Bronson Lakeview Hospital

All Charges

Charge

Type

Price

THERMAGE ARMS - 1 ARM

Professional

$1,200.00

Service Code	HCPCS 00145
Hospital Revenue Code	960
Min. Negotiated Rate	$480.00
Max. Negotiated Rate	$840.00
Rate for Payer: BCBS Complete	$480.00
Rate for Payer: Cash Price	$960.00
Rate for Payer: Priority Health Cigna Priority Health	$840.00

THERMAGE ARMS - BILATERAL

Professional

$2,100.00

Service Code	HCPCS 00146
Hospital Revenue Code	960
Min. Negotiated Rate	$840.00
Max. Negotiated Rate	$1,470.00
Rate for Payer: BCBS Complete	$840.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Priority Health Cigna Priority Health	$1,470.00

THERMAGE EYES

Professional

$950.00

Service Code	HCPCS 00140
Hospital Revenue Code	960
Min. Negotiated Rate	$380.00
Max. Negotiated Rate	$665.00
Rate for Payer: BCBS Complete	$380.00
Rate for Payer: Cash Price	$760.00
Rate for Payer: Priority Health Cigna Priority Health	$665.00

THERMAGE FACE

Professional

$2,000.00

Service Code	HCPCS 00139
Hospital Revenue Code	960
Min. Negotiated Rate	$800.00
Max. Negotiated Rate	$1,400.00
Rate for Payer: BCBS Complete	$800.00
Rate for Payer: Cash Price	$1,600.00
Rate for Payer: Priority Health Cigna Priority Health	$1,400.00

THERMAGE FACE & EYES

Professional

$2,700.00

Service Code	HCPCS 00142
Hospital Revenue Code	960
Min. Negotiated Rate	$1,080.00
Max. Negotiated Rate	$1,890.00
Rate for Payer: BCBS Complete	$1,080.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Priority Health Cigna Priority Health	$1,890.00

THERMAGE FACE & NECK

Professional

$2,800.00

Service Code	HCPCS 00143
Hospital Revenue Code	960
Min. Negotiated Rate	$1,120.00
Max. Negotiated Rate	$1,960.00
Rate for Payer: BCBS Complete	$1,120.00
Rate for Payer: Cash Price	$2,240.00
Rate for Payer: Priority Health Cigna Priority Health	$1,960.00

THERMAGE FACE, NECK, & EYES

Professional

$3,500.00

Service Code	HCPCS 00144
Hospital Revenue Code	960
Min. Negotiated Rate	$1,400.00
Max. Negotiated Rate	$2,450.00
Rate for Payer: BCBS Complete	$1,400.00
Rate for Payer: Cash Price	$2,800.00
Rate for Payer: Priority Health Cigna Priority Health	$2,450.00

THERMAGE KNEES - BILATERAL

Professional

$1,200.00

Service Code	HCPCS 00151
Hospital Revenue Code	960
Min. Negotiated Rate	$480.00
Max. Negotiated Rate	$840.00
Rate for Payer: BCBS Complete	$480.00
Rate for Payer: Cash Price	$960.00
Rate for Payer: Priority Health Cigna Priority Health	$840.00

THERMAGE NECK

Professional

$1,200.00

Service Code	HCPCS 00141
Hospital Revenue Code	960
Min. Negotiated Rate	$480.00
Max. Negotiated Rate	$840.00
Rate for Payer: BCBS Complete	$480.00
Rate for Payer: Cash Price	$960.00
Rate for Payer: Priority Health Cigna Priority Health	$840.00

THERMAGE THIGH - 1 THIGH

Professional

$1,900.00

Service Code	HCPCS 00147
Hospital Revenue Code	960
Min. Negotiated Rate	$760.00
Max. Negotiated Rate	$1,330.00
Rate for Payer: BCBS Complete	$760.00
Rate for Payer: Cash Price	$1,520.00
Rate for Payer: Priority Health Cigna Priority Health	$1,330.00

THERMAGE THIGH - BILATERAL

Professional

$3,100.00

Service Code	HCPCS 00148
Hospital Revenue Code	960
Min. Negotiated Rate	$1,240.00
Max. Negotiated Rate	$2,170.00
Rate for Payer: BCBS Complete	$1,240.00
Rate for Payer: Cash Price	$2,480.00
Rate for Payer: Priority Health Cigna Priority Health	$2,170.00

THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION

Facility IP

$24.04

Service Code	HCPCS J3411
Hospital Charge Code	7876
Hospital Revenue Code	636
Min. Negotiated Rate	$14.66
Max. Negotiated Rate	$21.64
Rate for Payer: Aetna Commercial	$20.43
Rate for Payer: Aetna Commercial	$24.00
Rate for Payer: BCBS Trust/PPO	$21.82
Rate for Payer: BCBS Trust/PPO	$18.58
Rate for Payer: BCN Commercial	$21.82
Rate for Payer: BCN Commercial	$18.58
Rate for Payer: Cash Price	$22.58
Rate for Payer: Cash Price	$19.23
Rate for Payer: Cofinity Commercial	$24.28
Rate for Payer: Cofinity Commercial	$20.67
Rate for Payer: Encore Health Key Benefits Commercial	$22.58
Rate for Payer: Encore Health Key Benefits Commercial	$19.23
Rate for Payer: Healthscope Commercial	$25.41
Rate for Payer: Healthscope Commercial	$21.64
Rate for Payer: Lakeland Regional Health Systems Commercial	$21.17
Rate for Payer: Lakeland Regional Health Systems Commercial	$18.03
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$24.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$20.43
Rate for Payer: PHP Commercial	$20.43
Rate for Payer: PHP Commercial	$24.00
Rate for Payer: Priority Health Cigna Priority Health	$19.76
Rate for Payer: Priority Health Cigna Priority Health	$16.83
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$20.91
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$24.56
Rate for Payer: Priority Health Narrow/Tiered Network	$17.22
Rate for Payer: Priority Health Narrow/Tiered Network	$14.66
Rate for Payer: UHC All Payor (Choice/PPO)	$24.84
Rate for Payer: UHC All Payor (Choice/PPO)	$21.16
Rate for Payer: UHC Core	$20.07
Rate for Payer: UHC Core	$23.57
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$18.03
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$21.17

THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET

Facility IP

$3.88

Service Code	NDC 7733393425
Hospital Charge Code	119871
Hospital Revenue Code	637
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$3.49
Rate for Payer: Aetna Commercial	$3.30
Rate for Payer: BCBS Trust/PPO	$3.00
Rate for Payer: BCN Commercial	$3.00
Rate for Payer: Cash Price	$3.10
Rate for Payer: Cofinity Commercial	$3.34
Rate for Payer: Encore Health Key Benefits Commercial	$3.10
Rate for Payer: Healthscope Commercial	$3.49
Rate for Payer: Lakeland Regional Health Systems Commercial	$2.91
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.30
Rate for Payer: PHP Commercial	$3.30
Rate for Payer: Priority Health Cigna Priority Health	$2.72
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3.38
Rate for Payer: Priority Health Narrow/Tiered Network	$2.37
Rate for Payer: UHC All Payor (Choice/PPO)	$3.41
Rate for Payer: UHC Core	$3.24
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$2.91

THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET

Facility IP

$387.75

Service Code	NDC 7733393410
Hospital Charge Code	119871
Hospital Revenue Code	637
Min. Negotiated Rate	$236.49
Max. Negotiated Rate	$348.98
Rate for Payer: Aetna Commercial	$329.59
Rate for Payer: BCBS Trust/PPO	$299.65
Rate for Payer: BCN Commercial	$299.65
Rate for Payer: Cash Price	$310.20
Rate for Payer: Cofinity Commercial	$333.46
Rate for Payer: Encore Health Key Benefits Commercial	$310.20
Rate for Payer: Healthscope Commercial	$348.98
Rate for Payer: Lakeland Regional Health Systems Commercial	$290.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$329.59
Rate for Payer: PHP Commercial	$329.59
Rate for Payer: Priority Health Cigna Priority Health	$271.42
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$337.34
Rate for Payer: Priority Health Narrow/Tiered Network	$236.49
Rate for Payer: UHC All Payor (Choice/PPO)	$341.22
Rate for Payer: UHC Core	$323.77
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$290.81

THIORIDAZINE 50 MG TABLET

Facility IP

$361.92

Service Code	NDC 0378-0616-01
Hospital Charge Code	7900
Hospital Revenue Code	637
Min. Negotiated Rate	$220.74
Max. Negotiated Rate	$325.73
Rate for Payer: Aetna Commercial	$307.63
Rate for Payer: BCBS Trust/PPO	$279.69
Rate for Payer: BCN Commercial	$279.69
Rate for Payer: Cash Price	$289.54
Rate for Payer: Cofinity Commercial	$311.25
Rate for Payer: Encore Health Key Benefits Commercial	$289.54
Rate for Payer: Healthscope Commercial	$325.73
Rate for Payer: Lakeland Regional Health Systems Commercial	$271.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$307.63
Rate for Payer: PHP Commercial	$307.63
Rate for Payer: Priority Health Cigna Priority Health	$253.34
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$314.87
Rate for Payer: Priority Health Narrow/Tiered Network	$220.74
Rate for Payer: UHC All Payor (Choice/PPO)	$318.49
Rate for Payer: UHC Core	$302.20
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$271.44

THROMBIN (BOVINE) 20,000 UNIT TOPICAL SPRAY

Facility IP

$795.39

Service Code	NDC 60793-217-21
Hospital Charge Code	108841
Hospital Revenue Code	250
Min. Negotiated Rate	$485.11
Max. Negotiated Rate	$715.85
Rate for Payer: Aetna Commercial	$676.08
Rate for Payer: BCBS Trust/PPO	$614.68
Rate for Payer: BCN Commercial	$614.68
Rate for Payer: Cash Price	$636.31
Rate for Payer: Cofinity Commercial	$684.04
Rate for Payer: Encore Health Key Benefits Commercial	$636.31
Rate for Payer: Healthscope Commercial	$715.85
Rate for Payer: Lakeland Regional Health Systems Commercial	$596.54
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$676.08
Rate for Payer: PHP Commercial	$676.08
Rate for Payer: Priority Health Cigna Priority Health	$556.77
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$691.99
Rate for Payer: Priority Health Narrow/Tiered Network	$485.11
Rate for Payer: UHC All Payor (Choice/PPO)	$699.94
Rate for Payer: UHC Core	$664.15
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$596.54

THROMBIN (BOVINE) 5,000 UNIT TOPICAL SPRAY SYRINGE

Facility IP

$187.98

Service Code	NDC 60793-705-05
Hospital Charge Code	87798
Hospital Revenue Code	250
Min. Negotiated Rate	$114.65
Max. Negotiated Rate	$169.18
Rate for Payer: Aetna Commercial	$159.78
Rate for Payer: BCBS Trust/PPO	$145.27
Rate for Payer: BCN Commercial	$145.27
Rate for Payer: Cash Price	$150.38
Rate for Payer: Cofinity Commercial	$161.66
Rate for Payer: Encore Health Key Benefits Commercial	$150.38
Rate for Payer: Healthscope Commercial	$169.18
Rate for Payer: Lakeland Regional Health Systems Commercial	$140.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$159.78
Rate for Payer: PHP Commercial	$159.78
Rate for Payer: Priority Health Cigna Priority Health	$131.59
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$163.54
Rate for Payer: Priority Health Narrow/Tiered Network	$114.65
Rate for Payer: UHC All Payor (Choice/PPO)	$165.42
Rate for Payer: UHC Core	$156.96
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$140.98

THYROID (PORK) 60 MG TABLET

Facility IP

$340.80

Service Code	NDC 42192-330-01
Hospital Charge Code	119105
Hospital Revenue Code	637
Min. Negotiated Rate	$207.85
Max. Negotiated Rate	$306.72
Rate for Payer: Aetna Commercial	$289.68
Rate for Payer: BCBS Trust/PPO	$263.37
Rate for Payer: BCN Commercial	$263.37
Rate for Payer: Cash Price	$272.64
Rate for Payer: Cofinity Commercial	$293.09
Rate for Payer: Encore Health Key Benefits Commercial	$272.64
Rate for Payer: Healthscope Commercial	$306.72
Rate for Payer: Lakeland Regional Health Systems Commercial	$255.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$289.68
Rate for Payer: PHP Commercial	$289.68
Rate for Payer: Priority Health Cigna Priority Health	$238.56
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$296.50
Rate for Payer: Priority Health Narrow/Tiered Network	$207.85
Rate for Payer: UHC All Payor (Choice/PPO)	$299.90
Rate for Payer: UHC Core	$284.57
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$255.60

TICAGRELOR 90 MG TABLET

Facility IP

$1,544.90

Service Code	NDC 0186-0777-60
Hospital Charge Code	153169
Hospital Revenue Code	637
Min. Negotiated Rate	$942.23
Max. Negotiated Rate	$1,390.41
Rate for Payer: Aetna Commercial	$1,313.16
Rate for Payer: BCBS Trust/PPO	$1,193.90
Rate for Payer: BCN Commercial	$1,193.90
Rate for Payer: Cash Price	$1,235.92
Rate for Payer: Cofinity Commercial	$1,328.61
Rate for Payer: Encore Health Key Benefits Commercial	$1,235.92
Rate for Payer: Healthscope Commercial	$1,390.41
Rate for Payer: Lakeland Regional Health Systems Commercial	$1,158.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,313.16
Rate for Payer: PHP Commercial	$1,313.16
Rate for Payer: Priority Health Cigna Priority Health	$1,081.43
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,344.06
Rate for Payer: Priority Health Narrow/Tiered Network	$942.23
Rate for Payer: UHC All Payor (Choice/PPO)	$1,359.51
Rate for Payer: UHC Core	$1,289.99
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1,158.68

TIMOLOL MALEATE 0.5 % EYE DROPS

Facility IP

$19.71

Service Code	NDC 61314-227-05
Hospital Charge Code	11562
Hospital Revenue Code	637
Min. Negotiated Rate	$12.02
Max. Negotiated Rate	$17.74
Rate for Payer: Aetna Commercial	$16.75
Rate for Payer: BCBS Trust/PPO	$15.23
Rate for Payer: BCN Commercial	$15.23
Rate for Payer: Cash Price	$15.77
Rate for Payer: Cofinity Commercial	$16.95
Rate for Payer: Encore Health Key Benefits Commercial	$15.77
Rate for Payer: Healthscope Commercial	$17.74
Rate for Payer: Lakeland Regional Health Systems Commercial	$14.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.75
Rate for Payer: PHP Commercial	$16.75
Rate for Payer: Priority Health Cigna Priority Health	$13.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17.15
Rate for Payer: Priority Health Narrow/Tiered Network	$12.02
Rate for Payer: UHC All Payor (Choice/PPO)	$17.34
Rate for Payer: UHC Core	$16.46
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$14.78

TIMOLOL MALEATE 0.5 % EYE DROPS

Facility IP

$26.60

Service Code	NDC 61314-227-10
Hospital Charge Code	11562
Hospital Revenue Code	637
Min. Negotiated Rate	$16.22
Max. Negotiated Rate	$23.94
Rate for Payer: Aetna Commercial	$22.61
Rate for Payer: BCBS Trust/PPO	$20.56
Rate for Payer: BCN Commercial	$20.56
Rate for Payer: Cash Price	$21.28
Rate for Payer: Cofinity Commercial	$22.88
Rate for Payer: Encore Health Key Benefits Commercial	$21.28
Rate for Payer: Healthscope Commercial	$23.94
Rate for Payer: Lakeland Regional Health Systems Commercial	$19.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.61
Rate for Payer: PHP Commercial	$22.61
Rate for Payer: Priority Health Cigna Priority Health	$18.62
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$23.14
Rate for Payer: Priority Health Narrow/Tiered Network	$16.22
Rate for Payer: UHC All Payor (Choice/PPO)	$23.41
Rate for Payer: UHC Core	$22.21
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$19.95

TIMOLOL MALEATE 0.5 % EYE DROPS

Facility IP

$22.91

Service Code	NDC 60758-801-05
Hospital Charge Code	11562
Hospital Revenue Code	637
Min. Negotiated Rate	$13.97
Max. Negotiated Rate	$20.62
Rate for Payer: Aetna Commercial	$19.47
Rate for Payer: BCBS Trust/PPO	$17.70
Rate for Payer: BCN Commercial	$17.70
Rate for Payer: Cash Price	$18.33
Rate for Payer: Cofinity Commercial	$19.70
Rate for Payer: Encore Health Key Benefits Commercial	$18.33
Rate for Payer: Healthscope Commercial	$20.62
Rate for Payer: Lakeland Regional Health Systems Commercial	$17.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$19.47
Rate for Payer: PHP Commercial	$19.47
Rate for Payer: Priority Health Cigna Priority Health	$16.04
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$19.93
Rate for Payer: Priority Health Narrow/Tiered Network	$13.97
Rate for Payer: UHC All Payor (Choice/PPO)	$20.16
Rate for Payer: UHC Core	$19.13
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$17.18

TIMOLOL MALEATE 0.5 % EYE DROPS

Facility IP

$35.81

Service Code	NDC 68682-813-05
Hospital Charge Code	11562
Hospital Revenue Code	637
Min. Negotiated Rate	$21.84
Max. Negotiated Rate	$32.23
Rate for Payer: Aetna Commercial	$30.44
Rate for Payer: BCBS Trust/PPO	$27.67
Rate for Payer: BCN Commercial	$27.67
Rate for Payer: Cash Price	$28.65
Rate for Payer: Cofinity Commercial	$30.80
Rate for Payer: Encore Health Key Benefits Commercial	$28.65
Rate for Payer: Healthscope Commercial	$32.23
Rate for Payer: Lakeland Regional Health Systems Commercial	$26.86
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$30.44
Rate for Payer: PHP Commercial	$30.44
Rate for Payer: Priority Health Cigna Priority Health	$25.07
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$31.15
Rate for Payer: Priority Health Narrow/Tiered Network	$21.84
Rate for Payer: UHC All Payor (Choice/PPO)	$31.51
Rate for Payer: UHC Core	$29.90
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$26.86

TIMOLOL MALEATE 0.5 % EYE DROPS

Facility IP

$28.25

Service Code	NDC 17478-288-10
Hospital Charge Code	11562
Hospital Revenue Code	637
Min. Negotiated Rate	$17.23
Max. Negotiated Rate	$25.42
Rate for Payer: Aetna Commercial	$24.01
Rate for Payer: BCBS Trust/PPO	$21.83
Rate for Payer: BCN Commercial	$21.83
Rate for Payer: Cash Price	$22.60
Rate for Payer: Cofinity Commercial	$24.30
Rate for Payer: Encore Health Key Benefits Commercial	$22.60
Rate for Payer: Healthscope Commercial	$25.42
Rate for Payer: Lakeland Regional Health Systems Commercial	$21.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$24.01
Rate for Payer: PHP Commercial	$24.01
Rate for Payer: Priority Health Cigna Priority Health	$19.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$24.58
Rate for Payer: Priority Health Narrow/Tiered Network	$17.23
Rate for Payer: UHC All Payor (Choice/PPO)	$24.86
Rate for Payer: UHC Core	$23.59
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$21.19

TIZANIDINE 2 MG TABLET

Facility IP

$144.24

Service Code	NDC 50268-759-15
Hospital Charge Code	14792
Hospital Revenue Code	637
Min. Negotiated Rate	$87.97
Max. Negotiated Rate	$129.82
Rate for Payer: Aetna Commercial	$122.60
Rate for Payer: BCBS Trust/PPO	$111.47
Rate for Payer: BCN Commercial	$111.47
Rate for Payer: Cash Price	$115.39
Rate for Payer: Cofinity Commercial	$124.05
Rate for Payer: Encore Health Key Benefits Commercial	$115.39
Rate for Payer: Healthscope Commercial	$129.82
Rate for Payer: Lakeland Regional Health Systems Commercial	$108.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$122.60
Rate for Payer: PHP Commercial	$122.60
Rate for Payer: Priority Health Cigna Priority Health	$100.97
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$125.49
Rate for Payer: Priority Health Narrow/Tiered Network	$87.97
Rate for Payer: UHC All Payor (Choice/PPO)	$126.93
Rate for Payer: UHC Core	$120.44
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$108.18

Price Transparency.

All Charges