Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

UROSTOMY/ILEOSTOMY POUCH

Facility

$29.00

Hospital Charge Code	27019018
Hospital Revenue Code	270
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$24.65
Rate for Payer: Cash Price	$18.85
Rate for Payer: Community Health Alliance Commercial	$24.65
Rate for Payer: Priority Health Commercial	$20.30
Rate for Payer: Priority Health PPO	$20.30

UROSTOMY/ILEOSTOMY WAFER

Facility

$46.00

Hospital Charge Code	27019000
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

UROVYSION FISH

Facility

$201.22

Hospital Charge Code	3101225
Hospital Revenue Code	310
Min. Negotiated Rate	$140.85
Max. Negotiated Rate	$171.04
Rate for Payer: Cash Price	$130.79
Rate for Payer: Community Health Alliance Commercial	$171.04
Rate for Payer: Priority Health Commercial	$140.85
Rate for Payer: Priority Health PPO	$140.85

US 3D/4D

Facility

$104.00

Hospital Charge Code	4000616
Hospital Revenue Code	402
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

US ABD (AAA) MCR SCREEENING

Facility

$235.00

Service Code	HCPCS 76706
Hospital Charge Code	4000311
Hospital Revenue Code	402
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$199.75
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$152.75
Rate for Payer: Cash Price	$152.75
Rate for Payer: Community Health Alliance Commercial	$199.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$164.50
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$164.50
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

US ABD AORTA

Facility

$268.00

Service Code	HCPCS 76775
Hospital Charge Code	4000270
Hospital Revenue Code	402
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$227.80
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$174.20
Rate for Payer: Cash Price	$174.20
Rate for Payer: Community Health Alliance Commercial	$227.80
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$187.60
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$187.60
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

US ABD. AORTA DOPPLER

Facility

$495.00

Service Code	HCPCS 93978
Hospital Charge Code	4000310
Hospital Revenue Code	921
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$420.75
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$321.75
Rate for Payer: Cash Price	$321.75
Rate for Payer: Community Health Alliance Commercial	$420.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$255.96
Rate for Payer: Meridian Health Plan Medicare	$255.96
Rate for Payer: Priority Health Commercial	$346.50
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$346.50
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

US ABDOMINAL COMPLETE

Facility

$325.00

Service Code	HCPCS 76700
Hospital Charge Code	4000280
Hospital Revenue Code	402
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$276.25
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$211.25
Rate for Payer: Cash Price	$211.25
Rate for Payer: Community Health Alliance Commercial	$276.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$227.50
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$227.50
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

US ABD PARACENTESIS W/ IMAGING

Facility

$1,258.00

Hospital Charge Code	4000193
Hospital Revenue Code	490
Min. Negotiated Rate	$880.60
Max. Negotiated Rate	$1,069.30
Rate for Payer: Cash Price	$817.70
Rate for Payer: Community Health Alliance Commercial	$1,069.30
Rate for Payer: Priority Health Commercial	$880.60
Rate for Payer: Priority Health PPO	$880.60

US ABD SOFT TISSUE ANY QUADRAN

Facility

$395.00

Service Code	HCPCS 76705
Hospital Charge Code	4000281
Hospital Revenue Code	402
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$335.75
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$256.75
Rate for Payer: Cash Price	$256.75
Rate for Payer: Community Health Alliance Commercial	$335.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$276.50
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$276.50
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

US ADULT ECHO WITH 2-D PRIMARY

Facility

$571.00

Service Code	HCPCS 93307
Hospital Charge Code	4000110
Hospital Revenue Code	483
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$485.35
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$371.15
Rate for Payer: Cash Price	$371.15
Rate for Payer: Community Health Alliance Commercial	$485.35
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$255.96
Rate for Payer: Meridian Health Plan Medicare	$255.96
Rate for Payer: Priority Health Commercial	$399.70
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$399.70
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

US AMNIOCENTESIS

Facility

$234.00

Hospital Charge Code	4000290
Hospital Revenue Code	402
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$198.90
Rate for Payer: Cash Price	$152.10
Rate for Payer: Community Health Alliance Commercial	$198.90
Rate for Payer: Priority Health Commercial	$163.80
Rate for Payer: Priority Health PPO	$163.80

US AMNIOCENTESIS

Facility

$216.00

Hospital Charge Code	4000219
Hospital Revenue Code	402
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$183.60
Rate for Payer: Cash Price	$140.40
Rate for Payer: Community Health Alliance Commercial	$183.60
Rate for Payer: Priority Health Commercial	$151.20
Rate for Payer: Priority Health PPO	$151.20

US ANKLE/BRACHIAL, BILATERAL

Facility

$328.00

Service Code	HCPCS 93922
Hospital Charge Code	4000299
Hospital Revenue Code	921
Min. Negotiated Rate	$62.80
Max. Negotiated Rate	$278.80
Rate for Payer: BCBS BCN 65	$142.73
Rate for Payer: Blue Care Network Medicare Advantage	$142.73
Rate for Payer: Cash Price	$213.20
Rate for Payer: Cash Price	$213.20
Rate for Payer: Community Health Alliance Commercial	$278.80
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$142.73
Rate for Payer: Meridian Health Plan Medicare	$142.73
Rate for Payer: Priority Health Commercial	$229.60
Rate for Payer: Priority Health Medicaid	$142.73
Rate for Payer: Priority Health Medicare	$142.73
Rate for Payer: Priority Health PPO	$229.60
Rate for Payer: United Health Care Medicaid	$142.73
Rate for Payer: United Health Care Medicare Advantage	$62.80

US ANKLE/BRACHIAL UNILATERAL

Facility

$164.00

Hospital Charge Code	4000298
Hospital Revenue Code	921
Min. Negotiated Rate	$114.80
Max. Negotiated Rate	$139.40
Rate for Payer: Cash Price	$106.60
Rate for Payer: Community Health Alliance Commercial	$139.40
Rate for Payer: Priority Health Commercial	$114.80
Rate for Payer: Priority Health PPO	$114.80

US BIOPSY

Facility

$3,839.00

Hospital Charge Code	4000221
Hospital Revenue Code	361
Min. Negotiated Rate	$2,687.30
Max. Negotiated Rate	$3,263.15
Rate for Payer: Cash Price	$2,495.35
Rate for Payer: Community Health Alliance Commercial	$3,263.15
Rate for Payer: Priority Health Commercial	$2,687.30
Rate for Payer: Priority Health PPO	$2,687.30

US BLADDER

Facility

$395.00

Hospital Charge Code	4000615
Hospital Revenue Code	402
Min. Negotiated Rate	$276.50
Max. Negotiated Rate	$335.75
Rate for Payer: Cash Price	$256.75
Rate for Payer: Community Health Alliance Commercial	$335.75
Rate for Payer: Priority Health Commercial	$276.50
Rate for Payer: Priority Health PPO	$276.50

US BL LOW.EXT.VENOUS THROMBOSI

Facility

$427.00

Service Code	HCPCS 93970
Hospital Charge Code	4000352
Hospital Revenue Code	921
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$362.95
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$277.55
Rate for Payer: Cash Price	$277.55
Rate for Payer: Community Health Alliance Commercial	$362.95
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$255.96
Rate for Payer: Meridian Health Plan Medicare	$255.96
Rate for Payer: Priority Health Commercial	$298.90
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$298.90
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

US BL UPPER EXTREMITY VENOUS

Facility

$459.00

Service Code	HCPCS 93970
Hospital Charge Code	4000402
Hospital Revenue Code	921
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$390.15
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$298.35
Rate for Payer: Cash Price	$298.35
Rate for Payer: Community Health Alliance Commercial	$390.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$255.96
Rate for Payer: Meridian Health Plan Medicare	$255.96
Rate for Payer: Priority Health Commercial	$321.30
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$321.30
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

US BREAST CYST ASPIRATION

Facility

$1,243.00

Service Code	HCPCS 19000
Hospital Charge Code	3500433
Hospital Revenue Code	361
Min. Negotiated Rate	$334.24
Max. Negotiated Rate	$1,056.55
Rate for Payer: BCBS BCN 65	$759.64
Rate for Payer: Blue Care Network Medicare Advantage	$759.64
Rate for Payer: Cash Price	$807.95
Rate for Payer: Cash Price	$807.95
Rate for Payer: Community Health Alliance Commercial	$1,056.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$759.64
Rate for Payer: Meridian Health Plan Medicare	$759.64
Rate for Payer: Priority Health Commercial	$870.10
Rate for Payer: Priority Health Medicaid	$759.64
Rate for Payer: Priority Health Medicare	$759.64
Rate for Payer: Priority Health PPO	$870.10
Rate for Payer: United Health Care Medicaid	$759.64
Rate for Payer: United Health Care Medicare Advantage	$334.24

US BREAST CYST ASP UNILATERAL

Facility

$210.00

Service Code	HCPCS 76942
Hospital Charge Code	4000020
Hospital Revenue Code	402
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$178.50
Rate for Payer: Cash Price	$136.50
Rate for Payer: Community Health Alliance Commercial	$178.50
Rate for Payer: Priority Health Commercial	$147.00
Rate for Payer: Priority Health PPO	$147.00

US BREAST LEFT COMPLETE

Facility

$236.00

Hospital Charge Code	4000466
Hospital Revenue Code	402
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$200.60
Rate for Payer: Cash Price	$153.40
Rate for Payer: Community Health Alliance Commercial	$200.60
Rate for Payer: Priority Health Commercial	$165.20
Rate for Payer: Priority Health PPO	$165.20

US BREAST LEFT LIMITED

Facility

$236.00

Hospital Charge Code	4000468
Hospital Revenue Code	402
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$200.60
Rate for Payer: Cash Price	$153.40
Rate for Payer: Community Health Alliance Commercial	$200.60
Rate for Payer: Priority Health Commercial	$165.20
Rate for Payer: Priority Health PPO	$165.20

US BREAST RIGHT COMPLETE

Facility

$236.00

Hospital Charge Code	4000465
Hospital Revenue Code	402
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$200.60
Rate for Payer: Cash Price	$153.40
Rate for Payer: Community Health Alliance Commercial	$200.60
Rate for Payer: Priority Health Commercial	$165.20
Rate for Payer: Priority Health PPO	$165.20

US BREAST RIGHT LIMITED

Facility

$236.00

Hospital Charge Code	4000467
Hospital Revenue Code	402
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$200.60
Rate for Payer: Cash Price	$153.40
Rate for Payer: Community Health Alliance Commercial	$200.60
Rate for Payer: Priority Health Commercial	$165.20
Rate for Payer: Priority Health PPO	$165.20

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges