Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

DERMABOND HIGH VISCOSITY

Facility

$140.00

Hospital Charge Code	27068647
Hospital Revenue Code	272
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$119.00
Rate for Payer: Cash Price	$91.00
Rate for Payer: Community Health Alliance Commercial	$119.00
Rate for Payer: Priority Health Commercial	$98.00
Rate for Payer: Priority Health PPO	$98.00

DERMOPLAST AEROSAL DRESSING

Facility

$58.00

Hospital Charge Code	27011171
Hospital Revenue Code	270
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$49.30
Rate for Payer: Cash Price	$37.70
Rate for Payer: Community Health Alliance Commercial	$49.30
Rate for Payer: Priority Health Commercial	$40.60
Rate for Payer: Priority Health PPO	$40.60

DESIPRAMINE (NORPRAMINE)

Facility

$8.00

Service Code	HCPCS G0480
Hospital Charge Code	3003660
Hospital Revenue Code	301
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$120.15
Rate for Payer: BCBS BCN 65	$120.15
Rate for Payer: Blue Care Network Medicare Advantage	$120.15
Rate for Payer: Cash Price	$5.20
Rate for Payer: Cash Price	$5.20
Rate for Payer: Community Health Alliance Commercial	$6.80
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$120.15
Rate for Payer: Meridian Health Plan Medicare	$120.15
Rate for Payer: Priority Health Commercial	$5.60
Rate for Payer: Priority Health Medicaid	$120.15
Rate for Payer: Priority Health Medicare	$120.15
Rate for Payer: Priority Health PPO	$5.60
Rate for Payer: United Health Care Medicaid	$120.15
Rate for Payer: United Health Care Medicare Advantage	$52.87

DESM1-LC

Facility

$42.50

Hospital Charge Code	3102737
Hospital Revenue Code	300
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$36.12
Rate for Payer: Cash Price	$27.63
Rate for Payer: Community Health Alliance Commercial	$36.12
Rate for Payer: Priority Health Commercial	$29.75
Rate for Payer: Priority Health PPO	$29.75

DESM2-LC

Facility

$42.50

Hospital Charge Code	3102738
Hospital Revenue Code	300
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$36.12
Rate for Payer: Cash Price	$27.63
Rate for Payer: Community Health Alliance Commercial	$36.12
Rate for Payer: Priority Health Commercial	$29.75
Rate for Payer: Priority Health PPO	$29.75

DESMOGLEIN 1,3

Facility

$85.00

Hospital Charge Code	3102736
Hospital Revenue Code	300
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$72.25
Rate for Payer: Cash Price	$55.25
Rate for Payer: Community Health Alliance Commercial	$72.25
Rate for Payer: Priority Health Commercial	$59.50
Rate for Payer: Priority Health PPO	$59.50

DESTROSE 5% NACL 0.45% 500ML B

Facility

$29.26

Service Code	NDC 338008503
Hospital Charge Code	2503711
Hospital Revenue Code	250
Min. Negotiated Rate	$20.48
Max. Negotiated Rate	$24.87
Rate for Payer: Cash Price	$19.02
Rate for Payer: Community Health Alliance Commercial	$24.87
Rate for Payer: Priority Health Commercial	$20.48
Rate for Payer: Priority Health PPO	$20.48

DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS

Facility

$215.23

Service Code	CPT 17111
Hospital Revenue Code	360
Min. Negotiated Rate	$94.70
Max. Negotiated Rate	$215.23
Rate for Payer: BCBS BCN 65	$215.23
Rate for Payer: Blue Care Network Medicare Advantage	$215.23
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$215.23
Rate for Payer: Meridian Health Plan Medicare	$215.23
Rate for Payer: Priority Health Medicaid	$215.23
Rate for Payer: Priority Health Medicare	$215.23
Rate for Payer: United Health Care Medicaid	$215.23
Rate for Payer: United Health Care Medicare Advantage	$94.70

DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)

Facility

$1,283.69

Service Code	CPT 46930
Hospital Revenue Code	360
Min. Negotiated Rate	$564.82
Max. Negotiated Rate	$1,283.69
Rate for Payer: BCBS BCN 65	$1,283.69
Rate for Payer: Blue Care Network Medicare Advantage	$1,283.69
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$1,283.69
Rate for Payer: Meridian Health Plan Medicare	$1,283.69
Rate for Payer: Priority Health Medicaid	$1,283.69
Rate for Payer: Priority Health Medicare	$1,283.69
Rate for Payer: United Health Care Medicaid	$1,283.69
Rate for Payer: United Health Care Medicare Advantage	$564.82

DESTRUCTION SKIN TAGS

Facility

$252.00

Hospital Charge Code	5150772
Hospital Revenue Code	960
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$214.20
Rate for Payer: Cash Price	$163.80
Rate for Payer: Community Health Alliance Commercial	$214.20
Rate for Payer: Priority Health Commercial	$176.40
Rate for Payer: Priority Health PPO	$176.40

DEVELOPMENTAL TESTING,EXTENDED

Facility

$307.00

Hospital Charge Code	4400017
Hospital Revenue Code	440
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$260.95
Rate for Payer: Cash Price	$199.55
Rate for Payer: Community Health Alliance Commercial	$260.95
Rate for Payer: Priority Health Commercial	$214.90
Rate for Payer: Priority Health PPO	$214.90

DEVELOPMENTAL TESTING, LIMITED

Facility

$250.00

Hospital Charge Code	4400016
Hospital Revenue Code	440
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$212.50
Rate for Payer: Cash Price	$162.50
Rate for Payer: Community Health Alliance Commercial	$212.50
Rate for Payer: Priority Health Commercial	$175.00
Rate for Payer: Priority Health PPO	$175.00

DEXAMETHASONE SERUM PLASMA

Facility

$34.21

Hospital Charge Code	3101065
Hospital Revenue Code	301
Min. Negotiated Rate	$23.95
Max. Negotiated Rate	$29.08
Rate for Payer: Cash Price	$22.24
Rate for Payer: Community Health Alliance Commercial	$29.08
Rate for Payer: Priority Health Commercial	$23.95
Rate for Payer: Priority Health PPO	$23.95

DEXAMETHASONE SUPRESSION TEST

Facility

$169.00

Hospital Charge Code	3009426
Hospital Revenue Code	301
Min. Negotiated Rate	$118.30
Max. Negotiated Rate	$143.65
Rate for Payer: Cash Price	$109.85
Rate for Payer: Community Health Alliance Commercial	$143.65
Rate for Payer: Priority Health Commercial	$118.30
Rate for Payer: Priority Health PPO	$118.30

DEXTROSE 5% 500 ML

Facility

$70.00

Service Code	HCPCS J7060
Hospital Charge Code	2510888
Hospital Revenue Code	636
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$59.50
Rate for Payer: Cash Price	$45.50
Rate for Payer: Community Health Alliance Commercial	$59.50
Rate for Payer: Priority Health Commercial	$49.00
Rate for Payer: Priority Health PPO	$49.00

DF-1

Facility

$39.25

Hospital Charge Code	3102192
Hospital Revenue Code	300
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$33.36
Rate for Payer: Cash Price	$25.51
Rate for Payer: Community Health Alliance Commercial	$33.36
Rate for Payer: Priority Health Commercial	$27.48
Rate for Payer: Priority Health PPO	$27.48

DF-2

Facility

$39.25

Hospital Charge Code	3102193
Hospital Revenue Code	300
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$33.36
Rate for Payer: Cash Price	$25.51
Rate for Payer: Community Health Alliance Commercial	$33.36
Rate for Payer: Priority Health Commercial	$27.48
Rate for Payer: Priority Health PPO	$27.48

DFD

Facility

$243.00

Hospital Charge Code	27265156
Hospital Revenue Code	272
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$206.55
Rate for Payer: Cash Price	$157.95
Rate for Payer: Community Health Alliance Commercial	$206.55
Rate for Payer: Priority Health Commercial	$170.10
Rate for Payer: Priority Health PPO	$170.10

DHEA

Facility

$4.89

Service Code	HCPCS 82626
Hospital Charge Code	3003645
Hospital Revenue Code	301
Min. Negotiated Rate	$3.42
Max. Negotiated Rate	$26.53
Rate for Payer: BCBS BCN 65	$26.53
Rate for Payer: Blue Care Network Medicare Advantage	$26.53
Rate for Payer: Cash Price	$3.18
Rate for Payer: Cash Price	$3.18
Rate for Payer: Community Health Alliance Commercial	$4.16
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$26.53
Rate for Payer: Meridian Health Plan Medicare	$26.53
Rate for Payer: Priority Health Commercial	$3.42
Rate for Payer: Priority Health Medicaid	$26.53
Rate for Payer: Priority Health Medicare	$26.53
Rate for Payer: Priority Health PPO	$3.42
Rate for Payer: United Health Care Medicaid	$26.53
Rate for Payer: United Health Care Medicare Advantage	$11.67

DHEA-SULFATE

Facility

$5.00

Service Code	HCPCS 82627
Hospital Charge Code	3003640
Hospital Revenue Code	301
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$23.34
Rate for Payer: BCBS BCN 65	$23.34
Rate for Payer: Blue Care Network Medicare Advantage	$23.34
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Community Health Alliance Commercial	$4.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$23.34
Rate for Payer: Meridian Health Plan Medicare	$23.34
Rate for Payer: Priority Health Commercial	$3.50
Rate for Payer: Priority Health Medicaid	$23.34
Rate for Payer: Priority Health Medicare	$23.34
Rate for Payer: Priority Health PPO	$3.50
Rate for Payer: United Health Care Medicaid	$23.34
Rate for Payer: United Health Care Medicare Advantage	$10.27

DHT-1

Facility

$119.10

Hospital Charge Code	3100786
Hospital Revenue Code	300
Min. Negotiated Rate	$83.37
Max. Negotiated Rate	$101.23
Rate for Payer: Cash Price	$77.42
Rate for Payer: Community Health Alliance Commercial	$101.23
Rate for Payer: Priority Health Commercial	$83.37
Rate for Payer: Priority Health PPO	$83.37

DHT-2

Facility

$119.10

Hospital Charge Code	3102215
Hospital Revenue Code	300
Min. Negotiated Rate	$83.37
Max. Negotiated Rate	$101.23
Rate for Payer: Cash Price	$77.42
Rate for Payer: Community Health Alliance Commercial	$101.23
Rate for Payer: Priority Health Commercial	$83.37
Rate for Payer: Priority Health PPO	$83.37

DHT-3

Facility

$119.05

Hospital Charge Code	3100788
Hospital Revenue Code	300
Min. Negotiated Rate	$83.33
Max. Negotiated Rate	$101.19
Rate for Payer: Cash Price	$77.38
Rate for Payer: Community Health Alliance Commercial	$101.19
Rate for Payer: Priority Health Commercial	$83.33
Rate for Payer: Priority Health PPO	$83.33

DIAG LAPARO SEP PROC

Facility

$876.00

Hospital Charge Code	5150785
Hospital Revenue Code	960
Min. Negotiated Rate	$613.20
Max. Negotiated Rate	$744.60
Rate for Payer: Cash Price	$569.40
Rate for Payer: Community Health Alliance Commercial	$744.60
Rate for Payer: Priority Health Commercial	$613.20
Rate for Payer: Priority Health PPO	$613.20

DIAGNOSTIC ANOSCOPY

Facility

$264.00

Hospital Charge Code	5150770
Hospital Revenue Code	960
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$224.40
Rate for Payer: Cash Price	$171.60
Rate for Payer: Community Health Alliance Commercial	$224.40
Rate for Payer: Priority Health Commercial	$184.80
Rate for Payer: Priority Health PPO	$184.80

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges