Ness County Hospital

All Charges

Charge

Type

Setting

Price

OP RM-ADM 2/MORE SGL/COMB VAC

Facility

$67.00

Service Code	HCPCS 90472
Hospital Charge Code	4590605
Hospital Revenue Code	761
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$64.99
Rate for Payer: BCBS Commercial	$8.08
Rate for Payer: Cash Price	$50.25
Rate for Payer: Cash Price	$50.25
Rate for Payer: Celtic Commercial/Exchange	$30.95
Rate for Payer: Health Partners Plans Commercial	$63.65
Rate for Payer: UnitedHealthcare Commercial	$64.99
Rate for Payer: WPPA Commercial	$56.28

OP RM-ADM 2/MORE SGL/COMB VAC

Facility

$67.00

Service Code	HCPCS 90472
Hospital Charge Code	4590605
Hospital Revenue Code	761
Min. Negotiated Rate	$54.94
Max. Negotiated Rate	$64.99
Rate for Payer: Cash Price	$50.25
Rate for Payer: Health Partners Plans Commercial	$63.65
Rate for Payer: UnitedHealthcare Commercial	$64.99
Rate for Payer: WPPA Commercial	$54.94

OP SITE DRESSING 11X4

Facility

$9.00

Hospital Charge Code	2722247
Hospital Revenue Code	272
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Celtic Commercial/Exchange	$4.16
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.56

OP SITE DRESSING 11X4

Facility

$9.00

Hospital Charge Code	2722247
Hospital Revenue Code	272
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.38

OPTIFOAM 3X3

Facility

$9.00

Hospital Charge Code	2723146LTC
Hospital Revenue Code	272
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.38

OPTIFOAM 3X3

Facility

$9.00

Hospital Charge Code	2723146LTC
Hospital Revenue Code	272
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Celtic Commercial/Exchange	$4.16
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.56

OPTIFOAM DRESSING

Facility

$9.00

Hospital Charge Code	2723146
Hospital Revenue Code	272
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.38

OPTIFOAM DRESSING

Facility

$9.00

Hospital Charge Code	2723146
Hospital Revenue Code	272
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Celtic Commercial/Exchange	$4.16
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.56

OPTIFOAM GENTLE EX 4X4

Facility

$9.00

Hospital Charge Code	2723145LTC
Hospital Revenue Code	272
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.38

OPTIFOAM GENTLE EX 4X4

Facility

$9.00

Hospital Charge Code	2723145LTC
Hospital Revenue Code	272
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Celtic Commercial/Exchange	$4.16
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.56

OPTIFOAM GENTLE SACRAL LG

Facility

$29.00

Hospital Charge Code	2709415
Hospital Revenue Code	272
Min. Negotiated Rate	$23.78
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$21.75
Rate for Payer: Health Partners Plans Commercial	$27.55
Rate for Payer: UnitedHealthcare Commercial	$28.13
Rate for Payer: WPPA Commercial	$23.78

OPTIFOAM GENTLE SACRAL LG

Facility

$29.00

Hospital Charge Code	2709415
Hospital Revenue Code	272
Min. Negotiated Rate	$13.40
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$21.75
Rate for Payer: Celtic Commercial/Exchange	$13.40
Rate for Payer: Health Partners Plans Commercial	$27.55
Rate for Payer: UnitedHealthcare Commercial	$28.13
Rate for Payer: WPPA Commercial	$24.36

OPTIFOAM GENTLE SACRAL SM

Facility

$19.00

Hospital Charge Code	2709414
Hospital Revenue Code	272
Min. Negotiated Rate	$15.58
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$14.25
Rate for Payer: Health Partners Plans Commercial	$18.05
Rate for Payer: UnitedHealthcare Commercial	$18.43
Rate for Payer: WPPA Commercial	$15.58

OPTIFOAM GENTLE SACRAL SM

Facility

$19.00

Hospital Charge Code	2709414
Hospital Revenue Code	272
Min. Negotiated Rate	$8.78
Max. Negotiated Rate	$18.43
Rate for Payer: Cash Price	$14.25
Rate for Payer: Celtic Commercial/Exchange	$8.78
Rate for Payer: Health Partners Plans Commercial	$18.05
Rate for Payer: UnitedHealthcare Commercial	$18.43
Rate for Payer: WPPA Commercial	$15.96

OPTIFOAM GENTLE SILICONE FOAM

Facility

$9.00

Hospital Charge Code	2723144
Hospital Revenue Code	272
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Celtic Commercial/Exchange	$4.16
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.56

OPTIFOAM GENTLE SILICONE FOAM

Facility

$9.00

Hospital Charge Code	2723144
Hospital Revenue Code	272
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.38

OPTIFOAM GENT. SILIC. BORD 3X3

Facility

$9.00

Hospital Charge Code	2709421
Hospital Revenue Code	272
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.38

OPTIFOAM GENT. SILIC. BORD 3X3

Facility

$9.00

Hospital Charge Code	2709421
Hospital Revenue Code	272
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Celtic Commercial/Exchange	$4.16
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.56

OPTIFOAM GENT. SILIC BORD 4X4

Facility

$9.00

Hospital Charge Code	2709420
Hospital Revenue Code	272
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.38

OPTIFOAM GENT. SILIC BORD 4X4

Facility

$9.00

Hospital Charge Code	2709420
Hospital Revenue Code	272
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Celtic Commercial/Exchange	$4.16
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.56

OPTIFOAM SACRAL LG LTC

Facility

$29.00

Hospital Charge Code	2709415LTC
Hospital Revenue Code	272
Min. Negotiated Rate	$23.78
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$21.75
Rate for Payer: Health Partners Plans Commercial	$27.55
Rate for Payer: UnitedHealthcare Commercial	$28.13
Rate for Payer: WPPA Commercial	$23.78

OPTIFOAM SACRAL LG LTC

Facility

$29.00

Hospital Charge Code	2709415LTC
Hospital Revenue Code	272
Min. Negotiated Rate	$13.40
Max. Negotiated Rate	$28.13
Rate for Payer: Cash Price	$21.75
Rate for Payer: Celtic Commercial/Exchange	$13.40
Rate for Payer: Health Partners Plans Commercial	$27.55
Rate for Payer: UnitedHealthcare Commercial	$28.13
Rate for Payer: WPPA Commercial	$24.36

ORAL CARE SINGLE USE

Facility

$9.00

Hospital Charge Code	2720101
Hospital Revenue Code	270
Min. Negotiated Rate	$7.38
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.38

ORAL CARE SINGLE USE

Facility

$9.00

Hospital Charge Code	2720101
Hospital Revenue Code	270
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$8.73
Rate for Payer: Cash Price	$6.75
Rate for Payer: Celtic Commercial/Exchange	$4.16
Rate for Payer: Health Partners Plans Commercial	$8.55
Rate for Payer: UnitedHealthcare Commercial	$8.73
Rate for Payer: WPPA Commercial	$7.56

ORAL CLEANSING & SUCTION SYST

Facility

$126.00

Hospital Charge Code	2720103
Hospital Revenue Code	270
Min. Negotiated Rate	$58.21
Max. Negotiated Rate	$122.22
Rate for Payer: Cash Price	$94.50
Rate for Payer: Celtic Commercial/Exchange	$58.21
Rate for Payer: Health Partners Plans Commercial	$119.70
Rate for Payer: UnitedHealthcare Commercial	$122.22
Rate for Payer: WPPA Commercial	$105.84

Know your out-of-pocket cost for care.

All Charges