Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR PERCUT ATHRECTOMY-ILIAC

Facility

$4,048.00

Service Code	HCPCS 0238T
Hospital Charge Code	3500421
Hospital Revenue Code	361
Min. Negotiated Rate	$2,833.60
Max. Negotiated Rate	$19,665.12
Rate for Payer: BCBS BCN 65	$19,665.12
Rate for Payer: Blue Care Network Medicare Advantage	$19,665.12
Rate for Payer: Cash Price	$2,631.20
Rate for Payer: Cash Price	$2,631.20
Rate for Payer: Community Health Alliance Commercial	$3,440.80
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$19,665.12
Rate for Payer: Meridian Health Plan Medicare	$19,665.12
Rate for Payer: Priority Health Commercial	$2,833.60
Rate for Payer: Priority Health Medicaid	$19,665.12
Rate for Payer: Priority Health Medicare	$19,665.12
Rate for Payer: Priority Health PPO	$2,833.60
Rate for Payer: United Health Care Medicaid	$19,665.12
Rate for Payer: United Health Care Medicare Advantage	$8,652.65

X RPR

Facility

$1.63

Hospital Charge Code	3101823
Hospital Revenue Code	300
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.39
Rate for Payer: Cash Price	$1.06
Rate for Payer: Community Health Alliance Commercial	$1.39
Rate for Payer: Priority Health Commercial	$1.14
Rate for Payer: Priority Health PPO	$1.14

XR PROCEDURE

Facility

$301.00

Hospital Charge Code	4000224
Hospital Revenue Code	361
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$255.85
Rate for Payer: Cash Price	$195.65
Rate for Payer: Community Health Alliance Commercial	$255.85
Rate for Payer: Priority Health Commercial	$210.70
Rate for Payer: Priority Health PPO	$210.70

X RPR QUNTIP ABS

Facility

$4.89

Hospital Charge Code	3102163
Hospital Revenue Code	300
Min. Negotiated Rate	$3.42
Max. Negotiated Rate	$4.16
Rate for Payer: Cash Price	$3.18
Rate for Payer: Community Health Alliance Commercial	$4.16
Rate for Payer: Priority Health Commercial	$3.42
Rate for Payer: Priority Health PPO	$3.42

X RPR REFLES QUANT/CONFIR, IP

Facility

$1.63

Hospital Charge Code	3101822
Hospital Revenue Code	300
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.39
Rate for Payer: Cash Price	$1.06
Rate for Payer: Community Health Alliance Commercial	$1.39
Rate for Payer: Priority Health Commercial	$1.14
Rate for Payer: Priority Health PPO	$1.14

XR RETROGRADE

Facility

$632.00

Service Code	HCPCS 74420
Hospital Charge Code	3200640
Hospital Revenue Code	320
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$537.20
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$410.80
Rate for Payer: Cash Price	$410.80
Rate for Payer: Community Health Alliance Commercial	$537.20
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	$442.40
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$442.40
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

XR RETROGRADE URETHRAL CYSTO

Facility

$570.00

Service Code	HCPCS 74450
Hospital Charge Code	3200193
Hospital Revenue Code	320
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$484.50
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$370.50
Rate for Payer: Cash Price	$370.50
Rate for Payer: Community Health Alliance Commercial	$484.50
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	$399.00
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$399.00
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

XR RETROGRADE,URETHRAL CYSTO

Facility

$510.00

Service Code	HCPCS 74450
Hospital Charge Code	3200645
Hospital Revenue Code	320
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$433.50
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$331.50
Rate for Payer: Cash Price	$331.50
Rate for Payer: Community Health Alliance Commercial	$433.50
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	$357.00
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$357.00
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

XR RIBS/CHEST MIN 3 VIEWS

Facility

$186.00

Hospital Charge Code	3200482
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 RIBS/CHEST MIN 4 VIEWS

Facility

$257.00

Hospital Charge Code	3200218
Hospital Revenue Code	320
Min. Negotiated Rate	$179.90
Max. Negotiated Rate	$218.45
Rate for Payer: Cash Price	$167.05
Rate for Payer: Community Health Alliance Commercial	$218.45
Rate for Payer: Priority Health Commercial	$179.90
Rate for Payer: Priority Health PPO	$179.90

XR RIBS LT, 2 VIEW

Facility

$186.00

Service Code	HCPCS 71100 LT
Hospital Charge Code	3200481
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 RIBS RT, 2 VIEW

Facility

$186.00

Service Code	HCPCS 71100 RT
Hospital Charge Code	3200480
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 SACROILIAC JOINTS, MIN 3 V

Facility

$186.00

Service Code	HCPCS 72202
Hospital Charge Code	3200510
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 SACRUM & COCCYX 2 VIEWS

Facility

$154.00

Service Code	HCPCS 72220
Hospital Charge Code	3200520
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$130.90
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
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	$93.36
Rate for Payer: Meridian Health Plan Medicare	$93.36
Rate for Payer: Priority Health Commercial	$107.80
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$107.80
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR SALIVARY GLANDS

Facility

$149.00

Service Code	HCPCS 70380
Hospital Charge Code	3200490
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

XR SCAPULA LT

Facility

$186.00

Service Code	HCPCS 73010 LT
Hospital Charge Code	3200501
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 SCAPULA RT

Facility

$186.00

Service Code	HCPCS 73010 RT
Hospital Charge Code	3200500
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 SCOLIOSIS STUDY

Facility

$153.00

Service Code	HCPCS 72083
Hospital Charge Code	3200540
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$130.05
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$99.45
Rate for Payer: Cash Price	$99.45
Rate for Payer: Community Health Alliance Commercial	$130.05
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	$107.10
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$107.10
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR SHOULDER LT 1 VIEW

Facility

$154.00

Service Code	HCPCS 73020 LT
Hospital Charge Code	3200561
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 SHOULDER LT, MIN 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73030 LT
Hospital Charge Code	3200581
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 SHOULDER RT 1 VIEW

Facility

$154.00

Service Code	HCPCS 73020 RT
Hospital Charge Code	3200560
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 SHOULDER RT, MIN 2 VIEWS

Facility

$186.00

Service Code	HCPCS 73030 RT
Hospital Charge Code	3200580
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 SHOULDERS, BILATERAL MIN 2V

Facility

$186.00

Service Code	HCPCS 73030 50
Hospital Charge Code	3200582
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 SHUNTOGRAM

Facility

$281.00

Hospital Charge Code	3200733
Hospital Revenue Code	320
Min. Negotiated Rate	$196.70
Max. Negotiated Rate	$238.85
Rate for Payer: Cash Price	$182.65
Rate for Payer: Community Health Alliance Commercial	$238.85
Rate for Payer: Priority Health Commercial	$196.70
Rate for Payer: Priority Health PPO	$196.70

XR SINUSES, MIN 3 VIEW

Facility

$186.00

Service Code	HCPCS 70220
Hospital Charge Code	3200670
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