Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

XR SKULL 1 TO 3 VIEWS

Facility

$126.00

Service Code	HCPCS 70250
Hospital Charge Code	3200730
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

XR SKULL 4 VIEWS

Facility

$252.00

Service Code	HCPCS 70260
Hospital Charge Code	3200740
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$214.20
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cash Price	$163.80
Rate for Payer: Community Health Alliance Commercial	$214.20
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	$176.40
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$176.40
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR SPINE/CERVICLE 2-3 VIEWS

Facility

$154.00

Service Code	HCPCS 72040
Hospital Charge Code	3200100
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 SPINE/CERVICLE 5 VIEWS

Facility

$311.00

Service Code	HCPCS 72050
Hospital Charge Code	3200101
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$264.35
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$202.15
Rate for Payer: Cash Price	$202.15
Rate for Payer: Community Health Alliance Commercial	$264.35
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	$217.70
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$217.70
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR SPINE/CERVICLE 7 VIEWS

Facility

$311.00

Service Code	HCPCS 72052
Hospital Charge Code	3200102
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$264.35
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$202.15
Rate for Payer: Cash Price	$202.15
Rate for Payer: Community Health Alliance Commercial	$264.35
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	$217.70
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$217.70
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR SPINE COMPLETE AP & LAT

Facility

$135.00

Service Code	HCPCS 72084
Hospital Charge Code	3200109
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$114.75
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$87.75
Rate for Payer: Cash Price	$87.75
Rate for Payer: Community Health Alliance Commercial	$114.75
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	$94.50
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$94.50
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR SPINE/LUMBAR 1 VIEW

Facility

$135.00

Service Code	HCPCS 72020
Hospital Charge Code	3200111
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$114.75
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$87.75
Rate for Payer: Cash Price	$87.75
Rate for Payer: Community Health Alliance Commercial	$114.75
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	$94.50
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$94.50
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR SPINE/LUMBAR 2-3 VIEWS

Facility

$155.00

Service Code	HCPCS 72100
Hospital Charge Code	3200106
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$131.75
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
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	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$108.50
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$108.50
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR SPINE/LUMBAR 5 VIEW (OBL)

Facility

$311.00

Service Code	HCPCS 72110
Hospital Charge Code	3200107
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$264.35
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$202.15
Rate for Payer: Cash Price	$202.15
Rate for Payer: Community Health Alliance Commercial	$264.35
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	$217.70
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$217.70
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR SPINE/LUMBAR MIN 6 W/FLEX-E

Facility

$257.00

Service Code	HCPCS 72114
Hospital Charge Code	3200108
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$218.45
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Community Health Alliance Commercial	$218.45
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	$179.90
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$179.90
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR SPINE/THORACIC 3 VIEWS

Facility

$186.00

Service Code	HCPCS 72072
Hospital Charge Code	3200103
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 SPINE/THORACIC W/OBLS (5)

Facility

$165.00

Service Code	HCPCS 72074
Hospital Charge Code	3200104
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$140.25
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$107.25
Rate for Payer: Cash Price	$107.25
Rate for Payer: Community Health Alliance Commercial	$140.25
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	$115.50
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$115.50
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR SPINE/THORACOLUMBER

Facility

$154.00

Service Code	HCPCS 72080
Hospital Charge Code	3200105
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 STERNOCLAVICULAR JTS,MIN 3V

Facility

$165.00

Service Code	HCPCS 71130
Hospital Charge Code	3200760
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$140.25
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$107.25
Rate for Payer: Cash Price	$107.25
Rate for Payer: Community Health Alliance Commercial	$140.25
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	$115.50
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$115.50
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

XR STERNUM, MIN 2 VIEW

Facility

$186.00

Service Code	HCPCS 71120
Hospital Charge Code	3200761
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 TIBIA & FIBULA LT 2 VIEWS

Facility

$154.00

Service Code	HCPCS 73590 LT
Hospital Charge Code	3200401
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 TIBIA & FIBULA RT 2 VIEWS

Facility

$154.00

Service Code	HCPCS 73590 RT
Hospital Charge Code	3200400
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 TMJ'S BILATERAL

Facility

$186.00

Service Code	HCPCS 70330
Hospital Charge Code	3200829
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 TOE(S) LT, MIN 2 VIEW

Facility

$186.00

Service Code	HCPCS 73660
Hospital Charge Code	3200841
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 TOE(S) RT, MIN 2 VIEW

Facility

$186.00

Service Code	HCPCS 73660
Hospital Charge Code	3200840
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 TOMOGRAMS

Facility

$249.00

Service Code	HCPCS 76100
Hospital Charge Code	3200830
Hospital Revenue Code	320
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$211.65
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
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	$112.15
Rate for Payer: Meridian Health Plan Medicare	$112.15
Rate for Payer: Priority Health Commercial	$174.30
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$174.30
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

XR VCU INTERVENTION

Facility

$168.00

Service Code	HCPCS 51600
Hospital Charge Code	3200881
Hospital Revenue Code	361
Min. Negotiated Rate	$117.60
Max. Negotiated Rate	$142.80
Rate for Payer: Cash Price	$109.20
Rate for Payer: Community Health Alliance Commercial	$142.80
Rate for Payer: Priority Health Commercial	$117.60
Rate for Payer: Priority Health PPO	$117.60

XR VENOCAVOGRAM

Facility

$1,888.00

Hospital Charge Code	3202725
Hospital Revenue Code	320
Min. Negotiated Rate	$1,321.60
Max. Negotiated Rate	$1,604.80
Rate for Payer: Cash Price	$1,227.20
Rate for Payer: Community Health Alliance Commercial	$1,604.80
Rate for Payer: Priority Health Commercial	$1,321.60
Rate for Payer: Priority Health PPO	$1,321.60

XR VENOGRAM DESCENDING L.

Facility

$1,699.00

Service Code	HCPCS 75825
Hospital Charge Code	3201041
Hospital Revenue Code	320
Min. Negotiated Rate	$1,189.30
Max. Negotiated Rate	$3,387.16
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$1,104.35
Rate for Payer: Cash Price	$1,104.35
Rate for Payer: Community Health Alliance Commercial	$1,444.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$1,189.30
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$1,189.30
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

XR VENOGRAM DESCENDING R.

Facility

$1,699.00

Service Code	HCPCS 75825
Hospital Charge Code	3201040
Hospital Revenue Code	320
Min. Negotiated Rate	$1,189.30
Max. Negotiated Rate	$3,387.16
Rate for Payer: BCBS BCN 65	$3,387.16
Rate for Payer: Blue Care Network Medicare Advantage	$3,387.16
Rate for Payer: Cash Price	$1,104.35
Rate for Payer: Cash Price	$1,104.35
Rate for Payer: Community Health Alliance Commercial	$1,444.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,387.16
Rate for Payer: Meridian Health Plan Medicare	$3,387.16
Rate for Payer: Priority Health Commercial	$1,189.30
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$1,189.30
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges