Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR LOOPOGRAM

Facility

$459.00

Service Code	HCPCS 74425
Hospital Charge Code	3200470
Hospital Revenue Code	320
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$390.15
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$298.35
Rate for Payer: Cash Price	$298.35
Rate for Payer: Community Health Alliance Commercial	$390.15
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	$321.30
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$321.30
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

XR LOWER EXT INFANT LT 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73592 LT
Hospital Charge Code	3200406
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 LOWER EXT INFANT RT 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73592 RT
Hospital Charge Code	3200405
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 MAM BILAT MAM (SPECIAL)

Facility

$65.00

Hospital Charge Code	3201373
Hospital Revenue Code	401
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$55.25
Rate for Payer: Cash Price	$42.25
Rate for Payer: Community Health Alliance Commercial	$55.25
Rate for Payer: Priority Health Commercial	$45.50
Rate for Payer: Priority Health PPO	$45.50

XR MAMMO 3D DIAG UNILATERAL

Facility

$403.00

Hospital Charge Code	3001312
Hospital Revenue Code	401
Min. Negotiated Rate	$282.10
Max. Negotiated Rate	$342.55
Rate for Payer: Cash Price	$261.95
Rate for Payer: Community Health Alliance Commercial	$342.55
Rate for Payer: Priority Health Commercial	$282.10
Rate for Payer: Priority Health PPO	$282.10

XR MAMMO 3D SCREEN UNILATERAL

Facility

$334.00

Hospital Charge Code	3001317
Hospital Revenue Code	403
Min. Negotiated Rate	$233.80
Max. Negotiated Rate	$283.90
Rate for Payer: Cash Price	$217.10
Rate for Payer: Community Health Alliance Commercial	$283.90
Rate for Payer: Priority Health Commercial	$233.80
Rate for Payer: Priority Health PPO	$233.80

XR MAMMO DIAG 3D BILATERAL

Facility

$469.00

Hospital Charge Code	3001310
Hospital Revenue Code	401
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$398.65
Rate for Payer: Cash Price	$304.85
Rate for Payer: Community Health Alliance Commercial	$398.65
Rate for Payer: Priority Health Commercial	$328.30
Rate for Payer: Priority Health PPO	$328.30

XR MAMMO DIAG DIGITAL BILATERA

Facility

$384.00

Service Code	HCPCS 77066
Hospital Charge Code	3001353
Hospital Revenue Code	401
Min. Negotiated Rate	$268.80
Max. Negotiated Rate	$326.40
Rate for Payer: Cash Price	$249.60
Rate for Payer: Community Health Alliance Commercial	$326.40
Rate for Payer: Priority Health Commercial	$268.80
Rate for Payer: Priority Health PPO	$268.80

XR MAMMO DIAG DIGITAL UNILATER

Facility

$318.00

Service Code	HCPCS 77065
Hospital Charge Code	3001354
Hospital Revenue Code	401
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$270.30
Rate for Payer: Cash Price	$206.70
Rate for Payer: Community Health Alliance Commercial	$270.30
Rate for Payer: Priority Health Commercial	$222.60
Rate for Payer: Priority Health PPO	$222.60

XR MAMMO DUCTOGRAM LT.

Facility

$341.00

Service Code	HCPCS 77053
Hospital Charge Code	3201372
Hospital Revenue Code	320
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$289.85
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
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	$255.96
Rate for Payer: Meridian Health Plan Medicare	$255.96
Rate for Payer: Priority Health Commercial	$238.70
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$238.70
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

XR MAMMO DUCTOGRAM RT.

Facility

$317.00

Service Code	HCPCS 77053
Hospital Charge Code	3201371
Hospital Revenue Code	320
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$269.45
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$206.05
Rate for Payer: Cash Price	$206.05
Rate for Payer: Community Health Alliance Commercial	$269.45
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	$221.90
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$221.90
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

XR MAMMO MAG VIEWS LT.

Facility

$318.00

Service Code	HCPCS 77065
Hospital Charge Code	3201367
Hospital Revenue Code	401
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$270.30
Rate for Payer: Cash Price	$206.70
Rate for Payer: Community Health Alliance Commercial	$270.30
Rate for Payer: Priority Health Commercial	$222.60
Rate for Payer: Priority Health PPO	$222.60

XR MAMMO MAG VIEWS RT.

Facility

$318.00

Service Code	HCPCS 77065
Hospital Charge Code	3201366
Hospital Revenue Code	401
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$270.30
Rate for Payer: Cash Price	$206.70
Rate for Payer: Community Health Alliance Commercial	$270.30
Rate for Payer: Priority Health Commercial	$222.60
Rate for Payer: Priority Health PPO	$222.60

XR MAMMO NEEDLE LOC LT.

Facility

$1,243.00

Service Code	HCPCS 19281
Hospital Charge Code	3201365
Hospital Revenue Code	320
Min. Negotiated Rate	$779.56
Max. Negotiated Rate	$1,771.74
Rate for Payer: BCBS BCN 65	$1,771.74
Rate for Payer: Blue Care Network Medicare Advantage	$1,771.74
Rate for Payer: Cash Price	$807.95
Rate for Payer: Cash Price	$807.95
Rate for Payer: Community Health Alliance Commercial	$1,056.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$1,771.74
Rate for Payer: Meridian Health Plan Medicare	$1,771.74
Rate for Payer: Priority Health Commercial	$870.10
Rate for Payer: Priority Health Medicaid	$1,771.74
Rate for Payer: Priority Health Medicare	$1,771.74
Rate for Payer: Priority Health PPO	$870.10
Rate for Payer: United Health Care Medicaid	$1,771.74
Rate for Payer: United Health Care Medicare Advantage	$779.56

XR MAMMO NEEDLE LOC RT.

Facility

$1,243.00

Service Code	HCPCS 19281
Hospital Charge Code	3201364
Hospital Revenue Code	320
Min. Negotiated Rate	$779.56
Max. Negotiated Rate	$1,771.74
Rate for Payer: BCBS BCN 65	$1,771.74
Rate for Payer: Blue Care Network Medicare Advantage	$1,771.74
Rate for Payer: Cash Price	$807.95
Rate for Payer: Cash Price	$807.95
Rate for Payer: Community Health Alliance Commercial	$1,056.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$1,771.74
Rate for Payer: Meridian Health Plan Medicare	$1,771.74
Rate for Payer: Priority Health Commercial	$870.10
Rate for Payer: Priority Health Medicaid	$1,771.74
Rate for Payer: Priority Health Medicare	$1,771.74
Rate for Payer: Priority Health PPO	$870.10
Rate for Payer: United Health Care Medicaid	$1,771.74
Rate for Payer: United Health Care Medicare Advantage	$779.56

XR MAMMO SCREEN 3D BILATERAL

Facility

$416.00

Hospital Charge Code	3001314
Hospital Revenue Code	403
Min. Negotiated Rate	$291.20
Max. Negotiated Rate	$353.60
Rate for Payer: Cash Price	$270.40
Rate for Payer: Community Health Alliance Commercial	$353.60
Rate for Payer: Priority Health Commercial	$291.20
Rate for Payer: Priority Health PPO	$291.20

XR MAMMO SCREEN DIGITAL BILATE

Facility

$331.00

Service Code	HCPCS 77067
Hospital Charge Code	3001352
Hospital Revenue Code	403
Min. Negotiated Rate	$231.70
Max. Negotiated Rate	$281.35
Rate for Payer: Cash Price	$215.15
Rate for Payer: Community Health Alliance Commercial	$281.35
Rate for Payer: Priority Health Commercial	$231.70
Rate for Payer: Priority Health PPO	$231.70

XR MAMMO SCREEN DIGITAL UNILAT

Facility

$249.00

Service Code	HCPCS 77067 52
Hospital Charge Code	3001355
Hospital Revenue Code	403
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$211.65
Rate for Payer: Cash Price	$161.85
Rate for Payer: Community Health Alliance Commercial	$211.65
Rate for Payer: Priority Health Commercial	$174.30
Rate for Payer: Priority Health PPO	$174.30

XR MAMMO SPECIMAN

Facility

$155.00

Service Code	HCPCS 76098
Hospital Charge Code	3201368
Hospital Revenue Code	320
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$586.16
Rate for Payer: BCBS BCN 65	$586.16
Rate for Payer: Blue Care Network Medicare Advantage	$586.16
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	$586.16
Rate for Payer: Meridian Health Plan Medicare	$586.16
Rate for Payer: Priority Health Commercial	$108.50
Rate for Payer: Priority Health Medicaid	$586.16
Rate for Payer: Priority Health Medicare	$586.16
Rate for Payer: Priority Health PPO	$108.50
Rate for Payer: United Health Care Medicaid	$586.16
Rate for Payer: United Health Care Medicare Advantage	$257.91

XR MAMMO TOMO 3D SCREEN BILAT

Facility

$85.00

Hospital Charge Code	3001316
Hospital Revenue Code	403
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$72.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Community Health Alliance Commercial	$72.25
Rate for Payer: Priority Health Commercial	$59.50
Rate for Payer: Priority Health PPO	$59.50

XR MAMMO TOMO DIAG BILATERAL

Facility

$85.00

Service Code	HCPCS G0279
Hospital Charge Code	3001311
Hospital Revenue Code	401
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$72.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Community Health Alliance Commercial	$72.25
Rate for Payer: Priority Health Commercial	$59.50
Rate for Payer: Priority Health PPO	$59.50

XR MAMMO TOMO DIAG UNILATERAL

Facility

$85.00

Service Code	HCPCS G0279
Hospital Charge Code	3001313
Hospital Revenue Code	401
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$72.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Community Health Alliance Commercial	$72.25
Rate for Payer: Priority Health Commercial	$59.50
Rate for Payer: Priority Health PPO	$59.50

XR MAMMO TOMO SCREEN UNILATERA

Facility

$85.00

Hospital Charge Code	3001319
Hospital Revenue Code	403
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$72.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Community Health Alliance Commercial	$72.25
Rate for Payer: Priority Health Commercial	$59.50
Rate for Payer: Priority Health PPO	$59.50

XR MANDIBLE, MIN 4 VIEW

Facility

$154.00

Service Code	HCPCS 70110
Hospital Charge Code	3200462
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 MASTOIDS, 3 VIEW/SIDE

Facility

$149.00

Service Code	HCPCS 70130
Hospital Charge Code	3200464
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$126.65
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
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	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$104.30
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$104.30
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges