Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR BONE LENGTH SCANOGRAM

Facility

$311.00

Service Code	HCPCS 77073
Hospital Charge Code	3200016
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$264.35
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$202.15
Rate for Payer: Cash Price	$202.15
Rate for Payer: Community Health Alliance Commercial	$264.35
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	$217.70
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$217.70
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR BONE SURVEY

Facility

$208.00

Service Code	HCPCS 77075
Hospital Charge Code	3200114
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$176.80
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Community Health Alliance Commercial	$176.80
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	$145.60
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$145.60
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR C ARM FLUORO

Facility

$533.00

Hospital Charge Code	3200091
Hospital Revenue Code	320
Min. Negotiated Rate	$373.10
Max. Negotiated Rate	$453.05
Rate for Payer: Cash Price	$346.45
Rate for Payer: Community Health Alliance Commercial	$453.05
Rate for Payer: Priority Health Commercial	$373.10
Rate for Payer: Priority Health PPO	$373.10

XR CAVERNOSOGRAM

Facility

$680.00

Hospital Charge Code	3200466
Hospital Revenue Code	320
Min. Negotiated Rate	$476.00
Max. Negotiated Rate	$578.00
Rate for Payer: Cash Price	$442.00
Rate for Payer: Community Health Alliance Commercial	$578.00
Rate for Payer: Priority Health Commercial	$476.00
Rate for Payer: Priority Health PPO	$476.00

XR CERVICAL SPINE ONE VIEW

Facility

$154.00

Service Code	HCPCS 72020
Hospital Charge Code	3200099
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$130.90
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$100.10
Rate for Payer: Cash Price	$100.10
Rate for Payer: Community Health Alliance Commercial	$130.90
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	$107.80
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$107.80
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR CHEST 2V (WITH FLUOROSCOPY)

Facility

$267.00

Service Code	HCPCS 71046
Hospital Charge Code	3200144
Hospital Revenue Code	324
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$226.95
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$173.55
Rate for Payer: Cash Price	$173.55
Rate for Payer: Community Health Alliance Commercial	$226.95
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	$186.90
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$186.90
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR CHEST 3 VIEWS

Facility

$154.00

Service Code	HCPCS 71047
Hospital Charge Code	3200142
Hospital Revenue Code	324
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$130.90
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$100.10
Rate for Payer: Cash Price	$100.10
Rate for Payer: Community Health Alliance Commercial	$130.90
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	$107.80
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$107.80
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR CHEST 4 VIEWS

Facility

$154.00

Service Code	HCPCS 71048
Hospital Charge Code	3200143
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$130.90
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$100.10
Rate for Payer: Cash Price	$100.10
Rate for Payer: Community Health Alliance Commercial	$130.90
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	$107.80
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$107.80
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR CHEST (DECUBITUS VIEW)

Facility

$149.00

Service Code	HCPCS 71046
Hospital Charge Code	3200145
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$126.65
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$96.85
Rate for Payer: Cash Price	$96.85
Rate for Payer: Community Health Alliance Commercial	$126.65
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	$104.30
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$104.30
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR CHEST PA & LAT

Facility

$137.00

Service Code	HCPCS 71046
Hospital Charge Code	3200141
Hospital Revenue Code	324
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$116.45
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$89.05
Rate for Payer: Cash Price	$89.05
Rate for Payer: Community Health Alliance Commercial	$116.45
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	$95.90
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$95.90
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR CHEST PA ONLY

Facility

$126.00

Service Code	HCPCS 71045
Hospital Charge Code	3200140
Hospital Revenue Code	324
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$107.10
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
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	$93.36
Rate for Payer: Meridian Health Plan Medicare	$93.36
Rate for Payer: Priority Health Commercial	$88.20
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$88.20
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR CHEST SCREENING SPECIAL

Facility

$30.00

Hospital Charge Code	3200149
Hospital Revenue Code	324
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$25.50
Rate for Payer: Cash Price	$19.50
Rate for Payer: Community Health Alliance Commercial	$25.50
Rate for Payer: Priority Health Commercial	$21.00
Rate for Payer: Priority Health PPO	$21.00

XR CHOLANGIOGRAM 1ST SET(OR)

Facility

$341.00

Service Code	HCPCS 74300
Hospital Charge Code	3202920
Hospital Revenue Code	320
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$289.85
Rate for Payer: Cash Price	$221.65
Rate for Payer: Community Health Alliance Commercial	$289.85
Rate for Payer: Priority Health Commercial	$238.70
Rate for Payer: Priority Health PPO	$238.70

XR CHOLANGIOGRAM 2ND SET (OR)

Facility

$341.00

Service Code	HCPCS 74301
Hospital Charge Code	3202921
Hospital Revenue Code	320
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$289.85
Rate for Payer: Cash Price	$221.65
Rate for Payer: Community Health Alliance Commercial	$289.85
Rate for Payer: Priority Health Commercial	$238.70
Rate for Payer: Priority Health PPO	$238.70

XR CLAVICLE LT

Facility

$186.00

Service Code	HCPCS 73000 LT
Hospital Charge Code	3202941
Hospital Revenue Code	320
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$158.10
Rate for Payer: Cash Price	$120.90
Rate for Payer: Community Health Alliance Commercial	$158.10
Rate for Payer: Priority Health Commercial	$130.20
Rate for Payer: Priority Health PPO	$130.20

XR CLAVICLE RT

Facility

$186.00

Service Code	HCPCS 73000 RT
Hospital Charge Code	3202940
Hospital Revenue Code	320
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$158.10
Rate for Payer: Cash Price	$120.90
Rate for Payer: Community Health Alliance Commercial	$158.10
Rate for Payer: Priority Health Commercial	$130.20
Rate for Payer: Priority Health PPO	$130.20

XR COLON TRANSIT STUDY

Facility

$165.00

Service Code	HCPCS 74018
Hospital Charge Code	3200014
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 CYSTOGRAM

Facility

$632.00

Service Code	HCPCS 74430
Hospital Charge Code	3200882
Hospital Revenue Code	320
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$537.20
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$410.80
Rate for Payer: Cash Price	$410.80
Rate for Payer: Community Health Alliance Commercial	$537.20
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$374.25
Rate for Payer: Meridian Health Plan Medicare	$374.25
Rate for Payer: Priority Health Commercial	$442.40
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$442.40
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

XR CYSTOGRAM VOIDING

Facility

$632.00

Service Code	HCPCS 74455
Hospital Charge Code	3200883
Hospital Revenue Code	320
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$537.20
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$410.80
Rate for Payer: Cash Price	$410.80
Rate for Payer: Community Health Alliance Commercial	$537.20
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	$442.40
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$442.40
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

XR DIAGNOSTIC LUMBAR PUNCTURE

Facility

$1,512.00

Service Code	HCPCS 62270
Hospital Charge Code	3400311
Hospital Revenue Code	361
Min. Negotiated Rate	$333.18
Max. Negotiated Rate	$1,285.20
Rate for Payer: BCBS BCN 65	$757.23
Rate for Payer: Blue Care Network Medicare Advantage	$757.23
Rate for Payer: Cash Price	$982.80
Rate for Payer: Cash Price	$982.80
Rate for Payer: Community Health Alliance Commercial	$1,285.20
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$757.23
Rate for Payer: Meridian Health Plan Medicare	$757.23
Rate for Payer: Priority Health Commercial	$1,058.40
Rate for Payer: Priority Health Medicaid	$757.23
Rate for Payer: Priority Health Medicare	$757.23
Rate for Payer: Priority Health PPO	$1,058.40
Rate for Payer: United Health Care Medicaid	$757.23
Rate for Payer: United Health Care Medicare Advantage	$333.18

XR DISKOGRAPHY CERVICAL/THORAC

Facility

$2,410.00

Service Code	HCPCS 72285
Hospital Charge Code	3200151
Hospital Revenue Code	320
Min. Negotiated Rate	$921.70
Max. Negotiated Rate	$2,094.77
Rate for Payer: BCBS BCN 65	$2,094.77
Rate for Payer: Blue Care Network Medicare Advantage	$2,094.77
Rate for Payer: Cash Price	$1,566.50
Rate for Payer: Cash Price	$1,566.50
Rate for Payer: Community Health Alliance Commercial	$2,048.50
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$2,094.77
Rate for Payer: Meridian Health Plan Medicare	$2,094.77
Rate for Payer: Priority Health Commercial	$1,687.00
Rate for Payer: Priority Health Medicaid	$2,094.77
Rate for Payer: Priority Health Medicare	$2,094.77
Rate for Payer: Priority Health PPO	$1,687.00
Rate for Payer: United Health Care Medicaid	$2,094.77
Rate for Payer: United Health Care Medicare Advantage	$921.70

XR DISKOGRAPHY LUMBAR

Facility

$2,410.00

Service Code	HCPCS 72295
Hospital Charge Code	3200161
Hospital Revenue Code	320
Min. Negotiated Rate	$921.70
Max. Negotiated Rate	$2,094.77
Rate for Payer: BCBS BCN 65	$2,094.77
Rate for Payer: Blue Care Network Medicare Advantage	$2,094.77
Rate for Payer: Cash Price	$1,566.50
Rate for Payer: Cash Price	$1,566.50
Rate for Payer: Community Health Alliance Commercial	$2,048.50
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$2,094.77
Rate for Payer: Meridian Health Plan Medicare	$2,094.77
Rate for Payer: Priority Health Commercial	$1,687.00
Rate for Payer: Priority Health Medicaid	$2,094.77
Rate for Payer: Priority Health Medicare	$2,094.77
Rate for Payer: Priority Health PPO	$1,687.00
Rate for Payer: United Health Care Medicaid	$2,094.77
Rate for Payer: United Health Care Medicare Advantage	$921.70

XR ELBOW LT, 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73070
Hospital Charge Code	3202981
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$158.10
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
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	$93.36
Rate for Payer: Meridian Health Plan Medicare	$93.36
Rate for Payer: Priority Health Commercial	$130.20
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$130.20
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR ELBOW LT, MIN 3 VIEWS

Facility

$186.00

Service Code	HCPCS 73080
Hospital Charge Code	3202983
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$158.10
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
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	$93.36
Rate for Payer: Meridian Health Plan Medicare	$93.36
Rate for Payer: Priority Health Commercial	$130.20
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$130.20
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR ELBOW RT, 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73070
Hospital Charge Code	3202980
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$158.10
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
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	$93.36
Rate for Payer: Meridian Health Plan Medicare	$93.36
Rate for Payer: Priority Health Commercial	$130.20
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$130.20
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges