Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

DIAGNOSTIC COLONOSCOPY P/C

Facility

$701.00

Hospital Charge Code	5150677
Hospital Revenue Code	960
Min. Negotiated Rate	$490.70
Max. Negotiated Rate	$595.85
Rate for Payer: Cash Price	$455.65
Rate for Payer: Community Health Alliance Commercial	$595.85
Rate for Payer: Priority Health Commercial	$490.70
Rate for Payer: Priority Health PPO	$490.70

DIFFERENTIAL MANUAL

Facility

$16.00

Hospital Charge Code	3003720
Hospital Revenue Code	305
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$13.60
Rate for Payer: Cash Price	$10.40
Rate for Payer: Community Health Alliance Commercial	$13.60
Rate for Payer: Priority Health Commercial	$11.20
Rate for Payer: Priority Health PPO	$11.20

DIGI-FLEX

Facility

$33.00

Hospital Charge Code	27022772
Hospital Revenue Code	270
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$28.05
Rate for Payer: Cash Price	$21.45
Rate for Payer: Community Health Alliance Commercial	$28.05
Rate for Payer: Priority Health Commercial	$23.10
Rate for Payer: Priority Health PPO	$23.10

DIGOXIN

Facility

$60.00

Service Code	HCPCS 80162
Hospital Charge Code	3003760
Hospital Revenue Code	301
Min. Negotiated Rate	$6.14
Max. Negotiated Rate	$51.00
Rate for Payer: BCBS BCN 65	$13.94
Rate for Payer: Blue Care Network Medicare Advantage	$13.94
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Community Health Alliance Commercial	$51.00
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$13.94
Rate for Payer: Meridian Health Plan Medicare	$13.94
Rate for Payer: Priority Health Commercial	$42.00
Rate for Payer: Priority Health Medicaid	$13.94
Rate for Payer: Priority Health Medicare	$13.94
Rate for Payer: Priority Health PPO	$42.00
Rate for Payer: United Health Care Medicaid	$13.94
Rate for Payer: United Health Care Medicare Advantage	$6.14

DIGOXIN SBMF

Facility

$5.25

Hospital Charge Code	3101153
Hospital Revenue Code	301
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$4.46
Rate for Payer: Cash Price	$3.41
Rate for Payer: Community Health Alliance Commercial	$4.46
Rate for Payer: Priority Health Commercial	$3.67
Rate for Payer: Priority Health PPO	$3.67

DIHYDROTESTOSTERONE

Facility

$23.83

Service Code	HCPCS 82642
Hospital Charge Code	3000252
Hospital Revenue Code	301
Min. Negotiated Rate	$13.53
Max. Negotiated Rate	$30.74
Rate for Payer: BCBS BCN 65	$30.74
Rate for Payer: Blue Care Network Medicare Advantage	$30.74
Rate for Payer: Cash Price	$15.49
Rate for Payer: Cash Price	$15.49
Rate for Payer: Community Health Alliance Commercial	$20.26
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$30.74
Rate for Payer: Meridian Health Plan Medicare	$30.74
Rate for Payer: Priority Health Commercial	$16.68
Rate for Payer: Priority Health Medicaid	$30.74
Rate for Payer: Priority Health Medicare	$30.74
Rate for Payer: Priority Health PPO	$16.68
Rate for Payer: United Health Care Medicaid	$30.74
Rate for Payer: United Health Care Medicare Advantage	$13.53

DILAMEZ INSERTER

Facility

$83.00

Hospital Charge Code	27060628
Hospital Revenue Code	270
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$70.55
Rate for Payer: Cash Price	$53.95
Rate for Payer: Community Health Alliance Commercial	$70.55
Rate for Payer: Priority Health Commercial	$58.10
Rate for Payer: Priority Health PPO	$58.10

DILANTIN (PHENYTOIN)

Facility

$60.00

Service Code	HCPCS 80185
Hospital Charge Code	3006560
Hospital Revenue Code	301
Min. Negotiated Rate	$6.12
Max. Negotiated Rate	$51.00
Rate for Payer: BCBS BCN 65	$13.91
Rate for Payer: Blue Care Network Medicare Advantage	$13.91
Rate for Payer: Cash Price	$39.00
Rate for Payer: Cash Price	$39.00
Rate for Payer: Community Health Alliance Commercial	$51.00
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$13.91
Rate for Payer: Meridian Health Plan Medicare	$13.91
Rate for Payer: Priority Health Commercial	$42.00
Rate for Payer: Priority Health Medicaid	$13.91
Rate for Payer: Priority Health Medicare	$13.91
Rate for Payer: Priority Health PPO	$42.00
Rate for Payer: United Health Care Medicaid	$13.91
Rate for Payer: United Health Care Medicare Advantage	$6.12

DILANTIN (PHENYTOIN)SBMF

Facility

$8.96

Hospital Charge Code	3101151
Hospital Revenue Code	301
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$7.62
Rate for Payer: Cash Price	$5.82
Rate for Payer: Community Health Alliance Commercial	$7.62
Rate for Payer: Priority Health Commercial	$6.27
Rate for Payer: Priority Health PPO	$6.27

DILATOR, 5 FRENCH

Facility

$29.00

Hospital Charge Code	27015107
Hospital Revenue Code	272
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$24.65
Rate for Payer: Cash Price	$18.85
Rate for Payer: Community Health Alliance Commercial	$24.65
Rate for Payer: Priority Health Commercial	$20.30
Rate for Payer: Priority Health PPO	$20.30

DILATOR,SAVARY-GILLIARD 48FR

Facility

$1,053.00

Hospital Charge Code	27262766
Hospital Revenue Code	272
Min. Negotiated Rate	$737.10
Max. Negotiated Rate	$895.05
Rate for Payer: Cash Price	$684.45
Rate for Payer: Community Health Alliance Commercial	$895.05
Rate for Payer: Priority Health Commercial	$737.10
Rate for Payer: Priority Health PPO	$737.10

DILATORS, CAVERNOTOME C & R

Facility

$795.00

Hospital Charge Code	27267813
Hospital Revenue Code	272
Min. Negotiated Rate	$556.50
Max. Negotiated Rate	$675.75
Rate for Payer: Cash Price	$516.75
Rate for Payer: Community Health Alliance Commercial	$675.75
Rate for Payer: Priority Health Commercial	$556.50
Rate for Payer: Priority Health PPO	$556.50

DILATOR,TD-4/.035

Facility

$29.00

Hospital Charge Code	27015008
Hospital Revenue Code	272
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$24.65
Rate for Payer: Cash Price	$18.85
Rate for Payer: Community Health Alliance Commercial	$24.65
Rate for Payer: Priority Health Commercial	$20.30
Rate for Payer: Priority Health PPO	$20.30

DIPTHERIA ANTIBODY

Facility

$8.15

Service Code	HCPCS 86317
Hospital Charge Code	3006490
Hospital Revenue Code	302
Min. Negotiated Rate	$5.71
Max. Negotiated Rate	$15.74
Rate for Payer: BCBS BCN 65	$15.74
Rate for Payer: Blue Care Network Medicare Advantage	$15.74
Rate for Payer: Cash Price	$5.30
Rate for Payer: Cash Price	$5.30
Rate for Payer: Community Health Alliance Commercial	$6.93
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$15.74
Rate for Payer: Meridian Health Plan Medicare	$15.74
Rate for Payer: Priority Health Commercial	$5.71
Rate for Payer: Priority Health Medicaid	$15.74
Rate for Payer: Priority Health Medicare	$15.74
Rate for Payer: Priority Health PPO	$5.71
Rate for Payer: United Health Care Medicaid	$15.74
Rate for Payer: United Health Care Medicare Advantage	$6.93

DIRECT COOMBS

Facility

$44.00

Service Code	HCPCS 86880
Hospital Charge Code	3003790
Hospital Revenue Code	300
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$37.40
Rate for Payer: BCBS BCN 65	$5.66
Rate for Payer: Blue Care Network Medicare Advantage	$5.66
Rate for Payer: Cash Price	$28.60
Rate for Payer: Cash Price	$28.60
Rate for Payer: Community Health Alliance Commercial	$37.40
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$5.66
Rate for Payer: Meridian Health Plan Medicare	$5.66
Rate for Payer: Priority Health Commercial	$30.80
Rate for Payer: Priority Health Medicaid	$5.66
Rate for Payer: Priority Health Medicare	$5.66
Rate for Payer: Priority Health PPO	$30.80
Rate for Payer: United Health Care Medicaid	$5.66
Rate for Payer: United Health Care Medicare Advantage	$2.49

DIRECTED DONOR EACH UNIT

Facility

$193.00

Hospital Charge Code	3000250
Hospital Revenue Code	940
Min. Negotiated Rate	$135.10
Max. Negotiated Rate	$164.05
Rate for Payer: Cash Price	$125.45
Rate for Payer: Community Health Alliance Commercial	$164.05
Rate for Payer: Priority Health Commercial	$135.10
Rate for Payer: Priority Health PPO	$135.10

DIRECT MEASURE 1 DL

Facility

$38.00

Service Code	HCPCS 83721
Hospital Charge Code	3003795
Hospital Revenue Code	301
Min. Negotiated Rate	$4.85
Max. Negotiated Rate	$32.30
Rate for Payer: BCBS BCN 65	$11.03
Rate for Payer: Blue Care Network Medicare Advantage	$11.03
Rate for Payer: Cash Price	$24.70
Rate for Payer: Cash Price	$24.70
Rate for Payer: Community Health Alliance Commercial	$32.30
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$11.03
Rate for Payer: Meridian Health Plan Medicare	$11.03
Rate for Payer: Priority Health Commercial	$26.60
Rate for Payer: Priority Health Medicaid	$11.03
Rate for Payer: Priority Health Medicare	$11.03
Rate for Payer: Priority Health PPO	$26.60
Rate for Payer: United Health Care Medicaid	$11.03
Rate for Payer: United Health Care Medicare Advantage	$4.85

DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)

Facility

$590.01

Service Code	CPT 66821
Hospital Revenue Code	360
Min. Negotiated Rate	$259.60
Max. Negotiated Rate	$590.01
Rate for Payer: BCBS BCN 65	$590.01
Rate for Payer: Blue Care Network Medicare Advantage	$590.01
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$590.01
Rate for Payer: Meridian Health Plan Medicare	$590.01
Rate for Payer: Priority Health Medicaid	$590.01
Rate for Payer: Priority Health Medicare	$590.01
Rate for Payer: United Health Care Medicaid	$590.01
Rate for Payer: United Health Care Medicare Advantage	$259.60

DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)

Facility

$590.01

Service Code	CPT 66821
Hospital Revenue Code	361
Min. Negotiated Rate	$259.60
Max. Negotiated Rate	$590.01
Rate for Payer: BCBS BCN 65	$590.01
Rate for Payer: Blue Care Network Medicare Advantage	$590.01
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$590.01
Rate for Payer: Meridian Health Plan Medicare	$590.01
Rate for Payer: Priority Health Medicaid	$590.01
Rate for Payer: Priority Health Medicare	$590.01
Rate for Payer: United Health Care Medicaid	$590.01
Rate for Payer: United Health Care Medicare Advantage	$259.60

DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (1 OR MORE STAGES)

Facility

$590.01

Service Code	CPT 66821
Hospital Revenue Code	490
Min. Negotiated Rate	$259.60
Max. Negotiated Rate	$590.01
Rate for Payer: BCBS BCN 65	$590.01
Rate for Payer: Blue Care Network Medicare Advantage	$590.01
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$590.01
Rate for Payer: Meridian Health Plan Medicare	$590.01
Rate for Payer: Priority Health Medicaid	$590.01
Rate for Payer: Priority Health Medicare	$590.01
Rate for Payer: United Health Care Medicaid	$590.01
Rate for Payer: United Health Care Medicare Advantage	$259.60

DISPOSABLE B LINE/ELBOW

Facility

$20.00

Hospital Charge Code	27017301
Hospital Revenue Code	272
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$17.00
Rate for Payer: Cash Price	$13.00
Rate for Payer: Community Health Alliance Commercial	$17.00
Rate for Payer: Priority Health Commercial	$14.00
Rate for Payer: Priority Health PPO	$14.00

DISTAL DRILL #1214-5300S

Facility

$422.00

Hospital Charge Code	27271583
Hospital Revenue Code	272
Min. Negotiated Rate	$295.40
Max. Negotiated Rate	$358.70
Rate for Payer: Cash Price	$274.30
Rate for Payer: Community Health Alliance Commercial	$358.70
Rate for Payer: Priority Health Commercial	$295.40
Rate for Payer: Priority Health PPO	$295.40

DISTAL RADIUS REPAIR COMPONENT

Facility

$3,962.00

Service Code	HCPCS C1713
Hospital Charge Code	27885151
Hospital Revenue Code	278
Min. Negotiated Rate	$2,773.40
Max. Negotiated Rate	$3,367.70
Rate for Payer: Cash Price	$2,575.30
Rate for Payer: Community Health Alliance Commercial	$3,367.70
Rate for Payer: Priority Health Commercial	$2,773.40
Rate for Payer: Priority Health PPO	$2,773.40

D LACTIC ACID

Facility

$87.00

Hospital Charge Code	3101090
Hospital Revenue Code	301
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$73.95
Rate for Payer: Cash Price	$56.55
Rate for Payer: Community Health Alliance Commercial	$73.95
Rate for Payer: Priority Health Commercial	$60.90
Rate for Payer: Priority Health PPO	$60.90

D METHAMPHETAMINE

Facility

$15.00

Service Code	HCPCS G0480
Hospital Charge Code	3101573
Hospital Revenue Code	300
Min. Negotiated Rate	$10.50
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	$9.75
Rate for Payer: Cash Price	$9.75
Rate for Payer: Community Health Alliance Commercial	$12.75
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	$10.50
Rate for Payer: Priority Health Medicaid	$120.15
Rate for Payer: Priority Health Medicare	$120.15
Rate for Payer: Priority Health PPO	$10.50
Rate for Payer: United Health Care Medicaid	$120.15
Rate for Payer: United Health Care Medicare Advantage	$52.87

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges