Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

ESTRONE

Facility

$10.00

Service Code	HCPCS 82679
Hospital Charge Code	3003461
Hospital Revenue Code	301
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$26.20
Rate for Payer: BCBS BCN 65	$26.20
Rate for Payer: Blue Care Network Medicare Advantage	$26.20
Rate for Payer: Cash Price	$6.50
Rate for Payer: Cash Price	$6.50
Rate for Payer: Community Health Alliance Commercial	$8.50
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$26.20
Rate for Payer: Meridian Health Plan Medicare	$26.20
Rate for Payer: Priority Health Commercial	$7.00
Rate for Payer: Priority Health Medicaid	$26.20
Rate for Payer: Priority Health Medicare	$26.20
Rate for Payer: Priority Health PPO	$7.00
Rate for Payer: United Health Care Medicaid	$26.20
Rate for Payer: United Health Care Medicare Advantage	$11.53

ETG/C CONFIRMATION CHARGE

Facility

$58.00

Hospital Charge Code	3009117
Hospital Revenue Code	301
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

ETG W CONF IF INDICATED

Facility

$21.00

Service Code	HCPCS 80307
Hospital Charge Code	3009118
Hospital Revenue Code	301
Min. Negotiated Rate	$14.70
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	$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	$65.25
Rate for Payer: Meridian Health Plan Medicare	$65.25
Rate for Payer: Priority Health Commercial	$14.70
Rate for Payer: Priority Health Medicaid	$65.25
Rate for Payer: Priority Health Medicare	$65.25
Rate for Payer: Priority Health PPO	$14.70
Rate for Payer: United Health Care Medicaid	$65.25
Rate for Payer: United Health Care Medicare Advantage	$28.71

ETHYLENE GLYCOL

Facility

$211.00

Service Code	HCPCS 82693
Hospital Charge Code	3004070
Hospital Revenue Code	301
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$179.35
Rate for Payer: BCBS BCN 65	$15.64
Rate for Payer: Blue Care Network Medicare Advantage	$15.64
Rate for Payer: Cash Price	$137.15
Rate for Payer: Cash Price	$137.15
Rate for Payer: Community Health Alliance Commercial	$179.35
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$15.64
Rate for Payer: Meridian Health Plan Medicare	$15.64
Rate for Payer: Priority Health Commercial	$147.70
Rate for Payer: Priority Health Medicaid	$15.64
Rate for Payer: Priority Health Medicare	$15.64
Rate for Payer: Priority Health PPO	$147.70
Rate for Payer: United Health Care Medicaid	$15.64
Rate for Payer: United Health Care Medicare Advantage	$6.88

ETHYL GLUCURONIDE AND ETHYL SU

Facility

$48.00

Hospital Charge Code	3101089
Hospital Revenue Code	301
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$40.80
Rate for Payer: Cash Price	$31.20
Rate for Payer: Community Health Alliance Commercial	$40.80
Rate for Payer: Priority Health Commercial	$33.60
Rate for Payer: Priority Health PPO	$33.60

EVAL OF SPEECH FLUENCY

Facility

$300.00

Hospital Charge Code	4400011
Hospital Revenue Code	444
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$255.00
Rate for Payer: Cash Price	$195.00
Rate for Payer: Community Health Alliance Commercial	$255.00
Rate for Payer: Priority Health Commercial	$210.00
Rate for Payer: Priority Health PPO	$210.00

EVAL OF SPEECH SOUND PROD/LANG

Facility

$504.00

Hospital Charge Code	4400013
Hospital Revenue Code	444
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$428.40
Rate for Payer: Cash Price	$327.60
Rate for Payer: Community Health Alliance Commercial	$428.40
Rate for Payer: Priority Health Commercial	$352.80
Rate for Payer: Priority Health PPO	$352.80

EVAL OF SPEECH SOUND PRODUCTIO

Facility

$244.00

Hospital Charge Code	4400012
Hospital Revenue Code	444
Min. Negotiated Rate	$170.80
Max. Negotiated Rate	$207.40
Rate for Payer: Cash Price	$158.60
Rate for Payer: Community Health Alliance Commercial	$207.40
Rate for Payer: Priority Health Commercial	$170.80
Rate for Payer: Priority Health PPO	$170.80

EVEROLIMUS

Facility

$118.00

Hospital Charge Code	3100935
Hospital Revenue Code	309
Min. Negotiated Rate	$82.60
Max. Negotiated Rate	$100.30
Rate for Payer: Cash Price	$76.70
Rate for Payer: Community Health Alliance Commercial	$100.30
Rate for Payer: Priority Health Commercial	$82.60
Rate for Payer: Priority Health PPO	$82.60

EVICEL, 2 ML

Facility

$510.00

Hospital Charge Code	27266245
Hospital Revenue Code	272
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$433.50
Rate for Payer: Cash Price	$331.50
Rate for Payer: Community Health Alliance Commercial	$433.50
Rate for Payer: Priority Health Commercial	$357.00
Rate for Payer: Priority Health PPO	$357.00

EVICEL 5ML KIT

Facility

$1,309.00

Hospital Charge Code	27271781
Hospital Revenue Code	272
Min. Negotiated Rate	$916.30
Max. Negotiated Rate	$1,112.65
Rate for Payer: Cash Price	$850.85
Rate for Payer: Community Health Alliance Commercial	$1,112.65
Rate for Payer: Priority Health Commercial	$916.30
Rate for Payer: Priority Health PPO	$916.30

E-VISIT 11-20 MINUTES

Facility

$20.88

Service Code	HCPCS G2062
Hospital Charge Code	4200292
Hospital Revenue Code	420
Min. Negotiated Rate	$14.62
Max. Negotiated Rate	$17.75
Rate for Payer: Cash Price	$13.57
Rate for Payer: Community Health Alliance Commercial	$17.75
Rate for Payer: Priority Health Commercial	$14.62
Rate for Payer: Priority Health PPO	$14.62

E-VISIT 11-20 MINUTES

Facility

$20.88

Service Code	HCPCS G2062
Hospital Charge Code	4400052
Hospital Revenue Code	440
Min. Negotiated Rate	$14.62
Max. Negotiated Rate	$17.75
Rate for Payer: Cash Price	$13.57
Rate for Payer: Community Health Alliance Commercial	$17.75
Rate for Payer: Priority Health Commercial	$14.62
Rate for Payer: Priority Health PPO	$14.62

E-VISIT 11-20 MINUTES

Facility

$20.88

Service Code	HCPCS G2062
Hospital Charge Code	4300102
Hospital Revenue Code	430
Min. Negotiated Rate	$14.62
Max. Negotiated Rate	$17.75
Rate for Payer: Cash Price	$13.57
Rate for Payer: Community Health Alliance Commercial	$17.75
Rate for Payer: Priority Health Commercial	$14.62
Rate for Payer: Priority Health PPO	$14.62

E-VISIT 21 MINUTES AND GREATER

Facility

$32.72

Service Code	HCPCS G2063
Hospital Charge Code	4400053
Hospital Revenue Code	440
Min. Negotiated Rate	$22.90
Max. Negotiated Rate	$27.81
Rate for Payer: Cash Price	$21.27
Rate for Payer: Community Health Alliance Commercial	$27.81
Rate for Payer: Priority Health Commercial	$22.90
Rate for Payer: Priority Health PPO	$22.90

E-VISIT 21 MINUTES AND GREATER

Facility

$32.72

Service Code	HCPCS G2063
Hospital Charge Code	4200293
Hospital Revenue Code	420
Min. Negotiated Rate	$22.90
Max. Negotiated Rate	$27.81
Rate for Payer: Cash Price	$21.27
Rate for Payer: Community Health Alliance Commercial	$27.81
Rate for Payer: Priority Health Commercial	$22.90
Rate for Payer: Priority Health PPO	$22.90

E-VISIT 21 MINUTES AND GREATER

Facility

$32.72

Service Code	HCPCS G2063
Hospital Charge Code	4300103
Hospital Revenue Code	430
Min. Negotiated Rate	$22.90
Max. Negotiated Rate	$27.81
Rate for Payer: Cash Price	$21.27
Rate for Payer: Community Health Alliance Commercial	$27.81
Rate for Payer: Priority Health Commercial	$22.90
Rate for Payer: Priority Health PPO	$22.90

E-VISIT 5-10 MINUTES

Facility

$11.31

Service Code	HCPCS G2061
Hospital Charge Code	4200291
Hospital Revenue Code	420
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$9.61
Rate for Payer: Cash Price	$7.35
Rate for Payer: Community Health Alliance Commercial	$9.61
Rate for Payer: Priority Health Commercial	$7.92
Rate for Payer: Priority Health PPO	$7.92

E-VISIT 5-10 MINUTES

Facility

$11.31

Service Code	HCPCS G2061
Hospital Charge Code	4300101
Hospital Revenue Code	430
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$9.61
Rate for Payer: Cash Price	$7.35
Rate for Payer: Community Health Alliance Commercial	$9.61
Rate for Payer: Priority Health Commercial	$7.92
Rate for Payer: Priority Health PPO	$7.92

E-VISIT 5-10- MINUTES

Facility

$11.31

Service Code	HCPCS G2061
Hospital Charge Code	4400051
Hospital Revenue Code	440
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$9.61
Rate for Payer: Cash Price	$7.35
Rate for Payer: Community Health Alliance Commercial	$9.61
Rate for Payer: Priority Health Commercial	$7.92
Rate for Payer: Priority Health PPO	$7.92

EXC ABD DES SC 3 CM/> PC

Facility

$1,003.00

Hospital Charge Code	5150744
Hospital Revenue Code	960
Min. Negotiated Rate	$702.10
Max. Negotiated Rate	$852.55
Rate for Payer: Cash Price	$651.95
Rate for Payer: Community Health Alliance Commercial	$852.55
Rate for Payer: Priority Health Commercial	$702.10
Rate for Payer: Priority Health PPO	$702.10

EXC ABD LESION SC <3 CM

Facility

$970.00

Hospital Charge Code	5150699
Hospital Revenue Code	960
Min. Negotiated Rate	$679.00
Max. Negotiated Rate	$824.50
Rate for Payer: Cash Price	$630.50
Rate for Payer: Community Health Alliance Commercial	$824.50
Rate for Payer: Priority Health Commercial	$679.00
Rate for Payer: Priority Health PPO	$679.00

EXC ARM/ELBOW LES SC 3CM/>

Facility

$984.00

Hospital Charge Code	5150784
Hospital Revenue Code	960
Min. Negotiated Rate	$688.80
Max. Negotiated Rate	$836.40
Rate for Payer: Cash Price	$639.60
Rate for Payer: Community Health Alliance Commercial	$836.40
Rate for Payer: Priority Health Commercial	$688.80
Rate for Payer: Priority Health PPO	$688.80

EXC BACK LES SC 3CM>

Facility

$1,129.00

Hospital Charge Code	5150697
Hospital Revenue Code	960
Min. Negotiated Rate	$790.30
Max. Negotiated Rate	$959.65
Rate for Payer: Cash Price	$733.85
Rate for Payer: Community Health Alliance Commercial	$959.65
Rate for Payer: Priority Health Commercial	$790.30
Rate for Payer: Priority Health PPO	$790.30

EXC BACK LES SC < 3CM PC

Facility

$1,368.00

Hospital Charge Code	5150706
Hospital Revenue Code	960
Min. Negotiated Rate	$957.60
Max. Negotiated Rate	$1,162.80
Rate for Payer: Cash Price	$889.20
Rate for Payer: Community Health Alliance Commercial	$1,162.80
Rate for Payer: Priority Health Commercial	$957.60
Rate for Payer: Priority Health PPO	$957.60

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges