Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR ABDOMEN 2 VIEWS

Facility

$126.00

Service Code	HCPCS 74019
Hospital Charge Code	3200012
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$112.15
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Community Health Alliance Commercial	$107.10
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	$88.20
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$88.20
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR ABDOMEN 3 OR MORE VIEWS

Facility

$186.00

Service Code	HCPCS 74021
Hospital Charge Code	3200013
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$158.10
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$120.90
Rate for Payer: Cash Price	$120.90
Rate for Payer: Community Health Alliance Commercial	$158.10
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	$130.20
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$130.20
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR AC JOINTS WO WEIGHTS

Facility

$165.00

Service Code	HCPCS 73050
Hospital Charge Code	3200020
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$140.25
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$107.25
Rate for Payer: Cash Price	$107.25
Rate for Payer: Community Health Alliance Commercial	$140.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$93.36
Rate for Payer: Meridian Health Plan Medicare	$93.36
Rate for Payer: Priority Health Commercial	$115.50
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$115.50
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR AC JOINTS W WEIGHTS

Facility

$155.00

Service Code	HCPCS 73050
Hospital Charge Code	3200021
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$131.75
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$100.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Community Health Alliance Commercial	$131.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$93.36
Rate for Payer: Meridian Health Plan Medicare	$93.36
Rate for Payer: Priority Health Commercial	$108.50
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$108.50
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR ACUTE ABDOMEN SERIES

Facility

$208.00

Hospital Charge Code	3200088
Hospital Revenue Code	320
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$176.80
Rate for Payer: Cash Price	$135.20
Rate for Payer: Community Health Alliance Commercial	$176.80
Rate for Payer: Priority Health Commercial	$145.60
Rate for Payer: Priority Health PPO	$145.60

XR ANGIO AORTA ABDOMEN

Facility

$4,568.00

Service Code	HCPCS 75625
Hospital Charge Code	3201311
Hospital Revenue Code	323
Min. Negotiated Rate	$1,490.35
Max. Negotiated Rate	$3,882.80
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$2,969.20
Rate for Payer: Cash Price	$2,969.20
Rate for Payer: Community Health Alliance Commercial	$3,882.80
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$3,197.60
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$3,197.60
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR ANGIO AORTA ABD/W BILAT FEM

Facility

$3,385.00

Service Code	HCPCS 75630
Hospital Charge Code	3201291
Hospital Revenue Code	323
Min. Negotiated Rate	$1,490.35
Max. Negotiated Rate	$3,387.16
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$2,200.25
Rate for Payer: Cash Price	$2,200.25
Rate for Payer: Community Health Alliance Commercial	$2,877.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$2,369.50
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$2,369.50
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR ANGIO AORTAGRAM THORACIC

Facility

$3,639.00

Service Code	HCPCS 75605
Hospital Charge Code	3201340
Hospital Revenue Code	323
Min. Negotiated Rate	$2,547.30
Max. Negotiated Rate	$5,969.26
Rate for Payer: BCBS BCN 65	$5,969.26
Rate for Payer: Blue Care Network Medicare Advantage	$5,969.26
Rate for Payer: Cash Price	$2,365.35
Rate for Payer: Cash Price	$2,365.35
Rate for Payer: Community Health Alliance Commercial	$3,093.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$5,969.26
Rate for Payer: Meridian Health Plan Medicare	$5,969.26
Rate for Payer: Priority Health Commercial	$2,547.30
Rate for Payer: Priority Health Medicaid	$5,969.26
Rate for Payer: Priority Health Medicare	$5,969.26
Rate for Payer: Priority Health PPO	$2,547.30
Rate for Payer: United Health Care Medicaid	$5,969.26
Rate for Payer: United Health Care Medicare Advantage	$2,626.47

XR ANGIO ARTHRECTOMY

Facility

$4,043.00

Service Code	HCPCS 75992
Hospital Charge Code	3201120
Hospital Revenue Code	323
Min. Negotiated Rate	$2,830.10
Max. Negotiated Rate	$3,436.55
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Community Health Alliance Commercial	$3,436.55
Rate for Payer: Priority Health Commercial	$2,830.10
Rate for Payer: Priority Health PPO	$2,830.10

XR ANGIO ARTHRECTOMY, RENAL

Facility

$1,722.00

Service Code	HCPCS 0234T
Hospital Charge Code	3201123
Hospital Revenue Code	323
Min. Negotiated Rate	$1,205.40
Max. Negotiated Rate	$12,383.94
Rate for Payer: BCBS BCN 65	$12,383.94
Rate for Payer: Blue Care Network Medicare Advantage	$12,383.94
Rate for Payer: Cash Price	$1,119.30
Rate for Payer: Cash Price	$1,119.30
Rate for Payer: Community Health Alliance Commercial	$1,463.70
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$12,383.94
Rate for Payer: Meridian Health Plan Medicare	$12,383.94
Rate for Payer: Priority Health Commercial	$1,205.40
Rate for Payer: Priority Health Medicaid	$12,383.94
Rate for Payer: Priority Health Medicare	$12,383.94
Rate for Payer: Priority Health PPO	$1,205.40
Rate for Payer: United Health Care Medicaid	$12,383.94
Rate for Payer: United Health Care Medicare Advantage	$5,448.93

XR ANGIO BRACHIAL RETROGRADE

Facility

$1,722.00

Service Code	HCPCS 75658
Hospital Charge Code	3201130
Hospital Revenue Code	323
Min. Negotiated Rate	$1,205.40
Max. Negotiated Rate	$1,463.70
Rate for Payer: Cash Price	$1,119.30
Rate for Payer: Community Health Alliance Commercial	$1,463.70
Rate for Payer: Priority Health Commercial	$1,205.40
Rate for Payer: Priority Health PPO	$1,205.40

XR ANGIO CAROTID CEREBRAL BIAL

Facility

$3,639.00

Service Code	HCPCS 36223
Hospital Charge Code	3201168
Hospital Revenue Code	323
Min. Negotiated Rate	$2,547.30
Max. Negotiated Rate	$5,969.26
Rate for Payer: BCBS BCN 65	$5,969.26
Rate for Payer: Blue Care Network Medicare Advantage	$5,969.26
Rate for Payer: Cash Price	$2,365.35
Rate for Payer: Cash Price	$2,365.35
Rate for Payer: Community Health Alliance Commercial	$3,093.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$5,969.26
Rate for Payer: Meridian Health Plan Medicare	$5,969.26
Rate for Payer: Priority Health Commercial	$2,547.30
Rate for Payer: Priority Health Medicaid	$5,969.26
Rate for Payer: Priority Health Medicare	$5,969.26
Rate for Payer: Priority Health PPO	$2,547.30
Rate for Payer: United Health Care Medicaid	$5,969.26
Rate for Payer: United Health Care Medicare Advantage	$2,626.47

XR ANGIO CAROTID CEREBRAL UNI

Facility

$4,043.00

Service Code	HCPCS 36223
Hospital Charge Code	3201161
Hospital Revenue Code	323
Min. Negotiated Rate	$2,626.47
Max. Negotiated Rate	$5,969.26
Rate for Payer: BCBS BCN 65	$5,969.26
Rate for Payer: Blue Care Network Medicare Advantage	$5,969.26
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Community Health Alliance Commercial	$3,436.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$5,969.26
Rate for Payer: Meridian Health Plan Medicare	$5,969.26
Rate for Payer: Priority Health Commercial	$2,830.10
Rate for Payer: Priority Health Medicaid	$5,969.26
Rate for Payer: Priority Health Medicare	$5,969.26
Rate for Payer: Priority Health PPO	$2,830.10
Rate for Payer: United Health Care Medicaid	$5,969.26
Rate for Payer: United Health Care Medicare Advantage	$2,626.47

XR ANGIO CAROTID CERV BILAT

Facility

$3,639.00

Service Code	HCPCS 36222
Hospital Charge Code	3201151
Hospital Revenue Code	323
Min. Negotiated Rate	$1,490.35
Max. Negotiated Rate	$3,387.16
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$2,365.35
Rate for Payer: Cash Price	$2,365.35
Rate for Payer: Community Health Alliance Commercial	$3,093.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$2,547.30
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$2,547.30
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR ANGIO CAROTID CERVICAL UNI

Facility

$4,043.00

Service Code	HCPCS 36222
Hospital Charge Code	3201141
Hospital Revenue Code	323
Min. Negotiated Rate	$1,490.35
Max. Negotiated Rate	$3,436.55
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Community Health Alliance Commercial	$3,436.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$2,830.10
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$2,830.10
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR ANGIO EXT.CAROTID CER.BILAT

Facility

$4,043.00

Service Code	HCPCS 36227
Hospital Charge Code	3201100
Hospital Revenue Code	323
Min. Negotiated Rate	$2,830.10
Max. Negotiated Rate	$3,436.55
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Community Health Alliance Commercial	$3,436.55
Rate for Payer: Priority Health Commercial	$2,830.10
Rate for Payer: Priority Health PPO	$2,830.10

XR ANGIO EXT.CAROTID CEREB UNI

Facility

$1,252.00

Service Code	HCPCS 36227
Hospital Charge Code	3201090
Hospital Revenue Code	323
Min. Negotiated Rate	$876.40
Max. Negotiated Rate	$1,064.20
Rate for Payer: Cash Price	$813.80
Rate for Payer: Community Health Alliance Commercial	$1,064.20
Rate for Payer: Priority Health Commercial	$876.40
Rate for Payer: Priority Health PPO	$876.40

XR ANGIO EXTREMITY BILATERAL

Facility

$4,446.00

Service Code	HCPCS 75716
Hospital Charge Code	3201081
Hospital Revenue Code	323
Min. Negotiated Rate	$1,490.35
Max. Negotiated Rate	$3,779.10
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$2,889.90
Rate for Payer: Cash Price	$2,889.90
Rate for Payer: Community Health Alliance Commercial	$3,779.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$3,112.20
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$3,112.20
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR ANGIO EXTREMITY - LEFT

Facility

$3,639.00

Service Code	HCPCS 75710
Hospital Charge Code	3201164
Hospital Revenue Code	323
Min. Negotiated Rate	$1,490.35
Max. Negotiated Rate	$3,387.16
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$2,365.35
Rate for Payer: Cash Price	$2,365.35
Rate for Payer: Community Health Alliance Commercial	$3,093.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$2,547.30
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$2,547.30
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR ANGIO EXTREMITY - RIGHT

Facility

$3,385.00

Service Code	HCPCS 75710
Hospital Charge Code	3201163
Hospital Revenue Code	323
Min. Negotiated Rate	$1,490.35
Max. Negotiated Rate	$3,387.16
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$2,200.25
Rate for Payer: Cash Price	$2,200.25
Rate for Payer: Community Health Alliance Commercial	$2,877.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$2,369.50
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$2,369.50
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR ANGIO PULMONARY BILAT

Facility

$4,043.00

Service Code	HCPCS 75743
Hospital Charge Code	3201250
Hospital Revenue Code	323
Min. Negotiated Rate	$1,490.35
Max. Negotiated Rate	$3,436.55
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Community Health Alliance Commercial	$3,436.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$2,830.10
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$2,830.10
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR ANGIO PULMONARY UNI

Facility

$1,722.00

Service Code	HCPCS 75741
Hospital Charge Code	3201170
Hospital Revenue Code	323
Min. Negotiated Rate	$1,205.40
Max. Negotiated Rate	$3,387.16
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$1,119.30
Rate for Payer: Cash Price	$1,119.30
Rate for Payer: Community Health Alliance Commercial	$1,463.70
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$1,205.40
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$1,205.40
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR ANGIO RENAL BILAT

Facility

$3,385.00

Service Code	HCPCS 75724
Hospital Charge Code	3201271
Hospital Revenue Code	323
Min. Negotiated Rate	$2,369.50
Max. Negotiated Rate	$2,877.25
Rate for Payer: Cash Price	$2,200.25
Rate for Payer: Community Health Alliance Commercial	$2,877.25
Rate for Payer: Priority Health Commercial	$2,369.50
Rate for Payer: Priority Health PPO	$2,369.50

XR ANGIO RENAL UNI

Facility

$4,043.00

Service Code	HCPCS 75722
Hospital Charge Code	3201260
Hospital Revenue Code	323
Min. Negotiated Rate	$2,830.10
Max. Negotiated Rate	$3,436.55
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Community Health Alliance Commercial	$3,436.55
Rate for Payer: Priority Health Commercial	$2,830.10
Rate for Payer: Priority Health PPO	$2,830.10

XR ANGIO VERTEBRAL UNI

Facility

$4,043.00

Service Code	HCPCS 36226
Hospital Charge Code	3201191
Hospital Revenue Code	323
Min. Negotiated Rate	$2,626.47
Max. Negotiated Rate	$5,969.26
Rate for Payer: BCBS BCN 65	$5,969.26
Rate for Payer: Blue Care Network Medicare Advantage	$5,969.26
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Community Health Alliance Commercial	$3,436.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$5,969.26
Rate for Payer: Meridian Health Plan Medicare	$5,969.26
Rate for Payer: Priority Health Commercial	$2,830.10
Rate for Payer: Priority Health Medicaid	$5,969.26
Rate for Payer: Priority Health Medicare	$5,969.26
Rate for Payer: Priority Health PPO	$2,830.10
Rate for Payer: United Health Care Medicaid	$5,969.26
Rate for Payer: United Health Care Medicare Advantage	$2,626.47

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges