Madison Medical Center

All Charges

Charge

Type

Setting

Price

CHLAMYDIA

Facility

$32.00

Service Code	CPT 86317
Hospital Charge Code	5286317
Hospital Revenue Code	521
Rate for Payer: Cash Price	$28.80

CHLAMYDIA AB

Facility

$199.00

Service Code	CPT 86631
Hospital Charge Code	223897
Hospital Revenue Code	302
Min. Negotiated Rate	$10.64
Max. Negotiated Rate	$142.09
Rate for Payer: Aetna Better Health Medicaid/QHP	$10.64
Rate for Payer: Aetna Medicare Advantage	$11.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$117.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$142.09
Rate for Payer: Cash Price	$179.10
Rate for Payer: Cash Price	$179.10
Rate for Payer: Cash Price	$179.10
Rate for Payer: Cigna Commercial HMO & PPO	$11.82
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$10.64
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11.38
Rate for Payer: Home State Health Plan Medicare Advantage	$11.82
Rate for Payer: Humana Commercial	$23.64
Rate for Payer: Humana Medicare Advantage	$11.82
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$10.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$71.64

CHLAMYDIA AB

Facility

$199.00

Service Code	CPT 86631
Hospital Charge Code	223897
Hospital Revenue Code	302
Rate for Payer: Cash Price	$179.10

CHLAMYDIA CULTURE

Facility

$35.00

Service Code	CPT 87110
Hospital Charge Code	5287110
Hospital Revenue Code	521
Rate for Payer: Cash Price	$31.50

CHLAMYDIA CULTURE

Facility

$35.00

Service Code	CPT 87110
Hospital Charge Code	5287110
Hospital Revenue Code	521
Min. Negotiated Rate	$15.88
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$17.64
Rate for Payer: Aetna Medicare Advantage	$19.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24.99
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial HMO & PPO	$19.60
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.88
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18.87
Rate for Payer: Home State Health Plan Medicare Advantage	$19.60
Rate for Payer: Humana Commercial	$39.20
Rate for Payer: Humana Medicare Advantage	$19.60
Rate for Payer: UnitedHealthcare Commercial	$23.34
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CHLAMYDIA DNA PROBE

Facility

$159.00

Service Code	CPT 87491
Hospital Charge Code	303007
Hospital Revenue Code	306
Rate for Payer: Cash Price	$143.10

CHLAMYDIA DNA PROBE

Facility

$159.00

Service Code	CPT 87491
Hospital Charge Code	303007
Hospital Revenue Code	306
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$113.53
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	$94.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$113.53
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial HMO & PPO	$35.09
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$31.58
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	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$31.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$57.24

CHLAMYDIA GC TRICHOMONAS BY NAA

Facility

$139.00

Service Code	CPT 87801
Hospital Charge Code	2287211
Hospital Revenue Code	306
Rate for Payer: Cash Price	$125.10

CHLAMYDIA GC TRICHOMONAS BY NAA

Facility

$139.00

Service Code	CPT 87801
Hospital Charge Code	2287211
Hospital Revenue Code	306
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$140.40
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	$82.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$99.25
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial HMO & PPO	$70.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$63.18
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	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$63.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$50.04

CHLORA PREP (10.5ML) SMALL 260715

Facility

$28.00

Hospital Charge Code	1217067
Hospital Revenue Code	272
Rate for Payer: Cash Price	$25.20

CHLORA PREP (10.5ML) SMALL 260715

Facility

$28.00

Hospital Charge Code	1217067
Hospital Revenue Code	272
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

CHLORA PREP (26ML) LARGE

Facility

$45.00

Hospital Charge Code	1217066
Hospital Revenue Code	272
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.13
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

CHLORA PREP (26ML) LARGE

Facility

$45.00

Hospital Charge Code	1217066
Hospital Revenue Code	272
Rate for Payer: Cash Price	$40.50

CHLORAPREP 3ML APP ORANGE TINT

Facility

$10.00

Hospital Charge Code	1217062
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.00

CHLORAPREP 3ML APP ORANGE TINT

Facility

$10.00

Hospital Charge Code	1217062
Hospital Revenue Code	272
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$7.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$5.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$7.14
Rate for Payer: Cash Price	$9.00
Rate for Payer: UnitedHealthcare Commercial	$6.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.60

CHLORASEPTIC SORE THROAT 177ML SPR

Facility

$75.00

Service Code	NDC 2.4385E+10
Hospital Charge Code	2654561
Hospital Revenue Code	250
Rate for Payer: Cash Price	$67.50

CHLORASEPTIC SORE THROAT 177ML SPR

Facility

$75.00

Service Code	NDC 2.4385E+10
Hospital Charge Code	2654561
Hospital Revenue Code	250
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$53.55
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: UnitedHealthcare Commercial	$50.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

CHLORDIAZEPOXIDE 10MG (LIBRIUM) CAP C4

Facility

$22.00

Service Code	NDC 555003302
Hospital Charge Code	2619466
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

CHLORDIAZEPOXIDE 10MG (LIBRIUM) CAP C4

Facility

$22.00

Service Code	NDC 555003302
Hospital Charge Code	2619466
Hospital Revenue Code	250
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

CHLORDIAZEPOXIDE (LIBRIUM)25MG CAP C4

Facility

$22.00

Service Code	NDC 555015902
Hospital Charge Code	2626604
Hospital Revenue Code	250
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

CHLORDIAZEPOXIDE (LIBRIUM)25MG CAP C4

Facility

$22.00

Service Code	NDC 555015902
Hospital Charge Code	2626604
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

CHLORHEXIDINE GLUCONATE 4% 118ML BOTTLE

Facility

$56.00

Service Code	NDC 234057504
Hospital Charge Code	2697637
Hospital Revenue Code	250
Rate for Payer: Cash Price	$50.40

CHLORHEXIDINE GLUCONATE 4% 118ML BOTTLE

Facility

$56.00

Service Code	NDC 234057504
Hospital Charge Code	2697637
Hospital Revenue Code	250
Min. Negotiated Rate	$20.16
Max. Negotiated Rate	$39.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$33.15
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.98
Rate for Payer: Cash Price	$50.40
Rate for Payer: UnitedHealthcare Commercial	$37.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.16

CHLORHEX ORAL RINSE 0.12% 473ML EMP

Facility

$60.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2697810
Hospital Revenue Code	250
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

CHLORHEX ORAL RINSE 0.12% 473ML EMP

Facility

$60.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2697810
Hospital Revenue Code	250
Rate for Payer: Cash Price	$54.00

Know your out-of-pocket cost for care.

All Charges