Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA RETACRIT 4000 UNITS/ML

Facility

$181.20

Service Code	HCPCS Q5106
Hospital Charge Code	2501532
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$154.02
Rate for Payer: BCBS BCN 65	$7.95
Rate for Payer: Blue Care Network Medicare Advantage	$7.95
Rate for Payer: Cash Price	$117.78
Rate for Payer: Cash Price	$117.78
Rate for Payer: Community Health Alliance Commercial	$154.02
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$7.95
Rate for Payer: Meridian Health Plan Medicare	$7.95
Rate for Payer: Priority Health Commercial	$126.84
Rate for Payer: Priority Health Medicaid	$7.95
Rate for Payer: Priority Health Medicare	$7.95
Rate for Payer: Priority Health PPO	$126.84
Rate for Payer: United Health Care Medicaid	$7.95
Rate for Payer: United Health Care Medicare Advantage	$3.50

PHA RISPERIDONE 0.5 MG TAB

Facility

$20.48

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505678
Hospital Revenue Code	637
Min. Negotiated Rate	$14.34
Max. Negotiated Rate	$17.41
Rate for Payer: Cash Price	$13.31
Rate for Payer: Community Health Alliance Commercial	$17.41
Rate for Payer: Priority Health Commercial	$14.34
Rate for Payer: Priority Health PPO	$14.34

PHA RITUXIMAB 500 MG INJ 0849

Facility

$12,852.63

Service Code	HCPCS j9312
Hospital Charge Code	2508985
Hospital Revenue Code	636
Min. Negotiated Rate	$8,996.84
Max. Negotiated Rate	$10,924.74
Rate for Payer: Cash Price	$8,354.21
Rate for Payer: Community Health Alliance Commercial	$10,924.74
Rate for Payer: Priority Health Commercial	$8,996.84
Rate for Payer: Priority Health PPO	$8,996.84

PHA RITUXIMAD 100MG

Facility

$2,570.52

Service Code	HCPCS J9312
Hospital Charge Code	2508986
Hospital Revenue Code	636
Min. Negotiated Rate	$34.54
Max. Negotiated Rate	$2,184.94
Rate for Payer: BCBS BCN 65	$78.51
Rate for Payer: Blue Care Network Medicare Advantage	$78.51
Rate for Payer: Cash Price	$1,670.84
Rate for Payer: Cash Price	$1,670.84
Rate for Payer: Community Health Alliance Commercial	$2,184.94
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$78.51
Rate for Payer: Meridian Health Plan Medicare	$78.51
Rate for Payer: Priority Health Commercial	$1,799.36
Rate for Payer: Priority Health Medicaid	$78.51
Rate for Payer: Priority Health Medicare	$78.51
Rate for Payer: Priority Health PPO	$1,799.36
Rate for Payer: United Health Care Medicaid	$78.51
Rate for Payer: United Health Care Medicare Advantage	$34.54

PHA RIVAROXABAN 10 MG TAB

Facility

$109.55

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503026
Hospital Revenue Code	637
Min. Negotiated Rate	$76.69
Max. Negotiated Rate	$93.12
Rate for Payer: Cash Price	$71.21
Rate for Payer: Community Health Alliance Commercial	$93.12
Rate for Payer: Priority Health Commercial	$76.69
Rate for Payer: Priority Health PPO	$76.69

PHA ROBERTSON'S DIAP CREAM30GM

Facility

$13.03

Service Code	HCPCS A9270 GY
Hospital Charge Code	2503855
Hospital Revenue Code	637
Min. Negotiated Rate	$9.12
Max. Negotiated Rate	$11.08
Rate for Payer: Cash Price	$8.47
Rate for Payer: Community Health Alliance Commercial	$11.08
Rate for Payer: Priority Health Commercial	$9.12
Rate for Payer: Priority Health PPO	$9.12

PHA ROCURONIUM BROMIDE 10MG/ML

Facility

$42.36

Service Code	HCPCS J3490
Hospital Charge Code	2509150
Hospital Revenue Code	636
Min. Negotiated Rate	$29.65
Max. Negotiated Rate	$36.01
Rate for Payer: Cash Price	$27.53
Rate for Payer: Community Health Alliance Commercial	$36.01
Rate for Payer: Priority Health Commercial	$29.65
Rate for Payer: Priority Health PPO	$29.65

PHA ROPINIROLE 2MG TABLET

Facility

$13.03

Service Code	NDC 43547027110
Hospital Charge Code	2510828
Hospital Revenue Code	637
Min. Negotiated Rate	$9.12
Max. Negotiated Rate	$11.08
Rate for Payer: Cash Price	$8.47
Rate for Payer: Community Health Alliance Commercial	$11.08
Rate for Payer: Priority Health Commercial	$9.12
Rate for Payer: Priority Health PPO	$9.12

PHA ROPINIROLE HYDROCHLORIDE

Facility

$13.03

Service Code	HCPCS A9270 GY
Hospital Charge Code	2507022
Hospital Revenue Code	637
Min. Negotiated Rate	$9.12
Max. Negotiated Rate	$11.08
Rate for Payer: Cash Price	$8.47
Rate for Payer: Community Health Alliance Commercial	$11.08
Rate for Payer: Priority Health Commercial	$9.12
Rate for Payer: Priority Health PPO	$9.12

PHA ROPIVACAINE HCL 0.5% 5MG

Facility

$90.73

Service Code	HCPCS J2795
Hospital Charge Code	2504123
Hospital Revenue Code	636
Min. Negotiated Rate	$63.51
Max. Negotiated Rate	$77.12
Rate for Payer: Cash Price	$58.97
Rate for Payer: Community Health Alliance Commercial	$77.12
Rate for Payer: Priority Health Commercial	$63.51
Rate for Payer: Priority Health PPO	$63.51

PHA ROPIVACAINE HCL 2MG/ML

Facility

$194.18

Service Code	NDC 63323028565
Hospital Charge Code	2507722
Hospital Revenue Code	250
Min. Negotiated Rate	$135.93
Max. Negotiated Rate	$165.05
Rate for Payer: Cash Price	$126.22
Rate for Payer: Community Health Alliance Commercial	$165.05
Rate for Payer: Priority Health Commercial	$135.93
Rate for Payer: Priority Health PPO	$135.93

PHA ROPIVACAINE HCL 400MG

Facility

$325.92

Service Code	HCPCS J2795
Hospital Charge Code	2507723
Hospital Revenue Code	636
Min. Negotiated Rate	$228.14
Max. Negotiated Rate	$277.03
Rate for Payer: Cash Price	$211.85
Rate for Payer: Community Health Alliance Commercial	$277.03
Rate for Payer: Priority Health Commercial	$228.14
Rate for Payer: Priority Health PPO	$228.14

PHA SALINE GEL 14.1 GM TUBE

Facility

$17.40

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500814
Hospital Revenue Code	637
Min. Negotiated Rate	$12.18
Max. Negotiated Rate	$14.79
Rate for Payer: Cash Price	$11.31
Rate for Payer: Community Health Alliance Commercial	$14.79
Rate for Payer: Priority Health Commercial	$12.18
Rate for Payer: Priority Health PPO	$12.18

PHA SANDOSTATIN 0.1 MG/ML AMP

Facility

$130.78

Service Code	HCPCS J2354
Hospital Charge Code	2507441
Hospital Revenue Code	637
Min. Negotiated Rate	$91.55
Max. Negotiated Rate	$111.16
Rate for Payer: Cash Price	$85.01
Rate for Payer: Community Health Alliance Commercial	$111.16
Rate for Payer: Priority Health Commercial	$91.55
Rate for Payer: Priority Health PPO	$91.55

PHA SCOPOLAMINE 1.5 MG PTCH

Facility

$101.73

Service Code	NDC 10019055301
Hospital Charge Code	2503101
Hospital Revenue Code	250
Min. Negotiated Rate	$71.21
Max. Negotiated Rate	$86.47
Rate for Payer: Cash Price	$66.12
Rate for Payer: Community Health Alliance Commercial	$86.47
Rate for Payer: Priority Health Commercial	$71.21
Rate for Payer: Priority Health PPO	$71.21

PHA SENNOSIDES 8.6MG TAB

Facility

$0.42

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509255
Hospital Revenue Code	637
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.27
Rate for Payer: Community Health Alliance Commercial	$0.36
Rate for Payer: Priority Health Commercial	$0.29
Rate for Payer: Priority Health PPO	$0.29

PHA SENNOSIDES-DOCUSATE SOD

Facility

$0.21

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509256
Hospital Revenue Code	637
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Community Health Alliance Commercial	$0.18
Rate for Payer: Priority Health Commercial	$0.15
Rate for Payer: Priority Health PPO	$0.15

PHA SERTRALINE HCL 50MG TAB

Facility

$2.08

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509220
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 SEVOFLURANE 250ML BTL

Facility

$491.81

Service Code	NDC 66794001525
Hospital Charge Code	2510310
Hospital Revenue Code	250
Min. Negotiated Rate	$344.27
Max. Negotiated Rate	$418.04
Rate for Payer: Cash Price	$319.68
Rate for Payer: Community Health Alliance Commercial	$418.04
Rate for Payer: Priority Health Commercial	$344.27
Rate for Payer: Priority Health PPO	$344.27

PHA SILVER NITRATE 1 APPLICATR

Facility

$1.25

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509260
Hospital Revenue Code	637
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.06
Rate for Payer: Cash Price	$0.81
Rate for Payer: Community Health Alliance Commercial	$1.06
Rate for Payer: Priority Health Commercial	$0.88
Rate for Payer: Priority Health PPO	$0.88

PHA SILVER SULFADIAZINE 25 GM

Facility

$62.06

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509245
Hospital Revenue Code	637
Min. Negotiated Rate	$43.44
Max. Negotiated Rate	$52.75
Rate for Payer: Cash Price	$40.34
Rate for Payer: Community Health Alliance Commercial	$52.75
Rate for Payer: Priority Health Commercial	$43.44
Rate for Payer: Priority Health PPO	$43.44

PHA SILVER SULFADIAZINE 400GM

Facility

$212.39

Service Code	NDC 591081046
Hospital Charge Code	2509240
Hospital Revenue Code	637
Min. Negotiated Rate	$148.67
Max. Negotiated Rate	$180.53
Rate for Payer: Cash Price	$138.05
Rate for Payer: Community Health Alliance Commercial	$180.53
Rate for Payer: Priority Health Commercial	$148.67
Rate for Payer: Priority Health PPO	$148.67

PHA SIMETHICONE 40MG/0.6ML ML

Facility

$13.49

Service Code	NDC 904506730
Hospital Charge Code	2509280
Hospital Revenue Code	637
Min. Negotiated Rate	$9.44
Max. Negotiated Rate	$11.47
Rate for Payer: Cash Price	$8.77
Rate for Payer: Community Health Alliance Commercial	$11.47
Rate for Payer: Priority Health Commercial	$9.44
Rate for Payer: Priority Health PPO	$9.44

PHA SIMETHICONE 80 MG CHW

Facility

$0.47

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509270
Hospital Revenue Code	637
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.31
Rate for Payer: Community Health Alliance Commercial	$0.40
Rate for Payer: Priority Health Commercial	$0.33
Rate for Payer: Priority Health PPO	$0.33

PHA SIMPONI ARIA 12.5MG/ML

Facility

$5,469.79

Service Code	HCPCS J1602
Hospital Charge Code	2509909
Hospital Revenue Code	636
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$4,649.32
Rate for Payer: BCBS BCN 65	$12.21
Rate for Payer: Blue Care Network Medicare Advantage	$12.21
Rate for Payer: Cash Price	$3,555.36
Rate for Payer: Cash Price	$3,555.36
Rate for Payer: Community Health Alliance Commercial	$4,649.32
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$12.21
Rate for Payer: Meridian Health Plan Medicare	$12.21
Rate for Payer: Priority Health Commercial	$3,828.85
Rate for Payer: Priority Health Medicaid	$12.21
Rate for Payer: Priority Health Medicare	$12.21
Rate for Payer: Priority Health PPO	$3,828.85
Rate for Payer: United Health Care Medicaid	$12.21
Rate for Payer: United Health Care Medicare Advantage	$5.37

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges