Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR INJ CERVICAL/THORACIC FACET

Facility

$2,125.00

Service Code	HCPCS 64490
Hospital Charge Code	3203021
Hospital Revenue Code	361
Min. Negotiated Rate	$417.48
Max. Negotiated Rate	$1,806.25
Rate for Payer: BCBS BCN 65	$948.81
Rate for Payer: Blue Care Network Medicare Advantage	$948.81
Rate for Payer: Cash Price	$1,381.25
Rate for Payer: Cash Price	$1,381.25
Rate for Payer: Community Health Alliance Commercial	$1,806.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$948.81
Rate for Payer: Meridian Health Plan Medicare	$948.81
Rate for Payer: Priority Health Commercial	$1,487.50
Rate for Payer: Priority Health Medicaid	$948.81
Rate for Payer: Priority Health Medicare	$948.81
Rate for Payer: Priority Health PPO	$1,487.50
Rate for Payer: United Health Care Medicaid	$948.81
Rate for Payer: United Health Care Medicare Advantage	$417.48

XR INJ CERV/THOR FACET ADDL LV

Facility

$560.00

Service Code	HCPCS 64491
Hospital Charge Code	3203023
Hospital Revenue Code	361
Min. Negotiated Rate	$392.00
Max. Negotiated Rate	$476.00
Rate for Payer: Cash Price	$364.00
Rate for Payer: Community Health Alliance Commercial	$476.00
Rate for Payer: Priority Health Commercial	$392.00
Rate for Payer: Priority Health PPO	$392.00

XR INJECT FACET/FLUOR GUIDANC

Facility

$492.00

Service Code	HCPCS 77003
Hospital Charge Code	3203022
Hospital Revenue Code	320
Min. Negotiated Rate	$344.40
Max. Negotiated Rate	$418.20
Rate for Payer: Cash Price	$319.80
Rate for Payer: Community Health Alliance Commercial	$418.20
Rate for Payer: Priority Health Commercial	$344.40
Rate for Payer: Priority Health PPO	$344.40

XR INJECTION FISTULAGRAM

Facility

$324.00

Hospital Charge Code	3200183
Hospital Revenue Code	361
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$275.40
Rate for Payer: Cash Price	$210.60
Rate for Payer: Community Health Alliance Commercial	$275.40
Rate for Payer: Priority Health Commercial	$226.80
Rate for Payer: Priority Health PPO	$226.80

XR INJECTION RETROGRADE

Facility

$279.00

Service Code	HCPCS 51610
Hospital Charge Code	3200191
Hospital Revenue Code	361
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$237.15
Rate for Payer: Cash Price	$181.35
Rate for Payer: Community Health Alliance Commercial	$237.15
Rate for Payer: Priority Health Commercial	$195.30
Rate for Payer: Priority Health PPO	$195.30

XR INJECTION VENOGRAM

Facility

$406.00

Service Code	HCPCS 36005
Hospital Charge Code	3203117
Hospital Revenue Code	361
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$345.10
Rate for Payer: Cash Price	$263.90
Rate for Payer: Community Health Alliance Commercial	$345.10
Rate for Payer: Priority Health Commercial	$284.20
Rate for Payer: Priority Health PPO	$284.20

XR INJECTION VERTEBROPLASTY

Facility

$2,460.00

Hospital Charge Code	3203120
Hospital Revenue Code	361
Min. Negotiated Rate	$1,722.00
Max. Negotiated Rate	$2,091.00
Rate for Payer: Cash Price	$1,599.00
Rate for Payer: Community Health Alliance Commercial	$2,091.00
Rate for Payer: Priority Health Commercial	$1,722.00
Rate for Payer: Priority Health PPO	$1,722.00

XR INJECTION VOIDING CYSTOGRAM

Facility

$360.00

Service Code	HCPCS 51600
Hospital Charge Code	3200190
Hospital Revenue Code	361
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$306.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Community Health Alliance Commercial	$306.00
Rate for Payer: Priority Health Commercial	$252.00
Rate for Payer: Priority Health PPO	$252.00

XR INJ. HIP ARTHROGRAM

Facility

$167.00

Service Code	HCPCS 27093
Hospital Charge Code	3201012
Hospital Revenue Code	361
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$141.95
Rate for Payer: Cash Price	$108.55
Rate for Payer: Community Health Alliance Commercial	$141.95
Rate for Payer: Priority Health Commercial	$116.90
Rate for Payer: Priority Health PPO	$116.90

XR INJ. KNEE ARTHROGRAM

Facility

$179.00

Service Code	HCPCS 27369
Hospital Charge Code	3200992
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

XR INJ.SHOULDER ARTHROGRAM

Facility

$184.00

Service Code	HCPCS 23350
Hospital Charge Code	3201002
Hospital Revenue Code	361
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$156.40
Rate for Payer: Cash Price	$119.60
Rate for Payer: Community Health Alliance Commercial	$156.40
Rate for Payer: Priority Health Commercial	$128.80
Rate for Payer: Priority Health PPO	$128.80

XR INJ. WRIST ARTHROGRAM

Facility

$179.00

Service Code	HCPCS 25246
Hospital Charge Code	3200982
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

X RITUXIMAB + ANTIBODIES

Facility

$423.00

Hospital Charge Code	3102411
Hospital Revenue Code	300
Min. Negotiated Rate	$296.10
Max. Negotiated Rate	$359.55
Rate for Payer: Cash Price	$274.95
Rate for Payer: Community Health Alliance Commercial	$359.55
Rate for Payer: Priority Health Commercial	$296.10
Rate for Payer: Priority Health PPO	$296.10

XR IVP (INTRAVENOUS) W KUB

Facility

$560.00

Service Code	HCPCS 74400
Hospital Charge Code	3200250
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$476.00
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$364.00
Rate for Payer: Cash Price	$364.00
Rate for Payer: Community Health Alliance Commercial	$476.00
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	$392.00
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$392.00
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR IVP/WITH TOMOGRAMS W KUB

Facility

$560.00

Service Code	HCPCS 74415
Hospital Charge Code	3200251
Hospital Revenue Code	320
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$476.00
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$364.00
Rate for Payer: Cash Price	$364.00
Rate for Payer: Community Health Alliance Commercial	$476.00
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	$392.00
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$392.00
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

XR KNEE LT, 1 OR 2 VIEW

Facility

$155.00

Service Code	HCPCS 73560 LT
Hospital Charge Code	3200331
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 KNEE LT, 3 VIEWS

Facility

$186.00

Service Code	HCPCS 73562 LT
Hospital Charge Code	3200333
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 KNEE LT, MIN 4 OR MORE VIEW

Facility

$248.00

Service Code	HCPCS 73564 LT
Hospital Charge Code	3200335
Hospital Revenue Code	320
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$210.80
Rate for Payer: Cash Price	$161.20
Rate for Payer: Community Health Alliance Commercial	$210.80
Rate for Payer: Priority Health Commercial	$173.60
Rate for Payer: Priority Health PPO	$173.60

XR KNEE RT, 1 OR 2 VIEW

Facility

$155.00

Service Code	HCPCS 73560 RT
Hospital Charge Code	3200330
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 KNEE RT, 3 VIEWS

Facility

$186.00

Service Code	HCPCS 73562 RT
Hospital Charge Code	3200332
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 KNEE RT, MIN 4 OR MORE VIEW

Facility

$248.00

Service Code	HCPCS 73564 RT
Hospital Charge Code	3200334
Hospital Revenue Code	320
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$210.80
Rate for Payer: Cash Price	$161.20
Rate for Payer: Community Health Alliance Commercial	$210.80
Rate for Payer: Priority Health Commercial	$173.60
Rate for Payer: Priority Health PPO	$173.60

XR KNEES AP STANDING

Facility

$186.00

Service Code	HCPCS 73565
Hospital Charge Code	3200336
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 KNEES BILATERAL, 1 OR 2 V

Facility

$138.00

Service Code	HCPCS 73560 50
Hospital Charge Code	3200337
Hospital Revenue Code	320
Min. Negotiated Rate	$96.60
Max. Negotiated Rate	$117.30
Rate for Payer: Cash Price	$89.70
Rate for Payer: Community Health Alliance Commercial	$117.30
Rate for Payer: Priority Health Commercial	$96.60
Rate for Payer: Priority Health PPO	$96.60

XR KNEES BILATERAL, 3 VIEWS

Facility

$154.00

Service Code	HCPCS 73562 50
Hospital Charge Code	3200338
Hospital Revenue Code	320
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$130.90
Rate for Payer: Cash Price	$100.10
Rate for Payer: Community Health Alliance Commercial	$130.90
Rate for Payer: Priority Health Commercial	$107.80
Rate for Payer: Priority Health PPO	$107.80

XR KNEES BILATERAL, 4 OR MORE

Facility

$248.00

Service Code	HCPCS 73564 50
Hospital Charge Code	3200339
Hospital Revenue Code	320
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$210.80
Rate for Payer: Cash Price	$161.20
Rate for Payer: Community Health Alliance Commercial	$210.80
Rate for Payer: Priority Health Commercial	$173.60
Rate for Payer: Priority Health PPO	$173.60

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges