Ness County Hospital

All Charges

Charge

Type

Setting

Price

FUNGITELL (1-3)-B-D-GLUCAN ASY

Facility

$150.00

Service Code	HCPCS 87449
Hospital Charge Code	8744901
Hospital Revenue Code	306
Min. Negotiated Rate	$54.84
Max. Negotiated Rate	$145.50
Rate for Payer: BCBS Commercial	$54.84
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cash Price	$112.50
Rate for Payer: Celtic Commercial/Exchange	$69.30
Rate for Payer: Health Partners Plans Commercial	$142.50
Rate for Payer: UnitedHealthcare Commercial	$145.50
Rate for Payer: WPPA Commercial	$126.00

FUNGITELL (1-3)-B-D-GLUCAN ASY

Facility

$150.00

Service Code	HCPCS 87449
Hospital Charge Code	8744901
Hospital Revenue Code	306
Min. Negotiated Rate	$123.00
Max. Negotiated Rate	$145.50
Rate for Payer: Cash Price	$112.50
Rate for Payer: Health Partners Plans Commercial	$142.50
Rate for Payer: UnitedHealthcare Commercial	$145.50
Rate for Payer: WPPA Commercial	$123.00

FX &/OR DISLOC PROC FOREARM/WR

Facility

$1,723.00

Service Code	HCPCS 25605
Hospital Charge Code	2560500
Hospital Revenue Code	450
Min. Negotiated Rate	$796.03
Max. Negotiated Rate	$2,000.51
Rate for Payer: BCBS Commercial	$2,000.51
Rate for Payer: Cash Price	$1,292.25
Rate for Payer: Cash Price	$1,292.25
Rate for Payer: Celtic Commercial/Exchange	$796.03
Rate for Payer: Health Partners Plans Commercial	$1,636.85
Rate for Payer: UnitedHealthcare Commercial	$1,671.31
Rate for Payer: WPPA Commercial	$1,447.32

FX &/OR DISLOC PROC FOREARM/WR

Facility

$1,723.00

Service Code	HCPCS 25605
Hospital Charge Code	2560500
Hospital Revenue Code	450
Min. Negotiated Rate	$1,412.86
Max. Negotiated Rate	$1,671.31
Rate for Payer: Cash Price	$1,292.25
Rate for Payer: Health Partners Plans Commercial	$1,636.85
Rate for Payer: UnitedHealthcare Commercial	$1,671.31
Rate for Payer: WPPA Commercial	$1,412.86

GABAPENTIN (NEURONTIN SERUM)

Facility

$108.00

Service Code	HCPCS 80299
Hospital Charge Code	8029909
Hospital Revenue Code	301
Min. Negotiated Rate	$88.56
Max. Negotiated Rate	$104.76
Rate for Payer: Cash Price	$81.00
Rate for Payer: Health Partners Plans Commercial	$102.60
Rate for Payer: UnitedHealthcare Commercial	$104.76
Rate for Payer: WPPA Commercial	$88.56

GABAPENTIN (NEURONTIN SERUM)

Facility

$108.00

Service Code	HCPCS 80299
Hospital Charge Code	8029909
Hospital Revenue Code	301
Min. Negotiated Rate	$49.90
Max. Negotiated Rate	$104.76
Rate for Payer: UnitedHealthcare Commercial	$104.76
Rate for Payer: BCBS Commercial	$65.71
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Celtic Commercial/Exchange	$49.90
Rate for Payer: Health Partners Plans Commercial	$102.60
Rate for Payer: WPPA Commercial	$90.72

GABAPENTIN NON-BLOOD SCREEN

Facility

$271.00

Service Code	HCPCS 80355
Hospital Charge Code	8035500
Hospital Revenue Code	300
Min. Negotiated Rate	$23.88
Max. Negotiated Rate	$262.87
Rate for Payer: BCBS Commercial	$23.88
Rate for Payer: Cash Price	$203.25
Rate for Payer: Cash Price	$203.25
Rate for Payer: Celtic Commercial/Exchange	$125.20
Rate for Payer: Health Partners Plans Commercial	$257.45
Rate for Payer: UnitedHealthcare Commercial	$262.87
Rate for Payer: WPPA Commercial	$227.64

GABAPENTIN NON-BLOOD SCREEN

Facility

$271.00

Service Code	HCPCS 80355
Hospital Charge Code	8035500
Hospital Revenue Code	300
Min. Negotiated Rate	$222.22
Max. Negotiated Rate	$262.87
Rate for Payer: Cash Price	$203.25
Rate for Payer: Health Partners Plans Commercial	$257.45
Rate for Payer: UnitedHealthcare Commercial	$262.87
Rate for Payer: WPPA Commercial	$222.22

GAIT BELT

Facility

$50.00

Hospital Charge Code	2700410
Hospital Revenue Code	272
Min. Negotiated Rate	$41.00
Max. Negotiated Rate	$48.50
Rate for Payer: Cash Price	$37.50
Rate for Payer: Health Partners Plans Commercial	$47.50
Rate for Payer: UnitedHealthcare Commercial	$48.50
Rate for Payer: WPPA Commercial	$41.00

GAIT BELT

Facility

$50.00

Hospital Charge Code	2700410
Hospital Revenue Code	272
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$48.50
Rate for Payer: Cash Price	$37.50
Rate for Payer: Celtic Commercial/Exchange	$23.10
Rate for Payer: Health Partners Plans Commercial	$47.50
Rate for Payer: UnitedHealthcare Commercial	$48.50
Rate for Payer: WPPA Commercial	$42.00

GAIT TRAINING, PER 15 MIN

Facility

$102.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	4200820
Hospital Revenue Code	420
Min. Negotiated Rate	$46.46
Max. Negotiated Rate	$98.94
Rate for Payer: BCBS Commercial	$46.46
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cash Price	$76.50
Rate for Payer: Celtic Commercial/Exchange	$47.12
Rate for Payer: Health Partners Plans Commercial	$96.90
Rate for Payer: UnitedHealthcare Commercial	$98.94
Rate for Payer: WPPA Commercial	$85.68

GAIT TRAINING, PER 15 MIN

Facility

$102.00

Service Code	HCPCS 97116 GP
Hospital Charge Code	4200820
Hospital Revenue Code	420
Min. Negotiated Rate	$83.64
Max. Negotiated Rate	$98.94
Rate for Payer: Cash Price	$76.50
Rate for Payer: Health Partners Plans Commercial	$96.90
Rate for Payer: UnitedHealthcare Commercial	$98.94
Rate for Payer: WPPA Commercial	$83.64

Gamastan 2 ml SDV (immune glob G (IgG)-glycine) IM solution

Facility

$352.00

Service Code	NDC 13533033504
Hospital Charge Code	2519569
Hospital Revenue Code	250
Min. Negotiated Rate	$162.62
Max. Negotiated Rate	$341.44
Rate for Payer: Cash Price	$264.21
Rate for Payer: Celtic Commercial/Exchange	$162.62
Rate for Payer: Health Partners Plans Commercial	$334.40
Rate for Payer: UnitedHealthcare Commercial	$341.44
Rate for Payer: WPPA Commercial	$295.68

Gamastan 2 ml SDV (immune glob G (IgG)-glycine) IM solution

Facility

$352.00

Service Code	NDC 13533033504
Hospital Charge Code	2519569
Hospital Revenue Code	250
Min. Negotiated Rate	$288.64
Max. Negotiated Rate	$341.44
Rate for Payer: Cash Price	$264.21
Rate for Payer: Health Partners Plans Commercial	$334.40
Rate for Payer: UnitedHealthcare Commercial	$341.44
Rate for Payer: WPPA Commercial	$288.64

Gammagard Liquid 1 gm - 10 ml

Facility

$610.00

Service Code	NDC 00944270002
Hospital Charge Code	2512242
Hospital Revenue Code	250
Min. Negotiated Rate	$500.20
Max. Negotiated Rate	$591.70
Rate for Payer: Cash Price	$457.70
Rate for Payer: Health Partners Plans Commercial	$579.50
Rate for Payer: UnitedHealthcare Commercial	$591.70
Rate for Payer: WPPA Commercial	$500.20

Gammagard Liquid 1 gm - 10 ml

Facility

$610.00

Service Code	NDC 00944270002
Hospital Charge Code	2512242
Hospital Revenue Code	250
Min. Negotiated Rate	$281.82
Max. Negotiated Rate	$591.70
Rate for Payer: Cash Price	$457.70
Rate for Payer: Celtic Commercial/Exchange	$281.82
Rate for Payer: Health Partners Plans Commercial	$579.50
Rate for Payer: UnitedHealthcare Commercial	$591.70
Rate for Payer: WPPA Commercial	$512.40

Gammagard Liquid 30 GM - 300 ml

Facility

$16,121.00

Service Code	NDC 00944270007
Hospital Charge Code	2519296
Hospital Revenue Code	250
Min. Negotiated Rate	$13,219.22
Max. Negotiated Rate	$15,637.37
Rate for Payer: Cash Price	$12,090.86
Rate for Payer: Health Partners Plans Commercial	$15,314.95
Rate for Payer: UnitedHealthcare Commercial	$15,637.37
Rate for Payer: WPPA Commercial	$13,219.22

Gammagard Liquid 30 GM - 300 ml

Facility

$16,121.00

Service Code	NDC 00944270007
Hospital Charge Code	2519296
Hospital Revenue Code	250
Min. Negotiated Rate	$7,447.90
Max. Negotiated Rate	$15,637.37
Rate for Payer: Cash Price	$12,090.86
Rate for Payer: Celtic Commercial/Exchange	$7,447.90
Rate for Payer: Health Partners Plans Commercial	$15,314.95
Rate for Payer: UnitedHealthcare Commercial	$15,637.37
Rate for Payer: WPPA Commercial	$13,541.64

GAMMAGARD LIQUID 30GM (immun glob G(IgG)-gly-IgA ov50) inj solution

Facility

$16,121.00

Service Code	NDC 00944270007
Hospital Charge Code	2519296
Hospital Revenue Code	250
Min. Negotiated Rate	$7,447.90
Max. Negotiated Rate	$15,637.37
Rate for Payer: Cash Price	$12,090.86
Rate for Payer: Celtic Commercial/Exchange	$7,447.90
Rate for Payer: Health Partners Plans Commercial	$15,314.95
Rate for Payer: UnitedHealthcare Commercial	$15,637.37
Rate for Payer: WPPA Commercial	$13,541.64

GAMMAGARD LIQUID 30GM (immun glob G(IgG)-gly-IgA ov50) inj solution

Facility

$16,121.00

Service Code	NDC 00944270007
Hospital Charge Code	2519296
Hospital Revenue Code	250
Min. Negotiated Rate	$13,219.22
Max. Negotiated Rate	$15,637.37
Rate for Payer: Cash Price	$12,090.86
Rate for Payer: Health Partners Plans Commercial	$15,314.95
Rate for Payer: UnitedHealthcare Commercial	$15,637.37
Rate for Payer: WPPA Commercial	$13,219.22

Gammagard Liquid 5 GM

Facility

$3,051.00

Service Code	NDC 00944270004
Hospital Charge Code	2512143
Hospital Revenue Code	250
Min. Negotiated Rate	$2,501.82
Max. Negotiated Rate	$2,959.47
Rate for Payer: Cash Price	$2,288.52
Rate for Payer: Health Partners Plans Commercial	$2,898.45
Rate for Payer: UnitedHealthcare Commercial	$2,959.47
Rate for Payer: WPPA Commercial	$2,501.82

Gammagard Liquid 5 GM

Facility

$3,051.00

Service Code	NDC 00944270004
Hospital Charge Code	2512143
Hospital Revenue Code	250
Min. Negotiated Rate	$1,409.56
Max. Negotiated Rate	$2,959.47
Rate for Payer: Cash Price	$2,288.52
Rate for Payer: Celtic Commercial/Exchange	$1,409.56
Rate for Payer: Health Partners Plans Commercial	$2,898.45
Rate for Payer: UnitedHealthcare Commercial	$2,959.47
Rate for Payer: WPPA Commercial	$2,562.84

GAMMAGLOB IGA,IGD,IGG,IGM,EACH

Facility

$139.00

Service Code	HCPCS 82784
Hospital Charge Code	8278400
Hospital Revenue Code	301
Min. Negotiated Rate	$113.98
Max. Negotiated Rate	$134.83
Rate for Payer: Cash Price	$104.25
Rate for Payer: Health Partners Plans Commercial	$132.05
Rate for Payer: UnitedHealthcare Commercial	$134.83
Rate for Payer: WPPA Commercial	$113.98

GAMMAGLOB IGA,IGD,IGG,IGM,EACH

Facility

$139.00

Service Code	HCPCS 82784
Hospital Charge Code	8278400
Hospital Revenue Code	301
Min. Negotiated Rate	$49.24
Max. Negotiated Rate	$134.83
Rate for Payer: BCBS Commercial	$49.24
Rate for Payer: Cash Price	$104.25
Rate for Payer: Cash Price	$104.25
Rate for Payer: Celtic Commercial/Exchange	$64.22
Rate for Payer: Health Partners Plans Commercial	$132.05
Rate for Payer: UnitedHealthcare Commercial	$134.83
Rate for Payer: WPPA Commercial	$116.76

GAMMAGLOB IMMUNOGLOB SUBCLASS

Facility

$93.00

Service Code	HCPCS 82787
Hospital Charge Code	8278700
Hospital Revenue Code	301
Min. Negotiated Rate	$33.74
Max. Negotiated Rate	$90.21
Rate for Payer: BCBS Commercial	$33.74
Rate for Payer: Cash Price	$69.75
Rate for Payer: Cash Price	$69.75
Rate for Payer: Celtic Commercial/Exchange	$42.97
Rate for Payer: Health Partners Plans Commercial	$88.35
Rate for Payer: UnitedHealthcare Commercial	$90.21
Rate for Payer: WPPA Commercial	$78.12

Know your out-of-pocket cost for care.

All Charges