Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA NIVOLUMAB 10MG/ML VIAL

Facility

$9,236.17

Service Code	HCPCS J9299
Hospital Charge Code	2507371
Hospital Revenue Code	636
Min. Negotiated Rate	$15.51
Max. Negotiated Rate	$7,850.74
Rate for Payer: BCBS BCN 65	$35.25
Rate for Payer: Blue Care Network Medicare Advantage	$35.25
Rate for Payer: Cash Price	$6,003.51
Rate for Payer: Cash Price	$6,003.51
Rate for Payer: Community Health Alliance Commercial	$7,850.74
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$35.25
Rate for Payer: Meridian Health Plan Medicare	$35.25
Rate for Payer: Priority Health Commercial	$6,465.32
Rate for Payer: Priority Health Medicaid	$35.25
Rate for Payer: Priority Health Medicare	$35.25
Rate for Payer: Priority Health PPO	$6,465.32
Rate for Payer: United Health Care Medicaid	$35.25
Rate for Payer: United Health Care Medicare Advantage	$15.51

PHANLANGEAL COMPONENT

Facility

$1,264.00

Service Code	HCPCS C1713
Hospital Charge Code	27817608
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

PHA NOREPINEPHRN BITART 1MG/ML

Facility

$99.02

Service Code	NDC 703115303
Hospital Charge Code	2507360
Hospital Revenue Code	250
Min. Negotiated Rate	$69.31
Max. Negotiated Rate	$84.17
Rate for Payer: Cash Price	$64.36
Rate for Payer: Community Health Alliance Commercial	$84.17
Rate for Payer: Priority Health Commercial	$69.31
Rate for Payer: Priority Health PPO	$69.31

PHA NYSTATIN

Facility

$8.02

Service Code	HCPCS A9270 GY
Hospital Charge Code	2507425
Hospital Revenue Code	637
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$6.82
Rate for Payer: Cash Price	$5.21
Rate for Payer: Community Health Alliance Commercial	$6.82
Rate for Payer: Priority Health Commercial	$5.61
Rate for Payer: Priority Health PPO	$5.61

PHA NYSTATIN 100000 U/GM BTL

Facility

$149.09

Service Code	HCPCS A9270 GY
Hospital Charge Code	2507420
Hospital Revenue Code	637
Min. Negotiated Rate	$104.36
Max. Negotiated Rate	$126.73
Rate for Payer: Cash Price	$96.91
Rate for Payer: Community Health Alliance Commercial	$126.73
Rate for Payer: Priority Health Commercial	$104.36
Rate for Payer: Priority Health PPO	$104.36

PHA NYSTATIN CREAM 30 GM TUBE

Facility

$104.48

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503005
Hospital Revenue Code	637
Min. Negotiated Rate	$73.14
Max. Negotiated Rate	$88.81
Rate for Payer: Cash Price	$67.91
Rate for Payer: Community Health Alliance Commercial	$88.81
Rate for Payer: Priority Health Commercial	$73.14
Rate for Payer: Priority Health PPO	$73.14

PHA NYSTATIN-TRIAMCINOLNE CRM

Facility

$308.95

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505150
Hospital Revenue Code	637
Min. Negotiated Rate	$216.26
Max. Negotiated Rate	$262.61
Rate for Payer: Cash Price	$200.82
Rate for Payer: Community Health Alliance Commercial	$262.61
Rate for Payer: Priority Health Commercial	$216.26
Rate for Payer: Priority Health PPO	$216.26

PHA OCTAGAM 10% 10G LIQUID

Facility

$5,314.68

Service Code	HCPCS J1568
Hospital Charge Code	2505621
Hospital Revenue Code	636
Min. Negotiated Rate	$21.89
Max. Negotiated Rate	$4,517.48
Rate for Payer: BCBS BCN 65	$49.76
Rate for Payer: Blue Care Network Medicare Advantage	$49.76
Rate for Payer: Cash Price	$3,454.54
Rate for Payer: Cash Price	$3,454.54
Rate for Payer: Community Health Alliance Commercial	$4,517.48
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$49.76
Rate for Payer: Meridian Health Plan Medicare	$49.76
Rate for Payer: Priority Health Commercial	$3,720.28
Rate for Payer: Priority Health Medicaid	$49.76
Rate for Payer: Priority Health Medicare	$49.76
Rate for Payer: Priority Health PPO	$3,720.28
Rate for Payer: United Health Care Medicaid	$49.76
Rate for Payer: United Health Care Medicare Advantage	$21.89

PHA OCTAGAM 20G/200ML BTL

Facility

$10,629.36

Service Code	HCPCS J1568
Hospital Charge Code	2510825
Hospital Revenue Code	636
Min. Negotiated Rate	$21.89
Max. Negotiated Rate	$9,034.96
Rate for Payer: BCBS BCN 65	$49.76
Rate for Payer: Blue Care Network Medicare Advantage	$49.76
Rate for Payer: Cash Price	$6,909.08
Rate for Payer: Cash Price	$6,909.08
Rate for Payer: Community Health Alliance Commercial	$9,034.96
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$49.76
Rate for Payer: Meridian Health Plan Medicare	$49.76
Rate for Payer: Priority Health Commercial	$7,440.55
Rate for Payer: Priority Health Medicaid	$49.76
Rate for Payer: Priority Health Medicare	$49.76
Rate for Payer: Priority Health PPO	$7,440.55
Rate for Payer: United Health Care Medicaid	$49.76
Rate for Payer: United Health Care Medicare Advantage	$21.89

PHA OENICILLIN G BENZATHINE

Facility

$407.85

Service Code	NDC 60793070110
Hospital Charge Code	2507684
Hospital Revenue Code	250
Min. Negotiated Rate	$285.50
Max. Negotiated Rate	$346.67
Rate for Payer: Cash Price	$265.10
Rate for Payer: Community Health Alliance Commercial	$346.67
Rate for Payer: Priority Health Commercial	$285.50
Rate for Payer: Priority Health PPO	$285.50

PHA OFLOXACIN 5 ML

Facility

$0.68

Service Code	HCPCS A9270 GY
Hospital Charge Code	2507445
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 OFLOXACIN (OTIC) 0.3% DROP

Facility

$425.81

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500314
Hospital Revenue Code	637
Min. Negotiated Rate	$298.07
Max. Negotiated Rate	$361.94
Rate for Payer: Cash Price	$276.78
Rate for Payer: Community Health Alliance Commercial	$361.94
Rate for Payer: Priority Health Commercial	$298.07
Rate for Payer: Priority Health PPO	$298.07

PHA OINTMENT NEOSPORIN

Facility

$15.00

Service Code	HCPCS A9270 GY
Hospital Charge Code	25910785
Hospital Revenue Code	637
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 OLANZAPINE 5 MG TAB

Facility

$60.55

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502893
Hospital Revenue Code	637
Min. Negotiated Rate	$42.38
Max. Negotiated Rate	$51.47
Rate for Payer: Cash Price	$39.36
Rate for Payer: Community Health Alliance Commercial	$51.47
Rate for Payer: Priority Health Commercial	$42.38
Rate for Payer: Priority Health PPO	$42.38

PHA OLANZIPINE 20MG TAB NF

Facility

$147.46

Service Code	NDC 33342007207
Hospital Charge Code	2510805
Hospital Revenue Code	637
Min. Negotiated Rate	$103.22
Max. Negotiated Rate	$125.34
Rate for Payer: Cash Price	$95.85
Rate for Payer: Community Health Alliance Commercial	$125.34
Rate for Payer: Priority Health Commercial	$103.22
Rate for Payer: Priority Health PPO	$103.22

PHA OMNIPAQUE 100ML VIAL

Facility

$300.70

Service Code	HCPCS Q9967
Hospital Charge Code	3500004
Hospital Revenue Code	636
Min. Negotiated Rate	$210.49
Max. Negotiated Rate	$255.59
Rate for Payer: Cash Price	$195.46
Rate for Payer: Community Health Alliance Commercial	$255.59
Rate for Payer: Priority Health Commercial	$210.49
Rate for Payer: Priority Health PPO	$210.49

PHA OMNIPAQUE 10 ML VIAL

Facility

$192.00

Service Code	HCPCS Q9967
Hospital Charge Code	3500005
Hospital Revenue Code	636
Min. Negotiated Rate	$134.40
Max. Negotiated Rate	$163.20
Rate for Payer: Cash Price	$124.80
Rate for Payer: Community Health Alliance Commercial	$163.20
Rate for Payer: Priority Health Commercial	$134.40
Rate for Payer: Priority Health PPO	$134.40

PHA ONDANSETRON 2 MG/ML 0768

Facility

$3.75

Service Code	HCPCS J2405
Hospital Charge Code	2507480
Hospital Revenue Code	636
Min. Negotiated Rate	$2.62
Max. Negotiated Rate	$3.19
Rate for Payer: Cash Price	$2.44
Rate for Payer: Community Health Alliance Commercial	$3.19
Rate for Payer: Priority Health Commercial	$2.62
Rate for Payer: Priority Health PPO	$2.62

PHA ONDANSETRON HCL 4 MG TAB

Facility

$102.09

Service Code	NDC 781523864
Hospital Charge Code	2507475
Hospital Revenue Code	637
Min. Negotiated Rate	$71.46
Max. Negotiated Rate	$86.78
Rate for Payer: Cash Price	$66.36
Rate for Payer: Community Health Alliance Commercial	$86.78
Rate for Payer: Priority Health Commercial	$71.46
Rate for Payer: Priority Health PPO	$71.46

PHA OPDIVO 240MG/24ML VIAL

Facility

$22,166.91

Service Code	HCPCS J9299
Hospital Charge Code	2510832
Hospital Revenue Code	636
Min. Negotiated Rate	$15.51
Max. Negotiated Rate	$18,841.87
Rate for Payer: BCBS BCN 65	$35.25
Rate for Payer: Blue Care Network Medicare Advantage	$35.25
Rate for Payer: Cash Price	$14,408.49
Rate for Payer: Cash Price	$14,408.49
Rate for Payer: Community Health Alliance Commercial	$18,841.87
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$35.25
Rate for Payer: Meridian Health Plan Medicare	$35.25
Rate for Payer: Priority Health Commercial	$15,516.84
Rate for Payer: Priority Health Medicaid	$35.25
Rate for Payer: Priority Health Medicare	$35.25
Rate for Payer: Priority Health PPO	$15,516.84
Rate for Payer: United Health Care Medicaid	$35.25
Rate for Payer: United Health Care Medicare Advantage	$15.51

PHA OPHTHALMIC IRRIG SOL 15ML

Facility

$69.52

Service Code	NDC 65079515
Hospital Charge Code	2502350
Hospital Revenue Code	250
Min. Negotiated Rate	$48.66
Max. Negotiated Rate	$59.09
Rate for Payer: Cash Price	$45.19
Rate for Payer: Community Health Alliance Commercial	$59.09
Rate for Payer: Priority Health Commercial	$48.66
Rate for Payer: Priority Health PPO	$48.66

PHA OPHTHALMIC IRRIG SOL 20 ML

Facility

$328.96

Service Code	NDC 65080050
Hospital Charge Code	2502355
Hospital Revenue Code	250
Min. Negotiated Rate	$230.27
Max. Negotiated Rate	$279.62
Rate for Payer: Cash Price	$213.82
Rate for Payer: Community Health Alliance Commercial	$279.62
Rate for Payer: Priority Health Commercial	$230.27
Rate for Payer: Priority Health PPO	$230.27

PHA ORPHENADRN CITRATE 30MG/ML

Facility

$101.68

Service Code	HCPCS J2360
Hospital Charge Code	2507500
Hospital Revenue Code	636
Min. Negotiated Rate	$71.18
Max. Negotiated Rate	$86.43
Rate for Payer: Cash Price	$66.09
Rate for Payer: Community Health Alliance Commercial	$86.43
Rate for Payer: Priority Health Commercial	$71.18
Rate for Payer: Priority Health PPO	$71.18

PHA OSELTAMIVIR PHOSPHATE 75

Facility

$83.49

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509109
Hospital Revenue Code	637
Min. Negotiated Rate	$58.44
Max. Negotiated Rate	$70.97
Rate for Payer: Cash Price	$54.27
Rate for Payer: Community Health Alliance Commercial	$70.97
Rate for Payer: Priority Health Commercial	$58.44
Rate for Payer: Priority Health PPO	$58.44

PHA OXALIPLATIN 100MG INJ

Facility

$1,699.76

Service Code	HCPCS J9263
Hospital Charge Code	2501234
Hospital Revenue Code	636
Min. Negotiated Rate	$1,189.83
Max. Negotiated Rate	$1,444.80
Rate for Payer: Cash Price	$1,104.84
Rate for Payer: Community Health Alliance Commercial	$1,444.80
Rate for Payer: Priority Health Commercial	$1,189.83
Rate for Payer: Priority Health PPO	$1,189.83

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges