Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR MYELOGRAM/CT INJECTION

Facility

$170.00

Service Code	HCPCS 62284
Hospital Charge Code	3201071
Hospital Revenue Code	361
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$144.50
Rate for Payer: Cash Price	$110.50
Rate for Payer: Community Health Alliance Commercial	$144.50
Rate for Payer: Priority Health Commercial	$119.00
Rate for Payer: Priority Health PPO	$119.00

XR MYELOGRAM SPINE LUMBAR

Facility

$1,726.00

Service Code	HCPCS 72265
Hospital Charge Code	3201060
Hospital Revenue Code	320
Min. Negotiated Rate	$370.02
Max. Negotiated Rate	$1,467.10
Rate for Payer: BCBS BCN 65	$840.95
Rate for Payer: Blue Care Network Medicare Advantage	$840.95
Rate for Payer: Cash Price	$1,121.90
Rate for Payer: Cash Price	$1,121.90
Rate for Payer: Community Health Alliance Commercial	$1,467.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$840.95
Rate for Payer: Meridian Health Plan Medicare	$840.95
Rate for Payer: Priority Health Commercial	$1,208.20
Rate for Payer: Priority Health Medicaid	$840.95
Rate for Payer: Priority Health Medicare	$840.95
Rate for Payer: Priority Health PPO	$1,208.20
Rate for Payer: United Health Care Medicaid	$840.95
Rate for Payer: United Health Care Medicare Advantage	$370.02

XR MYELOGRAM SPINE THORACIC

Facility

$1,726.00

Service Code	HCPCS 72255
Hospital Charge Code	3201050
Hospital Revenue Code	320
Min. Negotiated Rate	$370.02
Max. Negotiated Rate	$1,467.10
Rate for Payer: BCBS BCN 65	$840.95
Rate for Payer: Blue Care Network Medicare Advantage	$840.95
Rate for Payer: Cash Price	$1,121.90
Rate for Payer: Cash Price	$1,121.90
Rate for Payer: Community Health Alliance Commercial	$1,467.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$840.95
Rate for Payer: Meridian Health Plan Medicare	$840.95
Rate for Payer: Priority Health Commercial	$1,208.20
Rate for Payer: Priority Health Medicaid	$840.95
Rate for Payer: Priority Health Medicare	$840.95
Rate for Payer: Priority Health PPO	$1,208.20
Rate for Payer: United Health Care Medicaid	$840.95
Rate for Payer: United Health Care Medicare Advantage	$370.02

XR MYLEOGRAM SPINE CERVICAL

Facility

$1,726.00

Service Code	HCPCS 72240
Hospital Charge Code	3201070
Hospital Revenue Code	320
Min. Negotiated Rate	$370.02
Max. Negotiated Rate	$1,467.10
Rate for Payer: BCBS BCN 65	$840.95
Rate for Payer: Blue Care Network Medicare Advantage	$840.95
Rate for Payer: Cash Price	$1,121.90
Rate for Payer: Cash Price	$1,121.90
Rate for Payer: Community Health Alliance Commercial	$1,467.10
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$840.95
Rate for Payer: Meridian Health Plan Medicare	$840.95
Rate for Payer: Priority Health Commercial	$1,208.20
Rate for Payer: Priority Health Medicaid	$840.95
Rate for Payer: Priority Health Medicare	$840.95
Rate for Payer: Priority Health PPO	$1,208.20
Rate for Payer: United Health Care Medicaid	$840.95
Rate for Payer: United Health Care Medicare Advantage	$370.02

XR NASAL BONES, MIN 3 VIEW

Facility

$186.00

Service Code	HCPCS 70160
Hospital Charge Code	3200585
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 NECK SOFT TISSUE

Facility

$155.00

Service Code	HCPCS 70360
Hospital Charge Code	3200475
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$131.75
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
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	$93.36
Rate for Payer: Meridian Health Plan Medicare	$93.36
Rate for Payer: Priority Health Commercial	$108.50
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$108.50
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR NEPHROSTOGRAM

Facility

$560.00

Service Code	HCPCS 74425
Hospital Charge Code	3200590
Hospital Revenue Code	320
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$476.00
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
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	$374.25
Rate for Payer: Meridian Health Plan Medicare	$374.25
Rate for Payer: Priority Health Commercial	$392.00
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$392.00
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

XR NEPHROSTOMY PERCUTANEOUS

Facility

$453.00

Service Code	HCPCS 50433
Hospital Charge Code	3200595
Hospital Revenue Code	320
Min. Negotiated Rate	$317.10
Max. Negotiated Rate	$3,781.40
Rate for Payer: BCBS BCN 65	$3,781.40
Rate for Payer: Blue Care Network Medicare Advantage	$3,781.40
Rate for Payer: Cash Price	$294.45
Rate for Payer: Cash Price	$294.45
Rate for Payer: Community Health Alliance Commercial	$385.05
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,781.40
Rate for Payer: Meridian Health Plan Medicare	$3,781.40
Rate for Payer: Priority Health Commercial	$317.10
Rate for Payer: Priority Health Medicaid	$3,781.40
Rate for Payer: Priority Health Medicare	$3,781.40
Rate for Payer: Priority Health PPO	$317.10
Rate for Payer: United Health Care Medicaid	$3,781.40
Rate for Payer: United Health Care Medicare Advantage	$1,663.81

XR NOSE TO RECTUM FB (CHILD)

Facility

$155.00

Hospital Charge Code	3200033
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

X ROCKY MOUNTAIN SPOTTED FEVER

Facility

$23.64

Hospital Charge Code	3000961
Hospital Revenue Code	300
Min. Negotiated Rate	$16.55
Max. Negotiated Rate	$20.09
Rate for Payer: Cash Price	$15.37
Rate for Payer: Community Health Alliance Commercial	$20.09
Rate for Payer: Priority Health Commercial	$16.55
Rate for Payer: Priority Health PPO	$16.55

X ROHYPNOL URINE

Facility

$86.00

Hospital Charge Code	3102351
Hospital Revenue Code	300
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$73.10
Rate for Payer: Cash Price	$55.90
Rate for Payer: Community Health Alliance Commercial	$73.10
Rate for Payer: Priority Health Commercial	$60.20
Rate for Payer: Priority Health PPO	$60.20

XR OPTIC FORAMINA

Facility

$128.00

Service Code	HCPCS 70190
Hospital Charge Code	3200610
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$108.80
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Community Health Alliance Commercial	$108.80
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	$89.60
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$89.60
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR ORBIT-FB EYE

Facility

$153.00

Hospital Charge Code	3200019
Hospital Revenue Code	320
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$130.05
Rate for Payer: Cash Price	$99.45
Rate for Payer: Community Health Alliance Commercial	$130.05
Rate for Payer: Priority Health Commercial	$107.10
Rate for Payer: Priority Health PPO	$107.10

XR ORBITS

Facility

$186.00

Hospital Charge Code	3200622
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 ORBITS, MIN 4 VIEW ATT LEFT

Facility

$149.00

Service Code	HCPCS 70200
Hospital Charge Code	3200620
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

XR ORBITS, MIN 4 VIEW ATT RT

Facility

$149.00

Service Code	HCPCS 70200
Hospital Charge Code	3200621
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

XR OR CHOL SCOUT ONLY (KUB)

Facility

$149.00

Service Code	HCPCS 74018
Hospital Charge Code	3200650
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

X ROS1 GENE REARRANGEMENT FISH

Facility

$94.00

Hospital Charge Code	3100859
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 OS CALCIS (HEEL) LT 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73650
Hospital Charge Code	3200661
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 OS CALCIS (HEEL) RT 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73650
Hospital Charge Code	3200660
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 PACEMAKER INSERTION

Facility

$224.00

Hospital Charge Code	3200680
Hospital Revenue Code	320
Min. Negotiated Rate	$156.80
Max. Negotiated Rate	$190.40
Rate for Payer: Cash Price	$145.60
Rate for Payer: Community Health Alliance Commercial	$190.40
Rate for Payer: Priority Health Commercial	$156.80
Rate for Payer: Priority Health PPO	$156.80

XR PELVIMETRY

Facility

$224.00

Service Code	HCPCS 74710
Hospital Charge Code	3200700
Hospital Revenue Code	320
Min. Negotiated Rate	$156.80
Max. Negotiated Rate	$190.40
Rate for Payer: Cash Price	$145.60
Rate for Payer: Community Health Alliance Commercial	$190.40
Rate for Payer: Priority Health Commercial	$156.80
Rate for Payer: Priority Health PPO	$156.80

XR PELVIS 2-3 VIEWS HIPS

Facility

$126.00

Service Code	HCPCS 73502
Hospital Charge Code	3200720
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 PELVIS 3 0R MORE VIEWS

Facility

$186.00

Service Code	HCPCS 72190
Hospital Charge Code	3200530
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$158.10
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
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	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$130.20
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$130.20
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR PELVIS AP 1-2 VIEWS

Facility

$126.00

Service Code	HCPCS 72170
Hospital Charge Code	3200710
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$112.15
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
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	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$88.20
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$88.20
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