Ness County Hospital

All Charges

Charge

Type

Setting

Price

SYNTHROID 112 MCG TAB (LEVOTHYROXINE)

Facility

$3.00

Service Code	NDC 60687050811
Hospital Charge Code	2509172
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

SYNTHROID 112 MCG TAB (LEVOTHYROXINE)

Facility

$3.00

Service Code	NDC 60687050811
Hospital Charge Code	2509172
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

SYNTHROID 125 MCG TAB (LEVOTHYROXINE)

Facility

$4.00

Service Code	NDC 60687051911
Hospital Charge Code	2507945
Hospital Revenue Code	250
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$3.38
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

SYNTHROID 125 MCG TAB (LEVOTHYROXINE)

Facility

$4.00

Service Code	NDC 60687051911
Hospital Charge Code	2507945
Hospital Revenue Code	250
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$3.38
Rate for Payer: Health Partners Plans Commercial	$3.80
Rate for Payer: UnitedHealthcare Commercial	$3.88
Rate for Payer: WPPA Commercial	$3.28

SYNTHROID 150 MCG TAB (LEVOTHYROXINE)

Facility

$4.00

Service Code	NDC 60687053011
Hospital Charge Code	2510634
Hospital Revenue Code	250
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$3.38
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

SYNTHROID 150 MCG TAB (LEVOTHYROXINE)

Facility

$4.00

Service Code	NDC 60687053011
Hospital Charge Code	2510634
Hospital Revenue Code	250
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$3.38
Rate for Payer: Health Partners Plans Commercial	$3.80
Rate for Payer: UnitedHealthcare Commercial	$3.88
Rate for Payer: WPPA Commercial	$3.28

SYNTHROID 25 MCG TAB (LEVOTHYROXINE)

Facility

$1.00

Service Code	NDC 60687045311
Hospital Charge Code	2506798
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$1.27
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

SYNTHROID 25 MCG TAB (LEVOTHYROXINE)

Facility

$1.00

Service Code	NDC 60687045311
Hospital Charge Code	2506798
Hospital Revenue Code	250
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$0.97
Rate for Payer: Cash Price	$1.27
Rate for Payer: Health Partners Plans Commercial	$0.95
Rate for Payer: UnitedHealthcare Commercial	$0.97
Rate for Payer: WPPA Commercial	$0.82

SYNTHROID 50 MCG TAB (LEVOTHYROXINE)

Facility

$4.00

Service Code	NDC 60687046411
Hospital Charge Code	2519635
Hospital Revenue Code	250
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$3.22
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

SYNTHROID 50 MCG TAB (LEVOTHYROXINE)

Facility

$4.00

Service Code	NDC 60687046411
Hospital Charge Code	2519635
Hospital Revenue Code	250
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$3.88
Rate for Payer: Cash Price	$3.22
Rate for Payer: Health Partners Plans Commercial	$3.80
Rate for Payer: UnitedHealthcare Commercial	$3.88
Rate for Payer: WPPA Commercial	$3.28

SYNTHROID 88 MCG TAB (LEVOTHYROXINE)

Facility

$3.00

Service Code	NDC 60687048611
Hospital Charge Code	2507390
Hospital Revenue Code	250
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$2.92
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

SYNTHROID 88 MCG TAB (LEVOTHYROXINE)

Facility

$3.00

Service Code	NDC 60687048611
Hospital Charge Code	2507390
Hospital Revenue Code	250
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$2.91
Rate for Payer: Cash Price	$2.92
Rate for Payer: Health Partners Plans Commercial	$2.85
Rate for Payer: UnitedHealthcare Commercial	$2.91
Rate for Payer: WPPA Commercial	$2.46

Synvisc-One 6 ml syringe/48 mg

Facility

$4,931.00

Service Code	NDC 58468009003
Hospital Charge Code	2519882
Hospital Revenue Code	250
Min. Negotiated Rate	$4,043.42
Max. Negotiated Rate	$4,783.07
Rate for Payer: Cash Price	$3,698.89
Rate for Payer: Health Partners Plans Commercial	$4,684.45
Rate for Payer: UnitedHealthcare Commercial	$4,783.07
Rate for Payer: WPPA Commercial	$4,043.42

Synvisc-One 6 ml syringe/48 mg

Facility

$4,931.00

Service Code	NDC 58468009003
Hospital Charge Code	2519882
Hospital Revenue Code	250
Min. Negotiated Rate	$2,278.12
Max. Negotiated Rate	$4,783.07
Rate for Payer: Cash Price	$3,698.89
Rate for Payer: Celtic Commercial/Exchange	$2,278.12
Rate for Payer: Health Partners Plans Commercial	$4,684.45
Rate for Payer: UnitedHealthcare Commercial	$4,783.07
Rate for Payer: WPPA Commercial	$4,142.04

SYPHILIS TEST, QUAL.

Facility

$57.00

Service Code	HCPCS 86592
Hospital Charge Code	8659200
Hospital Revenue Code	302
Min. Negotiated Rate	$46.74
Max. Negotiated Rate	$55.29
Rate for Payer: Cash Price	$42.75
Rate for Payer: Health Partners Plans Commercial	$54.15
Rate for Payer: UnitedHealthcare Commercial	$55.29
Rate for Payer: WPPA Commercial	$46.74

SYPHILIS TEST, QUAL.

Facility

$57.00

Service Code	HCPCS 86592
Hospital Charge Code	8659200
Hospital Revenue Code	302
Min. Negotiated Rate	$16.26
Max. Negotiated Rate	$55.29
Rate for Payer: BCBS Commercial	$16.26
Rate for Payer: Cash Price	$42.75
Rate for Payer: Cash Price	$42.75
Rate for Payer: Celtic Commercial/Exchange	$26.33
Rate for Payer: Health Partners Plans Commercial	$54.15
Rate for Payer: UnitedHealthcare Commercial	$55.29
Rate for Payer: WPPA Commercial	$47.88

SYRINGE BULB EAR ULCER

Facility

$12.00

Hospital Charge Code	2707000
Hospital Revenue Code	272
Min. Negotiated Rate	$9.84
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$9.00
Rate for Payer: Health Partners Plans Commercial	$11.40
Rate for Payer: UnitedHealthcare Commercial	$11.64
Rate for Payer: WPPA Commercial	$9.84

SYRINGE BULB EAR ULCER

Facility

$12.00

Hospital Charge Code	2707000
Hospital Revenue Code	272
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$11.64
Rate for Payer: Cash Price	$9.00
Rate for Payer: Celtic Commercial/Exchange	$5.54
Rate for Payer: Health Partners Plans Commercial	$11.40
Rate for Payer: UnitedHealthcare Commercial	$11.64
Rate for Payer: WPPA Commercial	$10.08

SYSTEMIC LUPUS ERYTHEMATOSUS

Facility

$689.00

Hospital Charge Code	8888916
Hospital Revenue Code	302
Min. Negotiated Rate	$564.98
Max. Negotiated Rate	$668.33
Rate for Payer: Cash Price	$516.75
Rate for Payer: Health Partners Plans Commercial	$654.55
Rate for Payer: UnitedHealthcare Commercial	$668.33
Rate for Payer: WPPA Commercial	$564.98

SYSTEMIC LUPUS ERYTHEMATOSUS

Facility

$689.00

Hospital Charge Code	8888916
Hospital Revenue Code	302
Min. Negotiated Rate	$318.32
Max. Negotiated Rate	$668.33
Rate for Payer: Cash Price	$516.75
Rate for Payer: Celtic Commercial/Exchange	$318.32
Rate for Payer: Health Partners Plans Commercial	$654.55
Rate for Payer: UnitedHealthcare Commercial	$668.33
Rate for Payer: WPPA Commercial	$578.76

T3,T4,TSH

Facility

$220.00

Hospital Charge Code	8888830
Hospital Revenue Code	301
Min. Negotiated Rate	$180.40
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$165.00
Rate for Payer: Health Partners Plans Commercial	$209.00
Rate for Payer: UnitedHealthcare Commercial	$213.40
Rate for Payer: WPPA Commercial	$180.40

T3,T4,TSH

Facility

$220.00

Hospital Charge Code	8888830
Hospital Revenue Code	301
Min. Negotiated Rate	$101.64
Max. Negotiated Rate	$213.40
Rate for Payer: Cash Price	$165.00
Rate for Payer: Celtic Commercial/Exchange	$101.64
Rate for Payer: Health Partners Plans Commercial	$209.00
Rate for Payer: UnitedHealthcare Commercial	$213.40
Rate for Payer: WPPA Commercial	$184.80

TACROLIMUS

Facility

$176.00

Service Code	HCPCS 80197
Hospital Charge Code	8019700
Hospital Revenue Code	301
Min. Negotiated Rate	$144.32
Max. Negotiated Rate	$170.72
Rate for Payer: Cash Price	$132.00
Rate for Payer: Health Partners Plans Commercial	$167.20
Rate for Payer: UnitedHealthcare Commercial	$170.72
Rate for Payer: WPPA Commercial	$144.32

TACROLIMUS

Facility

$176.00

Service Code	HCPCS 80197
Hospital Charge Code	8019700
Hospital Revenue Code	301
Min. Negotiated Rate	$67.35
Max. Negotiated Rate	$170.72
Rate for Payer: BCBS Commercial	$67.35
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Celtic Commercial/Exchange	$81.31
Rate for Payer: Health Partners Plans Commercial	$167.20
Rate for Payer: UnitedHealthcare Commercial	$170.72
Rate for Payer: WPPA Commercial	$147.84

TAGAMET 300 MG TAB (CIMETIDINE)

Facility

$6.00

Service Code	NDC 00093819201
Hospital Charge Code	2506855
Hospital Revenue Code	250
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$5.82
Rate for Payer: Cash Price	$4.61
Rate for Payer: Celtic Commercial/Exchange	$2.77
Rate for Payer: Health Partners Plans Commercial	$5.70
Rate for Payer: UnitedHealthcare Commercial	$5.82
Rate for Payer: WPPA Commercial	$5.04

Know your out-of-pocket cost for care.

All Charges