Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA SODIUM CHLORIDE 3% 500ML B

Facility

$14.74

Service Code	NDC 338005403
Hospital Charge Code	2502611
Hospital Revenue Code	258
Min. Negotiated Rate	$10.32
Max. Negotiated Rate	$12.53
Rate for Payer: Cash Price	$9.58
Rate for Payer: Community Health Alliance Commercial	$12.53
Rate for Payer: Priority Health Commercial	$10.32
Rate for Payer: Priority Health PPO	$10.32

PHA SODIUM CHLORIDE 45 ML ML

Facility

$6.04

Service Code	HCPCS A9270 GY
Hospital Charge Code	2507440
Hospital Revenue Code	637
Min. Negotiated Rate	$4.23
Max. Negotiated Rate	$5.13
Rate for Payer: Cash Price	$3.93
Rate for Payer: Community Health Alliance Commercial	$5.13
Rate for Payer: Priority Health Commercial	$4.23
Rate for Payer: Priority Health PPO	$4.23

PHA SODIUM CHLORIDE 4MEQ/ML VL

Facility

$6.36

Service Code	NDC 51079072045
Hospital Charge Code	2509420
Hospital Revenue Code	250
Min. Negotiated Rate	$4.45
Max. Negotiated Rate	$5.41
Rate for Payer: Cash Price	$4.13
Rate for Payer: Community Health Alliance Commercial	$5.41
Rate for Payer: Priority Health Commercial	$4.45
Rate for Payer: Priority Health PPO	$4.45

PHA SODIUM CHLORIDE 50ML BAG

Facility

$240.10

Service Code	NDC 338004941
Hospital Charge Code	2510893
Hospital Revenue Code	250
Min. Negotiated Rate	$168.07
Max. Negotiated Rate	$204.09
Rate for Payer: Cash Price	$156.07
Rate for Payer: Community Health Alliance Commercial	$204.09
Rate for Payer: Priority Health Commercial	$168.07
Rate for Payer: Priority Health PPO	$168.07

PHA SODIUM CITRATE & CITRIC

Facility

$38.66

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502231
Hospital Revenue Code	637
Min. Negotiated Rate	$27.06
Max. Negotiated Rate	$32.86
Rate for Payer: Cash Price	$25.13
Rate for Payer: Community Health Alliance Commercial	$32.86
Rate for Payer: Priority Health Commercial	$27.06
Rate for Payer: Priority Health PPO	$27.06

PHA SODIUM HYALURONATE 20MG PE

Facility

$1,194.39

Service Code	HCPCS J7323
Hospital Charge Code	2501411
Hospital Revenue Code	636
Min. Negotiated Rate	$48.72
Max. Negotiated Rate	$1,015.23
Rate for Payer: BCBS BCN 65	$110.73
Rate for Payer: Blue Care Network Medicare Advantage	$110.73
Rate for Payer: Cash Price	$776.35
Rate for Payer: Cash Price	$776.35
Rate for Payer: Community Health Alliance Commercial	$1,015.23
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$110.73
Rate for Payer: Meridian Health Plan Medicare	$110.73
Rate for Payer: Priority Health Commercial	$836.07
Rate for Payer: Priority Health Medicaid	$110.73
Rate for Payer: Priority Health Medicare	$110.73
Rate for Payer: Priority Health PPO	$836.07
Rate for Payer: United Health Care Medicaid	$110.73
Rate for Payer: United Health Care Medicare Advantage	$48.72

PHA SOD POLYSTYRENE SULFONATE

Facility

$51.53

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509460
Hospital Revenue Code	637
Min. Negotiated Rate	$36.07
Max. Negotiated Rate	$43.80
Rate for Payer: Cash Price	$33.49
Rate for Payer: Community Health Alliance Commercial	$43.80
Rate for Payer: Priority Health Commercial	$36.07
Rate for Payer: Priority Health PPO	$36.07

PHA SOTALOL HCL 80 MG TAB

Facility

$13.34

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502211
Hospital Revenue Code	637
Min. Negotiated Rate	$9.34
Max. Negotiated Rate	$11.34
Rate for Payer: Cash Price	$8.67
Rate for Payer: Community Health Alliance Commercial	$11.34
Rate for Payer: Priority Health Commercial	$9.34
Rate for Payer: Priority Health PPO	$9.34

PHA SPIRONOLACTONE 25MG TAB

Facility

$1.20

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509480
Hospital Revenue Code	637
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.02
Rate for Payer: Cash Price	$0.78
Rate for Payer: Community Health Alliance Commercial	$1.02
Rate for Payer: Priority Health Commercial	$0.84
Rate for Payer: Priority Health PPO	$0.84

PHA STREPTOZOCIN 1000MG

Facility

$970.17

Service Code	HCPCS J9320
Hospital Charge Code	2508833
Hospital Revenue Code	636
Min. Negotiated Rate	$679.12
Max. Negotiated Rate	$824.64
Rate for Payer: Cash Price	$630.61
Rate for Payer: Community Health Alliance Commercial	$824.64
Rate for Payer: Priority Health Commercial	$679.12
Rate for Payer: Priority Health PPO	$679.12

PHA SUCCINYLCHOLINE 20 MG

Facility

$19.64

Service Code	HCPCS J0330
Hospital Charge Code	2500727
Hospital Revenue Code	636
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$16.69
Rate for Payer: Cash Price	$12.77
Rate for Payer: Community Health Alliance Commercial	$16.69
Rate for Payer: Priority Health Commercial	$13.75
Rate for Payer: Priority Health PPO	$13.75

PHA SUCRALFATE 1 GM TAB

Facility

$1.72

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509530
Hospital Revenue Code	637
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.46
Rate for Payer: Cash Price	$1.12
Rate for Payer: Community Health Alliance Commercial	$1.46
Rate for Payer: Priority Health Commercial	$1.20
Rate for Payer: Priority Health PPO	$1.20

PHA SUFENTANIL CITRAT 50MCG/ML

Facility

$30.58

Service Code	NDC 641611010
Hospital Charge Code	2509540
Hospital Revenue Code	250
Min. Negotiated Rate	$21.41
Max. Negotiated Rate	$25.99
Rate for Payer: Cash Price	$19.88
Rate for Payer: Community Health Alliance Commercial	$25.99
Rate for Payer: Priority Health Commercial	$21.41
Rate for Payer: Priority Health PPO	$21.41

PHA SUGAMMADEX 200MG/2ML VIAL

Facility

$473.42

Service Code	HCPCS J3490
Hospital Charge Code	2509545
Hospital Revenue Code	636
Min. Negotiated Rate	$331.39
Max. Negotiated Rate	$402.41
Rate for Payer: Cash Price	$307.72
Rate for Payer: Community Health Alliance Commercial	$402.41
Rate for Payer: Priority Health Commercial	$331.39
Rate for Payer: Priority Health PPO	$331.39

PHA SULFACETAMIDE SOD 15ML BTL

Facility

$256.95

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509400
Hospital Revenue Code	637
Min. Negotiated Rate	$179.87
Max. Negotiated Rate	$218.41
Rate for Payer: Cash Price	$167.02
Rate for Payer: Community Health Alliance Commercial	$218.41
Rate for Payer: Priority Health Commercial	$179.87
Rate for Payer: Priority Health PPO	$179.87

PHA SULFAMETHOXAZOLE W/TRIMETH

Facility

$24.90

Service Code	HCPCS A9270 GY
Hospital Charge Code	2502050
Hospital Revenue Code	637
Min. Negotiated Rate	$17.43
Max. Negotiated Rate	$21.16
Rate for Payer: Cash Price	$16.19
Rate for Payer: Community Health Alliance Commercial	$21.16
Rate for Payer: Priority Health Commercial	$17.43
Rate for Payer: Priority Health PPO	$17.43

PHA SULFAMETHOX W/TRIMETHOPRI

Facility

$1.67

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510240
Hospital Revenue Code	637
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.42
Rate for Payer: Cash Price	$1.09
Rate for Payer: Community Health Alliance Commercial	$1.42
Rate for Payer: Priority Health Commercial	$1.17
Rate for Payer: Priority Health PPO	$1.17

PHA SULFASALAZINE 500MG TAB

Facility

$1.35

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509560
Hospital Revenue Code	637
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.15
Rate for Payer: Cash Price	$0.88
Rate for Payer: Community Health Alliance Commercial	$1.15
Rate for Payer: Priority Health Commercial	$0.95
Rate for Payer: Priority Health PPO	$0.95

PHA SUMATRIPTAN SUCC 6MG/0.5ML

Facility

$60.46

Service Code	HCPCS J3030
Hospital Charge Code	2509580
Hospital Revenue Code	636
Min. Negotiated Rate	$42.32
Max. Negotiated Rate	$51.39
Rate for Payer: Cash Price	$39.30
Rate for Payer: Community Health Alliance Commercial	$51.39
Rate for Payer: Priority Health Commercial	$42.32
Rate for Payer: Priority Health PPO	$42.32

PHA SUMATRIPTAN SUCCINATE 50MG

Facility

$100.06

Service Code	NDC 62756052169
Hospital Charge Code	2509585
Hospital Revenue Code	637
Min. Negotiated Rate	$70.04
Max. Negotiated Rate	$85.05
Rate for Payer: Cash Price	$65.04
Rate for Payer: Community Health Alliance Commercial	$85.05
Rate for Payer: Priority Health Commercial	$70.04
Rate for Payer: Priority Health PPO	$70.04

PHA SYNVISC ONE

Facility

$3,747.27

Service Code	HCPCS J7325
Hospital Charge Code	2508221
Hospital Revenue Code	636
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$3,185.18
Rate for Payer: BCBS BCN 65	$7.94
Rate for Payer: Blue Care Network Medicare Advantage	$7.94
Rate for Payer: Cash Price	$2,435.73
Rate for Payer: Cash Price	$2,435.73
Rate for Payer: Community Health Alliance Commercial	$3,185.18
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$7.94
Rate for Payer: Meridian Health Plan Medicare	$7.94
Rate for Payer: Priority Health Commercial	$2,623.09
Rate for Payer: Priority Health Medicaid	$7.94
Rate for Payer: Priority Health Medicare	$7.94
Rate for Payer: Priority Health PPO	$2,623.09
Rate for Payer: United Health Care Medicaid	$7.94
Rate for Payer: United Health Care Medicare Advantage	$3.49

PHA TAMIFLU 6MG/ML 60 ML BOTTL

Facility

$503.04

Service Code	NDC 4082205
Hospital Charge Code	2509108
Hospital Revenue Code	250
Min. Negotiated Rate	$352.13
Max. Negotiated Rate	$427.58
Rate for Payer: Cash Price	$326.98
Rate for Payer: Community Health Alliance Commercial	$427.58
Rate for Payer: Priority Health Commercial	$352.13
Rate for Payer: Priority Health PPO	$352.13

PHA TAMSULOSIN 0.4 MG CAPSULE

Facility

$3.95

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500831
Hospital Revenue Code	637
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$3.36
Rate for Payer: Cash Price	$2.57
Rate for Payer: Community Health Alliance Commercial	$3.36
Rate for Payer: Priority Health Commercial	$2.77
Rate for Payer: Priority Health PPO	$2.77

PHA TAXOL 100MG/16.7 ML VIAL

Facility

$159.20

Service Code	HCPCS J9267
Hospital Charge Code	2509639
Hospital Revenue Code	636
Min. Negotiated Rate	$111.44
Max. Negotiated Rate	$135.32
Rate for Payer: Cash Price	$103.48
Rate for Payer: Community Health Alliance Commercial	$135.32
Rate for Payer: Priority Health Commercial	$111.44
Rate for Payer: Priority Health PPO	$111.44

PHA TEMAZEPAM 15MG CAP

Facility

$4.53

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509650
Hospital Revenue Code	637
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$3.85
Rate for Payer: Cash Price	$2.94
Rate for Payer: Community Health Alliance Commercial	$3.85
Rate for Payer: Priority Health Commercial	$3.17
Rate for Payer: Priority Health PPO	$3.17

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges