Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR ELBOW RT, MIN 3 VIEWS

Facility

$186.00

Service Code	HCPCS 73080
Hospital Charge Code	3202982
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 EMBOLIZATION FOLLOWUP

Facility

$341.00

Service Code	HCPCS 75898
Hospital Charge Code	3201232
Hospital Revenue Code	320
Min. Negotiated Rate	$238.70
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	$221.65
Rate for Payer: Cash Price	$221.65
Rate for Payer: Community Health Alliance Commercial	$289.85
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	$238.70
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$238.70
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR.ERCP PAN/BIL DUCT BOTH

Facility

$1,018.00

Service Code	HCPCS 74330
Hospital Charge Code	3203110
Hospital Revenue Code	320
Min. Negotiated Rate	$712.60
Max. Negotiated Rate	$865.30
Rate for Payer: Cash Price	$661.70
Rate for Payer: Community Health Alliance Commercial	$865.30
Rate for Payer: Priority Health Commercial	$712.60
Rate for Payer: Priority Health PPO	$712.60

XR.ERCP PANCREATIC DUCT

Facility

$414.00

Service Code	HCPCS 74329
Hospital Charge Code	3203100
Hospital Revenue Code	320
Min. Negotiated Rate	$289.80
Max. Negotiated Rate	$351.90
Rate for Payer: Cash Price	$269.10
Rate for Payer: Community Health Alliance Commercial	$351.90
Rate for Payer: Priority Health Commercial	$289.80
Rate for Payer: Priority Health PPO	$289.80

X RESP PATHOGEN PANEL

Facility

$245.00

Hospital Charge Code	3101339
Hospital Revenue Code	306
Min. Negotiated Rate	$171.50
Max. Negotiated Rate	$208.25
Rate for Payer: Cash Price	$159.25
Rate for Payer: Community Health Alliance Commercial	$208.25
Rate for Payer: Priority Health Commercial	$171.50
Rate for Payer: Priority Health PPO	$171.50

X RESP PATH PANEL PCR

Facility

$295.00

Hospital Charge Code	3101010
Hospital Revenue Code	306
Min. Negotiated Rate	$206.50
Max. Negotiated Rate	$250.75
Rate for Payer: Cash Price	$191.75
Rate for Payer: Community Health Alliance Commercial	$250.75
Rate for Payer: Priority Health Commercial	$206.50
Rate for Payer: Priority Health PPO	$206.50

X RET GENE REARRANGEMENT BY F

Facility

$94.00

Hospital Charge Code	3100858
Hospital Revenue Code	301
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$79.90
Rate for Payer: Cash Price	$61.10
Rate for Payer: Community Health Alliance Commercial	$79.90
Rate for Payer: Priority Health Commercial	$65.80
Rate for Payer: Priority Health PPO	$65.80

XR EXTREMITY UPPER INFANT LT

Facility

$155.00

Service Code	HCPCS 73092
Hospital Charge Code	3200851
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$131.75
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
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	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$108.50
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$108.50
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR EXTREMITY UPPER INFANT RT

Facility

$165.00

Service Code	HCPCS 73092
Hospital Charge Code	3200850
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$140.25
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
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	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$115.50
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$115.50
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR FACIAL BONES 2 VIEWS

Facility

$126.00

Service Code	HCPCS 70140
Hospital Charge Code	3203001
Hospital Revenue Code	320
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 FACIAL BONES 3 OR 4 VIEWS

Facility

$155.00

Service Code	HCPCS 70150
Hospital Charge Code	3203000
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$131.75
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
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	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$108.50
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$108.50
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR FEMUR LT

Facility

$155.00

Service Code	HCPCS 73552 LT
Hospital Charge Code	3203051
Hospital Revenue Code	320
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$131.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Community Health Alliance Commercial	$131.75
Rate for Payer: Priority Health Commercial	$108.50
Rate for Payer: Priority Health PPO	$108.50

XR FEMUR RT

Facility

$155.00

Service Code	HCPCS 73552 RT
Hospital Charge Code	3203050
Hospital Revenue Code	320
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$131.75
Rate for Payer: Cash Price	$100.75
Rate for Payer: Community Health Alliance Commercial	$131.75
Rate for Payer: Priority Health Commercial	$108.50
Rate for Payer: Priority Health PPO	$108.50

XR FINGERS LT, MIN 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73140 LT
Hospital Charge Code	3203041
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 FINGERS RT, MIN 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73140 RT
Hospital Charge Code	3203040
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 FISTULAGRAM (SINOGRAM)

Facility

$909.00

Hospital Charge Code	3200182
Hospital Revenue Code	320
Min. Negotiated Rate	$636.30
Max. Negotiated Rate	$772.65
Rate for Payer: Cash Price	$590.85
Rate for Payer: Community Health Alliance Commercial	$772.65
Rate for Payer: Priority Health Commercial	$636.30
Rate for Payer: Priority Health PPO	$636.30

XR FISTULAGRAM (SINOGRAM)

Facility

$341.00

Hospital Charge Code	3200180
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 FLUORO FOR VAD PLACEMENT

Facility

$338.00

Hospital Charge Code	3203029
Hospital Revenue Code	320
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$287.30
Rate for Payer: Cash Price	$219.70
Rate for Payer: Community Health Alliance Commercial	$287.30
Rate for Payer: Priority Health Commercial	$236.60
Rate for Payer: Priority Health PPO	$236.60

XR FLUORO TIME

Facility

$267.00

Service Code	HCPCS 76000
Hospital Charge Code	3203020
Hospital Revenue Code	320
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$255.96
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
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	$255.96
Rate for Payer: Meridian Health Plan Medicare	$255.96
Rate for Payer: Priority Health Commercial	$186.90
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$186.90
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

XR FOOT LT 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73620 LT
Hospital Charge Code	3203071
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 FOOT LT, MIN 3 VIEWS

Facility

$186.00

Service Code	HCPCS 73630 LT
Hospital Charge Code	3203081
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 FOOT RT 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73620 RT
Hospital Charge Code	3203070
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 FOOT RT, MIN 3 VIEWS

Facility

$186.00

Service Code	HCPCS 73630
Hospital Charge Code	3203080
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 FOREARM LT, 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73090
Hospital Charge Code	3200291
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 FOREARM RT, 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73090
Hospital Charge Code	3200290
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