Ness County Hospital

All Charges

Charge

Type

Setting

Price

LT DIAGNOSTIC MAMMO WITH CAD

Facility

$289.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	7706500
Hospital Revenue Code	401
Min. Negotiated Rate	$236.98
Max. Negotiated Rate	$280.33
Rate for Payer: Cash Price	$216.75
Rate for Payer: Health Partners Plans Commercial	$274.55
Rate for Payer: UnitedHealthcare Commercial	$280.33
Rate for Payer: WPPA Commercial	$236.98

LT DIAGNOSTIC MAMMO WITH CAD

Facility

$289.00

Service Code	HCPCS 77065 LT
Hospital Charge Code	7706500
Hospital Revenue Code	401
Min. Negotiated Rate	$123.22
Max. Negotiated Rate	$280.33
Rate for Payer: BCBS Commercial	$123.22
Rate for Payer: Cash Price	$216.75
Rate for Payer: Cash Price	$216.75
Rate for Payer: Celtic Commercial/Exchange	$133.52
Rate for Payer: Health Partners Plans Commercial	$274.55
Rate for Payer: UnitedHealthcare Commercial	$280.33
Rate for Payer: WPPA Commercial	$242.76

LUNG TRANSPLANT

Facility

$102,636.91

Service Code	MSDRG 007
Min. Negotiated Rate	$102,636.91
Max. Negotiated Rate	$102,636.91
Rate for Payer: BCBS Commercial	$102,636.91

LUPRON DEPOT 45 MG (6 MONTH) (LEUPROLIDE ACETATE) IM SYR. KIT

Facility

$40,048.00

Service Code	NDC 00074347303
Hospital Charge Code	2512705
Hospital Revenue Code	250
Min. Negotiated Rate	$18,502.18
Max. Negotiated Rate	$38,846.56
Rate for Payer: Cash Price	$30,036.24
Rate for Payer: Celtic Commercial/Exchange	$18,502.18
Rate for Payer: Health Partners Plans Commercial	$38,045.60
Rate for Payer: UnitedHealthcare Commercial	$38,846.56
Rate for Payer: WPPA Commercial	$33,640.32

LUPRON DEPOT 45 MG (6 MONTH) (LEUPROLIDE ACETATE) IM SYR. KIT

Facility

$40,048.00

Service Code	NDC 00074347303
Hospital Charge Code	2512705
Hospital Revenue Code	250
Min. Negotiated Rate	$32,839.36
Max. Negotiated Rate	$38,846.56
Rate for Payer: Cash Price	$30,036.24
Rate for Payer: Health Partners Plans Commercial	$38,045.60
Rate for Payer: UnitedHealthcare Commercial	$38,846.56
Rate for Payer: WPPA Commercial	$32,839.36

LUPUS ANTICOAGULANT EVAL W/

Facility

$264.00

Hospital Charge Code	8888880
Hospital Revenue Code	305
Min. Negotiated Rate	$216.48
Max. Negotiated Rate	$256.08
Rate for Payer: Cash Price	$198.00
Rate for Payer: Health Partners Plans Commercial	$250.80
Rate for Payer: UnitedHealthcare Commercial	$256.08
Rate for Payer: WPPA Commercial	$216.48

LUPUS ANTICOAGULANT EVAL W/

Facility

$264.00

Hospital Charge Code	8888880
Hospital Revenue Code	305
Min. Negotiated Rate	$121.97
Max. Negotiated Rate	$256.08
Rate for Payer: Cash Price	$198.00
Rate for Payer: Celtic Commercial/Exchange	$121.97
Rate for Payer: Health Partners Plans Commercial	$250.80
Rate for Payer: UnitedHealthcare Commercial	$256.08
Rate for Payer: WPPA Commercial	$221.76

LUTEIN 10 MG TAB

Facility

$1.00

Service Code	NDC 87701040812
Hospital Charge Code	2518876
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

LUTEIN 10 MG TAB

Facility

$1.00

Service Code	NDC 87701040812
Hospital Charge Code	2518876
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

LUTEINIZING RELEASING FACTOR

Facility

$82.00

Service Code	HCPCS 83727
Hospital Charge Code	8372700
Hospital Revenue Code	309
Min. Negotiated Rate	$37.88
Max. Negotiated Rate	$79.54
Rate for Payer: BCBS Commercial	$67.05
Rate for Payer: Cash Price	$61.50
Rate for Payer: Cash Price	$61.50
Rate for Payer: Celtic Commercial/Exchange	$37.88
Rate for Payer: Health Partners Plans Commercial	$77.90
Rate for Payer: UnitedHealthcare Commercial	$79.54
Rate for Payer: WPPA Commercial	$68.88

LUTEINIZING RELEASING FACTOR

Facility

$82.00

Service Code	HCPCS 83727
Hospital Charge Code	8372700
Hospital Revenue Code	309
Min. Negotiated Rate	$67.24
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$61.50
Rate for Payer: Health Partners Plans Commercial	$77.90
Rate for Payer: UnitedHealthcare Commercial	$79.54
Rate for Payer: WPPA Commercial	$67.24

LYMPHOCYTE TRANSF, MITOGEN OR

Facility

$300.00

Service Code	HCPCS 86353
Hospital Charge Code	8635300
Hospital Revenue Code	302
Min. Negotiated Rate	$246.00
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Health Partners Plans Commercial	$285.00
Rate for Payer: UnitedHealthcare Commercial	$291.00
Rate for Payer: WPPA Commercial	$246.00

LYMPHOCYTE TRANSF, MITOGEN OR

Facility

$300.00

Service Code	HCPCS 86353
Hospital Charge Code	8635300
Hospital Revenue Code	302
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$291.00
Rate for Payer: BCBS Commercial	$204.40
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Celtic Commercial/Exchange	$138.60
Rate for Payer: Health Partners Plans Commercial	$285.00
Rate for Payer: UnitedHealthcare Commercial	$291.00
Rate for Payer: WPPA Commercial	$252.00

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$22,283.67

Service Code	MSDRG 821
Min. Negotiated Rate	$22,283.67
Max. Negotiated Rate	$22,283.67
Rate for Payer: BCBS Commercial	$22,283.67

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$61,170.85

Service Code	MSDRG 820
Min. Negotiated Rate	$61,170.85
Max. Negotiated Rate	$61,170.85
Rate for Payer: BCBS Commercial	$61,170.85

LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$11,828.82

Service Code	MSDRG 822
Min. Negotiated Rate	$11,828.82
Max. Negotiated Rate	$11,828.82
Rate for Payer: BCBS Commercial	$11,828.82

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC

Facility

$14,392.52

Service Code	MSDRG 841
Min. Negotiated Rate	$14,392.52
Max. Negotiated Rate	$14,392.52
Rate for Payer: BCBS Commercial	$14,392.52

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC

Facility

$28,583.57

Service Code	MSDRG 840
Min. Negotiated Rate	$28,583.57
Max. Negotiated Rate	$28,583.57
Rate for Payer: BCBS Commercial	$28,583.57

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC

Facility

$21,996.50

Service Code	MSDRG 824
Min. Negotiated Rate	$21,996.50
Max. Negotiated Rate	$21,996.50
Rate for Payer: BCBS Commercial	$21,996.50

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC

Facility

$42,981.07

Service Code	MSDRG 823
Min. Negotiated Rate	$42,981.07
Max. Negotiated Rate	$42,981.07
Rate for Payer: BCBS Commercial	$42,981.07

LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$13,002.34

Service Code	MSDRG 825
Min. Negotiated Rate	$13,002.34
Max. Negotiated Rate	$13,002.34
Rate for Payer: BCBS Commercial	$13,002.34

LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$9,736.44

Service Code	MSDRG 842
Min. Negotiated Rate	$9,736.44
Max. Negotiated Rate	$9,736.44
Rate for Payer: BCBS Commercial	$9,736.44

LYRICA 25 MG CAP (PREGABALIN)

Facility

$4.00

Service Code	NDC 65862075890
Hospital Charge Code	2510139
Hospital Revenue Code	250
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$3.64
Rate for Payer: Celtic Commercial/Exchange	$1.85
Rate for Payer: Health Partners Plans Commercial	$3.80
Rate for Payer: UnitedHealthcare Commercial	$3.88
Rate for Payer: WPPA Commercial	$3.36

LYRICA 25 MG CAP (PREGABALIN)

Facility

$4.00

Service Code	NDC 65862075890
Hospital Charge Code	2510139
Hospital Revenue Code	250
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$3.64
Rate for Payer: Health Partners Plans Commercial	$3.80
Rate for Payer: UnitedHealthcare Commercial	$3.88
Rate for Payer: WPPA Commercial	$3.28

LYRICA 50 MG CAP

Facility

$32.00

Hospital Charge Code	2519270
Hospital Revenue Code	250
Min. Negotiated Rate	$26.24
Max. Negotiated Rate	$31.04
Rate for Payer: Cash Price	$24.30
Rate for Payer: Health Partners Plans Commercial	$30.40
Rate for Payer: UnitedHealthcare Commercial	$31.04
Rate for Payer: WPPA Commercial	$26.24

Know your out-of-pocket cost for care.

All Charges