Ness County Hospital

All Charges

Charge

Type

Setting

Price

LOCOST SKN SUB AP F/N/HF/G 25

Facility

$581.00

Service Code	HCPCS C5275
Hospital Charge Code	C527523
Hospital Revenue Code	761
Min. Negotiated Rate	$268.42
Max. Negotiated Rate	$563.57
Rate for Payer: BCBS Commercial	$371.68
Rate for Payer: Cash Price	$435.75
Rate for Payer: Cash Price	$435.75
Rate for Payer: Celtic Commercial/Exchange	$268.42
Rate for Payer: Health Partners Plans Commercial	$551.95
Rate for Payer: UnitedHealthcare Commercial	$563.57
Rate for Payer: WPPA Commercial	$488.04

LOCOST SKN SUB AP F/N/HF/G ADD

Facility

$250.00

Service Code	HCPCS C5276
Hospital Charge Code	C527623
Hospital Revenue Code	761
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$187.50
Rate for Payer: Celtic Commercial/Exchange	$115.50
Rate for Payer: Health Partners Plans Commercial	$237.50
Rate for Payer: UnitedHealthcare Commercial	$242.50
Rate for Payer: WPPA Commercial	$210.00

LOCOST SKN SUB AP F/N/HF/G ADD

Facility

$250.00

Service Code	HCPCS C5278
Hospital Charge Code	C527823
Hospital Revenue Code	761
Min. Negotiated Rate	$205.00
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$187.50
Rate for Payer: Health Partners Plans Commercial	$237.50
Rate for Payer: UnitedHealthcare Commercial	$242.50
Rate for Payer: WPPA Commercial	$205.00

LOCOST SKN SUB AP F/N/HF/G ADD

Facility

$250.00

Service Code	HCPCS C5278
Hospital Charge Code	C527823
Hospital Revenue Code	761
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$187.50
Rate for Payer: Celtic Commercial/Exchange	$115.50
Rate for Payer: Health Partners Plans Commercial	$237.50
Rate for Payer: UnitedHealthcare Commercial	$242.50
Rate for Payer: WPPA Commercial	$210.00

LOCOST SKN SUB AP F/N/HF/G ADD

Facility

$250.00

Service Code	HCPCS C5276
Hospital Charge Code	C527623
Hospital Revenue Code	761
Min. Negotiated Rate	$205.00
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$187.50
Rate for Payer: Health Partners Plans Commercial	$237.50
Rate for Payer: UnitedHealthcare Commercial	$242.50
Rate for Payer: WPPA Commercial	$205.00

LO COST SKN SUB APP T/A/L 25CM

Facility

$581.00

Service Code	HCPCS C5271
Hospital Charge Code	C527123
Hospital Revenue Code	761
Min. Negotiated Rate	$268.42
Max. Negotiated Rate	$563.57
Rate for Payer: BCBS Commercial	$371.68
Rate for Payer: Cash Price	$435.75
Rate for Payer: Cash Price	$435.75
Rate for Payer: Celtic Commercial/Exchange	$268.42
Rate for Payer: Health Partners Plans Commercial	$551.95
Rate for Payer: UnitedHealthcare Commercial	$563.57
Rate for Payer: WPPA Commercial	$488.04

LO COST SKN SUB APP T/A/L 25CM

Facility

$581.00

Service Code	HCPCS C5271
Hospital Charge Code	C527123
Hospital Revenue Code	761
Min. Negotiated Rate	$476.42
Max. Negotiated Rate	$563.57
Rate for Payer: Cash Price	$435.75
Rate for Payer: Health Partners Plans Commercial	$551.95
Rate for Payer: UnitedHealthcare Commercial	$563.57
Rate for Payer: WPPA Commercial	$476.42

LO COST SKN SUB APP T/A/L ADDL

Facility

$250.00

Service Code	HCPCS C5272
Hospital Charge Code	C527223
Hospital Revenue Code	761
Min. Negotiated Rate	$205.00
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$187.50
Rate for Payer: Health Partners Plans Commercial	$237.50
Rate for Payer: UnitedHealthcare Commercial	$242.50
Rate for Payer: WPPA Commercial	$205.00

LO COST SKN SUB APP T/A/L ADDL

Facility

$250.00

Service Code	HCPCS C5272
Hospital Charge Code	C527223
Hospital Revenue Code	761
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$187.50
Rate for Payer: Celtic Commercial/Exchange	$115.50
Rate for Payer: Health Partners Plans Commercial	$237.50
Rate for Payer: UnitedHealthcare Commercial	$242.50
Rate for Payer: WPPA Commercial	$210.00

LO COST SKN SUB APP T/A/L ADDL

Facility

$250.00

Service Code	HCPCS C5274
Hospital Charge Code	C527423
Hospital Revenue Code	761
Min. Negotiated Rate	$205.00
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$187.50
Rate for Payer: Health Partners Plans Commercial	$237.50
Rate for Payer: UnitedHealthcare Commercial	$242.50
Rate for Payer: WPPA Commercial	$205.00

LO COST SKN SUB APP T/A/L ADDL

Facility

$250.00

Service Code	HCPCS C5274
Hospital Charge Code	C527423
Hospital Revenue Code	761
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$242.50
Rate for Payer: Cash Price	$187.50
Rate for Payer: Celtic Commercial/Exchange	$115.50
Rate for Payer: Health Partners Plans Commercial	$237.50
Rate for Payer: UnitedHealthcare Commercial	$242.50
Rate for Payer: WPPA Commercial	$210.00

LO COST SKN SUB APP T/A/LG>100

Facility

$1,750.00

Service Code	HCPCS C5273
Hospital Charge Code	C527323
Hospital Revenue Code	761
Min. Negotiated Rate	$1,435.00
Max. Negotiated Rate	$1,697.50
Rate for Payer: Cash Price	$1,312.50
Rate for Payer: Health Partners Plans Commercial	$1,662.50
Rate for Payer: UnitedHealthcare Commercial	$1,697.50
Rate for Payer: WPPA Commercial	$1,435.00

LO COST SKN SUB APP T/A/LG>100

Facility

$1,750.00

Service Code	HCPCS C5273
Hospital Charge Code	C527323
Hospital Revenue Code	761
Min. Negotiated Rate	$808.50
Max. Negotiated Rate	$1,697.50
Rate for Payer: BCBS Commercial	$809.01
Rate for Payer: Cash Price	$1,312.50
Rate for Payer: Cash Price	$1,312.50
Rate for Payer: Celtic Commercial/Exchange	$808.50
Rate for Payer: Health Partners Plans Commercial	$1,662.50
Rate for Payer: UnitedHealthcare Commercial	$1,697.50
Rate for Payer: WPPA Commercial	$1,470.00

LOMOTIL 2.5/0.025 MG TAB (DIPHENOXYLATE + ATROPINE)

Facility

$3.00

Service Code	NDC 62559049001
Hospital Charge Code	2504058
Hospital Revenue Code	250
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$2.62
Rate for Payer: Health Partners Plans Commercial	$2.85
Rate for Payer: UnitedHealthcare Commercial	$2.91
Rate for Payer: WPPA Commercial	$2.46

LOMOTIL 2.5/0.025 MG TAB (DIPHENOXYLATE + ATROPINE)

Facility

$3.00

Service Code	NDC 62559049001
Hospital Charge Code	2504058
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$2.62
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

LONG IV ARM BOARD

Facility

$18.00

Hospital Charge Code	2700409
Hospital Revenue Code	270
Min. Negotiated Rate	$14.76
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$13.50
Rate for Payer: Health Partners Plans Commercial	$17.10
Rate for Payer: UnitedHealthcare Commercial	$17.46
Rate for Payer: WPPA Commercial	$14.76

LONG IV ARM BOARD

Facility

$18.00

Hospital Charge Code	2700409
Hospital Revenue Code	270
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$17.46
Rate for Payer: Cash Price	$13.50
Rate for Payer: Celtic Commercial/Exchange	$8.32
Rate for Payer: Health Partners Plans Commercial	$17.10
Rate for Payer: UnitedHealthcare Commercial	$17.46
Rate for Payer: WPPA Commercial	$15.12

LOPID 600 MG TAB (GEMFIBROZIL)

Facility

$13.00

Service Code	NDC 60687022411
Hospital Charge Code	2504066
Hospital Revenue Code	250
Min. Negotiated Rate	$6.01
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$9.98
Rate for Payer: Celtic Commercial/Exchange	$6.01
Rate for Payer: Health Partners Plans Commercial	$12.35
Rate for Payer: UnitedHealthcare Commercial	$12.61
Rate for Payer: WPPA Commercial	$10.92

LOPID 600 MG TAB (GEMFIBROZIL)

Facility

$13.00

Service Code	NDC 60687022411
Hospital Charge Code	2504066
Hospital Revenue Code	250
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$12.61
Rate for Payer: Cash Price	$9.98
Rate for Payer: Health Partners Plans Commercial	$12.35
Rate for Payer: UnitedHealthcare Commercial	$12.61
Rate for Payer: WPPA Commercial	$10.66

LOPRESSOR 25 MG TAB (METOPROLOL TARTRATE)

Facility

$1.00

Service Code	NDC 62584026511
Hospital Charge Code	2518637
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.75
Rate for Payer: Celtic Commercial/Exchange	$0.46
Rate for Payer: Health Partners Plans Commercial	$0.95
Rate for Payer: UnitedHealthcare Commercial	$0.97
Rate for Payer: WPPA Commercial	$0.84

LOPRESSOR 25 MG TAB (METOPROLOL TARTRATE)

Facility

$1.00

Service Code	NDC 62584026511
Hospital Charge Code	2518637
Hospital Revenue Code	250
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$0.75
Rate for Payer: Health Partners Plans Commercial	$0.95
Rate for Payer: UnitedHealthcare Commercial	$0.97
Rate for Payer: WPPA Commercial	$0.82

LOPRESSOR 5 MG/5 ML INJ. (METPPROLOL TARTRATE)

Facility

$21.00

Service Code	NDC 25021030305
Hospital Charge Code	2513927
Hospital Revenue Code	250
Min. Negotiated Rate	$9.70
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$15.94
Rate for Payer: Celtic Commercial/Exchange	$9.70
Rate for Payer: Health Partners Plans Commercial	$19.95
Rate for Payer: UnitedHealthcare Commercial	$20.37
Rate for Payer: WPPA Commercial	$17.64

LOPRESSOR 5 MG/5 ML INJ. (METPPROLOL TARTRATE)

Facility

$21.00

Service Code	NDC 25021030305
Hospital Charge Code	2513927
Hospital Revenue Code	250
Min. Negotiated Rate	$17.22
Max. Negotiated Rate	$20.37
Rate for Payer: Cash Price	$15.94
Rate for Payer: Health Partners Plans Commercial	$19.95
Rate for Payer: UnitedHealthcare Commercial	$20.37
Rate for Payer: WPPA Commercial	$17.22

LORTAB 5/325 MG TAB (HYDROCODONE/ACE) (NORCO)

Facility

$2.00

Service Code	NDC 60687039611
Hospital Charge Code	2518785
Hospital Revenue Code	250
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Partners Plans Commercial	$1.90
Rate for Payer: UnitedHealthcare Commercial	$1.94
Rate for Payer: WPPA Commercial	$1.64

LORTAB 5/325 MG TAB (HYDROCODONE/ACE) (NORCO)

Facility

$2.00

Service Code	NDC 60687039611
Hospital Charge Code	2518785
Hospital Revenue Code	250
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.94
Rate for Payer: Cash Price	$1.80
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

Know your out-of-pocket cost for care.

All Charges