Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

DRUG SCREEN, FORENSIC

Facility

$58.00

Service Code	HCPCS 80306
Hospital Charge Code	3003900
Hospital Revenue Code	301
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$49.30
Rate for Payer: BCBS BCN 65	$18.00
Rate for Payer: Blue Care Network Medicare Advantage	$18.00
Rate for Payer: Cash Price	$37.70
Rate for Payer: Cash Price	$37.70
Rate for Payer: Community Health Alliance Commercial	$49.30
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$18.00
Rate for Payer: Meridian Health Plan Medicare	$18.00
Rate for Payer: Priority Health Commercial	$40.60
Rate for Payer: Priority Health Medicaid	$18.00
Rate for Payer: Priority Health Medicare	$18.00
Rate for Payer: Priority Health PPO	$40.60
Rate for Payer: United Health Care Medicaid	$18.00
Rate for Payer: United Health Care Medicare Advantage	$7.92

DRUG SCREEN OXYCODONE URINE

Facility

$13.00

Service Code	HCPCS G6056
Hospital Charge Code	3100891
Hospital Revenue Code	300
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$11.05
Rate for Payer: Cash Price	$8.45
Rate for Payer: Community Health Alliance Commercial	$11.05
Rate for Payer: Priority Health Commercial	$9.10
Rate for Payer: Priority Health PPO	$9.10

DRUG SCREEN SERUM

Facility

$54.00

Service Code	HCPCS 80307
Hospital Charge Code	3003870
Hospital Revenue Code	301
Min. Negotiated Rate	$28.71
Max. Negotiated Rate	$65.25
Rate for Payer: BCBS BCN 65	$65.25
Rate for Payer: Blue Care Network Medicare Advantage	$65.25
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Community Health Alliance Commercial	$45.90
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$65.25
Rate for Payer: Meridian Health Plan Medicare	$65.25
Rate for Payer: Priority Health Commercial	$37.80
Rate for Payer: Priority Health Medicaid	$65.25
Rate for Payer: Priority Health Medicare	$65.25
Rate for Payer: Priority Health PPO	$37.80
Rate for Payer: United Health Care Medicaid	$65.25
Rate for Payer: United Health Care Medicare Advantage	$28.71

dRVVT CONFIRM

Facility

$24.44

Hospital Charge Code	3101966
Hospital Revenue Code	300
Min. Negotiated Rate	$17.11
Max. Negotiated Rate	$20.77
Rate for Payer: Cash Price	$15.89
Rate for Payer: Community Health Alliance Commercial	$20.77
Rate for Payer: Priority Health Commercial	$17.11
Rate for Payer: Priority Health PPO	$17.11

DRVVT MIX

Facility

$24.44

Hospital Charge Code	3101967
Hospital Revenue Code	300
Min. Negotiated Rate	$17.11
Max. Negotiated Rate	$20.77
Rate for Payer: Cash Price	$15.89
Rate for Payer: Community Health Alliance Commercial	$20.77
Rate for Payer: Priority Health Commercial	$17.11
Rate for Payer: Priority Health PPO	$17.11

DSDNA AB-LC

Facility

$21.91

Hospital Charge Code	31027384
Hospital Revenue Code	300
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$18.62
Rate for Payer: Cash Price	$14.24
Rate for Payer: Community Health Alliance Commercial	$18.62
Rate for Payer: Priority Health Commercial	$15.34
Rate for Payer: Priority Health PPO	$15.34

DSM-1

Facility

$52.06

Hospital Charge Code	3101170
Hospital Revenue Code	300
Min. Negotiated Rate	$36.44
Max. Negotiated Rate	$44.25
Rate for Payer: Cash Price	$33.84
Rate for Payer: Community Health Alliance Commercial	$44.25
Rate for Payer: Priority Health Commercial	$36.44
Rate for Payer: Priority Health PPO	$36.44

DSM-2

Facility

$52.06

Hospital Charge Code	3101171
Hospital Revenue Code	300
Min. Negotiated Rate	$36.44
Max. Negotiated Rate	$44.25
Rate for Payer: Cash Price	$33.84
Rate for Payer: Community Health Alliance Commercial	$44.25
Rate for Payer: Priority Health Commercial	$36.44
Rate for Payer: Priority Health PPO	$36.44

DUCHENNE BECKER NUSCULAR DYST

Facility

$610.00

Hospital Charge Code	3101097
Hospital Revenue Code	302
Min. Negotiated Rate	$427.00
Max. Negotiated Rate	$518.50
Rate for Payer: Cash Price	$396.50
Rate for Payer: Community Health Alliance Commercial	$518.50
Rate for Payer: Priority Health Commercial	$427.00
Rate for Payer: Priority Health PPO	$427.00

DUODERM CFG 4X4

Facility

$30.00

Hospital Charge Code	27017038
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

DUODERM CFG 6X8

Facility

$99.00

Hospital Charge Code	27017046
Hospital Revenue Code	272
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$84.15
Rate for Payer: Cash Price	$64.35
Rate for Payer: Community Health Alliance Commercial	$84.15
Rate for Payer: Priority Health Commercial	$69.30
Rate for Payer: Priority Health PPO	$69.30

DURASPHERE INJ BULBING AGENT

Facility

$533.00

Hospital Charge Code	27267177
Hospital Revenue Code	272
Min. Negotiated Rate	$373.10
Max. Negotiated Rate	$453.05
Rate for Payer: Cash Price	$346.45
Rate for Payer: Community Health Alliance Commercial	$453.05
Rate for Payer: Priority Health Commercial	$373.10
Rate for Payer: Priority Health PPO	$373.10

E-1

Facility

$28.40

Hospital Charge Code	3102372
Hospital Revenue Code	300
Min. Negotiated Rate	$19.88
Max. Negotiated Rate	$24.14
Rate for Payer: Cash Price	$18.46
Rate for Payer: Community Health Alliance Commercial	$24.14
Rate for Payer: Priority Health Commercial	$19.88
Rate for Payer: Priority Health PPO	$19.88

E12-15

Facility

$107.92

Hospital Charge Code	31027691
Hospital Revenue Code	300
Min. Negotiated Rate	$75.54
Max. Negotiated Rate	$91.73
Rate for Payer: Cash Price	$70.15
Rate for Payer: Community Health Alliance Commercial	$91.73
Rate for Payer: Priority Health Commercial	$75.54
Rate for Payer: Priority Health PPO	$75.54

E-2

Facility

$28.40

Hospital Charge Code	3102373
Hospital Revenue Code	300
Min. Negotiated Rate	$19.88
Max. Negotiated Rate	$24.14
Rate for Payer: Cash Price	$18.46
Rate for Payer: Community Health Alliance Commercial	$24.14
Rate for Payer: Priority Health Commercial	$19.88
Rate for Payer: Priority Health PPO	$19.88

E-3

Facility

$28.40

Hospital Charge Code	3102374
Hospital Revenue Code	300
Min. Negotiated Rate	$19.88
Max. Negotiated Rate	$24.14
Rate for Payer: Cash Price	$18.46
Rate for Payer: Community Health Alliance Commercial	$24.14
Rate for Payer: Priority Health Commercial	$19.88
Rate for Payer: Priority Health PPO	$19.88

E-4

Facility

$28.40

Hospital Charge Code	3102375
Hospital Revenue Code	300
Min. Negotiated Rate	$19.88
Max. Negotiated Rate	$24.14
Rate for Payer: Cash Price	$18.46
Rate for Payer: Community Health Alliance Commercial	$24.14
Rate for Payer: Priority Health Commercial	$19.88
Rate for Payer: Priority Health PPO	$19.88

E-5

Facility

$28.40

Hospital Charge Code	3102376
Hospital Revenue Code	300
Min. Negotiated Rate	$19.88
Max. Negotiated Rate	$24.14
Rate for Payer: Cash Price	$18.46
Rate for Payer: Community Health Alliance Commercial	$24.14
Rate for Payer: Priority Health Commercial	$19.88
Rate for Payer: Priority Health PPO	$19.88

EACH ADDITIONAL DRUG

Facility

$63.33

Hospital Charge Code	3000617
Hospital Revenue Code	306
Min. Negotiated Rate	$44.33
Max. Negotiated Rate	$53.83
Rate for Payer: Cash Price	$41.16
Rate for Payer: Community Health Alliance Commercial	$53.83
Rate for Payer: Priority Health Commercial	$44.33
Rate for Payer: Priority Health PPO	$44.33

EACH ADDITIONAL DRUG

Facility

$63.33

Hospital Charge Code	3000619
Hospital Revenue Code	306
Min. Negotiated Rate	$44.33
Max. Negotiated Rate	$53.83
Rate for Payer: Cash Price	$41.16
Rate for Payer: Community Health Alliance Commercial	$53.83
Rate for Payer: Priority Health Commercial	$44.33
Rate for Payer: Priority Health PPO	$44.33

EACH ADDITIONAL DRUG

Facility

$63.33

Hospital Charge Code	3000618
Hospital Revenue Code	306
Min. Negotiated Rate	$44.33
Max. Negotiated Rate	$53.83
Rate for Payer: Cash Price	$41.16
Rate for Payer: Community Health Alliance Commercial	$53.83
Rate for Payer: Priority Health Commercial	$44.33
Rate for Payer: Priority Health PPO	$44.33

EACH ADDITIONAL DRUG

Facility

$63.33

Hospital Charge Code	3000622
Hospital Revenue Code	306
Min. Negotiated Rate	$44.33
Max. Negotiated Rate	$53.83
Rate for Payer: Cash Price	$41.16
Rate for Payer: Community Health Alliance Commercial	$53.83
Rate for Payer: Priority Health Commercial	$44.33
Rate for Payer: Priority Health PPO	$44.33

EACH ADDITIONAL DRUG

Facility

$63.33

Hospital Charge Code	3000623
Hospital Revenue Code	306
Min. Negotiated Rate	$44.33
Max. Negotiated Rate	$53.83
Rate for Payer: Cash Price	$41.16
Rate for Payer: Community Health Alliance Commercial	$53.83
Rate for Payer: Priority Health Commercial	$44.33
Rate for Payer: Priority Health PPO	$44.33

EACH ADDITIONAL DRUG TEST

Facility

$105.00

Hospital Charge Code	3000834
Hospital Revenue Code	306
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$89.25
Rate for Payer: Cash Price	$68.25
Rate for Payer: Community Health Alliance Commercial	$89.25
Rate for Payer: Priority Health Commercial	$73.50
Rate for Payer: Priority Health PPO	$73.50

EACH ADDITIONAL DRUG TEST

Facility

$105.00

Hospital Charge Code	3000818
Hospital Revenue Code	306
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$89.25
Rate for Payer: Cash Price	$68.25
Rate for Payer: Community Health Alliance Commercial	$89.25
Rate for Payer: Priority Health Commercial	$73.50
Rate for Payer: Priority Health PPO	$73.50

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges