Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

CT LIVER CYST ASPIRATION

Facility

$2,854.00

Service Code	HCPCS 49405
Hospital Charge Code	3500434
Hospital Revenue Code	361
Min. Negotiated Rate	$779.56
Max. Negotiated Rate	$2,425.90
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	$1,855.10
Rate for Payer: Cash Price	$1,855.10
Rate for Payer: Community Health Alliance Commercial	$2,425.90
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	$1,997.80
Rate for Payer: Priority Health Medicaid	$1,771.74
Rate for Payer: Priority Health Medicare	$1,771.74
Rate for Payer: Priority Health PPO	$1,997.80
Rate for Payer: United Health Care Medicaid	$1,771.74
Rate for Payer: United Health Care Medicare Advantage	$779.56

CT LOW DOSE CANCER SCREENING

Facility

$153.00

Hospital Charge Code	3500146
Hospital Revenue Code	350
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

CT LOW DOSE CANCER SCREEN MCR

Facility

$153.00

Service Code	HCPCS 71271
Hospital Charge Code	3500145
Hospital Revenue Code	350
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

CT LUMBAR SPINE W CONTRAST

Facility

$1,059.00

Service Code	HCPCS 72132
Hospital Charge Code	3500250
Hospital Revenue Code	350
Min. Negotiated Rate	$164.67
Max. Negotiated Rate	$900.15
Rate for Payer: BCBS BCN 65	$374.25
Rate for Payer: Blue Care Network Medicare Advantage	$374.25
Rate for Payer: Cash Price	$688.35
Rate for Payer: Cash Price	$688.35
Rate for Payer: Community Health Alliance Commercial	$900.15
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	$741.30
Rate for Payer: Priority Health Medicaid	$374.25
Rate for Payer: Priority Health Medicare	$374.25
Rate for Payer: Priority Health PPO	$741.30
Rate for Payer: United Health Care Medicaid	$374.25
Rate for Payer: United Health Care Medicare Advantage	$164.67

CT LUMBAR SPINE WO CONTRAST

Facility

$876.00

Service Code	HCPCS 72131
Hospital Charge Code	3500240
Hospital Revenue Code	350
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$744.60
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$569.40
Rate for Payer: Cash Price	$569.40
Rate for Payer: Community Health Alliance Commercial	$744.60
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	$613.20
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$613.20
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

CT LUMBAR SPINE W/WO CONTRAST

Facility

$1,213.00

Service Code	HCPCS 72133
Hospital Charge Code	3500230
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$1,031.05
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$788.45
Rate for Payer: Cash Price	$788.45
Rate for Payer: Community Health Alliance Commercial	$1,031.05
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$849.10
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$849.10
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

CT MAXILLOFACIAL W CONTRAST

Facility

$1,059.00

Service Code	HCPCS 70487
Hospital Charge Code	3500080
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$900.15
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$688.35
Rate for Payer: Cash Price	$688.35
Rate for Payer: Community Health Alliance Commercial	$900.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$741.30
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$741.30
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

CT MAXILLOFACIAL WO CONTRAST

Facility

$1,069.00

Service Code	HCPCS 70486
Hospital Charge Code	3500100
Hospital Revenue Code	350
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$908.65
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$694.85
Rate for Payer: Cash Price	$694.85
Rate for Payer: Community Health Alliance Commercial	$908.65
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	$748.30
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$748.30
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

CT MAXILLOFACIAL W/WO CONTRAST

Facility

$1,213.00

Service Code	HCPCS 70488
Hospital Charge Code	3500070
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$1,031.05
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$788.45
Rate for Payer: Cash Price	$788.45
Rate for Payer: Community Health Alliance Commercial	$1,031.05
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$849.10
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$849.10
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

CT NECK W CONTRAST

Facility

$1,059.00

Service Code	HCPCS 70491
Hospital Charge Code	3500200
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$900.15
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$688.35
Rate for Payer: Cash Price	$688.35
Rate for Payer: Community Health Alliance Commercial	$900.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$741.30
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$741.30
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

CT NECK WO CONTRAST

Facility

$721.00

Service Code	HCPCS 70490
Hospital Charge Code	3500170
Hospital Revenue Code	350
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$612.85
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$468.65
Rate for Payer: Cash Price	$468.65
Rate for Payer: Community Health Alliance Commercial	$612.85
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	$504.70
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$504.70
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

CT NECK W/WO CONTRAST

Facility

$1,370.00

Service Code	HCPCS 70492
Hospital Charge Code	3500180
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$1,164.50
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$890.50
Rate for Payer: Cash Price	$890.50
Rate for Payer: Community Health Alliance Commercial	$1,164.50
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$959.00
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$959.00
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

CT NEEDLE GUIDANCE

Facility

$953.00

Service Code	HCPCS 77012
Hospital Charge Code	3500360
Hospital Revenue Code	350
Min. Negotiated Rate	$667.10
Max. Negotiated Rate	$810.05
Rate for Payer: Cash Price	$619.45
Rate for Payer: Community Health Alliance Commercial	$810.05
Rate for Payer: Priority Health Commercial	$667.10
Rate for Payer: Priority Health PPO	$667.10

CT NON-IONIC CONTRAST

Facility

$418.00

Service Code	HCPCS Q9967
Hospital Charge Code	3500001
Hospital Revenue Code	636
Min. Negotiated Rate	$292.60
Max. Negotiated Rate	$355.30
Rate for Payer: Cash Price	$271.70
Rate for Payer: Community Health Alliance Commercial	$355.30
Rate for Payer: Priority Health Commercial	$292.60
Rate for Payer: Priority Health PPO	$292.60

CT ORBITS/P.FOSSA/IAC W

Facility

$1,164.00

Service Code	HCPCS 70481
Hospital Charge Code	3500050
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$989.40
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$756.60
Rate for Payer: Cash Price	$756.60
Rate for Payer: Community Health Alliance Commercial	$989.40
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$814.80
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$814.80
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

CT ORBITS/P.FOSSA/IAC WO

Facility

$876.00

Service Code	HCPCS 70480
Hospital Charge Code	3500040
Hospital Revenue Code	350
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$744.60
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$569.40
Rate for Payer: Cash Price	$569.40
Rate for Payer: Community Health Alliance Commercial	$744.60
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	$613.20
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$613.20
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

CT ORBITS/P.FOSSA/IAC W/WO

Facility

$1,674.00

Service Code	HCPCS 70482
Hospital Charge Code	3500060
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$1,422.90
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$1,088.10
Rate for Payer: Cash Price	$1,088.10
Rate for Payer: Community Health Alliance Commercial	$1,422.90
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$1,171.80
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$1,171.80
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

CT PELVIS W CONTRAST

Facility

$1,158.00

Service Code	HCPCS 72193
Hospital Charge Code	3500090
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$984.30
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$752.70
Rate for Payer: Cash Price	$752.70
Rate for Payer: Community Health Alliance Commercial	$984.30
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$810.60
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$810.60
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

CT PELVIS WO CONTRAST

Facility

$881.00

Service Code	HCPCS 72192
Hospital Charge Code	3500260
Hospital Revenue Code	350
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$748.85
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$572.65
Rate for Payer: Cash Price	$572.65
Rate for Payer: Community Health Alliance Commercial	$748.85
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	$616.70
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$616.70
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

CT PELVIS W/WO CONTRAST

Facility

$1,481.00

Service Code	HCPCS 72194
Hospital Charge Code	3500280
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$1,258.85
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$962.65
Rate for Payer: Cash Price	$962.65
Rate for Payer: Community Health Alliance Commercial	$1,258.85
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$1,036.70
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$1,036.70
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

CT REFORM COR,SAG &/OR OBLIQUE

Facility

$158.00

Service Code	HCPCS 76376
Hospital Charge Code	3500445
Hospital Revenue Code	350
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$134.30
Rate for Payer: Cash Price	$102.70
Rate for Payer: Community Health Alliance Commercial	$134.30
Rate for Payer: Priority Health Commercial	$110.60
Rate for Payer: Priority Health PPO	$110.60

CT RENAL CYST ASPIRATION

Facility

$1,709.00

Service Code	HCPCS 50390
Hospital Charge Code	3500436
Hospital Revenue Code	361
Min. Negotiated Rate	$334.24
Max. Negotiated Rate	$1,452.65
Rate for Payer: BCBS BCN 65	$759.64
Rate for Payer: Blue Care Network Medicare Advantage	$759.64
Rate for Payer: Cash Price	$1,110.85
Rate for Payer: Cash Price	$1,110.85
Rate for Payer: Community Health Alliance Commercial	$1,452.65
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$759.64
Rate for Payer: Meridian Health Plan Medicare	$759.64
Rate for Payer: Priority Health Commercial	$1,196.30
Rate for Payer: Priority Health Medicaid	$759.64
Rate for Payer: Priority Health Medicare	$759.64
Rate for Payer: Priority Health PPO	$1,196.30
Rate for Payer: United Health Care Medicaid	$759.64
Rate for Payer: United Health Care Medicare Advantage	$334.24

CT RIGHT LOWER EXT W CONTRAST

Facility

$1,059.00

Service Code	HCPCS 73701
Hospital Charge Code	3500310
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$900.15
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$688.35
Rate for Payer: Cash Price	$688.35
Rate for Payer: Community Health Alliance Commercial	$900.15
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$741.30
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$741.30
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

CT RIGHT LOWER EXT WO CONTRAST

Facility

$721.00

Service Code	HCPCS 73700
Hospital Charge Code	3500290
Hospital Revenue Code	350
Min. Negotiated Rate	$49.35
Max. Negotiated Rate	$612.85
Rate for Payer: BCBS BCN 65	$112.15
Rate for Payer: Blue Care Network Medicare Advantage	$112.15
Rate for Payer: Cash Price	$468.65
Rate for Payer: Cash Price	$468.65
Rate for Payer: Community Health Alliance Commercial	$612.85
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	$504.70
Rate for Payer: Priority Health Medicaid	$112.15
Rate for Payer: Priority Health Medicare	$112.15
Rate for Payer: Priority Health PPO	$504.70
Rate for Payer: United Health Care Medicaid	$112.15
Rate for Payer: United Health Care Medicare Advantage	$49.35

CT RIGHT LOWER EXT W/WO CONTRA

Facility

$1,213.00

Service Code	HCPCS 73702
Hospital Charge Code	3500340
Hospital Revenue Code	350
Min. Negotiated Rate	$82.79
Max. Negotiated Rate	$1,031.05
Rate for Payer: BCBS BCN 65	$188.16
Rate for Payer: Blue Care Network Medicare Advantage	$188.16
Rate for Payer: Cash Price	$788.45
Rate for Payer: Cash Price	$788.45
Rate for Payer: Community Health Alliance Commercial	$1,031.05
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$188.16
Rate for Payer: Meridian Health Plan Medicare	$188.16
Rate for Payer: Priority Health Commercial	$849.10
Rate for Payer: Priority Health Medicaid	$188.16
Rate for Payer: Priority Health Medicare	$188.16
Rate for Payer: Priority Health PPO	$849.10
Rate for Payer: United Health Care Medicaid	$188.16
Rate for Payer: United Health Care Medicare Advantage	$82.79

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges