$2.57
Rate for Payer: Cash Price	$1.96
Rate for Payer: Community Health Alliance Commercial	$2.57
Rate for Payer: Priority Health Commercial	$2.11
Rate for Payer: Priority Health PPO	$2.11

PHA METRONIDAZOLE 5MG/ML BAG

Facility

$11.98

Service Code	NDC 409781124
Hospital Charge Code	2502190
Hospital Revenue Code	250
Min. Negotiated Rate	$8.39
Max. Negotiated Rate	$10.18
Rate for Payer: Cash Price	$7.79
Rate for Payer: Community Health Alliance Commercial	$10.18
Rate for Payer: Priority Health Commercial	$8.39
Rate for Payer: Priority Health PPO	$8.39

PHA MIACALCIN 3.7ML NASAL SPRA

Facility

$2,364.40

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502562
Hospital Revenue Code	637
Min. Negotiated Rate	$1,655.08
Max. Negotiated Rate	$2,009.74
Rate for Payer: Cash Price	$1,536.86
Rate for Payer: Community Health Alliance Commercial	$2,009.74
Rate for Payer: Priority Health Commercial	$1,655.08
Rate for Payer: Priority Health PPO	$1,655.08

PHA MICONAZOLE NITRATE 2% TUBE

Facility

$52.44

Service Code	HCPCS A9270 GY
Hospital Charge Code	2504130
Hospital Revenue Code	637
Min. Negotiated Rate	$36.71
Max. Negotiated Rate	$44.57
Rate for Payer: Cash Price	$34.09
Rate for Payer: Community Health Alliance Commercial	$44.57
Rate for Payer: Priority Health Commercial	$36.71
Rate for Payer: Priority Health PPO	$36.71

PHA MIDAZOLAM HCL 2MG/2ML CAPU

Facility

$6.25

Service Code	HCPCS J2250
Hospital Charge Code	2508943
Hospital Revenue Code	636
Min. Negotiated Rate	$4.38
Max. Negotiated Rate	$5.31
Rate for Payer: Cash Price	$4.06
Rate for Payer: Community Health Alliance Commercial	$5.31
Rate for Payer: Priority Health Commercial	$4.38
Rate for Payer: Priority Health PPO	$4.38

PHA MIDAZOLAM HCL 2 MG/ML

Facility

$38.19

Service Code	HCPCS J2250
Hospital Charge Code	2503145
Hospital Revenue Code	636
Min. Negotiated Rate	$26.73
Max. Negotiated Rate	$32.46
Rate for Payer: Cash Price	$24.82
Rate for Payer: Community Health Alliance Commercial	$32.46
Rate for Payer: Priority Health Commercial	$26.73
Rate for Payer: Priority Health PPO	$26.73

PHA MIDAZOLAM HCL 50MG/10 ML V

Facility

$46.99

Service Code	HCPCS J2250
Hospital Charge Code	2501232
Hospital Revenue Code	636
Min. Negotiated Rate	$32.89
Max. Negotiated Rate	$39.94
Rate for Payer: Cash Price	$30.54
Rate for Payer: Community Health Alliance Commercial	$39.94
Rate for Payer: Priority Health Commercial	$32.89
Rate for Payer: Priority Health PPO	$32.89

PHA MIDAZOLAM HCL 5MG/ML VIAL

Facility

$7.50

Service Code	HCPCS J2250
Hospital Charge Code	2503140
Hospital Revenue Code	636
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$6.38
Rate for Payer: Cash Price	$4.88
Rate for Payer: Community Health Alliance Commercial	$6.38
Rate for Payer: Priority Health Commercial	$5.25
Rate for Payer: Priority Health PPO	$5.25

PHA MILRINONE LACTATE 1 MG

Facility

$50.75

Service Code	HCPCS J2260
Hospital Charge Code	2503155
Hospital Revenue Code	636
Min. Negotiated Rate	$35.52
Max. Negotiated Rate	$43.14
Rate for Payer: Cash Price	$32.99
Rate for Payer: Community Health Alliance Commercial	$43.14
Rate for Payer: Priority Health Commercial	$35.52
Rate for Payer: Priority Health PPO	$35.52

PHA MINERAL OIL 30ML UDCUP

Facility

$312.16

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503160
Hospital Revenue Code	637
Min. Negotiated Rate	$218.51
Max. Negotiated Rate	$265.34
Rate for Payer: Cash Price	$202.90
Rate for Payer: Community Health Alliance Commercial	$265.34
Rate for Payer: Priority Health Commercial	$218.51
Rate for Payer: Priority Health PPO	$218.51

PHA MINERAL OIL 55% VIAL

Facility

$123.98

Service Code	NDC 63323025410
Hospital Charge Code	2503170
Hospital Revenue Code	250
Min. Negotiated Rate	$86.79
Max. Negotiated Rate	$105.38
Rate for Payer: Cash Price	$80.59
Rate for Payer: Community Health Alliance Commercial	$105.38
Rate for Payer: Priority Health Commercial	$86.79
Rate for Payer: Priority Health PPO	$86.79

PHA MIRTAZAPINE 15 MG TAB

Facility

$14.90

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503171
Hospital Revenue Code	637
Min. Negotiated Rate	$10.43
Max. Negotiated Rate	$12.66
Rate for Payer: Cash Price	$9.69
Rate for Payer: Community Health Alliance Commercial	$12.66
Rate for Payer: Priority Health Commercial	$10.43
Rate for Payer: Priority Health PPO	$10.43

PHA MISOPROSTOL 100MCG TAB

Facility

$12.92

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503180
Hospital Revenue Code	637
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$10.98
Rate for Payer: Cash Price	$8.40
Rate for Payer: Community Health Alliance Commercial	$10.98
Rate for Payer: Priority Health Commercial	$9.04
Rate for Payer: Priority Health PPO	$9.04

PHA MISOPROSTOL 6 X 100 MCG

Facility

$32.49

Service Code	HCPCS S0191
Hospital Charge Code	2506413
Hospital Revenue Code	637
Min. Negotiated Rate	$22.74
Max. Negotiated Rate	$27.62
Rate for Payer: Cash Price	$21.12
Rate for Payer: Community Health Alliance Commercial	$27.62
Rate for Payer: Priority Health Commercial	$22.74
Rate for Payer: Priority Health PPO	$22.74

PHA MITOMYCIN 20 MG/40 ML VIAL

Facility

$473.29

Service Code	HCPCS J9280
Hospital Charge Code	2504488
Hospital Revenue Code	636
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$402.30
Rate for Payer: BCBS BCN 65	$27.41
Rate for Payer: Blue Care Network Medicare Advantage	$27.41
Rate for Payer: Cash Price	$307.64
Rate for Payer: Cash Price	$307.64
Rate for Payer: Community Health Alliance Commercial	$402.30
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$27.41
Rate for Payer: Meridian Health Plan Medicare	$27.41
Rate for Payer: Priority Health Commercial	$331.30
Rate for Payer: Priority Health Medicaid	$27.41
Rate for Payer: Priority Health Medicare	$27.41
Rate for Payer: Priority Health PPO	$331.30
Rate for Payer: United Health Care Medicaid	$27.41
Rate for Payer: United Health Care Medicare Advantage	$12.06

PHA MITOMYCIN 40 MG VIAL

Facility

$3,227.66

Service Code	HCPCS J9280
Hospital Charge Code	2504489
Hospital Revenue Code	636
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$2,743.51
Rate for Payer: BCBS BCN 65	$27.41
Rate for Payer: Blue Care Network Medicare Advantage	$27.41
Rate for Payer: Cash Price	$2,097.98
Rate for Payer: Cash Price	$2,097.98
Rate for Payer: Community Health Alliance Commercial	$2,743.51
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$27.41
Rate for Payer: Meridian Health Plan Medicare	$27.41
Rate for Payer: Priority Health Commercial	$2,259.36
Rate for Payer: Priority Health Medicaid	$27.41
Rate for Payer: Priority Health Medicare	$27.41
Rate for Payer: Priority Health PPO	$2,259.36
Rate for Payer: United Health Care Medicaid	$27.41
Rate for Payer: United Health Care Medicare Advantage	$12.06

PHA MITOXANTRONE 20 MG VIAL

Facility

$571.51

Service Code	HCPCS J9293
Hospital Charge Code	2503321
Hospital Revenue Code	636
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$485.78
Rate for Payer: BCBS BCN 65	$32.42
Rate for Payer: Blue Care Network Medicare Advantage	$32.42
Rate for Payer: Cash Price	$371.48
Rate for Payer: Cash Price	$371.48
Rate for Payer: Community Health Alliance Commercial	$485.78
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$32.42
Rate for Payer: Meridian Health Plan Medicare	$32.42
Rate for Payer: Priority Health Commercial	$400.06
Rate for Payer: Priority Health Medicaid	$32.42
Rate for Payer: Priority Health Medicare	$32.42
Rate for Payer: Priority Health PPO	$400.06
Rate for Payer: United Health Care Medicaid	$32.42
Rate for Payer: United Health Care Medicare Advantage	$14.27

PHA MONTELUKAST SODIUM 10 MG

Facility

$2.08

Service Code	HCPCS A9270 GY
Hospital Charge Code	2504145
Hospital Revenue Code	637
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$1.77
Rate for Payer: Cash Price	$1.35
Rate for Payer: Community Health Alliance Commercial	$1.77
Rate for Payer: Priority Health Commercial	$1.46
Rate for Payer: Priority Health PPO	$1.46

PHA MONTELUKAST SODIUM 4 MG

Facility

$31.16

Service Code	HCPCS A9270 GY
Hospital Charge Code	2504147
Hospital Revenue Code	637
Min. Negotiated Rate	$21.81
Max. Negotiated Rate	$26.49
Rate for Payer: Cash Price	$20.25
Rate for Payer: Community Health Alliance Commercial	$26.49
Rate for Payer: Priority Health Commercial	$21.81
Rate for Payer: Priority Health PPO	$21.81

PHA MORPHINE SULFATE 10MG 7010

Facility

$15.94

Service Code	HCPCS J2270
Hospital Charge Code	2504150
Hospital Revenue Code	636
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$13.55
Rate for Payer: Cash Price	$10.36
Rate for Payer: Community Health Alliance Commercial	$13.55
Rate for Payer: Priority Health Commercial	$11.16
Rate for Payer: Priority Health PPO	$11.16

PHA MORPHINE SULFATE 10MGUDCUP

Facility

$8.49

Service Code	HCPCS A9270 GY
Hospital Charge Code	2504180
Hospital Revenue Code	637
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$7.22
Rate for Payer: Cash Price	$5.52
Rate for Payer: Community Health Alliance Commercial	$7.22
Rate for Payer: Priority Health Commercial	$5.94
Rate for Payer: Priority Health PPO	$5.94

PHA MORPHINE SULFATE 15MG TAB

Facility

$10.63

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505120
Hospital Revenue Code	637
Min. Negotiated Rate	$7.44
Max. Negotiated Rate	$9.04
Rate for Payer: Cash Price	$6.91
Rate for Payer: Community Health Alliance Commercial	$9.04
Rate for Payer: Priority Health Commercial	$7.44
Rate for Payer: Priority Health PPO	$7.44

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges