Sturgis Hospital Inc.

All Charges

Charge

Type

Setting

Price

GEL DIFFUSION EACH ANTIGEN

Facility

$33.00

Hospital Charge Code	3008007
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-RED CELL PREP FWRBC

Facility

$11.00

Hospital Charge Code	3101418
Hospital Revenue Code	300
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$9.35
Rate for Payer: Cash Price	$7.15
Rate for Payer: Community Health Alliance Commercial	$9.35
Rate for Payer: Priority Health Commercial	$7.70
Rate for Payer: Priority Health PPO	$7.70

GEN II RETRACTOR RIN

Facility

$126.00

Hospital Charge Code	27267433
Hospital Revenue Code	272
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$107.10
Rate for Payer: Cash Price	$81.90
Rate for Payer: Community Health Alliance Commercial	$107.10
Rate for Payer: Priority Health Commercial	$88.20
Rate for Payer: Priority Health PPO	$88.20

GENPROBE GC

Facility

$56.00

Service Code	HCPCS 87591
Hospital Charge Code	3004515
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

GENTAMYCIN, PEAK

Facility

$10.52

Service Code	HCPCS 80170
Hospital Charge Code	3004520
Hospital Revenue Code	301
Min. Negotiated Rate	$7.36
Max. Negotiated Rate	$17.20
Rate for Payer: BCBS BCN 65	$17.20
Rate for Payer: Blue Care Network Medicare Advantage	$17.20
Rate for Payer: Cash Price	$6.84
Rate for Payer: Cash Price	$6.84
Rate for Payer: Community Health Alliance Commercial	$8.94
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$17.20
Rate for Payer: Meridian Health Plan Medicare	$17.20
Rate for Payer: Priority Health Commercial	$7.36
Rate for Payer: Priority Health Medicaid	$17.20
Rate for Payer: Priority Health Medicare	$17.20
Rate for Payer: Priority Health PPO	$7.36
Rate for Payer: United Health Care Medicaid	$17.20
Rate for Payer: United Health Care Medicare Advantage	$7.57

GENTAMYCIN PEAK SBMF

Facility

$27.30

Hospital Charge Code	3101154
Hospital Revenue Code	301
Min. Negotiated Rate	$19.11
Max. Negotiated Rate	$23.20
Rate for Payer: Cash Price	$17.75
Rate for Payer: Community Health Alliance Commercial	$23.20
Rate for Payer: Priority Health Commercial	$19.11
Rate for Payer: Priority Health PPO	$19.11

GENTAMYCIN TROUGH

Facility

$10.52

Service Code	HCPCS 80170
Hospital Charge Code	3004540
Hospital Revenue Code	301
Min. Negotiated Rate	$7.36
Max. Negotiated Rate	$17.20
Rate for Payer: BCBS BCN 65	$17.20
Rate for Payer: Blue Care Network Medicare Advantage	$17.20
Rate for Payer: Cash Price	$6.84
Rate for Payer: Cash Price	$6.84
Rate for Payer: Community Health Alliance Commercial	$8.94
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$17.20
Rate for Payer: Meridian Health Plan Medicare	$17.20
Rate for Payer: Priority Health Commercial	$7.36
Rate for Payer: Priority Health Medicaid	$17.20
Rate for Payer: Priority Health Medicare	$17.20
Rate for Payer: Priority Health PPO	$7.36
Rate for Payer: United Health Care Medicaid	$17.20
Rate for Payer: United Health Care Medicare Advantage	$7.57

GENTAMYCIN TROUGH-SBMF

Facility

$27.30

Hospital Charge Code	3101156
Hospital Revenue Code	301
Min. Negotiated Rate	$19.11
Max. Negotiated Rate	$23.20
Rate for Payer: Cash Price	$17.75
Rate for Payer: Community Health Alliance Commercial	$23.20
Rate for Payer: Priority Health Commercial	$19.11
Rate for Payer: Priority Health PPO	$19.11

GGPD 1

Facility

$42.00

Service Code	HCPCS 82955
Hospital Charge Code	3004880
Hospital Revenue Code	301
Min. Negotiated Rate	$4.48
Max. Negotiated Rate	$35.70
Rate for Payer: BCBS BCN 65	$10.19
Rate for Payer: Blue Care Network Medicare Advantage	$10.19
Rate for Payer: Cash Price	$27.30
Rate for Payer: Cash Price	$27.30
Rate for Payer: Community Health Alliance Commercial	$35.70
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$10.19
Rate for Payer: Meridian Health Plan Medicare	$10.19
Rate for Payer: Priority Health Commercial	$29.40
Rate for Payer: Priority Health Medicaid	$10.19
Rate for Payer: Priority Health Medicare	$10.19
Rate for Payer: Priority Health PPO	$29.40
Rate for Payer: United Health Care Medicaid	$10.19
Rate for Payer: United Health Care Medicare Advantage	$4.48

GGPD-2

Facility

$3.00

Hospital Charge Code	3102075
Hospital Revenue Code	300
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$2.55
Rate for Payer: Cash Price	$1.95
Rate for Payer: Community Health Alliance Commercial	$2.55
Rate for Payer: Priority Health Commercial	$2.10
Rate for Payer: Priority Health PPO	$2.10

GGTP

Facility

$2.00

Service Code	HCPCS 82977
Hospital Charge Code	3004480
Hospital Revenue Code	301
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$7.56
Rate for Payer: BCBS BCN 65	$7.56
Rate for Payer: Blue Care Network Medicare Advantage	$7.56
Rate for Payer: Cash Price	$1.30
Rate for Payer: Cash Price	$1.30
Rate for Payer: Community Health Alliance Commercial	$1.70
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$7.56
Rate for Payer: Meridian Health Plan Medicare	$7.56
Rate for Payer: Priority Health Commercial	$1.40
Rate for Payer: Priority Health Medicaid	$7.56
Rate for Payer: Priority Health Medicare	$7.56
Rate for Payer: Priority Health PPO	$1.40
Rate for Payer: United Health Care Medicaid	$7.56
Rate for Payer: United Health Care Medicare Advantage	$3.33

GHB GAMMA HYDROXY BUTYRIC ACID

Facility

$65.63

Service Code	HCPCS 80307
Hospital Charge Code	3004485
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	$42.66
Rate for Payer: Cash Price	$42.66
Rate for Payer: Community Health Alliance Commercial	$55.79
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	$45.94
Rate for Payer: Priority Health Medicaid	$65.25
Rate for Payer: Priority Health Medicare	$65.25
Rate for Payer: Priority Health PPO	$45.94
Rate for Payer: United Health Care Medicaid	$65.25
Rate for Payer: United Health Care Medicare Advantage	$28.71

GHRELI TOTAL

Facility

$305.00

Hospital Charge Code	3102001
Hospital Revenue Code	300
Min. Negotiated Rate	$213.50
Max. Negotiated Rate	$259.25
Rate for Payer: Cash Price	$198.25
Rate for Payer: Community Health Alliance Commercial	$259.25
Rate for Payer: Priority Health Commercial	$213.50
Rate for Payer: Priority Health PPO	$213.50

GIARDA LAMBLIA

Facility

$87.00

Hospital Charge Code	3006228
Hospital Revenue Code	302
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$73.95
Rate for Payer: Cash Price	$56.55
Rate for Payer: Community Health Alliance Commercial	$73.95
Rate for Payer: Priority Health Commercial	$60.90
Rate for Payer: Priority Health PPO	$60.90

GIARDIA AG LC

Facility

$8.15

Hospital Charge Code	3102437
Hospital Revenue Code	300
Min. Negotiated Rate	$5.71
Max. Negotiated Rate	$6.93
Rate for Payer: Cash Price	$5.30
Rate for Payer: Community Health Alliance Commercial	$6.93
Rate for Payer: Priority Health Commercial	$5.71
Rate for Payer: Priority Health PPO	$5.71

GIARDIA ANTIGEN

Facility

$71.00

Service Code	HCPCS 87329
Hospital Charge Code	3003621
Hospital Revenue Code	306
Min. Negotiated Rate	$5.53
Max. Negotiated Rate	$60.35
Rate for Payer: BCBS BCN 65	$12.58
Rate for Payer: Blue Care Network Medicare Advantage	$12.58
Rate for Payer: Cash Price	$46.15
Rate for Payer: Cash Price	$46.15
Rate for Payer: Community Health Alliance Commercial	$60.35
Rate for Payer: Meridian Health Plan Medicaid/Meridian MI Child	$12.58
Rate for Payer: Meridian Health Plan Medicare	$12.58
Rate for Payer: Priority Health Commercial	$49.70
Rate for Payer: Priority Health Medicaid	$12.58
Rate for Payer: Priority Health Medicare	$12.58
Rate for Payer: Priority Health PPO	$49.70
Rate for Payer: United Health Care Medicaid	$12.58
Rate for Payer: United Health Care Medicare Advantage	$5.53

GLIADIN PEPTIDE AB,IGA

Facility

$3.67

Hospital Charge Code	3101485
Hospital Revenue Code	300
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$3.12
Rate for Payer: Cash Price	$2.39
Rate for Payer: Community Health Alliance Commercial	$3.12
Rate for Payer: Priority Health Commercial	$2.57
Rate for Payer: Priority Health PPO	$2.57

GLIDESCOPE BLADE SIZE 3

Facility

$38.42

Hospital Charge Code	27275815
Hospital Revenue Code	272
Min. Negotiated Rate	$26.89
Max. Negotiated Rate	$32.66
Rate for Payer: Cash Price	$24.97
Rate for Payer: Community Health Alliance Commercial	$32.66
Rate for Payer: Priority Health Commercial	$26.89
Rate for Payer: Priority Health PPO	$26.89

GLIDEWIRE

Facility

$258.00

Service Code	HCPCS C1769
Hospital Charge Code	27061485
Hospital Revenue Code	272
Min. Negotiated Rate	$180.60
Max. Negotiated Rate	$219.30
Rate for Payer: Cash Price	$167.70
Rate for Payer: Community Health Alliance Commercial	$219.30
Rate for Payer: Priority Health Commercial	$180.60
Rate for Payer: Priority Health PPO	$180.60

GLIDEWIRE, ANGLED

Facility

$152.00

Service Code	HCPCS C1769
Hospital Charge Code	27267037
Hospital Revenue Code	272
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$129.20
Rate for Payer: Cash Price	$98.80
Rate for Payer: Community Health Alliance Commercial	$129.20
Rate for Payer: Priority Health Commercial	$106.40
Rate for Payer: Priority Health PPO	$106.40

GLIDEWIRE, ANGLED

Facility

$168.00

Service Code	HCPCS C1769
Hospital Charge Code	27015123
Hospital Revenue Code	272
Min. Negotiated Rate	$117.60
Max. Negotiated Rate	$142.80
Rate for Payer: Cash Price	$109.20
Rate for Payer: Community Health Alliance Commercial	$142.80
Rate for Payer: Priority Health Commercial	$117.60
Rate for Payer: Priority Health PPO	$117.60

GLIDEWIRE, ANGLED

Facility

$268.00

Service Code	HCPCS C1769
Hospital Charge Code	27015024
Hospital Revenue Code	272
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$227.80
Rate for Payer: Cash Price	$174.20
Rate for Payer: Community Health Alliance Commercial	$227.80
Rate for Payer: Priority Health Commercial	$187.60
Rate for Payer: Priority Health PPO	$187.60

GLIDEWIRE, ANGLED 3 CM

Facility

$139.00

Service Code	HCPCS C1769
Hospital Charge Code	27055855
Hospital Revenue Code	272
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$118.15
Rate for Payer: Cash Price	$90.35
Rate for Payer: Community Health Alliance Commercial	$118.15
Rate for Payer: Priority Health Commercial	$97.30
Rate for Payer: Priority Health PPO	$97.30

GLIDEWIRE, JAGWIRE

Facility

$518.00

Service Code	HCPCS C1769
Hospital Charge Code	27265049
Hospital Revenue Code	272
Min. Negotiated Rate	$362.60
Max. Negotiated Rate	$440.30
Rate for Payer: Cash Price	$336.70
Rate for Payer: Community Health Alliance Commercial	$440.30
Rate for Payer: Priority Health Commercial	$362.60
Rate for Payer: Priority Health PPO	$362.60

GLIDEWIRE, M STRAIGHT TIP

Facility

$136.00

Service Code	HCPCS C1769
Hospital Charge Code	27061436
Hospital Revenue Code	272
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$115.60
Rate for Payer: Cash Price	$88.40
Rate for Payer: Community Health Alliance Commercial	$115.60
Rate for Payer: Priority Health Commercial	$95.20
Rate for Payer: Priority Health PPO	$95.20

Sturgis Hospital Inc.

Know your out-of-pocket cost for care.

All Charges