Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

US PREG 1ST TRI ADDL FETUS

Facility

$204.00

Service Code	HCPCS 76802
Hospital Charge Code	4000093
Hospital Revenue Code	402
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$173.40
Rate for Payer: Cash Price	$132.60
Rate for Payer: Community Health Alliance Commercial	$173.40
Rate for Payer: Priority Health Commercial	$142.80
Rate for Payer: Priority Health PPO	$142.80

US PREG 1ST TRIMESTER

Facility

$395.00

Service Code	HCPCS 76801
Hospital Charge Code	4000092
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 PREG 2ND&3RD TRI ADDL FETUS

Facility

$395.00

Service Code	HCPCS 76810
Hospital Charge Code	4000095
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 PREG 2ND & 3RD TRIMESTER

Facility

$395.00

Service Code	HCPCS 76805
Hospital Charge Code	4000094
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 PREG FOLLOW UP

Facility

$204.00

Service Code	HCPCS 76816
Hospital Charge Code	4000096
Hospital Revenue Code	402
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$173.40
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$132.60
Rate for Payer: Cash Price	$132.60
Rate for Payer: Community Health Alliance Commercial	$173.40
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	$142.80
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$142.80
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

US PROSTATE

Facility

$395.00

Service Code	HCPCS 76872
Hospital Charge Code	4000100
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 PYLORIC STENOSIS

Facility

$324.00

Service Code	HCPCS 76705
Hospital Charge Code	4000085
Hospital Revenue Code	402
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$275.40
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cash Price	$210.60
Rate for Payer: Community Health Alliance Commercial	$275.40
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	$226.80
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$226.80
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

US RENAL

Facility

$395.00

Service Code	HCPCS 76770
Hospital Charge Code	4000120
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 RENAL CYST ASPIRATION

Facility

$1,107.00

Service Code	HCPCS 50390
Hospital Charge Code	3500437
Hospital Revenue Code	361
Min. Negotiated Rate	$334.24
Max. Negotiated Rate	$940.95
Rate for Payer: BCBS BCN 65	$759.64
Rate for Payer: Blue Care Network Medicare Advantage	$759.64
Rate for Payer: Cash Price	$719.55
Rate for Payer: Cash Price	$719.55
Rate for Payer: Community Health Alliance Commercial	$940.95
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	$774.90
Rate for Payer: Priority Health Medicaid	$759.64
Rate for Payer: Priority Health Medicare	$759.64
Rate for Payer: Priority Health PPO	$774.90
Rate for Payer: United Health Care Medicaid	$759.64
Rate for Payer: United Health Care Medicare Advantage	$334.24

US RENAL DOPPLER

Facility

$518.00

Service Code	HCPCS 93975
Hospital Charge Code	4000121
Hospital Revenue Code	921
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$440.30
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$336.70
Rate for Payer: Cash Price	$336.70
Rate for Payer: Community Health Alliance Commercial	$440.30
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	$362.60
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$362.60
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

US RENAL TRANSPLANT W/DOPP

Facility

$679.00

Hospital Charge Code	4000272
Hospital Revenue Code	402
Min. Negotiated Rate	$475.30
Max. Negotiated Rate	$577.15
Rate for Payer: Cash Price	$441.35
Rate for Payer: Community Health Alliance Commercial	$577.15
Rate for Payer: Priority Health Commercial	$475.30
Rate for Payer: Priority Health PPO	$475.30

US RENAL VEIN DOPPLER

Facility

$510.00

Service Code	HCPCS 93975
Hospital Charge Code	4000410
Hospital Revenue Code	921
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$433.50
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$331.50
Rate for Payer: Cash Price	$331.50
Rate for Payer: Community Health Alliance Commercial	$433.50
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	$357.00
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$357.00
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

US R SOFT TISSUE ARM

Facility

$268.00

Service Code	HCPCS 76882
Hospital Charge Code	4000140
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 R SOFT TISSUE LEGS

Facility

$325.00

Service Code	HCPCS 76882
Hospital Charge Code	4000160
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 RT BREAST BIOPSY

Facility

$210.00

Service Code	HCPCS 76942
Hospital Charge Code	4000230
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 RT BREAST CORE BX W/CLIP

Facility

$1,866.00

Hospital Charge Code	4000265
Hospital Revenue Code	402
Min. Negotiated Rate	$1,306.20
Max. Negotiated Rate	$1,586.10
Rate for Payer: Cash Price	$1,212.90
Rate for Payer: Community Health Alliance Commercial	$1,586.10
Rate for Payer: Priority Health Commercial	$1,306.20
Rate for Payer: Priority Health PPO	$1,306.20

US R UPPER EXTREMITY VENOUS

Facility

$268.00

Service Code	HCPCS 93971
Hospital Charge Code	4000400
Hospital Revenue Code	921
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 SCROTUM/TESTICULAR

Facility

$395.00

Service Code	HCPCS 76870
Hospital Charge Code	4000130
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 SMA ARTERY/DOPPLER

Facility

$510.00

Service Code	HCPCS 93975
Hospital Charge Code	4000430
Hospital Revenue Code	921
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$433.50
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$331.50
Rate for Payer: Cash Price	$331.50
Rate for Payer: Community Health Alliance Commercial	$433.50
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	$357.00
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$357.00
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

US SOFT TISSUE

Facility

$325.00

Service Code	HCPCS 76882
Hospital Charge Code	4000141
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 SOFT TISSUE HEAD AND NECK

Facility

$395.00

Service Code	HCPCS 76536
Hospital Charge Code	4000150
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 SPINAL CANAL AND CONTENTS

Facility

$319.00

Service Code	HCPCS 76800
Hospital Charge Code	4000425
Hospital Revenue Code	402
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$271.15
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$207.35
Rate for Payer: Cash Price	$207.35
Rate for Payer: Community Health Alliance Commercial	$271.15
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	$223.30
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$223.30
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

US SPLEEN

Facility

$395.00

Service Code	HCPCS 76705
Hospital Charge Code	4000170
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 STRESS ECHOCARDIOGRAPHY

Facility

$635.00

Hospital Charge Code	4000175
Hospital Revenue Code	483
Min. Negotiated Rate	$444.50
Max. Negotiated Rate	$539.75
Rate for Payer: Cash Price	$412.75
Rate for Payer: Community Health Alliance Commercial	$539.75
Rate for Payer: Priority Health Commercial	$444.50
Rate for Payer: Priority Health PPO	$444.50

USTEKINUMAB 1

Facility

$62.50

Hospital Charge Code	3102136
Hospital Revenue Code	300
Min. Negotiated Rate	$43.75
Max. Negotiated Rate	$53.12
Rate for Payer: Cash Price	$40.63
Rate for Payer: Community Health Alliance Commercial	$53.12
Rate for Payer: Priority Health Commercial	$43.75
Rate for Payer: Priority Health PPO	$43.75

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges