Ness County Hospital

All Charges

Charge

Type

Setting

Price

LEVEL VI-SURG PATH, GROSS &

Facility

$777.00

Service Code	HCPCS 88309
Hospital Charge Code	8830900
Hospital Revenue Code	310
Min. Negotiated Rate	$637.14
Max. Negotiated Rate	$753.69
Rate for Payer: Cash Price	$582.75
Rate for Payer: Health Partners Plans Commercial	$738.15
Rate for Payer: UnitedHealthcare Commercial	$753.69
Rate for Payer: WPPA Commercial	$637.14

LEVEL V-SURG PATH, GROSS &

Facility

$325.00

Service Code	HCPCS 88307
Hospital Charge Code	8830700
Hospital Revenue Code	310
Min. Negotiated Rate	$266.50
Max. Negotiated Rate	$315.25
Rate for Payer: Cash Price	$243.75
Rate for Payer: Health Partners Plans Commercial	$308.75
Rate for Payer: UnitedHealthcare Commercial	$315.25
Rate for Payer: WPPA Commercial	$266.50

LEVEL V-SURG PATH, GROSS &

Facility

$325.00

Service Code	HCPCS 88307
Hospital Charge Code	8830700
Hospital Revenue Code	310
Min. Negotiated Rate	$150.15
Max. Negotiated Rate	$315.25
Rate for Payer: BCBS Commercial	$271.81
Rate for Payer: Cash Price	$243.75
Rate for Payer: Cash Price	$243.75
Rate for Payer: Celtic Commercial/Exchange	$150.15
Rate for Payer: Health Partners Plans Commercial	$308.75
Rate for Payer: UnitedHealthcare Commercial	$315.25
Rate for Payer: WPPA Commercial	$273.00

LEVETIRACETAM

Facility

$206.00

Service Code	HCPCS 80177
Hospital Charge Code	8017700
Hospital Revenue Code	301
Min. Negotiated Rate	$168.92
Max. Negotiated Rate	$199.82
Rate for Payer: Cash Price	$154.50
Rate for Payer: Health Partners Plans Commercial	$195.70
Rate for Payer: UnitedHealthcare Commercial	$199.82
Rate for Payer: WPPA Commercial	$168.92

LEVETIRACETAM

Facility

$206.00

Service Code	HCPCS 80177
Hospital Charge Code	8017700
Hospital Revenue Code	301
Min. Negotiated Rate	$36.45
Max. Negotiated Rate	$199.82
Rate for Payer: BCBS Commercial	$36.45
Rate for Payer: Cash Price	$154.50
Rate for Payer: Cash Price	$154.50
Rate for Payer: Celtic Commercial/Exchange	$95.17
Rate for Payer: Health Partners Plans Commercial	$195.70
Rate for Payer: UnitedHealthcare Commercial	$199.82
Rate for Payer: WPPA Commercial	$173.04

LEVIN STOMACH TUBE

Facility

$11.00

Hospital Charge Code	2720340
Hospital Revenue Code	272
Min. Negotiated Rate	$9.02
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$8.25
Rate for Payer: Health Partners Plans Commercial	$10.45
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: WPPA Commercial	$9.02

LEVIN STOMACH TUBE

Facility

$11.00

Hospital Charge Code	2720340
Hospital Revenue Code	272
Min. Negotiated Rate	$5.08
Max. Negotiated Rate	$10.67
Rate for Payer: Cash Price	$8.25
Rate for Payer: Celtic Commercial/Exchange	$5.08
Rate for Payer: Health Partners Plans Commercial	$10.45
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: WPPA Commercial	$9.24

Levophed 4 mg/4 ml vial (norepinephrine bitartrate)

Facility

$75.00

Service Code	NDC 67457085204
Hospital Charge Code	2513528
Hospital Revenue Code	250
Min. Negotiated Rate	$34.65
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$56.90
Rate for Payer: Celtic Commercial/Exchange	$34.65
Rate for Payer: Health Partners Plans Commercial	$71.25
Rate for Payer: UnitedHealthcare Commercial	$72.75
Rate for Payer: WPPA Commercial	$63.00

Levophed 4 mg/4 ml vial (norepinephrine bitartrate)

Facility

$75.00

Service Code	NDC 67457085204
Hospital Charge Code	2513528
Hospital Revenue Code	250
Min. Negotiated Rate	$61.50
Max. Negotiated Rate	$72.75
Rate for Payer: Cash Price	$56.90
Rate for Payer: Health Partners Plans Commercial	$71.25
Rate for Payer: UnitedHealthcare Commercial	$72.75
Rate for Payer: WPPA Commercial	$61.50

LEVSIN PEDIATRIC DROPS (HYOSYNE)

Facility

$180.00

Service Code	NDC 54838050615
Hospital Charge Code	2515898
Hospital Revenue Code	250
Min. Negotiated Rate	$83.16
Max. Negotiated Rate	$174.60
Rate for Payer: Cash Price	$135.00
Rate for Payer: Celtic Commercial/Exchange	$83.16
Rate for Payer: Health Partners Plans Commercial	$171.00
Rate for Payer: UnitedHealthcare Commercial	$174.60
Rate for Payer: WPPA Commercial	$151.20

LEVSIN PEDIATRIC DROPS (HYOSYNE)

Facility

$180.00

Service Code	NDC 54838050615
Hospital Charge Code	2515898
Hospital Revenue Code	250
Min. Negotiated Rate	$147.60
Max. Negotiated Rate	$174.60
Rate for Payer: Cash Price	$135.00
Rate for Payer: Health Partners Plans Commercial	$171.00
Rate for Payer: UnitedHealthcare Commercial	$174.60
Rate for Payer: WPPA Commercial	$147.60

LEVSIN TAB 0.125 MG TAB (HYOSCYAMINE SULFATE)

Facility

$3.00

Service Code	NDC 42192033801
Hospital Charge Code	2511020
Hospital Revenue Code	250
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$2.55
Rate for Payer: Health Partners Plans Commercial	$2.85
Rate for Payer: UnitedHealthcare Commercial	$2.91
Rate for Payer: WPPA Commercial	$2.46

LEVSIN TAB 0.125 MG TAB (HYOSCYAMINE SULFATE)

Facility

$3.00

Service Code	NDC 42192033801
Hospital Charge Code	2511020
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$2.55
Rate for Payer: Celtic Commercial/Exchange	$1.39
Rate for Payer: Health Partners Plans Commercial	$2.85
Rate for Payer: UnitedHealthcare Commercial	$2.91
Rate for Payer: WPPA Commercial	$2.52

LEXAPRO 10 MG TAB (ESCITALOPRAM OXALATE)

Facility

$15.00

Service Code	NDC 68084061711
Hospital Charge Code	2515351
Hospital Revenue Code	250
Min. Negotiated Rate	$12.30
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$11.92
Rate for Payer: Health Partners Plans Commercial	$14.25
Rate for Payer: UnitedHealthcare Commercial	$14.55
Rate for Payer: WPPA Commercial	$12.30

LEXAPRO 10 MG TAB (ESCITALOPRAM OXALATE)

Facility

$15.00

Service Code	NDC 68084061711
Hospital Charge Code	2515351
Hospital Revenue Code	250
Min. Negotiated Rate	$6.93
Max. Negotiated Rate	$14.55
Rate for Payer: Cash Price	$11.92
Rate for Payer: Celtic Commercial/Exchange	$6.93
Rate for Payer: Health Partners Plans Commercial	$14.25
Rate for Payer: UnitedHealthcare Commercial	$14.55
Rate for Payer: WPPA Commercial	$12.60

LG GEL CUSHION

Facility

$87.00

Hospital Charge Code	2700444
Hospital Revenue Code	270
Min. Negotiated Rate	$71.34
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$65.25
Rate for Payer: Health Partners Plans Commercial	$82.65
Rate for Payer: UnitedHealthcare Commercial	$84.39
Rate for Payer: WPPA Commercial	$71.34

LG GEL CUSHION

Facility

$87.00

Hospital Charge Code	2700444
Hospital Revenue Code	270
Min. Negotiated Rate	$40.19
Max. Negotiated Rate	$84.39
Rate for Payer: Cash Price	$65.25
Rate for Payer: Celtic Commercial/Exchange	$40.19
Rate for Payer: Health Partners Plans Commercial	$82.65
Rate for Payer: UnitedHealthcare Commercial	$84.39
Rate for Payer: WPPA Commercial	$73.08

LIBRIUM 5 MG TAB (CHLORDIAZEPOXIDE)

Facility

$2.00

Service Code	NDC 51079037420
Hospital Charge Code	2503977
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.84
Rate for Payer: Celtic Commercial/Exchange	$0.92
Rate for Payer: Health Partners Plans Commercial	$1.90
Rate for Payer: UnitedHealthcare Commercial	$1.94
Rate for Payer: WPPA Commercial	$1.68

LIBRIUM 5 MG TAB (CHLORDIAZEPOXIDE)

Facility

$2.00

Service Code	NDC 51079037420
Hospital Charge Code	2503977
Hospital Revenue Code	250
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.84
Rate for Payer: Health Partners Plans Commercial	$1.90
Rate for Payer: UnitedHealthcare Commercial	$1.94
Rate for Payer: WPPA Commercial	$1.64

LIDEX CREAM 15 tube (FLUOCINONIDE CREAM)

Facility

$136.00

Service Code	NDC 00093026215
Hospital Charge Code	2512044
Hospital Revenue Code	250
Min. Negotiated Rate	$62.83
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$102.49
Rate for Payer: Celtic Commercial/Exchange	$62.83
Rate for Payer: Health Partners Plans Commercial	$129.20
Rate for Payer: UnitedHealthcare Commercial	$131.92
Rate for Payer: WPPA Commercial	$114.24

LIDEX CREAM 15 tube (FLUOCINONIDE CREAM)

Facility

$136.00

Service Code	NDC 00093026215
Hospital Charge Code	2512044
Hospital Revenue Code	250
Min. Negotiated Rate	$111.52
Max. Negotiated Rate	$131.92
Rate for Payer: Cash Price	$102.49
Rate for Payer: Health Partners Plans Commercial	$129.20
Rate for Payer: UnitedHealthcare Commercial	$131.92
Rate for Payer: WPPA Commercial	$111.52

LIDOCAIE OINTMENT 5% (LIDOCAINE TOPICAL) 35 GM

Facility

$950.00

Service Code	NDC 64380078932
Hospital Charge Code	2513257
Hospital Revenue Code	250
Min. Negotiated Rate	$438.90
Max. Negotiated Rate	$921.50
Rate for Payer: Cash Price	$712.50
Rate for Payer: Celtic Commercial/Exchange	$438.90
Rate for Payer: Health Partners Plans Commercial	$902.50
Rate for Payer: UnitedHealthcare Commercial	$921.50
Rate for Payer: WPPA Commercial	$798.00

LIDOCAIE OINTMENT 5% (LIDOCAINE TOPICAL) 35 GM

Facility

$950.00

Service Code	NDC 64380078932
Hospital Charge Code	2513257
Hospital Revenue Code	250
Min. Negotiated Rate	$779.00
Max. Negotiated Rate	$921.50
Rate for Payer: Cash Price	$712.50
Rate for Payer: Health Partners Plans Commercial	$902.50
Rate for Payer: UnitedHealthcare Commercial	$921.50
Rate for Payer: WPPA Commercial	$779.00

LIDOCAINE

Facility

$3.00

Hospital Charge Code	2517812
Hospital Revenue Code	272
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$2.25
Rate for Payer: Celtic Commercial/Exchange	$1.39
Rate for Payer: Health Partners Plans Commercial	$2.85
Rate for Payer: UnitedHealthcare Commercial	$2.91
Rate for Payer: WPPA Commercial	$2.52

LIDOCAINE

Facility

$3.00

Hospital Charge Code	2517812
Hospital Revenue Code	272
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$2.25
Rate for Payer: Health Partners Plans Commercial	$2.85
Rate for Payer: UnitedHealthcare Commercial	$2.91
Rate for Payer: WPPA Commercial	$2.46

Know your out-of-pocket cost for care.

All Charges