Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

AMITRIPTYLINE/NORTRIPTYLINE

Facility

$8.00

Hospital Charge Code	3100701
Hospital Revenue Code	301
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

A/M/M/M-1

Facility

$16.50

Hospital Charge Code	3102108
Hospital Revenue Code	300
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$14.03
Rate for Payer: Cash Price	$10.73
Rate for Payer: Community Health Alliance Commercial	$14.03
Rate for Payer: Priority Health Commercial	$11.55
Rate for Payer: Priority Health PPO	$11.55

A/M/M/M-2

Facility

$16.50

Hospital Charge Code	3102109
Hospital Revenue Code	300
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$14.03
Rate for Payer: Cash Price	$10.73
Rate for Payer: Community Health Alliance Commercial	$14.03
Rate for Payer: Priority Health Commercial	$11.55
Rate for Payer: Priority Health PPO	$11.55

AMMONIA

Facility

$65.00

Service Code	HCPCS 82140
Hospital Charge Code	3000660
Hospital Revenue Code	301
Min. Negotiated Rate	$6.73
Max. Negotiated Rate	$55.25
Rate for Payer: BCBS BCN 65	$15.30
Rate for Payer: Blue Care Network Medicare Advantage	$15.30
Rate for Payer: Cash Price	$42.25
Rate for Payer: Cash Price	$42.25
Rate for Payer: Community Health Alliance Commercial	$55.25
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$15.30
Rate for Payer: Meridian Health Plan Medicare	$15.30
Rate for Payer: Priority Health Commercial	$45.50
Rate for Payer: Priority Health Medicaid	$15.30
Rate for Payer: Priority Health Medicare	$15.30
Rate for Payer: Priority Health PPO	$45.50
Rate for Payer: United Health Care Medicaid	$15.30
Rate for Payer: United Health Care Medicare Advantage	$6.73

AMMONIA SBMF

Facility

$5.00

Hospital Charge Code	3101567
Hospital Revenue Code	300
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$3.25
Rate for Payer: Community Health Alliance Commercial	$4.25
Rate for Payer: Priority Health Commercial	$3.50
Rate for Payer: Priority Health PPO	$3.50

AMMONIUM 24 HR URINE

Facility

$14.00

Hospital Charge Code	3101070
Hospital Revenue Code	300
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$11.90
Rate for Payer: Cash Price	$9.10
Rate for Payer: Community Health Alliance Commercial	$11.90
Rate for Payer: Priority Health Commercial	$9.80
Rate for Payer: Priority Health PPO	$9.80

AMNIOCENTESIS

Facility

$257.00

Service Code	HCPCS 59000
Hospital Charge Code	4000291
Hospital Revenue Code	361
Min. Negotiated Rate	$179.90
Max. Negotiated Rate	$988.05
Rate for Payer: BCBS BCN 65	$988.05
Rate for Payer: Blue Care Network Medicare Advantage	$988.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Cash Price	$167.05
Rate for Payer: Community Health Alliance Commercial	$218.45
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$988.05
Rate for Payer: Meridian Health Plan Medicare	$988.05
Rate for Payer: Priority Health Commercial	$179.90
Rate for Payer: Priority Health Medicaid	$988.05
Rate for Payer: Priority Health Medicare	$988.05
Rate for Payer: Priority Health PPO	$179.90
Rate for Payer: United Health Care Medicaid	$988.05
Rate for Payer: United Health Care Medicare Advantage	$434.74

AMNIOTIC FLUID

Facility

$581.00

Hospital Charge Code	3000714
Hospital Revenue Code	311
Min. Negotiated Rate	$406.70
Max. Negotiated Rate	$493.85
Rate for Payer: Cash Price	$377.65
Rate for Payer: Community Health Alliance Commercial	$493.85
Rate for Payer: Priority Health Commercial	$406.70
Rate for Payer: Priority Health PPO	$406.70

AMPHET 2

Facility

$17.50

Hospital Charge Code	3101337
Hospital Revenue Code	301
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$14.88
Rate for Payer: Cash Price	$11.38
Rate for Payer: Community Health Alliance Commercial	$14.88
Rate for Payer: Priority Health Commercial	$12.25
Rate for Payer: Priority Health PPO	$12.25

AMPHET A

Facility

$17.50

Hospital Charge Code	3101336
Hospital Revenue Code	301
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$14.88
Rate for Payer: Cash Price	$11.38
Rate for Payer: Community Health Alliance Commercial	$14.88
Rate for Payer: Priority Health Commercial	$12.25
Rate for Payer: Priority Health PPO	$12.25

AMPHETAMINE CONFIRMATION

Facility

$12.74

Hospital Charge Code	3101602
Hospital Revenue Code	300
Min. Negotiated Rate	$8.92
Max. Negotiated Rate	$10.83
Rate for Payer: Cash Price	$8.28
Rate for Payer: Community Health Alliance Commercial	$10.83
Rate for Payer: Priority Health Commercial	$8.92
Rate for Payer: Priority Health PPO	$8.92

AMPHETAMINE CONFIRM UR-LC

Facility

$14.70

Hospital Charge Code	31027373
Hospital Revenue Code	300
Min. Negotiated Rate	$10.29
Max. Negotiated Rate	$12.49
Rate for Payer: Cash Price	$9.56
Rate for Payer: Community Health Alliance Commercial	$12.49
Rate for Payer: Priority Health Commercial	$10.29
Rate for Payer: Priority Health PPO	$10.29

AMPHETAMINES QUANT URINE

Facility

$35.00

Service Code	HCPCS G0480
Hospital Charge Code	3100899
Hospital Revenue Code	301
Min. Negotiated Rate	$24.50
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	$22.75
Rate for Payer: Cash Price	$22.75
Rate for Payer: Community Health Alliance Commercial	$29.75
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	$24.50
Rate for Payer: Priority Health Medicaid	$120.15
Rate for Payer: Priority Health Medicare	$120.15
Rate for Payer: Priority Health PPO	$24.50
Rate for Payer: United Health Care Medicaid	$120.15
Rate for Payer: United Health Care Medicare Advantage	$52.87

AMPHIPHYSIN AB WB

Facility

$103.92

Hospital Charge Code	3101204
Hospital Revenue Code	300
Min. Negotiated Rate	$72.74
Max. Negotiated Rate	$88.33
Rate for Payer: Cash Price	$67.55
Rate for Payer: Community Health Alliance Commercial	$88.33
Rate for Payer: Priority Health Commercial	$72.74
Rate for Payer: Priority Health PPO	$72.74

AMPHIPHYSIN WESTERN BLOT

Facility

$122.00

Hospital Charge Code	3100059
Hospital Revenue Code	300
Min. Negotiated Rate	$85.40
Max. Negotiated Rate	$103.70
Rate for Payer: Cash Price	$79.30
Rate for Payer: Community Health Alliance Commercial	$103.70
Rate for Payer: Priority Health Commercial	$85.40
Rate for Payer: Priority Health PPO	$85.40

AMPLATZ EXTRA STIFF WIRE GUIDE

Facility

$163.00

Service Code	HCPCS C1769
Hospital Charge Code	27014647
Hospital Revenue Code	272
Min. Negotiated Rate	$114.10
Max. Negotiated Rate	$138.55
Rate for Payer: Cash Price	$105.95
Rate for Payer: Community Health Alliance Commercial	$138.55
Rate for Payer: Priority Health Commercial	$114.10
Rate for Payer: Priority Health PPO	$114.10

AMPLATZ RENAL DILATOR SET

Facility

$768.00

Service Code	HCPCS C1769
Hospital Charge Code	27014605
Hospital Revenue Code	272
Min. Negotiated Rate	$537.60
Max. Negotiated Rate	$652.80
Rate for Payer: Cash Price	$499.20
Rate for Payer: Community Health Alliance Commercial	$652.80
Rate for Payer: Priority Health Commercial	$537.60
Rate for Payer: Priority Health PPO	$537.60

AMPLIF NA PROBE NOS AGENT JC V

Facility

$329.00

Hospital Charge Code	3100132
Hospital Revenue Code	300
Min. Negotiated Rate	$230.30
Max. Negotiated Rate	$279.65
Rate for Payer: Cash Price	$213.85
Rate for Payer: Community Health Alliance Commercial	$279.65
Rate for Payer: Priority Health Commercial	$230.30
Rate for Payer: Priority Health PPO	$230.30

AMPLIF NA PROBE NOS AGENT PERC

Facility

$37.50

Hospital Charge Code	3100551
Hospital Revenue Code	300
Min. Negotiated Rate	$26.25
Max. Negotiated Rate	$31.88
Rate for Payer: Cash Price	$24.38
Rate for Payer: Community Health Alliance Commercial	$31.88
Rate for Payer: Priority Health Commercial	$26.25
Rate for Payer: Priority Health PPO	$26.25

AMPLIF NA PROBE NOS AGENT PERC

Facility

$37.50

Hospital Charge Code	3100549
Hospital Revenue Code	300
Min. Negotiated Rate	$26.25
Max. Negotiated Rate	$31.88
Rate for Payer: Cash Price	$24.38
Rate for Payer: Community Health Alliance Commercial	$31.88
Rate for Payer: Priority Health Commercial	$26.25
Rate for Payer: Priority Health PPO	$26.25

AMPLIF NA PROB NOS AGENT VIRUS

Facility

$125.00

Hospital Charge Code	3100256
Hospital Revenue Code	306
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$106.25
Rate for Payer: Cash Price	$81.25
Rate for Payer: Community Health Alliance Commercial	$106.25
Rate for Payer: Priority Health Commercial	$87.50
Rate for Payer: Priority Health PPO	$87.50

AMPUTATION, TOE; INTERPHALANGEAL JOINT

Facility

$3,510.01

Service Code	CPT 28825
Hospital Revenue Code	360
Min. Negotiated Rate	$1,544.41
Max. Negotiated Rate	$3,510.01
Rate for Payer: BCBS BCN 65	$3,510.01
Rate for Payer: Blue Care Network Medicare Advantage	$3,510.01
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,510.01
Rate for Payer: Meridian Health Plan Medicare	$3,510.01
Rate for Payer: Priority Health Medicaid	$3,510.01
Rate for Payer: Priority Health Medicare	$3,510.01
Rate for Payer: United Health Care Medicaid	$3,510.01
Rate for Payer: United Health Care Medicare Advantage	$1,544.41

AMPUTATION, TOE; METATARSOPHALANGEAL JOINT

Facility

$3,510.01

Service Code	CPT 28820
Hospital Revenue Code	360
Min. Negotiated Rate	$1,544.41
Max. Negotiated Rate	$3,510.01
Rate for Payer: BCBS BCN 65	$3,510.01
Rate for Payer: Blue Care Network Medicare Advantage	$3,510.01
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$3,510.01
Rate for Payer: Meridian Health Plan Medicare	$3,510.01
Rate for Payer: Priority Health Medicaid	$3,510.01
Rate for Payer: Priority Health Medicare	$3,510.01
Rate for Payer: United Health Care Medicaid	$3,510.01
Rate for Payer: United Health Care Medicare Advantage	$1,544.41

AMS 800 ACCESSORY KIT

Facility

$935.00

Hospital Charge Code	27263883
Hospital Revenue Code	272
Min. Negotiated Rate	$654.50
Max. Negotiated Rate	$794.75
Rate for Payer: Cash Price	$607.75
Rate for Payer: Community Health Alliance Commercial	$794.75
Rate for Payer: Priority Health Commercial	$654.50
Rate for Payer: Priority Health PPO	$654.50

AMS ST CUFF

Facility

$4,829.00

Hospital Charge Code	27263830
Hospital Revenue Code	272
Min. Negotiated Rate	$3,380.30
Max. Negotiated Rate	$4,104.65
Rate for Payer: Cash Price	$3,138.85
Rate for Payer: Community Health Alliance Commercial	$4,104.65
Rate for Payer: Priority Health Commercial	$3,380.30
Rate for Payer: Priority Health PPO	$3,380.30

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges