Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

TENNIS ELBOW BAND

Facility

$46.00

Hospital Charge Code	27021147
Hospital Revenue Code	270
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

TENOTOMY, PERCUTANEOUS, TOE; MULTIPLE TENDONS

Facility

$1,724.96

Service Code	CPT 28011
Hospital Revenue Code	360
Min. Negotiated Rate	$758.98
Max. Negotiated Rate	$1,724.96
Rate for Payer: BCBS BCN 65	$1,724.96
Rate for Payer: Blue Care Network Medicare Advantage	$1,724.96
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$1,724.96
Rate for Payer: Meridian Health Plan Medicare	$1,724.96
Rate for Payer: Priority Health Medicaid	$1,724.96
Rate for Payer: Priority Health Medicare	$1,724.96
Rate for Payer: United Health Care Medicaid	$1,724.96
Rate for Payer: United Health Care Medicare Advantage	$758.98

TEST F&D1

Facility

$3.26

Hospital Charge Code	31027511
Hospital Revenue Code	300
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$2.77
Rate for Payer: Cash Price	$2.12
Rate for Payer: Community Health Alliance Commercial	$2.77
Rate for Payer: Priority Health Commercial	$2.28
Rate for Payer: Priority Health PPO	$2.28

TEST F&D2

Facility

$3.26

Hospital Charge Code	31027512
Hospital Revenue Code	300
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$2.77
Rate for Payer: Cash Price	$2.12
Rate for Payer: Community Health Alliance Commercial	$2.77
Rate for Payer: Priority Health Commercial	$2.28
Rate for Payer: Priority Health PPO	$2.28

TEST FEM C-LC

Facility

$6.65

Hospital Charge Code	3102575
Hospital Revenue Code	300
Min. Negotiated Rate	$4.66
Max. Negotiated Rate	$5.65
Rate for Payer: Cash Price	$4.32
Rate for Payer: Community Health Alliance Commercial	$5.65
Rate for Payer: Priority Health Commercial	$4.66
Rate for Payer: Priority Health PPO	$4.66

TEST FREE&DIRECT

Facility

$6.52

Hospital Charge Code	31027510
Hospital Revenue Code	300
Min. Negotiated Rate	$4.56
Max. Negotiated Rate	$5.54
Rate for Payer: Cash Price	$4.24
Rate for Payer: Community Health Alliance Commercial	$5.54
Rate for Payer: Priority Health Commercial	$4.56
Rate for Payer: Priority Health PPO	$4.56

TEST, FREE & WB W TOTAL TESTER

Facility

$52.00

Hospital Charge Code	3101800
Hospital Revenue Code	300
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$44.20
Rate for Payer: Cash Price	$33.80
Rate for Payer: Community Health Alliance Commercial	$44.20
Rate for Payer: Priority Health Commercial	$36.40
Rate for Payer: Priority Health PPO	$36.40

TESTING CABLE

Facility

$86.00

Hospital Charge Code	27265536
Hospital Revenue Code	272
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$73.10
Rate for Payer: Cash Price	$55.90
Rate for Payer: Community Health Alliance Commercial	$73.10
Rate for Payer: Priority Health Commercial	$60.20
Rate for Payer: Priority Health PPO	$60.20

TEST-LC

Facility

$3.26

Hospital Charge Code	3102574
Hospital Revenue Code	300
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$2.77
Rate for Payer: Cash Price	$2.12
Rate for Payer: Community Health Alliance Commercial	$2.77
Rate for Payer: Priority Health Commercial	$2.28
Rate for Payer: Priority Health PPO	$2.28

TESTOSTERONE,BIOAVAILABLE 1

Facility

$39.00

Service Code	HCPCS 82040
Hospital Charge Code	3007831
Hospital Revenue Code	301
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$33.15
Rate for Payer: BCBS BCN 65	$5.20
Rate for Payer: Blue Care Network Medicare Advantage	$5.20
Rate for Payer: Cash Price	$25.35
Rate for Payer: Cash Price	$25.35
Rate for Payer: Community Health Alliance Commercial	$33.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$5.20
Rate for Payer: Meridian Health Plan Medicare	$5.20
Rate for Payer: Priority Health Commercial	$27.30
Rate for Payer: Priority Health Medicaid	$5.20
Rate for Payer: Priority Health Medicare	$5.20
Rate for Payer: Priority Health PPO	$27.30
Rate for Payer: United Health Care Medicaid	$5.20
Rate for Payer: United Health Care Medicare Advantage	$2.29

TESTOSTERONE,BIOAVAILABLE 2

Facility

$39.00

Service Code	HCPCS 84403
Hospital Charge Code	3007832
Hospital Revenue Code	301
Min. Negotiated Rate	$11.92
Max. Negotiated Rate	$33.15
Rate for Payer: BCBS BCN 65	$27.10
Rate for Payer: Blue Care Network Medicare Advantage	$27.10
Rate for Payer: Cash Price	$25.35
Rate for Payer: Cash Price	$25.35
Rate for Payer: Community Health Alliance Commercial	$33.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$27.10
Rate for Payer: Meridian Health Plan Medicare	$27.10
Rate for Payer: Priority Health Commercial	$27.30
Rate for Payer: Priority Health Medicaid	$27.10
Rate for Payer: Priority Health Medicare	$27.10
Rate for Payer: Priority Health PPO	$27.30
Rate for Payer: United Health Care Medicaid	$27.10
Rate for Payer: United Health Care Medicare Advantage	$11.92

TESTOSTERONE,BIOAVAILABLE 3

Facility

$102.00

Service Code	HCPCS 84270
Hospital Charge Code	3007833
Hospital Revenue Code	301
Min. Negotiated Rate	$10.04
Max. Negotiated Rate	$86.70
Rate for Payer: BCBS BCN 65	$22.82
Rate for Payer: Blue Care Network Medicare Advantage	$22.82
Rate for Payer: Cash Price	$66.30
Rate for Payer: Cash Price	$66.30
Rate for Payer: Community Health Alliance Commercial	$86.70
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$22.82
Rate for Payer: Meridian Health Plan Medicare	$22.82
Rate for Payer: Priority Health Commercial	$71.40
Rate for Payer: Priority Health Medicaid	$22.82
Rate for Payer: Priority Health Medicare	$22.82
Rate for Payer: Priority Health PPO	$71.40
Rate for Payer: United Health Care Medicaid	$22.82
Rate for Payer: United Health Care Medicare Advantage	$10.04

TESTOSTERONE, FREE

Facility

$3.26

Service Code	HCPCS 84402
Hospital Charge Code	3007840
Hospital Revenue Code	301
Min. Negotiated Rate	$2.28
Max. Negotiated Rate	$26.74
Rate for Payer: BCBS BCN 65	$26.74
Rate for Payer: Blue Care Network Medicare Advantage	$26.74
Rate for Payer: Cash Price	$2.12
Rate for Payer: Cash Price	$2.12
Rate for Payer: Community Health Alliance Commercial	$2.77
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$26.74
Rate for Payer: Meridian Health Plan Medicare	$26.74
Rate for Payer: Priority Health Commercial	$2.28
Rate for Payer: Priority Health Medicaid	$26.74
Rate for Payer: Priority Health Medicare	$26.74
Rate for Payer: Priority Health PPO	$2.28
Rate for Payer: United Health Care Medicaid	$26.74
Rate for Payer: United Health Care Medicare Advantage	$11.77

TESTOSTERONE FREE CALC

Facility

$40.40

Hospital Charge Code	3101091
Hospital Revenue Code	301
Min. Negotiated Rate	$28.28
Max. Negotiated Rate	$34.34
Rate for Payer: Cash Price	$26.26
Rate for Payer: Community Health Alliance Commercial	$34.34
Rate for Payer: Priority Health Commercial	$28.28
Rate for Payer: Priority Health PPO	$28.28

TESTOSTERONE FREE & TOTAL

Facility

$169.00

Hospital Charge Code	3100084
Hospital Revenue Code	301
Min. Negotiated Rate	$118.30
Max. Negotiated Rate	$143.65
Rate for Payer: Cash Price	$109.85
Rate for Payer: Community Health Alliance Commercial	$143.65
Rate for Payer: Priority Health Commercial	$118.30
Rate for Payer: Priority Health PPO	$118.30

TESTOSTERONE TOTAL

Facility

$1.26

Hospital Charge Code	3101094
Hospital Revenue Code	301
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.07
Rate for Payer: Cash Price	$0.82
Rate for Payer: Community Health Alliance Commercial	$1.07
Rate for Payer: Priority Health Commercial	$0.88
Rate for Payer: Priority Health PPO	$0.88

TESTOSTERONE, TOTAL

Facility

$34.50

Service Code	HCPCS 84403
Hospital Charge Code	3007820
Hospital Revenue Code	301
Min. Negotiated Rate	$11.92
Max. Negotiated Rate	$29.32
Rate for Payer: BCBS BCN 65	$27.10
Rate for Payer: Blue Care Network Medicare Advantage	$27.10
Rate for Payer: Cash Price	$22.43
Rate for Payer: Cash Price	$22.43
Rate for Payer: Community Health Alliance Commercial	$29.32
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$27.10
Rate for Payer: Meridian Health Plan Medicare	$27.10
Rate for Payer: Priority Health Commercial	$24.15
Rate for Payer: Priority Health Medicaid	$27.10
Rate for Payer: Priority Health Medicare	$27.10
Rate for Payer: Priority Health PPO	$24.15
Rate for Payer: United Health Care Medicaid	$27.10
Rate for Payer: United Health Care Medicare Advantage	$11.92

TESTOSTERONE TOTAL LC-MS

Facility

$15.69

Hospital Charge Code	3101473
Hospital Revenue Code	300
Min. Negotiated Rate	$10.98
Max. Negotiated Rate	$13.34
Rate for Payer: Cash Price	$10.20
Rate for Payer: Community Health Alliance Commercial	$13.34
Rate for Payer: Priority Health Commercial	$10.98
Rate for Payer: Priority Health PPO	$10.98

TETANUS ANTIBODY

Facility

$7.33

Service Code	HCPCS 86317
Hospital Charge Code	3008270
Hospital Revenue Code	302
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$15.74
Rate for Payer: BCBS BCN 65	$15.74
Rate for Payer: Blue Care Network Medicare Advantage	$15.74
Rate for Payer: Cash Price	$4.76
Rate for Payer: Cash Price	$4.76
Rate for Payer: Community Health Alliance Commercial	$6.23
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$15.74
Rate for Payer: Meridian Health Plan Medicare	$15.74
Rate for Payer: Priority Health Commercial	$5.13
Rate for Payer: Priority Health Medicaid	$15.74
Rate for Payer: Priority Health Medicare	$15.74
Rate for Payer: Priority Health PPO	$5.13
Rate for Payer: United Health Care Medicaid	$15.74
Rate for Payer: United Health Care Medicare Advantage	$6.93

TETANUS IgG ANTIBODY PRE/POST

Facility

$269.00

Service Code	HCPCS 86774
Hospital Charge Code	3007842
Hospital Revenue Code	302
Min. Negotiated Rate	$6.84
Max. Negotiated Rate	$228.65
Rate for Payer: BCBS BCN 65	$15.54
Rate for Payer: Blue Care Network Medicare Advantage	$15.54
Rate for Payer: Cash Price	$174.85
Rate for Payer: Cash Price	$174.85
Rate for Payer: Community Health Alliance Commercial	$228.65
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$15.54
Rate for Payer: Meridian Health Plan Medicare	$15.54
Rate for Payer: Priority Health Commercial	$188.30
Rate for Payer: Priority Health Medicaid	$15.54
Rate for Payer: Priority Health Medicare	$15.54
Rate for Payer: Priority Health PPO	$188.30
Rate for Payer: United Health Care Medicaid	$15.54
Rate for Payer: United Health Care Medicare Advantage	$6.84

TFP-1

Facility

$1.25

Hospital Charge Code	3101667
Hospital Revenue Code	300
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

THALLIUM

Facility

$60.00

Service Code	HCPCS 83018
Hospital Charge Code	3007845
Hospital Revenue Code	301
Min. Negotiated Rate	$10.15
Max. Negotiated Rate	$51.00
Rate for Payer: BCBS BCN 65	$23.06
Rate for Payer: Blue Care Network Medicare Advantage	$23.06
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Community Health Alliance Commercial	$51.00
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$23.06
Rate for Payer: Meridian Health Plan Medicare	$23.06
Rate for Payer: Priority Health Commercial	$42.00
Rate for Payer: Priority Health Medicaid	$23.06
Rate for Payer: Priority Health Medicare	$23.06
Rate for Payer: Priority Health PPO	$42.00
Rate for Payer: United Health Care Medicaid	$23.06
Rate for Payer: United Health Care Medicare Advantage	$10.15

THEOPHYLLINE

Facility

$5.00

Service Code	HCPCS 80198
Hospital Charge Code	3007860
Hospital Revenue Code	301
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$14.85
Rate for Payer: BCBS BCN 65	$14.85
Rate for Payer: Blue Care Network Medicare Advantage	$14.85
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Community Health Alliance Commercial	$4.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$14.85
Rate for Payer: Meridian Health Plan Medicare	$14.85
Rate for Payer: Priority Health Commercial	$3.50
Rate for Payer: Priority Health Medicaid	$14.85
Rate for Payer: Priority Health Medicare	$14.85
Rate for Payer: Priority Health PPO	$3.50
Rate for Payer: United Health Care Medicaid	$14.85
Rate for Payer: United Health Care Medicare Advantage	$6.53

THERAPEUTIC ACTIVITIES EA 15MN

Facility

$104.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	4200400
Hospital Revenue Code	420
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$88.40
Rate for Payer: Cash Price	$67.60
Rate for Payer: Community Health Alliance Commercial	$88.40
Rate for Payer: Priority Health Commercial	$72.80
Rate for Payer: Priority Health PPO	$72.80

THERAPEUTIC EXERCISES/15 MIN

Facility

$95.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	4200390
Hospital Revenue Code	420
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$80.75
Rate for Payer: Cash Price	$61.75
Rate for Payer: Community Health Alliance Commercial	$80.75
Rate for Payer: Priority Health Commercial	$66.50
Rate for Payer: Priority Health PPO	$66.50

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges