Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR GI BARIUM SWALLOW (ONLY)

Facility

$246.00

Service Code	HCPCS 74230
Hospital Charge Code	3200875
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$209.10
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Community Health Alliance Commercial	$209.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$172.20
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$172.20
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR GI ESOPHAGUS (ONLY)

Facility

$246.00

Service Code	HCPCS 74220
Hospital Charge Code	3200874
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$209.10
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Community Health Alliance Commercial	$209.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$172.20
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$172.20
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR GI LOWER (BE) WITH AIR/KUB

Facility

$384.00

Service Code	HCPCS 74280
Hospital Charge Code	3200873
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$326.40
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$249.60
Rate for Payer: Cash Price	$249.60
Rate for Payer: Community Health Alliance Commercial	$326.40
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$268.80
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$268.80
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR GI LOWER (BE) WO AIR/KUB

Facility

$302.00

Service Code	HCPCS 74270
Hospital Charge Code	3200872
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$256.70
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$196.30
Rate for Payer: Cash Price	$196.30
Rate for Payer: Community Health Alliance Commercial	$256.70
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$211.40
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$211.40
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR GI SMALL BOWEL W KUB

Facility

$366.00

Service Code	HCPCS 74250
Hospital Charge Code	3200871
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$311.10
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$237.90
Rate for Payer: Cash Price	$237.90
Rate for Payer: Community Health Alliance Commercial	$311.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$256.20
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$256.20
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR GI UPPER AIR W/SM BOWEL

Facility

$502.00

Service Code	HCPCS 74249
Hospital Charge Code	3200877
Hospital Revenue Code	320
Min. Negotiated Rate	$351.40
Max. Negotiated Rate	$426.70
Rate for Payer: Cash Price	$326.30
Rate for Payer: Community Health Alliance Commercial	$426.70
Rate for Payer: Priority Health Commercial	$351.40
Rate for Payer: Priority Health PPO	$351.40

XR GI UPPER W/AIR & ESOPHAGUS

Facility

$301.00

Service Code	HCPCS 74246
Hospital Charge Code	3200878
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$255.85
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$195.65
Rate for Payer: Cash Price	$195.65
Rate for Payer: Community Health Alliance Commercial	$255.85
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$210.70
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$210.70
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR GI UPPER WITH AIR

Facility

$366.00

Service Code	HCPCS 74246
Hospital Charge Code	3200870
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$311.10
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$237.90
Rate for Payer: Cash Price	$237.90
Rate for Payer: Community Health Alliance Commercial	$311.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$256.20
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$256.20
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR GI UPPER W/O AIR

Facility

$246.00

Service Code	HCPCS 74240
Hospital Charge Code	3200869
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$209.10
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$159.90
Rate for Payer: Cash Price	$159.90
Rate for Payer: Community Health Alliance Commercial	$209.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$172.20
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$172.20
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR GI UPPER W/O AIR & ESOPHAGU

Facility

$275.00

Service Code	HCPCS 74240
Hospital Charge Code	3200868
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$233.75
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$178.75
Rate for Payer: Cash Price	$178.75
Rate for Payer: Community Health Alliance Commercial	$233.75
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$192.50
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$192.50
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR GI UPPER W/SMALL BOWEL

Facility

$468.00

Service Code	HCPCS 74245
Hospital Charge Code	3200876
Hospital Revenue Code	320
Min. Negotiated Rate	$327.60
Max. Negotiated Rate	$397.80
Rate for Payer: Cash Price	$304.20
Rate for Payer: Community Health Alliance Commercial	$397.80
Rate for Payer: Priority Health Commercial	$327.60
Rate for Payer: Priority Health PPO	$327.60

XR HAND LT, MIN 3 VIEW

Facility

$186.00

Service Code	HCPCS 73130 LT
Hospital Charge Code	3200241
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 HAND RT, MIN 3 VIEW

Facility

$186.00

Service Code	HCPCS 73130 RT
Hospital Charge Code	3200240
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 HIP LT, MIN 2 VIEW

Facility

$126.00

Service Code	HCPCS 73502 LT
Hospital Charge Code	3200321
Hospital Revenue Code	320
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$107.10
Rate for Payer: Cash Price	$81.90
Rate for Payer: Community Health Alliance Commercial	$107.10
Rate for Payer: Priority Health Commercial	$88.20
Rate for Payer: Priority Health PPO	$88.20

XR HIP LT OR

Facility

$208.00

Service Code	HCPCS 73502
Hospital Charge Code	3200352
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$176.80
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
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	$93.36
Rate for Payer: Meridian Health Plan Medicare	$93.36
Rate for Payer: Priority Health Commercial	$145.60
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$145.60
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR HIP RT 1 VIEW

Facility

$149.00

Service Code	HCPCS 73501 RT
Hospital Charge Code	3200270
Hospital Revenue Code	320
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$126.65
Rate for Payer: Cash Price	$96.85
Rate for Payer: Community Health Alliance Commercial	$126.65
Rate for Payer: Priority Health Commercial	$104.30
Rate for Payer: Priority Health PPO	$104.30

XR HIP RT, MIN 2 VIEW

Facility

$126.00

Service Code	HCPCS 73502 RT
Hospital Charge Code	3200320
Hospital Revenue Code	320
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$107.10
Rate for Payer: Cash Price	$81.90
Rate for Payer: Community Health Alliance Commercial	$107.10
Rate for Payer: Priority Health Commercial	$88.20
Rate for Payer: Priority Health PPO	$88.20

XR HIP RT OR

Facility

$249.00

Service Code	HCPCS 73502
Hospital Charge Code	3200353
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$211.65
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$161.85
Rate for Payer: Cash Price	$161.85
Rate for Payer: Community Health Alliance Commercial	$211.65
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	$174.30
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$174.30
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR HIPS, BILATERAL, MIN 5 VIEW

Facility

$208.00

Service Code	HCPCS 73523
Hospital Charge Code	3200325
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 HUMERUS LT 2 VIEWS

Facility

$126.00

Service Code	HCPCS 73060 LT
Hospital Charge Code	3200301
Hospital Revenue Code	320
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$107.10
Rate for Payer: Cash Price	$81.90
Rate for Payer: Community Health Alliance Commercial	$107.10
Rate for Payer: Priority Health Commercial	$88.20
Rate for Payer: Priority Health PPO	$88.20

XR HUMERUS RT 2 VIEWS

Facility

$126.00

Service Code	HCPCS 73060 RT
Hospital Charge Code	3200300
Hospital Revenue Code	320
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$107.10
Rate for Payer: Cash Price	$81.90
Rate for Payer: Community Health Alliance Commercial	$107.10
Rate for Payer: Priority Health Commercial	$88.20
Rate for Payer: Priority Health PPO	$88.20

XR HYSTEROSALPINGOGRAM

Facility

$756.00

Hospital Charge Code	3200220
Hospital Revenue Code	320
Min. Negotiated Rate	$529.20
Max. Negotiated Rate	$642.60
Rate for Payer: Cash Price	$491.40
Rate for Payer: Community Health Alliance Commercial	$642.60
Rate for Payer: Priority Health Commercial	$529.20
Rate for Payer: Priority Health PPO	$529.20

XR HYSTEROSALPINGOGRAM

Facility

$822.00

Hospital Charge Code	3200223
Hospital Revenue Code	320
Min. Negotiated Rate	$575.40
Max. Negotiated Rate	$698.70
Rate for Payer: Cash Price	$534.30
Rate for Payer: Community Health Alliance Commercial	$698.70
Rate for Payer: Priority Health Commercial	$575.40
Rate for Payer: Priority Health PPO	$575.40

XR INFANT BONE SURVEY

Facility

$208.00

Service Code	HCPCS 77076
Hospital Charge Code	3200115
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 INJ. ANKLE ARTHROGRAM

Facility

$179.00

Service Code	HCPCS 27648
Hospital Charge Code	3200952
Hospital Revenue Code	361
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$152.15
Rate for Payer: Cash Price	$116.35
Rate for Payer: Community Health Alliance Commercial	$152.15
Rate for Payer: Priority Health Commercial	$125.30
Rate for Payer: Priority Health PPO	$125.30

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges