Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA SINCALIDE 5 MCG VIAL

Facility

$432.11

Service Code	HCPCS J2805
Hospital Charge Code	2509290
Hospital Revenue Code	636
Min. Negotiated Rate	$302.48
Max. Negotiated Rate	$367.29
Rate for Payer: Cash Price	$280.87
Rate for Payer: Community Health Alliance Commercial	$367.29
Rate for Payer: Priority Health Commercial	$302.48
Rate for Payer: Priority Health PPO	$302.48

PHA SITAGLIPTIN PHOSPHATE 50MG

Facility

$16.39

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509898
Hospital Revenue Code	637
Min. Negotiated Rate	$11.47
Max. Negotiated Rate	$13.93
Rate for Payer: Cash Price	$10.65
Rate for Payer: Community Health Alliance Commercial	$13.93
Rate for Payer: Priority Health Commercial	$11.47
Rate for Payer: Priority Health PPO	$11.47

PHA SOD BECARBONATE 4.2% INJ

Facility

$59.40

Service Code	NDC 409553434
Hospital Charge Code	2502250
Hospital Revenue Code	250
Min. Negotiated Rate	$41.58
Max. Negotiated Rate	$50.49
Rate for Payer: Cash Price	$38.61
Rate for Payer: Community Health Alliance Commercial	$50.49
Rate for Payer: Priority Health Commercial	$41.58
Rate for Payer: Priority Health PPO	$41.58

PHA SOD BICARBONATE 8.4% INJ

Facility

$108.23

Service Code	NDC 76329335201
Hospital Charge Code	2502260
Hospital Revenue Code	250
Min. Negotiated Rate	$75.76
Max. Negotiated Rate	$92.00
Rate for Payer: Cash Price	$70.35
Rate for Payer: Community Health Alliance Commercial	$92.00
Rate for Payer: Priority Health Commercial	$75.76
Rate for Payer: Priority Health PPO	$75.76

PHA SOD CHL BACTERIOSTATIC 0.9

Facility

$13.18

Service Code	NDC 409196612
Hospital Charge Code	2500328
Hospital Revenue Code	250
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$11.20
Rate for Payer: Cash Price	$8.57
Rate for Payer: Community Health Alliance Commercial	$11.20
Rate for Payer: Priority Health Commercial	$9.23
Rate for Payer: Priority Health PPO	$9.23

PHA SOD CHLOR 0.9% 500ml

Facility

$233.80

Service Code	HCPCS J7040
Hospital Charge Code	2510897
Hospital Revenue Code	636
Min. Negotiated Rate	$163.66
Max. Negotiated Rate	$198.73
Rate for Payer: Cash Price	$151.97
Rate for Payer: Community Health Alliance Commercial	$198.73
Rate for Payer: Priority Health Commercial	$163.66
Rate for Payer: Priority Health PPO	$163.66

PHA SOD CHLORIDE 0.45% 1000ML

Facility

$29.26

Hospital Charge Code	2509300
Hospital Revenue Code	258
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$24.87
Rate for Payer: Cash Price	$19.02
Rate for Payer: Community Health Alliance Commercial	$24.87
Rate for Payer: Priority Health Commercial	$20.48
Rate for Payer: Priority Health PPO	$20.48

PHA SOD CHLORIDE .9% 1000ML BG

Facility

$27.08

Hospital Charge Code	2509315
Hospital Revenue Code	258
Min. Negotiated Rate	$18.96
Max. Negotiated Rate	$23.02
Rate for Payer: Cash Price	$17.60
Rate for Payer: Community Health Alliance Commercial	$23.02
Rate for Payer: Priority Health Commercial	$18.96
Rate for Payer: Priority Health PPO	$18.96

PHA SOD CHLORIDE .9% 1000ML BT

Facility

$29.26

Hospital Charge Code	2509440
Hospital Revenue Code	258
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$24.87
Rate for Payer: Cash Price	$19.02
Rate for Payer: Community Health Alliance Commercial	$24.87
Rate for Payer: Priority Health Commercial	$20.48
Rate for Payer: Priority Health PPO	$20.48

PHA SOD CHLORIDE .9% 100ML BAG

Facility

$27.08

Hospital Charge Code	2509320
Hospital Revenue Code	258
Min. Negotiated Rate	$18.96
Max. Negotiated Rate	$23.02
Rate for Payer: Cash Price	$17.60
Rate for Payer: Community Health Alliance Commercial	$23.02
Rate for Payer: Priority Health Commercial	$18.96
Rate for Payer: Priority Health PPO	$18.96

PHA SOD CHLORIDE .9% 250ML BAG

Facility

$46.00

Hospital Charge Code	2509330
Hospital Revenue Code	258
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$39.10
Rate for Payer: Cash Price	$29.90
Rate for Payer: Community Health Alliance Commercial	$39.10
Rate for Payer: Priority Health Commercial	$32.20
Rate for Payer: Priority Health PPO	$32.20

PHA SOD CHLORIDE .9% 30ML VIAL

Facility

$18.00

Hospital Charge Code	2509170
Hospital Revenue Code	258
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$15.30
Rate for Payer: Cash Price	$11.70
Rate for Payer: Community Health Alliance Commercial	$15.30
Rate for Payer: Priority Health Commercial	$12.60
Rate for Payer: Priority Health PPO	$12.60

PHA SOD CHLORIDE .9% 500ML BAG

Facility

$24.27

Service Code	NDC 264780020
Hospital Charge Code	2509336
Hospital Revenue Code	258
Min. Negotiated Rate	$16.99
Max. Negotiated Rate	$20.63
Rate for Payer: Cash Price	$15.78
Rate for Payer: Community Health Alliance Commercial	$20.63
Rate for Payer: Priority Health Commercial	$16.99
Rate for Payer: Priority Health PPO	$16.99

PHA SOD CHLORIDE .9% 500ML BAG

Facility

$27.08

Hospital Charge Code	2509350
Hospital Revenue Code	258
Min. Negotiated Rate	$18.96
Max. Negotiated Rate	$23.02
Rate for Payer: Cash Price	$17.60
Rate for Payer: Community Health Alliance Commercial	$23.02
Rate for Payer: Priority Health Commercial	$18.96
Rate for Payer: Priority Health PPO	$18.96

PHA SOD CHLORIDE .9% 500ML BTL

Facility

$27.08

Hospital Charge Code	2509450
Hospital Revenue Code	258
Min. Negotiated Rate	$18.96
Max. Negotiated Rate	$23.02
Rate for Payer: Cash Price	$17.60
Rate for Payer: Community Health Alliance Commercial	$23.02
Rate for Payer: Priority Health Commercial	$18.96
Rate for Payer: Priority Health PPO	$18.96

PHA SOD CHLORIDE .9% 50 ML BAG

Facility

$22.24

Service Code	NDC 338004941
Hospital Charge Code	2509365
Hospital Revenue Code	258
Min. Negotiated Rate	$15.57
Max. Negotiated Rate	$18.90
Rate for Payer: Cash Price	$14.46
Rate for Payer: Community Health Alliance Commercial	$18.90
Rate for Payer: Priority Health Commercial	$15.57
Rate for Payer: Priority Health PPO	$15.57

PHA SOD FERRIC CLUC 62.5MG INJ

Facility

$151.88

Service Code	HCPCS J2916
Hospital Charge Code	2507055
Hospital Revenue Code	636
Min. Negotiated Rate	$106.32
Max. Negotiated Rate	$129.10
Rate for Payer: Cash Price	$98.72
Rate for Payer: Community Health Alliance Commercial	$129.10
Rate for Payer: Priority Health Commercial	$106.32
Rate for Payer: Priority Health PPO	$106.32

PHA SODIUM ACETATE 40 MEQ/20ML

Facility

$3.80

Service Code	NDC 409729973
Hospital Charge Code	2507736
Hospital Revenue Code	250
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$3.23
Rate for Payer: Cash Price	$2.47
Rate for Payer: Community Health Alliance Commercial	$3.23
Rate for Payer: Priority Health Commercial	$2.66
Rate for Payer: Priority Health PPO	$2.66

PHA SODIUM BICARBONATE 8.4%

Facility

$54.04

Service Code	NDC 409662514
Hospital Charge Code	2504561
Hospital Revenue Code	250
Min. Negotiated Rate	$37.83
Max. Negotiated Rate	$45.93
Rate for Payer: Cash Price	$35.13
Rate for Payer: Community Health Alliance Commercial	$45.93
Rate for Payer: Priority Health Commercial	$37.83
Rate for Payer: Priority Health PPO	$37.83

PHA SODIUM CHLORIDE 0.9%

Facility

$233.80

Service Code	NDC 338055318
Hospital Charge Code	2510895
Hospital Revenue Code	250
Min. Negotiated Rate	$163.66
Max. Negotiated Rate	$198.73
Rate for Payer: Cash Price	$151.97
Rate for Payer: Community Health Alliance Commercial	$198.73
Rate for Payer: Priority Health Commercial	$163.66
Rate for Payer: Priority Health PPO	$163.66

PHA SODIUM CHLORIDE 0.9%

Facility

$6.81

Service Code	HCPCS J7050
Hospital Charge Code	2509381
Hospital Revenue Code	636
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$5.79
Rate for Payer: Cash Price	$4.43
Rate for Payer: Community Health Alliance Commercial	$5.79
Rate for Payer: Priority Health Commercial	$4.77
Rate for Payer: Priority Health PPO	$4.77

PHA SODIUM CHLORIDE 0.9%

Facility

$0.63

Service Code	NDC 487930133
Hospital Charge Code	2507411
Hospital Revenue Code	250
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.41
Rate for Payer: Community Health Alliance Commercial	$0.54
Rate for Payer: Priority Health Commercial	$0.44
Rate for Payer: Priority Health PPO	$0.44

PHA SODIUM CHLORIDE 0.9% 1000M

Facility

$233.80

Service Code	HCPCS J7030
Hospital Charge Code	2510898
Hospital Revenue Code	636
Min. Negotiated Rate	$163.66
Max. Negotiated Rate	$198.73
Rate for Payer: Cash Price	$151.97
Rate for Payer: Community Health Alliance Commercial	$198.73
Rate for Payer: Priority Health Commercial	$163.66
Rate for Payer: Priority Health PPO	$163.66

PHA SODIUM CHLORIDE 0.9 100ML

Facility

$70.00

Service Code	NDC 338004948
Hospital Charge Code	2510894
Hospital Revenue Code	250
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$59.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Community Health Alliance Commercial	$59.50
Rate for Payer: Priority Health Commercial	$49.00
Rate for Payer: Priority Health PPO	$49.00

PHA SODIUM CHLORIDE 1G TABLET

Facility

$0.87

Service Code	NDC 69367022001
Hospital Charge Code	2509415
Hospital Revenue Code	637
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.74
Rate for Payer: Cash Price	$0.57
Rate for Payer: Community Health Alliance Commercial	$0.74
Rate for Payer: Priority Health Commercial	$0.61
Rate for Payer: Priority Health PPO	$0.61

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges