Ness County Hospital

All Charges

Charge

Type

Setting

Price

NUTRITION THER-REASSESSMENT

Facility

$44.00

Service Code	HCPCS 97803
Hospital Charge Code	9420027
Hospital Revenue Code	942
Min. Negotiated Rate	$36.08
Max. Negotiated Rate	$42.68
Rate for Payer: Cash Price	$33.00
Rate for Payer: Health Partners Plans Commercial	$41.80
Rate for Payer: UnitedHealthcare Commercial	$42.68
Rate for Payer: WPPA Commercial	$36.08

NUTRITION THER-REASSESSMENT

Facility

$44.00

Service Code	HCPCS 97803
Hospital Charge Code	9420027
Hospital Revenue Code	942
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$42.68
Rate for Payer: BCBS Commercial	$14.70
Rate for Payer: Cash Price	$33.00
Rate for Payer: Cash Price	$33.00
Rate for Payer: Celtic Commercial/Exchange	$20.33
Rate for Payer: Health Partners Plans Commercial	$41.80
Rate for Payer: UnitedHealthcare Commercial	$42.68
Rate for Payer: WPPA Commercial	$36.96

NUTR THER,INIT ASSESS ea. 15 min

Facility

$25.00

Service Code	HCPCS 97802
Hospital Charge Code	9780200
Hospital Revenue Code	942
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$24.25
Rate for Payer: BCBS Commercial	$14.70
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

NUTR THER,INIT ASSESS ea. 15 min

Facility

$25.00

Service Code	HCPCS 97802
Hospital Charge Code	9780200
Hospital Revenue Code	942
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

NYSTATIN OS 500,000 U/5 ml U.D.

Facility

$5.00

Service Code	NDC 00121086805
Hospital Charge Code	2517985
Hospital Revenue Code	250
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.82
Rate for Payer: Health Partners Plans Commercial	$4.75
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: WPPA Commercial	$4.10

NYSTATIN OS 500,000 U/5 ml U.D.

Facility

$5.00

Service Code	NDC 00121086805
Hospital Charge Code	2517985
Hospital Revenue Code	250
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.82
Rate for Payer: Celtic Commercial/Exchange	$2.31
Rate for Payer: Health Partners Plans Commercial	$4.75
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: WPPA Commercial	$4.20

NYSTATIN PWD 100,000 U/GM (NYSTOP) 15 GM

Facility

$82.00

Service Code	NDC 00574200815
Hospital Charge Code	2518629
Hospital Revenue Code	250
Min. Negotiated Rate	$67.24
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$61.80
Rate for Payer: Health Partners Plans Commercial	$77.90
Rate for Payer: UnitedHealthcare Commercial	$79.54
Rate for Payer: WPPA Commercial	$67.24

NYSTATIN PWD 100,000 U/GM (NYSTOP) 15 GM

Facility

$82.00

Service Code	NDC 00574200815
Hospital Charge Code	2518629
Hospital Revenue Code	250
Min. Negotiated Rate	$37.88
Max. Negotiated Rate	$79.54
Rate for Payer: Cash Price	$61.80
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

O2 CONNECTING TUBE, 25 FT

Facility

$11.00

Hospital Charge Code	4100327
Hospital Revenue Code	270
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

O2 CONNECTING TUBE, 25 FT

Facility

$11.00

Hospital Charge Code	4100327
Hospital Revenue Code	270
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

O2 CONNECTOR SUPPLY TUBING

Facility

$5.00

Hospital Charge Code	4100329
Hospital Revenue Code	270
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.75
Rate for Payer: Celtic Commercial/Exchange	$2.31
Rate for Payer: Health Partners Plans Commercial	$4.75
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: WPPA Commercial	$4.20

O2 CONNECTOR SUPPLY TUBING

Facility

$5.00

Hospital Charge Code	4100329
Hospital Revenue Code	270
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.75
Rate for Payer: Health Partners Plans Commercial	$4.75
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: WPPA Commercial	$4.10

O2 CONNECTOR SWIVEL LTC

Facility

$5.00

Hospital Charge Code	4100502LTC
Hospital Revenue Code	272
Min. Negotiated Rate	$2.31
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.75
Rate for Payer: Celtic Commercial/Exchange	$2.31
Rate for Payer: Health Partners Plans Commercial	$4.75
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: WPPA Commercial	$4.20

O2 CONNECTOR SWIVEL LTC

Facility

$5.00

Hospital Charge Code	4100502LTC
Hospital Revenue Code	272
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$4.85
Rate for Payer: Cash Price	$3.75
Rate for Payer: Health Partners Plans Commercial	$4.75
Rate for Payer: UnitedHealthcare Commercial	$4.85
Rate for Payer: WPPA Commercial	$4.10

O2 TUBING 25'

Facility

$11.00

Hospital Charge Code	4100327LTC
Hospital Revenue Code	270
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

O2 TUBING 25'

Facility

$11.00

Hospital Charge Code	4100327LTC
Hospital Revenue Code	270
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

O2 TUBING 7"

Facility

$11.00

Hospital Charge Code	4100328
Hospital Revenue Code	270
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

O2 TUBING 7"

Facility

$11.00

Hospital Charge Code	4100328
Hospital Revenue Code	270
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

O2 TUBING 7' LTC

Facility

$11.00

Hospital Charge Code	4100328LTC
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

O2 TUBING 7' LTC

Facility

$11.00

Hospital Charge Code	4100328LTC
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

O2 WATER TRAP

Facility

$10.00

Hospital Charge Code	2709712
Hospital Revenue Code	270
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$7.50
Rate for Payer: Celtic Commercial/Exchange	$4.62
Rate for Payer: Health Partners Plans Commercial	$9.50
Rate for Payer: UnitedHealthcare Commercial	$9.70
Rate for Payer: WPPA Commercial	$8.40

O2 WATER TRAP

Facility

$10.00

Hospital Charge Code	2709712
Hospital Revenue Code	270
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$7.50
Rate for Payer: Health Partners Plans Commercial	$9.50
Rate for Payer: UnitedHealthcare Commercial	$9.70
Rate for Payer: WPPA Commercial	$8.20

O2 WATER TRAP LTC

Facility

$10.00

Hospital Charge Code	2709712LTC
Hospital Revenue Code	272
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$7.50
Rate for Payer: Celtic Commercial/Exchange	$4.62
Rate for Payer: Health Partners Plans Commercial	$9.50
Rate for Payer: UnitedHealthcare Commercial	$9.70
Rate for Payer: WPPA Commercial	$8.40

O2 WATER TRAP LTC

Facility

$10.00

Hospital Charge Code	2709712LTC
Hospital Revenue Code	272
Min. Negotiated Rate	$8.20
Max. Negotiated Rate	$9.70
Rate for Payer: Cash Price	$7.50
Rate for Payer: Health Partners Plans Commercial	$9.50
Rate for Payer: UnitedHealthcare Commercial	$9.70
Rate for Payer: WPPA Commercial	$8.20

OB PACK

Facility

$49.00

Hospital Charge Code	2709757
Hospital Revenue Code	270
Min. Negotiated Rate	$22.64
Max. Negotiated Rate	$47.53
Rate for Payer: Cash Price	$36.75
Rate for Payer: Celtic Commercial/Exchange	$22.64
Rate for Payer: Health Partners Plans Commercial	$46.55
Rate for Payer: UnitedHealthcare Commercial	$47.53
Rate for Payer: WPPA Commercial	$41.16

Know your out-of-pocket cost for care.

All Charges