Madison Medical Center

All Charges

Charge

Type

Setting

Price

CETUXIMAB (ERBITUX) 200MG/100ML IVP

Facility

$11,993.00

Service Code	HCPCS J9055
Hospital Charge Code	2626575
Hospital Revenue Code	335
Min. Negotiated Rate	$81.67
Max. Negotiated Rate	$8,563.00
Rate for Payer: Aetna Medicare Advantage	$81.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7,099.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$8,563.00
Rate for Payer: Cash Price	$10,793.70
Rate for Payer: Cash Price	$10,793.70
Rate for Payer: Cigna Commercial HMO & PPO	$81.67
Rate for Payer: Home State Health Plan Medicare Advantage	$81.67
Rate for Payer: Humana Commercial	$163.34
Rate for Payer: Humana Medicare Advantage	$81.67
Rate for Payer: UnitedHealthcare Commercial	$7,999.33
Rate for Payer: UnitedHealthcare Medicare Advantage	$4,317.48

CETUXIMAB (ERBITUX) 200MG/100ML IVP

Facility

$11,993.00

Service Code	HCPCS J9055
Hospital Charge Code	2626575
Hospital Revenue Code	335
Rate for Payer: Cash Price	$10,793.70

CEVIMELINE (EVOXAC) 30 MG CAPS EMP

Facility

$9.00

Service Code	NDC 6.3395E+10
Hospital Charge Code	2623001
Hospital Revenue Code	250
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$6.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$5.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$6.43
Rate for Payer: Cash Price	$8.10
Rate for Payer: UnitedHealthcare Commercial	$6.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.24

CEVIMELINE (EVOXAC) 30 MG CAPS EMP

Facility

$9.00

Service Code	NDC 6.3395E+10
Hospital Charge Code	2623001
Hospital Revenue Code	250
Rate for Payer: Cash Price	$8.10

C G F BORDER

Facility

$112.00

Hospital Charge Code	283247
Hospital Revenue Code	271
Rate for Payer: Cash Price	$100.80

C G F BORDER

Facility

$112.00

Hospital Charge Code	283247
Hospital Revenue Code	271
Min. Negotiated Rate	$40.32
Max. Negotiated Rate	$79.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$66.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$79.97
Rate for Payer: Cash Price	$100.80
Rate for Payer: UnitedHealthcare Commercial	$74.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.32

C G F WAFER X-TRA THIN

Facility

$48.00

Hospital Charge Code	283249
Hospital Revenue Code	271
Min. Negotiated Rate	$17.28
Max. Negotiated Rate	$34.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$28.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$34.27
Rate for Payer: Cash Price	$43.20
Rate for Payer: UnitedHealthcare Commercial	$32.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.28

C G F WAFER X-TRA THIN

Facility

$48.00

Hospital Charge Code	283249
Hospital Revenue Code	271
Rate for Payer: Cash Price	$43.20

CH50

Facility

$166.00

Service Code	CPT 86162
Hospital Charge Code	223527
Hospital Revenue Code	301
Min. Negotiated Rate	$18.29
Max. Negotiated Rate	$118.52
Rate for Payer: Aetna Better Health Medicaid/QHP	$18.29
Rate for Payer: Aetna Medicare Advantage	$20.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$98.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$118.52
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cigna Commercial HMO & PPO	$20.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$18.29
Rate for Payer: Home State Health Plan Medicaid Managed Care	$19.57
Rate for Payer: Home State Health Plan Medicare Advantage	$20.32
Rate for Payer: Humana Commercial	$40.64
Rate for Payer: Humana Medicare Advantage	$20.32
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$18.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$59.76

CH50

Facility

$166.00

Service Code	CPT 86162
Hospital Charge Code	223527
Hospital Revenue Code	301
Rate for Payer: Cash Price	$149.40

CHANTIX 0.5MG TAB EMP

Facility

$24.00

Service Code	NDC 69046856
Hospital Charge Code	2623201
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

CHANTIX 0.5MG TAB EMP

Facility

$24.00

Service Code	NDC 69046856
Hospital Charge Code	2623201
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.14
Rate for Payer: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

CHANTIX 1MG MAINTENANCE PAK EMP

Facility

$1,889.00

Service Code	NDC 69046903
Hospital Charge Code	2623319
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,700.10

CHANTIX 1MG MAINTENANCE PAK EMP

Facility

$1,889.00

Service Code	NDC 69046903
Hospital Charge Code	2623319
Hospital Revenue Code	250
Min. Negotiated Rate	$680.04
Max. Negotiated Rate	$1,348.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,118.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,348.75
Rate for Payer: Cash Price	$1,700.10
Rate for Payer: UnitedHealthcare Commercial	$1,259.96
Rate for Payer: UnitedHealthcare Medicare Advantage	$680.04

CHANTIX 1MG TAB EMP

Facility

$24.00

Service Code	NDC 1E+11
Hospital Charge Code	2622160
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

CHANTIX 1MG TAB EMP

Facility

$24.00

Service Code	NDC 1E+11
Hospital Charge Code	2622160
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.14
Rate for Payer: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

CHANTIX STARTING MONTH PAK EMP

Facility

$1,889.00

Service Code	NDC 69047103
Hospital Charge Code	2623233
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,700.10

CHANTIX STARTING MONTH PAK EMP

Facility

$1,889.00

Service Code	NDC 69047103
Hospital Charge Code	2623233
Hospital Revenue Code	250
Min. Negotiated Rate	$680.04
Max. Negotiated Rate	$1,348.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,118.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,348.75
Rate for Payer: Cash Price	$1,700.10
Rate for Payer: UnitedHealthcare Commercial	$1,259.96
Rate for Payer: UnitedHealthcare Medicare Advantage	$680.04

CHEANEY INFLUENZA A&B TEST

Facility

$123.00

Service Code	CPT 87502
Hospital Charge Code	5287502
Hospital Revenue Code	521
Rate for Payer: Cash Price	$110.70

CHEANEY INFLUENZA A&B TEST

Facility

$123.00

Service Code	CPT 87502
Hospital Charge Code	5287502
Hospital Revenue Code	521
Min. Negotiated Rate	$72.82
Max. Negotiated Rate	$191.60
Rate for Payer: Aetna Better Health Medicaid/QHP	$86.22
Rate for Payer: Aetna Medicare Advantage	$95.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$72.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$87.82
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cigna Commercial HMO & PPO	$95.80
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$77.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$92.26
Rate for Payer: Home State Health Plan Medicare Advantage	$95.80
Rate for Payer: Humana Commercial	$191.60
Rate for Payer: Humana Medicare Advantage	$95.80
Rate for Payer: UnitedHealthcare Commercial	$82.04
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$86.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CHEANEY RSV

Facility

$123.00

Service Code	CPT 87634
Hospital Charge Code	5287634
Hospital Revenue Code	521
Min. Negotiated Rate	$56.86
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$63.18
Rate for Payer: Aetna Medicare Advantage	$70.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$72.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$87.82
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cigna Commercial HMO & PPO	$70.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$56.86
Rate for Payer: Home State Health Plan Medicaid Managed Care	$67.60
Rate for Payer: Home State Health Plan Medicare Advantage	$70.20
Rate for Payer: Humana Commercial	$140.40
Rate for Payer: Humana Medicare Advantage	$70.20
Rate for Payer: UnitedHealthcare Commercial	$82.04
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$63.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CHEANEY RSV

Facility

$123.00

Service Code	CPT 87634
Hospital Charge Code	5287634
Hospital Revenue Code	521
Rate for Payer: Cash Price	$110.70

CHEANEY STREP

Facility

$75.00

Service Code	CPT 87651
Hospital Charge Code	5287651
Hospital Revenue Code	521
Rate for Payer: Cash Price	$67.50

CHEANEY STREP

Facility

$75.00

Service Code	CPT 87651
Hospital Charge Code	5287651
Hospital Revenue Code	521
Min. Negotiated Rate	$28.42
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$31.58
Rate for Payer: Aetna Medicare Advantage	$35.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$53.55
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial HMO & PPO	$35.09
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$28.42
Rate for Payer: Home State Health Plan Medicaid Managed Care	$33.79
Rate for Payer: Home State Health Plan Medicare Advantage	$35.09
Rate for Payer: Humana Commercial	$70.18
Rate for Payer: Humana Medicare Advantage	$35.09
Rate for Payer: UnitedHealthcare Commercial	$50.02
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$31.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CHEANEY URINE DIP

Facility

$27.00

Service Code	CPT 81002
Hospital Charge Code	5281002
Hospital Revenue Code	521
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$3.13
Rate for Payer: Aetna Medicare Advantage	$3.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$15.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.28
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial HMO & PPO	$3.48
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$2.82
Rate for Payer: Home State Health Plan Medicaid Managed Care	$3.35
Rate for Payer: Home State Health Plan Medicare Advantage	$3.48
Rate for Payer: Humana Commercial	$6.96
Rate for Payer: Humana Medicare Advantage	$3.48
Rate for Payer: UnitedHealthcare Commercial	$18.01
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$3.13
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Know your out-of-pocket cost for care.

All Charges