Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

PHA TOBRAMYCIN SULFATE 40MG

Facility

$6.56

Service Code	NDC 63323030751
Hospital Charge Code	2505657
Hospital Revenue Code	250
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$5.58
Rate for Payer: Cash Price	$4.26
Rate for Payer: Community Health Alliance Commercial	$5.58
Rate for Payer: Priority Health Commercial	$4.59
Rate for Payer: Priority Health PPO	$4.59

PHA TOBRAMYCIN SULFATE 5ML BTL

Facility

$135.24

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510060
Hospital Revenue Code	637
Min. Negotiated Rate	$94.67
Max. Negotiated Rate	$114.95
Rate for Payer: Cash Price	$87.91
Rate for Payer: Community Health Alliance Commercial	$114.95
Rate for Payer: Priority Health Commercial	$94.67
Rate for Payer: Priority Health PPO	$94.67

PHA TOBRAMYCIN SULFATE 80MG/ML

Facility

$16.27

Service Code	HCPCS J3260
Hospital Charge Code	2510040
Hospital Revenue Code	636
Min. Negotiated Rate	$11.39
Max. Negotiated Rate	$13.83
Rate for Payer: Cash Price	$10.58
Rate for Payer: Community Health Alliance Commercial	$13.83
Rate for Payer: Priority Health Commercial	$11.39
Rate for Payer: Priority Health PPO	$11.39

PHA TOLTERODINE TART 1MG TAB

Facility

$37.77

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500823
Hospital Revenue Code	637
Min. Negotiated Rate	$26.44
Max. Negotiated Rate	$32.10
Rate for Payer: Cash Price	$24.55
Rate for Payer: Community Health Alliance Commercial	$32.10
Rate for Payer: Priority Health Commercial	$26.44
Rate for Payer: Priority Health PPO	$26.44

PHA TOLTERODINE TARTRATE CAP

Facility

$49.83

Service Code	HCPCS A9270 GY
Hospital Charge Code	2500828
Hospital Revenue Code	637
Min. Negotiated Rate	$34.88
Max. Negotiated Rate	$42.36
Rate for Payer: Cash Price	$32.39
Rate for Payer: Community Health Alliance Commercial	$42.36
Rate for Payer: Priority Health Commercial	$34.88
Rate for Payer: Priority Health PPO	$34.88

PHA TORADOL 15 MG/ML 1ML VIAL

Facility

$23.45

Service Code	NDC 63323016101
Hospital Charge Code	2510851
Hospital Revenue Code	250
Min. Negotiated Rate	$16.41
Max. Negotiated Rate	$19.93
Rate for Payer: Cash Price	$15.24
Rate for Payer: Community Health Alliance Commercial	$19.93
Rate for Payer: Priority Health Commercial	$16.41
Rate for Payer: Priority Health PPO	$16.41

PHA TORSEMIDE 10MG TAB

Facility

$3.70

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510110
Hospital Revenue Code	637
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$3.15
Rate for Payer: Cash Price	$2.41
Rate for Payer: Community Health Alliance Commercial	$3.15
Rate for Payer: Priority Health Commercial	$2.59
Rate for Payer: Priority Health PPO	$2.59

PHA TRACE MINR(CR-CU-MN-ZN)1ML

Facility

$14.33

Service Code	NDC 39769005702
Hospital Charge Code	2510130
Hospital Revenue Code	250
Min. Negotiated Rate	$10.03
Max. Negotiated Rate	$12.18
Rate for Payer: Cash Price	$9.31
Rate for Payer: Community Health Alliance Commercial	$12.18
Rate for Payer: Priority Health Commercial	$10.03
Rate for Payer: Priority Health PPO	$10.03

PHA TRAMADOL HCL 50MG TAB

Facility

$4.53

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510140
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

PHA TRANDATE 200MG/40ML VIAL

Facility

$109.45

Service Code	NDC 47781058656
Hospital Charge Code	2510921
Hospital Revenue Code	636
Min. Negotiated Rate	$76.61
Max. Negotiated Rate	$93.03
Rate for Payer: Cash Price	$71.14
Rate for Payer: Community Health Alliance Commercial	$93.03
Rate for Payer: Priority Health Commercial	$76.61
Rate for Payer: Priority Health PPO	$76.61

PHA TRANEXAMIC ACID 1000MG/10

Facility

$106.62

Service Code	NDC 47781060191
Hospital Charge Code	2502913
Hospital Revenue Code	250
Min. Negotiated Rate	$74.63
Max. Negotiated Rate	$90.63
Rate for Payer: Cash Price	$69.30
Rate for Payer: Community Health Alliance Commercial	$90.63
Rate for Payer: Priority Health Commercial	$74.63
Rate for Payer: Priority Health PPO	$74.63

PHA TRASTUZUMAB 150 MG VIAL

Facility

$4,263.83

Service Code	HCPCS J9355
Hospital Charge Code	2510766
Hospital Revenue Code	636
Min. Negotiated Rate	$33.95
Max. Negotiated Rate	$3,624.26
Rate for Payer: BCBS BCN 65	$77.15
Rate for Payer: Blue Care Network Medicare Advantage	$77.15
Rate for Payer: Cash Price	$2,771.49
Rate for Payer: Cash Price	$2,771.49
Rate for Payer: Community Health Alliance Commercial	$3,624.26
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$77.15
Rate for Payer: Meridian Health Plan Medicare	$77.15
Rate for Payer: Priority Health Commercial	$2,984.68
Rate for Payer: Priority Health Medicaid	$77.15
Rate for Payer: Priority Health Medicare	$77.15
Rate for Payer: Priority Health PPO	$2,984.68
Rate for Payer: United Health Care Medicaid	$77.15
Rate for Payer: United Health Care Medicare Advantage	$33.95

PHA TRASTUZUMAB 440 MG INJ

Facility

$12,507.26

Service Code	HCPCS J9355
Hospital Charge Code	2509025
Hospital Revenue Code	636
Min. Negotiated Rate	$33.95
Max. Negotiated Rate	$10,631.17
Rate for Payer: BCBS BCN 65	$77.15
Rate for Payer: Blue Care Network Medicare Advantage	$77.15
Rate for Payer: Cash Price	$8,129.72
Rate for Payer: Cash Price	$8,129.72
Rate for Payer: Community Health Alliance Commercial	$10,631.17
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$77.15
Rate for Payer: Meridian Health Plan Medicare	$77.15
Rate for Payer: Priority Health Commercial	$8,755.08
Rate for Payer: Priority Health Medicaid	$77.15
Rate for Payer: Priority Health Medicare	$77.15
Rate for Payer: Priority Health PPO	$8,755.08
Rate for Payer: United Health Care Medicaid	$77.15
Rate for Payer: United Health Care Medicare Advantage	$33.95

PHA TRAVATAN Z 0.004% EYE DRP

Facility

$18.70

Service Code	NDC 66758009575
Hospital Charge Code	2510819
Hospital Revenue Code	637
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$15.89
Rate for Payer: Cash Price	$12.16
Rate for Payer: Community Health Alliance Commercial	$15.89
Rate for Payer: Priority Health Commercial	$13.09
Rate for Payer: Priority Health PPO	$13.09

PHA TRAZODONE HCL 50MG TAB

Facility

$0.83

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510160
Hospital Revenue Code	637
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$0.71
Rate for Payer: Cash Price	$0.54
Rate for Payer: Community Health Alliance Commercial	$0.71
Rate for Payer: Priority Health Commercial	$0.58
Rate for Payer: Priority Health PPO	$0.58

PHA TRIAMCINOLON ACET 0.1%15GM

Facility

$18.76

Service Code	HCPCS A9270 GY
Hospital Charge Code	2510190
Hospital Revenue Code	637
Min. Negotiated Rate	$13.13
Max. Negotiated Rate	$15.95
Rate for Payer: Cash Price	$12.19
Rate for Payer: Community Health Alliance Commercial	$15.95
Rate for Payer: Priority Health Commercial	$13.13
Rate for Payer: Priority Health PPO	$13.13

PHA TRIAMCINOLONE ACET 40MG/ML

Facility

$50.59

Service Code	NDC 703024101
Hospital Charge Code	2510180
Hospital Revenue Code	250
Min. Negotiated Rate	$35.41
Max. Negotiated Rate	$43.00
Rate for Payer: Cash Price	$32.88
Rate for Payer: Community Health Alliance Commercial	$43.00
Rate for Payer: Priority Health Commercial	$35.41
Rate for Payer: Priority Health PPO	$35.41

PHA TRILEPTAL 300 MG TAB NF

Facility

$13.60

Service Code	NDC 68462013801
Hospital Charge Code	2510806
Hospital Revenue Code	637
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$11.56
Rate for Payer: Cash Price	$8.84
Rate for Payer: Community Health Alliance Commercial	$11.56
Rate for Payer: Priority Health Commercial	$9.52
Rate for Payer: Priority Health PPO	$9.52

PHA TRIMETHOPRIM-POLYMYXIN B

Facility

$58.94

Service Code	HCPCS A9270 GY
Hospital Charge Code	2508265
Hospital Revenue Code	637
Min. Negotiated Rate	$41.26
Max. Negotiated Rate	$50.10
Rate for Payer: Cash Price	$38.31
Rate for Payer: Community Health Alliance Commercial	$50.10
Rate for Payer: Priority Health Commercial	$41.26
Rate for Payer: Priority Health PPO	$41.26

PHA TRIMETHOPRIM/SULFAMETHOX

Facility

$68.93

Service Code	NDC 703951403
Hospital Charge Code	2509210
Hospital Revenue Code	250
Min. Negotiated Rate	$48.25
Max. Negotiated Rate	$58.59
Rate for Payer: Cash Price	$44.80
Rate for Payer: Community Health Alliance Commercial	$58.59
Rate for Payer: Priority Health Commercial	$48.25
Rate for Payer: Priority Health PPO	$48.25

PHA TRIPTORELIN PAMOATE

Facility

$4,146.75

Service Code	HCPCS J3315
Hospital Charge Code	2505858
Hospital Revenue Code	636
Min. Negotiated Rate	$214.00
Max. Negotiated Rate	$3,524.74
Rate for Payer: BCBS BCN 65	$486.36
Rate for Payer: Blue Care Network Medicare Advantage	$486.36
Rate for Payer: Cash Price	$2,695.39
Rate for Payer: Cash Price	$2,695.39
Rate for Payer: Community Health Alliance Commercial	$3,524.74
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$486.36
Rate for Payer: Meridian Health Plan Medicare	$486.36
Rate for Payer: Priority Health Commercial	$2,902.72
Rate for Payer: Priority Health Medicaid	$486.36
Rate for Payer: Priority Health Medicare	$486.36
Rate for Payer: Priority Health PPO	$2,902.72
Rate for Payer: United Health Care Medicaid	$486.36
Rate for Payer: United Health Care Medicare Advantage	$214.00

PHA TROP/CYCLO/PHENEPH/KETOR

Facility

$48.46

Service Code	NDC 71266824001
Hospital Charge Code	2510957
Hospital Revenue Code	250
Min. Negotiated Rate	$33.92
Max. Negotiated Rate	$41.19
Rate for Payer: Cash Price	$31.50
Rate for Payer: Community Health Alliance Commercial	$41.19
Rate for Payer: Priority Health Commercial	$33.92
Rate for Payer: Priority Health PPO	$33.92

PHA TROPICAMIDE 1% SOL

Facility

$0.76

Service Code	NDC 61314035501
Hospital Charge Code	2500824
Hospital Revenue Code	250
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Community Health Alliance Commercial	$0.65
Rate for Payer: Priority Health Commercial	$0.53
Rate for Payer: Priority Health PPO	$0.53

PHA TRUVADA TABLET NF

Facility

$195.92

Service Code	NDC 61958070101
Hospital Charge Code	2510822
Hospital Revenue Code	250
Min. Negotiated Rate	$137.14
Max. Negotiated Rate	$166.53
Rate for Payer: Cash Price	$127.35
Rate for Payer: Community Health Alliance Commercial	$166.53
Rate for Payer: Priority Health Commercial	$137.14
Rate for Payer: Priority Health PPO	$137.14

PHA TRYPAN BLUE 0.06% 0.5ML

Facility

$286.93

Service Code	HCPCS A9270 GY
Hospital Charge Code	2505353
Hospital Revenue Code	637
Min. Negotiated Rate	$200.85
Max. Negotiated Rate	$243.89
Rate for Payer: Cash Price	$186.50
Rate for Payer: Community Health Alliance Commercial	$243.89
Rate for Payer: Priority Health Commercial	$200.85
Rate for Payer: Priority Health PPO	$200.85

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges