Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

GASTROSTOMY TUBE, 18FR

Facility

$95.00

Hospital Charge Code	27022806
Hospital Revenue Code	272
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$80.75
Rate for Payer: Cash Price	$61.75
Rate for Payer: Community Health Alliance Commercial	$80.75
Rate for Payer: Priority Health Commercial	$66.50
Rate for Payer: Priority Health PPO	$66.50

GASTRO TUBE REPLACEMENT

Facility

$730.00

Hospital Charge Code	27263601
Hospital Revenue Code	272
Min. Negotiated Rate	$511.00
Max. Negotiated Rate	$620.50
Rate for Payer: Cash Price	$474.50
Rate for Payer: Community Health Alliance Commercial	$620.50
Rate for Payer: Priority Health Commercial	$511.00
Rate for Payer: Priority Health PPO	$511.00

GAUZE 4X4X4

Facility

$14.00

Hospital Charge Code	27275321
Hospital Revenue Code	272
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

GAUZE FLUFFS, STERILE, 5/PKG

Facility

$16.00

Hospital Charge Code	27010876
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

GAUZE SPONGE

Facility

$14.00

Hospital Charge Code	27012203
Hospital Revenue Code	270
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

GAUZE SPONGE - 4X4X16 10'S

Facility

$14.00

Hospital Charge Code	27010090
Hospital Revenue Code	270
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

GC GENPROBE SWAB RML

Facility

$56.00

Service Code	HCPCS 87591
Hospital Charge Code	3004510
Hospital Revenue Code	306
Min. Negotiated Rate	$16.21
Max. Negotiated Rate	$47.60
Rate for Payer: BCBS BCN 65	$36.84
Rate for Payer: Blue Care Network Medicare Advantage	$36.84
Rate for Payer: Cash Price	$36.40
Rate for Payer: Cash Price	$36.40
Rate for Payer: Community Health Alliance Commercial	$47.60
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$36.84
Rate for Payer: Meridian Health Plan Medicare	$36.84
Rate for Payer: Priority Health Commercial	$39.20
Rate for Payer: Priority Health Medicaid	$36.84
Rate for Payer: Priority Health Medicare	$36.84
Rate for Payer: Priority Health PPO	$39.20
Rate for Payer: United Health Care Medicaid	$36.84
Rate for Payer: United Health Care Medicare Advantage	$16.21

GC-LC

Facility

$6.92

Hospital Charge Code	3102431
Hospital Revenue Code	300
Min. Negotiated Rate	$4.84
Max. Negotiated Rate	$5.88
Rate for Payer: Cash Price	$4.50
Rate for Payer: Community Health Alliance Commercial	$5.88
Rate for Payer: Priority Health Commercial	$4.84
Rate for Payer: Priority Health PPO	$4.84

GCMS AMPHETAMINES

Facility

$65.00

Service Code	HCPCS 80307
Hospital Charge Code	3001532
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	$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	$65.25
Rate for Payer: Meridian Health Plan Medicare	$65.25
Rate for Payer: Priority Health Commercial	$45.50
Rate for Payer: Priority Health Medicaid	$65.25
Rate for Payer: Priority Health Medicare	$65.25
Rate for Payer: Priority Health PPO	$45.50
Rate for Payer: United Health Care Medicaid	$65.25
Rate for Payer: United Health Care Medicare Advantage	$28.71

GCMS AMPHETAMINES BLOOD

Facility

$95.00

Service Code	HCPCS G0480
Hospital Charge Code	3100908
Hospital Revenue Code	301
Min. Negotiated Rate	$52.87
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	$61.75
Rate for Payer: Cash Price	$61.75
Rate for Payer: Community Health Alliance Commercial	$80.75
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	$66.50
Rate for Payer: Priority Health Medicaid	$120.15
Rate for Payer: Priority Health Medicare	$120.15
Rate for Payer: Priority Health PPO	$66.50
Rate for Payer: United Health Care Medicaid	$120.15
Rate for Payer: United Health Care Medicare Advantage	$52.87

GCMS BARBITURATE

Facility

$65.00

Service Code	HCPCS G0480
Hospital Charge Code	3001531
Hospital Revenue Code	301
Min. Negotiated Rate	$45.50
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	$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	$120.15
Rate for Payer: Meridian Health Plan Medicare	$120.15
Rate for Payer: Priority Health Commercial	$45.50
Rate for Payer: Priority Health Medicaid	$120.15
Rate for Payer: Priority Health Medicare	$120.15
Rate for Payer: Priority Health PPO	$45.50
Rate for Payer: United Health Care Medicaid	$120.15
Rate for Payer: United Health Care Medicare Advantage	$52.87

GCMS CONFIRM MECONIUM

Facility

$193.00

Hospital Charge Code	3004478
Hospital Revenue Code	301
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

GCMS MEC COCAINE

Facility

$14.70

Service Code	HCPCS 83993
Hospital Charge Code	3004477
Hospital Revenue Code	301
Min. Negotiated Rate	$9.07
Max. Negotiated Rate	$20.61
Rate for Payer: BCBS BCN 65	$20.61
Rate for Payer: Blue Care Network Medicare Advantage	$20.61
Rate for Payer: Cash Price	$9.56
Rate for Payer: Cash Price	$9.56
Rate for Payer: Community Health Alliance Commercial	$12.49
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$20.61
Rate for Payer: Meridian Health Plan Medicare	$20.61
Rate for Payer: Priority Health Commercial	$10.29
Rate for Payer: Priority Health Medicaid	$20.61
Rate for Payer: Priority Health Medicare	$20.61
Rate for Payer: Priority Health PPO	$10.29
Rate for Payer: United Health Care Medicaid	$20.61
Rate for Payer: United Health Care Medicare Advantage	$9.07

GCMS MEC THC

Facility

$150.00

Service Code	HCPCS G0480
Hospital Charge Code	3005855
Hospital Revenue Code	301
Min. Negotiated Rate	$52.87
Max. Negotiated Rate	$127.50
Rate for Payer: BCBS BCN 65	$120.15
Rate for Payer: Blue Care Network Medicare Advantage	$120.15
Rate for Payer: Cash Price	$97.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Community Health Alliance Commercial	$127.50
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	$105.00
Rate for Payer: Priority Health Medicaid	$120.15
Rate for Payer: Priority Health Medicare	$120.15
Rate for Payer: Priority Health PPO	$105.00
Rate for Payer: United Health Care Medicaid	$120.15
Rate for Payer: United Health Care Medicare Advantage	$52.87

GCMS OPIATES

Facility

$167.00

Hospital Charge Code	3005856
Hospital Revenue Code	301
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$141.95
Rate for Payer: Cash Price	$108.55
Rate for Payer: Community Health Alliance Commercial	$141.95
Rate for Payer: Priority Health Commercial	$116.90
Rate for Payer: Priority Health PPO	$116.90

GC NAA SWAB

Facility

$9.00

Hospital Charge Code	3101596
Hospital Revenue Code	306
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.85
Rate for Payer: Community Health Alliance Commercial	$7.65
Rate for Payer: Priority Health Commercial	$6.30
Rate for Payer: Priority Health PPO	$6.30

GC NAA THINPREP

Facility

$12.00

Hospital Charge Code	3101597
Hospital Revenue Code	306
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$10.20
Rate for Payer: Cash Price	$7.80
Rate for Payer: Community Health Alliance Commercial	$10.20
Rate for Payer: Priority Health Commercial	$8.40
Rate for Payer: Priority Health PPO	$8.40

GC NAA URINE

Facility

$12.00

Hospital Charge Code	3101598
Hospital Revenue Code	306
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$10.20
Rate for Payer: Cash Price	$7.80
Rate for Payer: Community Health Alliance Commercial	$10.20
Rate for Payer: Priority Health Commercial	$8.40
Rate for Payer: Priority Health PPO	$8.40

GC-P

Facility

$9.00

Hospital Charge Code	3102162
Hospital Revenue Code	300
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$7.65
Rate for Payer: Cash Price	$5.85
Rate for Payer: Community Health Alliance Commercial	$7.65
Rate for Payer: Priority Health Commercial	$6.30
Rate for Payer: Priority Health PPO	$6.30

GD-1

Facility

$105.00

Hospital Charge Code	3102518
Hospital Revenue Code	300
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

GD-2

Facility

$105.00

Hospital Charge Code	3102519
Hospital Revenue Code	300
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

GEL DIFFUSION EACH ANTIGEN

Facility

$33.00

Hospital Charge Code	3008006
Hospital Revenue Code	302
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

GEL DIFFUSION EACH ANTIGEN

Facility

$33.00

Hospital Charge Code	3008005
Hospital Revenue Code	302
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

GEL DIFFUSION EACH ANTIGEN

Facility

$33.00

Hospital Charge Code	3008008
Hospital Revenue Code	302
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

GEL DIFFUSION EACH ANTIGEN

Facility

$33.00

Hospital Charge Code	3008009
Hospital Revenue Code	302
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

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges