Ness County Hospital

All Charges

Charge

Type

Setting

Price

LESION DIAMETER 06 TO 1.0 CM

Facility

$353.00

Service Code	HCPCS 11401
Hospital Charge Code	1140100
Hospital Revenue Code	450
Min. Negotiated Rate	$163.09
Max. Negotiated Rate	$499.41
Rate for Payer: BCBS Commercial	$499.41
Rate for Payer: Cash Price	$264.75
Rate for Payer: Cash Price	$264.75
Rate for Payer: Celtic Commercial/Exchange	$163.09
Rate for Payer: Health Partners Plans Commercial	$335.35
Rate for Payer: UnitedHealthcare Commercial	$342.41
Rate for Payer: WPPA Commercial	$296.52

LESION DIAMETER 1.1 TO 2.0 C.M

Facility

$684.00

Service Code	HCPCS 11622
Hospital Charge Code	1162200
Hospital Revenue Code	450
Min. Negotiated Rate	$560.88
Max. Negotiated Rate	$663.48
Rate for Payer: Cash Price	$513.00
Rate for Payer: Health Partners Plans Commercial	$649.80
Rate for Payer: UnitedHealthcare Commercial	$663.48
Rate for Payer: WPPA Commercial	$560.88

LESION DIAMETER 1.1 TO 2.0 C.M

Facility

$684.00

Service Code	HCPCS 11622
Hospital Charge Code	1162200
Hospital Revenue Code	450
Min. Negotiated Rate	$316.01
Max. Negotiated Rate	$783.57
Rate for Payer: BCBS Commercial	$783.57
Rate for Payer: Cash Price	$513.00
Rate for Payer: Cash Price	$513.00
Rate for Payer: Celtic Commercial/Exchange	$316.01
Rate for Payer: Health Partners Plans Commercial	$649.80
Rate for Payer: UnitedHealthcare Commercial	$663.48
Rate for Payer: WPPA Commercial	$574.56

LESION DIAMETER .6 TO 1.0 CM

Facility

$684.00

Service Code	HCPCS 11641
Hospital Charge Code	1164100
Hospital Revenue Code	450
Min. Negotiated Rate	$316.01
Max. Negotiated Rate	$663.48
Rate for Payer: BCBS Commercial	$657.51
Rate for Payer: Cash Price	$513.00
Rate for Payer: Cash Price	$513.00
Rate for Payer: Celtic Commercial/Exchange	$316.01
Rate for Payer: Health Partners Plans Commercial	$649.80
Rate for Payer: UnitedHealthcare Commercial	$663.48
Rate for Payer: WPPA Commercial	$574.56

LESION DIAMETER .6 TO 1.0 CM

Facility

$684.00

Service Code	HCPCS 11641
Hospital Charge Code	1164100
Hospital Revenue Code	450
Min. Negotiated Rate	$560.88
Max. Negotiated Rate	$663.48
Rate for Payer: Cash Price	$513.00
Rate for Payer: Health Partners Plans Commercial	$649.80
Rate for Payer: UnitedHealthcare Commercial	$663.48
Rate for Payer: WPPA Commercial	$560.88

LESION DIAMETER OVER 4.0 CM

Facility

$2,604.00

Service Code	HCPCS 11626
Hospital Charge Code	1162600
Hospital Revenue Code	450
Min. Negotiated Rate	$2,135.28
Max. Negotiated Rate	$2,525.88
Rate for Payer: Cash Price	$1,953.00
Rate for Payer: Health Partners Plans Commercial	$2,473.80
Rate for Payer: UnitedHealthcare Commercial	$2,525.88
Rate for Payer: WPPA Commercial	$2,135.28

LESION DIAMETER OVER 4.0 CM

Facility

$2,604.00

Service Code	HCPCS 11626
Hospital Charge Code	1162600
Hospital Revenue Code	450
Min. Negotiated Rate	$1,203.05
Max. Negotiated Rate	$3,084.55
Rate for Payer: BCBS Commercial	$3,084.55
Rate for Payer: Cash Price	$1,953.00
Rate for Payer: Cash Price	$1,953.00
Rate for Payer: Celtic Commercial/Exchange	$1,203.05
Rate for Payer: Health Partners Plans Commercial	$2,473.80
Rate for Payer: UnitedHealthcare Commercial	$2,525.88
Rate for Payer: WPPA Commercial	$2,187.36

LEUKOCYTE ASSESS,FECAL,QUAL.OR

Facility

$47.00

Service Code	HCPCS 89055
Hospital Charge Code	8905500
Hospital Revenue Code	309
Min. Negotiated Rate	$38.54
Max. Negotiated Rate	$45.59
Rate for Payer: Cash Price	$35.25
Rate for Payer: Health Partners Plans Commercial	$44.65
Rate for Payer: UnitedHealthcare Commercial	$45.59
Rate for Payer: WPPA Commercial	$38.54

LEUKOCYTE ASSESS,FECAL,QUAL.OR

Facility

$47.00

Service Code	HCPCS 89055
Hospital Charge Code	8905500
Hospital Revenue Code	309
Min. Negotiated Rate	$15.06
Max. Negotiated Rate	$45.59
Rate for Payer: BCBS Commercial	$15.06
Rate for Payer: Cash Price	$35.25
Rate for Payer: Cash Price	$35.25
Rate for Payer: Celtic Commercial/Exchange	$21.71
Rate for Payer: Health Partners Plans Commercial	$44.65
Rate for Payer: UnitedHealthcare Commercial	$45.59
Rate for Payer: WPPA Commercial	$39.48

LEUKOCYTE HISTAMINE RELEASE

Facility

$25.00

Service Code	HCPCS 86343
Hospital Charge Code	8634300
Hospital Revenue Code	302
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$24.25
Rate for Payer: BCBS Commercial	$17.85
Rate for Payer: Cash Price	$18.75
Rate for Payer: Cash Price	$18.75
Rate for Payer: Celtic Commercial/Exchange	$11.55
Rate for Payer: Health Partners Plans Commercial	$23.75
Rate for Payer: UnitedHealthcare Commercial	$24.25
Rate for Payer: WPPA Commercial	$21.00

LEUKOCYTE HISTAMINE RELEASE

Facility

$25.00

Service Code	HCPCS 86343
Hospital Charge Code	8634300
Hospital Revenue Code	302
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$24.25
Rate for Payer: Cash Price	$18.75
Rate for Payer: Health Partners Plans Commercial	$23.75
Rate for Payer: UnitedHealthcare Commercial	$24.25
Rate for Payer: WPPA Commercial	$20.50

LEUKOCYTE PHAGOCYTOSIS

Facility

$63.00

Service Code	HCPCS 86344
Hospital Charge Code	8634400
Hospital Revenue Code	302
Min. Negotiated Rate	$51.66
Max. Negotiated Rate	$61.11
Rate for Payer: Cash Price	$47.25
Rate for Payer: Health Partners Plans Commercial	$59.85
Rate for Payer: UnitedHealthcare Commercial	$61.11
Rate for Payer: WPPA Commercial	$51.66

LEUKOCYTE PHAGOCYTOSIS

Facility

$63.00

Service Code	HCPCS 86344
Hospital Charge Code	8634400
Hospital Revenue Code	302
Min. Negotiated Rate	$17.85
Max. Negotiated Rate	$61.11
Rate for Payer: BCBS Commercial	$17.85
Rate for Payer: Cash Price	$47.25
Rate for Payer: Cash Price	$47.25
Rate for Payer: Celtic Commercial/Exchange	$29.11
Rate for Payer: Health Partners Plans Commercial	$59.85
Rate for Payer: UnitedHealthcare Commercial	$61.11
Rate for Payer: WPPA Commercial	$52.92

LEVAQUIN 250 MG PREMIX (LEVOFLOXACIN IN D5W) IV

Facility

$68.00

Service Code	NDC 00143931501
Hospital Charge Code	2516375
Hospital Revenue Code	250
Min. Negotiated Rate	$31.42
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$51.38
Rate for Payer: Celtic Commercial/Exchange	$31.42
Rate for Payer: Health Partners Plans Commercial	$64.60
Rate for Payer: UnitedHealthcare Commercial	$65.96
Rate for Payer: WPPA Commercial	$57.12

LEVAQUIN 250 MG PREMIX (LEVOFLOXACIN IN D5W) IV

Facility

$68.00

Service Code	NDC 00143931501
Hospital Charge Code	2516375
Hospital Revenue Code	250
Min. Negotiated Rate	$55.76
Max. Negotiated Rate	$65.96
Rate for Payer: Cash Price	$51.38
Rate for Payer: Health Partners Plans Commercial	$64.60
Rate for Payer: UnitedHealthcare Commercial	$65.96
Rate for Payer: WPPA Commercial	$55.76

LEVAQUIN 500 MG PREMIX (LEVOFLOXACIN IN D5W) IV

Facility

$137.00

Service Code	NDC 00143931601
Hospital Charge Code	2515468
Hospital Revenue Code	250
Min. Negotiated Rate	$63.29
Max. Negotiated Rate	$132.89
Rate for Payer: Cash Price	$102.75
Rate for Payer: Celtic Commercial/Exchange	$63.29
Rate for Payer: Health Partners Plans Commercial	$130.15
Rate for Payer: UnitedHealthcare Commercial	$132.89
Rate for Payer: WPPA Commercial	$115.08

LEVAQUIN 500 MG PREMIX (LEVOFLOXACIN IN D5W) IV

Facility

$137.00

Service Code	NDC 00143931601
Hospital Charge Code	2515468
Hospital Revenue Code	250
Min. Negotiated Rate	$112.34
Max. Negotiated Rate	$132.89
Rate for Payer: Cash Price	$102.75
Rate for Payer: Health Partners Plans Commercial	$130.15
Rate for Payer: UnitedHealthcare Commercial	$132.89
Rate for Payer: WPPA Commercial	$112.34

LEVAQUIN 500 MG TAB (LEVOFLOXACIN)

Facility

$56.00

Service Code	NDC 00904635261
Hospital Charge Code	2503829
Hospital Revenue Code	250
Min. Negotiated Rate	$45.92
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$42.53
Rate for Payer: Health Partners Plans Commercial	$53.20
Rate for Payer: UnitedHealthcare Commercial	$54.32
Rate for Payer: WPPA Commercial	$45.92

LEVAQUIN 500 MG TAB (LEVOFLOXACIN)

Facility

$56.00

Service Code	NDC 00904635261
Hospital Charge Code	2503829
Hospital Revenue Code	250
Min. Negotiated Rate	$25.87
Max. Negotiated Rate	$54.32
Rate for Payer: Cash Price	$42.53
Rate for Payer: Celtic Commercial/Exchange	$25.87
Rate for Payer: Health Partners Plans Commercial	$53.20
Rate for Payer: UnitedHealthcare Commercial	$54.32
Rate for Payer: WPPA Commercial	$47.04

LEVAQUIN 750 MG PREMIX (LEVOFLOXACIN IN D5W) IV

Facility

$181.00

Service Code	NDC 00409444401
Hospital Charge Code	2512481
Hospital Revenue Code	250
Min. Negotiated Rate	$83.62
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$136.35
Rate for Payer: Celtic Commercial/Exchange	$83.62
Rate for Payer: Health Partners Plans Commercial	$171.95
Rate for Payer: UnitedHealthcare Commercial	$175.57
Rate for Payer: WPPA Commercial	$152.04

LEVAQUIN 750 MG PREMIX (LEVOFLOXACIN IN D5W) IV

Facility

$181.00

Service Code	NDC 00409444401
Hospital Charge Code	2512481
Hospital Revenue Code	250
Min. Negotiated Rate	$148.42
Max. Negotiated Rate	$175.57
Rate for Payer: Cash Price	$136.35
Rate for Payer: Health Partners Plans Commercial	$171.95
Rate for Payer: UnitedHealthcare Commercial	$175.57
Rate for Payer: WPPA Commercial	$148.42

LEVEL 1 FOLLOW-UP VISIT

Facility

$100.00

Service Code	HCPCS 99211
Hospital Charge Code	9921123
Hospital Revenue Code	761
Min. Negotiated Rate	$82.00
Max. Negotiated Rate	$97.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Health Partners Plans Commercial	$95.00
Rate for Payer: UnitedHealthcare Commercial	$97.00
Rate for Payer: WPPA Commercial	$82.00

LEVEL 1 FOLLOW-UP VISIT

Facility

$100.00

Service Code	HCPCS 99211
Hospital Charge Code	9921123
Hospital Revenue Code	761
Min. Negotiated Rate	$42.50
Max. Negotiated Rate	$97.00
Rate for Payer: BCBS Commercial	$42.50
Rate for Payer: Cash Price	$75.00
Rate for Payer: Cash Price	$75.00
Rate for Payer: Celtic Commercial/Exchange	$46.20
Rate for Payer: Health Partners Plans Commercial	$95.00
Rate for Payer: UnitedHealthcare Commercial	$97.00
Rate for Payer: WPPA Commercial	$84.00

LEVEL 2 FOLLOW-UP VISIT

Facility

$130.00

Service Code	HCPCS 99212
Hospital Charge Code	9921223
Hospital Revenue Code	761
Min. Negotiated Rate	$106.60
Max. Negotiated Rate	$126.10
Rate for Payer: Cash Price	$97.50
Rate for Payer: Health Partners Plans Commercial	$123.50
Rate for Payer: UnitedHealthcare Commercial	$126.10
Rate for Payer: WPPA Commercial	$106.60

LEVEL 2 FOLLOW-UP VISIT

Facility

$130.00

Service Code	HCPCS 99212
Hospital Charge Code	9921223
Hospital Revenue Code	761
Min. Negotiated Rate	$60.06
Max. Negotiated Rate	$126.10
Rate for Payer: BCBS Commercial	$85.38
Rate for Payer: Cash Price	$97.50
Rate for Payer: Cash Price	$97.50
Rate for Payer: Celtic Commercial/Exchange	$60.06
Rate for Payer: Health Partners Plans Commercial	$123.50
Rate for Payer: UnitedHealthcare Commercial	$126.10
Rate for Payer: WPPA Commercial	$109.20

Know your out-of-pocket cost for care.

All Charges