Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

X XR ANGIO AORTA ABD

Facility

$626.00

Hospital Charge Code	3201310
Hospital Revenue Code	323
Min. Negotiated Rate	$438.20
Max. Negotiated Rate	$532.10
Rate for Payer: Cash Price	$406.90
Rate for Payer: Community Health Alliance Commercial	$532.10
Rate for Payer: Priority Health Commercial	$438.20
Rate for Payer: Priority Health PPO	$438.20

X XR ANGIO AORTA ABD/W BILAT F

Facility

$4,632.00

Hospital Charge Code	3201290
Hospital Revenue Code	323
Min. Negotiated Rate	$3,242.40
Max. Negotiated Rate	$3,937.20
Rate for Payer: Cash Price	$3,010.80
Rate for Payer: Community Health Alliance Commercial	$3,937.20
Rate for Payer: Priority Health Commercial	$3,242.40
Rate for Payer: Priority Health PPO	$3,242.40

X XR ANGIO CAROTID CEREBRAL BI

Facility

$1,510.00

Hospital Charge Code	3201167
Hospital Revenue Code	323
Min. Negotiated Rate	$1,057.00
Max. Negotiated Rate	$1,283.50
Rate for Payer: Cash Price	$981.50
Rate for Payer: Community Health Alliance Commercial	$1,283.50
Rate for Payer: Priority Health Commercial	$1,057.00
Rate for Payer: Priority Health PPO	$1,057.00

X XR ANGIO CAROTID CEREBRAL UN

Facility

$1,201.00

Hospital Charge Code	3201160
Hospital Revenue Code	323
Min. Negotiated Rate	$840.70
Max. Negotiated Rate	$1,020.85
Rate for Payer: Cash Price	$780.65
Rate for Payer: Community Health Alliance Commercial	$1,020.85
Rate for Payer: Priority Health Commercial	$840.70
Rate for Payer: Priority Health PPO	$840.70

X XR ANGIO CAROTID CERV. BILAT

Facility

$1,843.00

Hospital Charge Code	3201150
Hospital Revenue Code	323
Min. Negotiated Rate	$1,290.10
Max. Negotiated Rate	$1,566.55
Rate for Payer: Cash Price	$1,197.95
Rate for Payer: Community Health Alliance Commercial	$1,566.55
Rate for Payer: Priority Health Commercial	$1,290.10
Rate for Payer: Priority Health PPO	$1,290.10

X XR ANGIO CAROTID CERVICAL UN

Facility

$850.00

Hospital Charge Code	3201140
Hospital Revenue Code	323
Min. Negotiated Rate	$595.00
Max. Negotiated Rate	$722.50
Rate for Payer: Cash Price	$552.50
Rate for Payer: Community Health Alliance Commercial	$722.50
Rate for Payer: Priority Health Commercial	$595.00
Rate for Payer: Priority Health PPO	$595.00

X XR ANGIO EXTREMITY BILAT

Facility

$4,043.00

Service Code	HCPCS 75716
Hospital Charge Code	3201080
Hospital Revenue Code	323
Min. Negotiated Rate	$1,490.35
Max. Negotiated Rate	$3,436.55
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	$2,627.95
Rate for Payer: Cash Price	$2,627.95
Rate for Payer: Community Health Alliance Commercial	$3,436.55
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	$2,830.10
Rate for Payer: Priority Health Medicaid	$3,387.16
Rate for Payer: Priority Health Medicare	$3,387.16
Rate for Payer: Priority Health PPO	$2,830.10
Rate for Payer: United Health Care Medicaid	$3,387.16
Rate for Payer: United Health Care Medicare Advantage	$1,490.35

X XR ANGIO RENAL BILAT

Facility

$1,510.00

Hospital Charge Code	3201270
Hospital Revenue Code	323
Min. Negotiated Rate	$1,057.00
Max. Negotiated Rate	$1,283.50
Rate for Payer: Cash Price	$981.50
Rate for Payer: Community Health Alliance Commercial	$1,283.50
Rate for Payer: Priority Health Commercial	$1,057.00
Rate for Payer: Priority Health PPO	$1,057.00

X XR ANGIO VERTEBRAL UNI

Facility

$611.00

Hospital Charge Code	3201190
Hospital Revenue Code	323
Min. Negotiated Rate	$427.70
Max. Negotiated Rate	$519.35
Rate for Payer: Cash Price	$397.15
Rate for Payer: Community Health Alliance Commercial	$519.35
Rate for Payer: Priority Health Commercial	$427.70
Rate for Payer: Priority Health PPO	$427.70

X XR ARTHOGRAM HIP LEFT

Facility

$697.00

Service Code	HCPCS 73525
Hospital Charge Code	3201011
Hospital Revenue Code	322
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$592.45
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$453.05
Rate for Payer: Cash Price	$453.05
Rate for Payer: Community Health Alliance Commercial	$592.45
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	$487.90
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$487.90
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

X XR ARTHOGRAM HIP RIGHT

Facility

$697.00

Service Code	HCPCS 73525
Hospital Charge Code	3201010
Hospital Revenue Code	322
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$592.45
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$453.05
Rate for Payer: Cash Price	$453.05
Rate for Payer: Community Health Alliance Commercial	$592.45
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	$487.90
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$487.90
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

X XR ARTHROGRAM ANKLE LT

Facility

$697.00

Service Code	HCPCS 73615
Hospital Charge Code	3200951
Hospital Revenue Code	322
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$592.45
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$453.05
Rate for Payer: Cash Price	$453.05
Rate for Payer: Community Health Alliance Commercial	$592.45
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	$487.90
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$487.90
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

X XR ARTHROGRAM ANKLE RT

Facility

$697.00

Service Code	HCPCS 73615
Hospital Charge Code	3200950
Hospital Revenue Code	322
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$592.45
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$453.05
Rate for Payer: Cash Price	$453.05
Rate for Payer: Community Health Alliance Commercial	$592.45
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	$487.90
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$487.90
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

X XR ARTHROGRAM KNEE - RIGHT

Facility

$394.00

Service Code	HCPCS 73580
Hospital Charge Code	3200990
Hospital Revenue Code	322
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$374.25
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$256.10
Rate for Payer: Cash Price	$256.10
Rate for Payer: Community Health Alliance Commercial	$334.90
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	$275.80
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$275.80
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

X XR ARTHROGRAM SHOULDER - LT

Facility

$697.00

Service Code	HCPCS 73040
Hospital Charge Code	3201001
Hospital Revenue Code	322
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$592.45
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$453.05
Rate for Payer: Cash Price	$453.05
Rate for Payer: Community Health Alliance Commercial	$592.45
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	$487.90
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$487.90
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

X XR ARTHROGRAM SHOULDER - RT

Facility

$697.00

Service Code	HCPCS 73040
Hospital Charge Code	3201000
Hospital Revenue Code	322
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$592.45
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$453.05
Rate for Payer: Cash Price	$453.05
Rate for Payer: Community Health Alliance Commercial	$592.45
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	$487.90
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$487.90
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

X XR ARTHROGRAM WRIST LT

Facility

$697.00

Service Code	HCPCS 73115
Hospital Charge Code	3200981
Hospital Revenue Code	322
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$592.45
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$453.05
Rate for Payer: Cash Price	$453.05
Rate for Payer: Community Health Alliance Commercial	$592.45
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	$487.90
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$487.90
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

X XR ARTHROGRAM WRIST RT

Facility

$697.00

Service Code	HCPCS 73115
Hospital Charge Code	3200980
Hospital Revenue Code	322
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$592.45
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$453.05
Rate for Payer: Cash Price	$453.05
Rate for Payer: Community Health Alliance Commercial	$592.45
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	$487.90
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$487.90
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

X XR CYSTOGRAM VOID W/INTERVEN

Facility

$247.00

Service Code	HCPCS 74455
Hospital Charge Code	3200880
Hospital Revenue Code	320
Min. Negotiated Rate	$112.62
Max. Negotiated Rate	$255.96
Rate for Payer: BCBS BCN 65	$255.96
Rate for Payer: Blue Care Network Medicare Advantage	$255.96
Rate for Payer: Cash Price	$160.55
Rate for Payer: Cash Price	$160.55
Rate for Payer: Community Health Alliance Commercial	$209.95
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	$172.90
Rate for Payer: Priority Health Medicaid	$255.96
Rate for Payer: Priority Health Medicare	$255.96
Rate for Payer: Priority Health PPO	$172.90
Rate for Payer: United Health Care Medicaid	$255.96
Rate for Payer: United Health Care Medicare Advantage	$112.62

X XR CYSTOGRAM W/VCU INTERVENT

Facility

$510.00

Service Code	HCPCS 74430
Hospital Charge Code	3200879
Hospital Revenue Code	320
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$433.50
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
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	$374.25
Rate for Payer: Meridian Health Plan Medicare	$374.25
Rate for Payer: Priority Health Commercial	$357.00
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$357.00
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

X XR DISKOGRAPHY CERVICAL/THOR

Facility

$1,107.00

Hospital Charge Code	3200150
Hospital Revenue Code	320
Min. Negotiated Rate	$774.90
Max. Negotiated Rate	$940.95
Rate for Payer: Cash Price	$719.55
Rate for Payer: Community Health Alliance Commercial	$940.95
Rate for Payer: Priority Health Commercial	$774.90
Rate for Payer: Priority Health PPO	$774.90

X XR DISKOGRAPHY LUMBAR

Facility

$1,107.00

Hospital Charge Code	3200160
Hospital Revenue Code	320
Min. Negotiated Rate	$774.90
Max. Negotiated Rate	$940.95
Rate for Payer: Cash Price	$719.55
Rate for Payer: Community Health Alliance Commercial	$940.95
Rate for Payer: Priority Health Commercial	$774.90
Rate for Payer: Priority Health PPO	$774.90

X XR ERCP

Facility

$423.00

Service Code	HCPCS 74328
Hospital Charge Code	3203090
Hospital Revenue Code	320
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

X XR HIP LT OR

Facility

$208.00

Service Code	HCPCS 73502
Hospital Charge Code	3200351
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$176.80
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Community Health Alliance Commercial	$176.80
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	$145.60
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$145.60
Rate for Payer: United Health Care Medicaid	$93.36
Rate for Payer: United Health Care Medicare Advantage	$41.08

X XR HIP RT OR

Facility

$249.00

Service Code	HCPCS 73502
Hospital Charge Code	3200350
Hospital Revenue Code	320
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$211.65
Rate for Payer: BCBS BCN 65	$93.36
Rate for Payer: Blue Care Network Medicare Advantage	$93.36
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	$93.36
Rate for Payer: Meridian Health Plan Medicare	$93.36
Rate for Payer: Priority Health Commercial	$174.30
Rate for Payer: Priority Health Medicaid	$93.36
Rate for Payer: Priority Health Medicare	$93.36
Rate for Payer: Priority Health PPO	$174.30
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