Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA TEMSIROLIMUS 25MG/ML VIAL

Facility

$5,746.53

Service Code	HCPCS J9330
Hospital Charge Code	2505509
Hospital Revenue Code	636
Min. Negotiated Rate	$9.39
Max. Negotiated Rate	$4,884.55
Rate for Payer: BCBS BCN 65	$21.34
Rate for Payer: Blue Care Network Medicare Advantage	$21.34
Rate for Payer: Cash Price	$3,735.24
Rate for Payer: Cash Price	$3,735.24
Rate for Payer: Community Health Alliance Commercial	$4,884.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$21.34
Rate for Payer: Meridian Health Plan Medicare	$21.34
Rate for Payer: Priority Health Commercial	$4,022.57
Rate for Payer: Priority Health Medicaid	$21.34
Rate for Payer: Priority Health Medicare	$21.34
Rate for Payer: Priority Health PPO	$4,022.57
Rate for Payer: United Health Care Medicaid	$21.34
Rate for Payer: United Health Care Medicare Advantage	$9.39

PHA TENECTEPLASE 50MG KIT

Facility

$18,402.77

Service Code	NDC 50242012001
Hospital Charge Code	2510908
Hospital Revenue Code	250
Min. Negotiated Rate	$12,881.94
Max. Negotiated Rate	$15,642.35
Rate for Payer: Cash Price	$11,961.80
Rate for Payer: Community Health Alliance Commercial	$15,642.35
Rate for Payer: Priority Health Commercial	$12,881.94
Rate for Payer: Priority Health PPO	$12,881.94

PHA TENIVAC 5 UNIT SYRINGE

Facility

$183.03

Service Code	NDC 49281021515
Hospital Charge Code	2503013
Hospital Revenue Code	250
Min. Negotiated Rate	$128.12
Max. Negotiated Rate	$155.58
Rate for Payer: Cash Price	$118.97
Rate for Payer: Community Health Alliance Commercial	$155.58
Rate for Payer: Priority Health Commercial	$128.12
Rate for Payer: Priority Health PPO	$128.12

PHA TERAZOSIN HCL 1 MG

Facility

$8.39

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509655
Hospital Revenue Code	637
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$7.13
Rate for Payer: Cash Price	$5.45
Rate for Payer: Community Health Alliance Commercial	$7.13
Rate for Payer: Priority Health Commercial	$5.87
Rate for Payer: Priority Health PPO	$5.87

PHA TERAZOSIN HCL 5MG CAP

Facility

$8.39

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500722
Hospital Revenue Code	637
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$7.13
Rate for Payer: Cash Price	$5.45
Rate for Payer: Community Health Alliance Commercial	$7.13
Rate for Payer: Priority Health Commercial	$5.87
Rate for Payer: Priority Health PPO	$5.87

PHA TERBUTALINE SULF 1MG/ML

Facility

$25.01

Service Code	HCPCS J3105
Hospital Charge Code	2509660
Hospital Revenue Code	636
Min. Negotiated Rate	$17.51
Max. Negotiated Rate	$21.26
Rate for Payer: Cash Price	$16.26
Rate for Payer: Community Health Alliance Commercial	$21.26
Rate for Payer: Priority Health Commercial	$17.51
Rate for Payer: Priority Health PPO	$17.51

PHA TESTOSTERONE CYP 200MG/ML

Facility

$106.16

Service Code	HCPCS J1071
Hospital Charge Code	2509690
Hospital Revenue Code	636
Min. Negotiated Rate	$74.31
Max. Negotiated Rate	$90.24
Rate for Payer: Cash Price	$69.00
Rate for Payer: Community Health Alliance Commercial	$90.24
Rate for Payer: Priority Health Commercial	$74.31
Rate for Payer: Priority Health PPO	$74.31

PHA TETANUS IMM GLOB 250U 0908

Facility

$1,935.50

Service Code	HCPCS J1670
Hospital Charge Code	2509700
Hospital Revenue Code	636
Min. Negotiated Rate	$271.91
Max. Negotiated Rate	$1,645.17
Rate for Payer: BCBS BCN 65	$617.97
Rate for Payer: Blue Care Network Medicare Advantage	$617.97
Rate for Payer: Cash Price	$1,258.08
Rate for Payer: Cash Price	$1,258.08
Rate for Payer: Community Health Alliance Commercial	$1,645.17
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$617.97
Rate for Payer: Meridian Health Plan Medicare	$617.97
Rate for Payer: Priority Health Commercial	$1,354.85
Rate for Payer: Priority Health Medicaid	$617.97
Rate for Payer: Priority Health Medicare	$617.97
Rate for Payer: Priority Health PPO	$1,354.85
Rate for Payer: United Health Care Medicaid	$617.97
Rate for Payer: United Health Care Medicare Advantage	$271.91

PHA TETANUS TOX-DIP-ACEL PERT

Facility

$199.46

Service Code	NDC 58160084252
Hospital Charge Code	2509103
Hospital Revenue Code	636
Min. Negotiated Rate	$139.62
Max. Negotiated Rate	$169.54
Rate for Payer: Cash Price	$129.65
Rate for Payer: Community Health Alliance Commercial	$169.54
Rate for Payer: Priority Health Commercial	$139.62
Rate for Payer: Priority Health PPO	$139.62

PHA TETRACAINE HCL 1 ML DRO

Facility

$50.52

Service Code	NDC 65074112
Hospital Charge Code	2509720
Hospital Revenue Code	250
Min. Negotiated Rate	$35.36
Max. Negotiated Rate	$42.94
Rate for Payer: Cash Price	$32.84
Rate for Payer: Community Health Alliance Commercial	$42.94
Rate for Payer: Priority Health Commercial	$35.36
Rate for Payer: Priority Health PPO	$35.36

PHA TETRACAINE HCL 20MG AMP

Facility

$304.37

Service Code	NDC 17478004532
Hospital Charge Code	2506905
Hospital Revenue Code	250
Min. Negotiated Rate	$213.06
Max. Negotiated Rate	$258.71
Rate for Payer: Cash Price	$197.84
Rate for Payer: Community Health Alliance Commercial	$258.71
Rate for Payer: Priority Health Commercial	$213.06
Rate for Payer: Priority Health PPO	$213.06

PHA THEOPHYLLINE 300 MG TAB

Facility

$22.40

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509770
Hospital Revenue Code	637
Min. Negotiated Rate	$15.68
Max. Negotiated Rate	$19.04
Rate for Payer: Cash Price	$14.56
Rate for Payer: Community Health Alliance Commercial	$19.04
Rate for Payer: Priority Health Commercial	$15.68
Rate for Payer: Priority Health PPO	$15.68

PHA THEOPHYLLINE 80 MG SYRUP

Facility

$64.94

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509791
Hospital Revenue Code	637
Min. Negotiated Rate	$45.46
Max. Negotiated Rate	$55.20
Rate for Payer: Cash Price	$42.21
Rate for Payer: Community Health Alliance Commercial	$55.20
Rate for Payer: Priority Health Commercial	$45.46
Rate for Payer: Priority Health PPO	$45.46

PHA THIAMINE HCL 100MG/ML VIAL

Facility

$54.69

Service Code	HCPCS J3411
Hospital Charge Code	2509820
Hospital Revenue Code	636
Min. Negotiated Rate	$38.28
Max. Negotiated Rate	$46.49
Rate for Payer: Cash Price	$35.55
Rate for Payer: Community Health Alliance Commercial	$46.49
Rate for Payer: Priority Health Commercial	$38.28
Rate for Payer: Priority Health PPO	$38.28

PHA THIAMINE HCL 100 MG TAB

Facility

$1.62

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509810
Hospital Revenue Code	637
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$1.05
Rate for Payer: Community Health Alliance Commercial	$1.38
Rate for Payer: Priority Health Commercial	$1.13
Rate for Payer: Priority Health PPO	$1.13

PHA THROAT LOZENGES 1 EACH LOZ

Facility

$1.62

Service Code	HCPCS A9270 GY
Hospital Charge Code	2509870
Hospital Revenue Code	637
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$1.05
Rate for Payer: Community Health Alliance Commercial	$1.38
Rate for Payer: Priority Health Commercial	$1.13
Rate for Payer: Priority Health PPO	$1.13

PHA THROMBIN 5000 U KIT

Facility

$303.74

Service Code	NDC 60793021505
Hospital Charge Code	2509860
Hospital Revenue Code	250
Min. Negotiated Rate	$212.62
Max. Negotiated Rate	$258.18
Rate for Payer: Cash Price	$197.43
Rate for Payer: Community Health Alliance Commercial	$258.18
Rate for Payer: Priority Health Commercial	$212.62
Rate for Payer: Priority Health PPO	$212.62

PHA TIGECYCLINE 50 MG/5 ML VL

Facility

$331.20

Service Code	HCPCS J3243
Hospital Charge Code	2507711
Hospital Revenue Code	636
Min. Negotiated Rate	$231.84
Max. Negotiated Rate	$281.52
Rate for Payer: Cash Price	$215.28
Rate for Payer: Community Health Alliance Commercial	$281.52
Rate for Payer: Priority Health Commercial	$231.84
Rate for Payer: Priority Health PPO	$231.84

PHA TIMOLOL 0.25% 2.5ML BTL

Facility

$68.70

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510020
Hospital Revenue Code	637
Min. Negotiated Rate	$48.09
Max. Negotiated Rate	$58.40
Rate for Payer: Cash Price	$44.66
Rate for Payer: Community Health Alliance Commercial	$58.40
Rate for Payer: Priority Health Commercial	$48.09
Rate for Payer: Priority Health PPO	$48.09

PHA TIMOLOL MALEATE 0.5% 2.5ML

Facility

$45.07

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510030
Hospital Revenue Code	637
Min. Negotiated Rate	$31.55
Max. Negotiated Rate	$38.31
Rate for Payer: Cash Price	$29.30
Rate for Payer: Community Health Alliance Commercial	$38.31
Rate for Payer: Priority Health Commercial	$31.55
Rate for Payer: Priority Health PPO	$31.55

PHA TIZANIDINE HYDROCHLORIDE

Facility

$13.29

Service Code	HCPCS A9270 GY
Hospital Charge Code	2507825
Hospital Revenue Code	637
Min. Negotiated Rate	$9.30
Max. Negotiated Rate	$11.30
Rate for Payer: Cash Price	$8.64
Rate for Payer: Community Health Alliance Commercial	$11.30
Rate for Payer: Priority Health Commercial	$9.30
Rate for Payer: Priority Health PPO	$9.30

PHA TOBRAMYCIN 0.3% TUBE

Facility

$1,019.16

Service Code	NDC 78081301
Hospital Charge Code	2510046
Hospital Revenue Code	250
Min. Negotiated Rate	$713.41
Max. Negotiated Rate	$866.29
Rate for Payer: Cash Price	$662.45
Rate for Payer: Community Health Alliance Commercial	$866.29
Rate for Payer: Priority Health Commercial	$713.41
Rate for Payer: Priority Health PPO	$713.41

PHA TOBRAMYCIN-DEXAMETH 3.5 GM

Facility

$1,085.01

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510045
Hospital Revenue Code	637
Min. Negotiated Rate	$759.51
Max. Negotiated Rate	$922.26
Rate for Payer: Cash Price	$705.26
Rate for Payer: Community Health Alliance Commercial	$922.26
Rate for Payer: Priority Health Commercial	$759.51
Rate for Payer: Priority Health PPO	$759.51

PHA TOBRAMYCIN-DEXAMETHAS 5 ML

Facility

$202.67

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510051
Hospital Revenue Code	637
Min. Negotiated Rate	$141.87
Max. Negotiated Rate	$172.27
Rate for Payer: Cash Price	$131.74
Rate for Payer: Community Health Alliance Commercial	$172.27
Rate for Payer: Priority Health Commercial	$141.87
Rate for Payer: Priority Health PPO	$141.87

PHA TOBRAMYCIN SULFATE 1.2GM

Facility

$100.00

Service Code	NDC 39822041201
Hospital Charge Code	2510041
Hospital Revenue Code	250
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$85.00
Rate for Payer: Cash Price	$65.00
Rate for Payer: Community Health Alliance Commercial	$85.00
Rate for Payer: Priority Health Commercial	$70.00
Rate for Payer: Priority Health PPO	$70.00

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges