Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

DRAIN-SHIRLEY SUMP

Facility

$83.00

Hospital Charge Code	27012856
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

DRAIN-SUMP, XRAY, WEIGHTED

Facility

$221.00

Hospital Charge Code	27012864
Hospital Revenue Code	270
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$187.85
Rate for Payer: Cash Price	$143.65
Rate for Payer: Community Health Alliance Commercial	$187.85
Rate for Payer: Priority Health Commercial	$154.70
Rate for Payer: Priority Health PPO	$154.70

DRAW FEE-CATHETER

Facility

$115.00

Hospital Charge Code	3003586
Hospital Revenue Code	300
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$97.75
Rate for Payer: Cash Price	$74.75
Rate for Payer: Community Health Alliance Commercial	$97.75
Rate for Payer: Priority Health Commercial	$80.50
Rate for Payer: Priority Health PPO	$80.50

DRAW FEE-CATHETER/SPECIAL CLIN

Facility

$121.00

Hospital Charge Code	3003576
Hospital Revenue Code	300
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$102.85
Rate for Payer: Cash Price	$78.65
Rate for Payer: Community Health Alliance Commercial	$102.85
Rate for Payer: Priority Health Commercial	$84.70
Rate for Payer: Priority Health PPO	$84.70

DRAW FEE/MISC

Facility

$21.00

Service Code	HCPCS 36415
Hospital Charge Code	3003580
Hospital Revenue Code	300
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$17.85
Rate for Payer: BCBS BCN 65	$9.81
Rate for Payer: Blue Care Network Medicare Advantage	$9.81
Rate for Payer: Cash Price	$13.65
Rate for Payer: Cash Price	$13.65
Rate for Payer: Community Health Alliance Commercial	$17.85
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$9.81
Rate for Payer: Meridian Health Plan Medicare	$9.81
Rate for Payer: Priority Health Commercial	$14.70
Rate for Payer: Priority Health Medicaid	$9.81
Rate for Payer: Priority Health Medicare	$9.81
Rate for Payer: Priority Health PPO	$14.70
Rate for Payer: United Health Care Medicaid	$9.81
Rate for Payer: United Health Care Medicare Advantage	$4.32

DRAW FEE/SPECIALTY CLINIC

Facility

$23.00

Service Code	HCPCS 36415
Hospital Charge Code	3003579
Hospital Revenue Code	300
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$19.55
Rate for Payer: BCBS BCN 65	$9.81
Rate for Payer: Blue Care Network Medicare Advantage	$9.81
Rate for Payer: Cash Price	$14.95
Rate for Payer: Cash Price	$14.95
Rate for Payer: Community Health Alliance Commercial	$19.55
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$9.81
Rate for Payer: Meridian Health Plan Medicare	$9.81
Rate for Payer: Priority Health Commercial	$16.10
Rate for Payer: Priority Health Medicaid	$9.81
Rate for Payer: Priority Health Medicare	$9.81
Rate for Payer: Priority Health PPO	$16.10
Rate for Payer: United Health Care Medicaid	$9.81
Rate for Payer: United Health Care Medicare Advantage	$4.32

DRESSING-AIRSTRIP

Facility

$18.00

Hospital Charge Code	27010991
Hospital Revenue Code	272
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$15.30
Rate for Payer: Cash Price	$11.70
Rate for Payer: Community Health Alliance Commercial	$15.30
Rate for Payer: Priority Health Commercial	$12.60
Rate for Payer: Priority Health PPO	$12.60

DRESSING, AIRSTRIP 8.5CM X 6CM

Facility

$20.00

Hospital Charge Code	27017665
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

DRESSING, ALGISITE 4 X 4

Facility

$18.00

Hospital Charge Code	27066856
Hospital Revenue Code	272
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$15.30
Rate for Payer: Cash Price	$11.70
Rate for Payer: Community Health Alliance Commercial	$15.30
Rate for Payer: Priority Health Commercial	$12.60
Rate for Payer: Priority Health PPO	$12.60

DRESSING,ALLEVYN 5 X 5

Facility

$21.00

Hospital Charge Code	27066823
Hospital Revenue Code	272
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$17.85
Rate for Payer: Cash Price	$13.65
Rate for Payer: Community Health Alliance Commercial	$17.85
Rate for Payer: Priority Health Commercial	$14.70
Rate for Payer: Priority Health PPO	$14.70

DRESSING AQUACAL AG RIBBON

Facility

$174.00

Hospital Charge Code	27078242
Hospital Revenue Code	270
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$147.90
Rate for Payer: Cash Price	$113.10
Rate for Payer: Community Health Alliance Commercial	$147.90
Rate for Payer: Priority Health Commercial	$121.80
Rate for Payer: Priority Health PPO	$121.80

DRESSING AQUACEL AG 4X4.7

Facility

$77.00

Hospital Charge Code	27078169
Hospital Revenue Code	270
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$65.45
Rate for Payer: Cash Price	$50.05
Rate for Payer: Community Health Alliance Commercial	$65.45
Rate for Payer: Priority Health Commercial	$53.90
Rate for Payer: Priority Health PPO	$53.90

DRESSING CHANGE TRAY

Facility

$38.00

Hospital Charge Code	27012898
Hospital Revenue Code	272
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$32.30
Rate for Payer: Cash Price	$24.70
Rate for Payer: Community Health Alliance Commercial	$32.30
Rate for Payer: Priority Health Commercial	$26.60
Rate for Payer: Priority Health PPO	$26.60

DRESSING DUODERM SIGNAL 6X6

Facility

$34.00

Hospital Charge Code	27277450
Hospital Revenue Code	272
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$28.90
Rate for Payer: Cash Price	$22.10
Rate for Payer: Community Health Alliance Commercial	$28.90
Rate for Payer: Priority Health Commercial	$23.80
Rate for Payer: Priority Health PPO	$23.80

DRESSING ENLUXTRA 4X4

Facility

$29.00

Hospital Charge Code	27283687
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

DRESSING ENLUXTRA 6 X 6

Facility

$64.00

Hospital Charge Code	27284399
Hospital Revenue Code	272
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$54.40
Rate for Payer: Cash Price	$41.60
Rate for Payer: Community Health Alliance Commercial	$54.40
Rate for Payer: Priority Health Commercial	$44.80
Rate for Payer: Priority Health PPO	$44.80

DRESSING MEPILEX BORDER 3 X 3

Facility

$6.00

Hospital Charge Code	27275785
Hospital Revenue Code	272
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$5.10
Rate for Payer: Cash Price	$3.90
Rate for Payer: Community Health Alliance Commercial	$5.10
Rate for Payer: Priority Health Commercial	$4.20
Rate for Payer: Priority Health PPO	$4.20

DRESSING MEPILEX BORDER 4X4

Facility

$8.00

Hospital Charge Code	27078565
Hospital Revenue Code	270
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$6.80
Rate for Payer: Cash Price	$5.20
Rate for Payer: Community Health Alliance Commercial	$6.80
Rate for Payer: Priority Health Commercial	$5.60
Rate for Payer: Priority Health PPO	$5.60

DRESSING MEPITEL ONE 3 X 4

Facility

$10.58

Hospital Charge Code	27278416
Hospital Revenue Code	272
Min. Negotiated Rate	$7.41
Max. Negotiated Rate	$8.99
Rate for Payer: Cash Price	$6.88
Rate for Payer: Community Health Alliance Commercial	$8.99
Rate for Payer: Priority Health Commercial	$7.41
Rate for Payer: Priority Health PPO	$7.41

DRESSING, REPLICARE THIN

Facility

$18.00

Hospital Charge Code	27066815
Hospital Revenue Code	272
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$15.30
Rate for Payer: Cash Price	$11.70
Rate for Payer: Community Health Alliance Commercial	$15.30
Rate for Payer: Priority Health Commercial	$12.60
Rate for Payer: Priority Health PPO	$12.60

DRESSING SILVERCEL NON-ADHEREN

Facility

$30.00

Hospital Charge Code	27277939
Hospital Revenue Code	272
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$25.50
Rate for Payer: Cash Price	$19.50
Rate for Payer: Community Health Alliance Commercial	$25.50
Rate for Payer: Priority Health Commercial	$21.00
Rate for Payer: Priority Health PPO	$21.00

DRESSING SORBACT

Facility

$16.00

Hospital Charge Code	27277110
Hospital Revenue Code	272
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

DRESSING SORBACT GEL 3X6

Facility

$17.00

Hospital Charge Code	27278079
Hospital Revenue Code	272
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$14.45
Rate for Payer: Cash Price	$11.05
Rate for Payer: Community Health Alliance Commercial	$14.45
Rate for Payer: Priority Health Commercial	$11.90
Rate for Payer: Priority Health PPO	$11.90

DRESSING,SORBSAN 3 x 3

Facility

$31.00

Hospital Charge Code	27019588
Hospital Revenue Code	272
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$26.35
Rate for Payer: Cash Price	$20.15
Rate for Payer: Community Health Alliance Commercial	$26.35
Rate for Payer: Priority Health Commercial	$21.70
Rate for Payer: Priority Health PPO	$21.70

DRESSING-VPM, LARGE

Facility

$20.00

Hospital Charge Code	27010710
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

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges