Madison Medical Center

All Charges

Charge

Type

Setting

Price

ACYCLOVIR 5% OINT 5GM

Facility

$423.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2697393
Hospital Revenue Code	250
Min. Negotiated Rate	$152.28
Max. Negotiated Rate	$302.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$250.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$302.02
Rate for Payer: Cash Price	$380.70
Rate for Payer: UnitedHealthcare Commercial	$282.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$152.28

ACYCLOVIR (ZOVIRAX) 1000MG IVPB

Facility

$195.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2626610
Hospital Revenue Code	250
Rate for Payer: Cash Price	$175.50

ACYCLOVIR (ZOVIRAX) 1000MG IVPB

Facility

$195.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2626610
Hospital Revenue Code	250
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$139.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$115.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$139.23
Rate for Payer: Cash Price	$175.50
Rate for Payer: UnitedHealthcare Commercial	$130.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$70.20

ACYCLOVIR (ZOVIRAX) 200MG/5ML SUSP

Facility

$24.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2657102
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

ACYCLOVIR (ZOVIRAX) 200MG/5ML SUSP

Facility

$24.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2657102
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

ACYCLOVIR (ZOVIRAX) 200MG CAP EMP

Facility

$39.00

Service Code	NDC 7.5834E+10
Hospital Charge Code	2625130
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.10

ACYCLOVIR (ZOVIRAX) 200MG CAP EMP

Facility

$39.00

Service Code	NDC 7.5834E+10
Hospital Charge Code	2625130
Hospital Revenue Code	250
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

ACYCLOVIR (ZOVIRAX) 400MG TAB

Facility

$39.00

Service Code	NDC 2.3155E+10
Hospital Charge Code	2626515
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.10

ACYCLOVIR (ZOVIRAX) 400MG TAB

Facility

$39.00

Service Code	NDC 2.3155E+10
Hospital Charge Code	2626515
Hospital Revenue Code	250
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

ACYCLOVIR (ZOVIRAX) 400MG TAB EMP

Facility

$39.00

Service Code	NDC 2.3155E+10
Hospital Charge Code	2623042
Hospital Revenue Code	250
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

ACYCLOVIR (ZOVIRAX) 400MG TAB EMP

Facility

$39.00

Service Code	NDC 2.3155E+10
Hospital Charge Code	2623042
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.10

ACYCLOVIR (ZOVIRAX) 500MG VL

Facility

$183.00

Service Code	NDC 5.515E+10
Hospital Charge Code	2684670
Hospital Revenue Code	250
Min. Negotiated Rate	$65.88
Max. Negotiated Rate	$130.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$108.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$130.66
Rate for Payer: Cash Price	$164.70
Rate for Payer: UnitedHealthcare Commercial	$122.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$65.88

ACYCLOVIR (ZOVIRAX) 500MG VL

Facility

$183.00

Service Code	NDC 5.515E+10
Hospital Charge Code	2684670
Hospital Revenue Code	250
Rate for Payer: Cash Price	$164.70

ACYLCARNITINE

Facility

$247.00

Service Code	CPT 82017
Hospital Charge Code	2282017
Hospital Revenue Code	301
Rate for Payer: Cash Price	$222.30

ACYLCARNITINE

Facility

$247.00

Service Code	CPT 82017
Hospital Charge Code	2282017
Hospital Revenue Code	301
Min. Negotiated Rate	$15.18
Max. Negotiated Rate	$176.36
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.18
Rate for Payer: Aetna Medicare Advantage	$16.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$146.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$176.36
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cigna Commercial HMO & PPO	$16.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.18
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.24
Rate for Payer: Home State Health Plan Medicare Advantage	$16.87
Rate for Payer: Humana Commercial	$33.74
Rate for Payer: Humana Medicare Advantage	$16.87
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$88.92

.ADALIMUMAB ANTIBODY

Facility

$323.00

Service Code	CPT 86777
Hospital Charge Code	2282397
Hospital Revenue Code	302
Rate for Payer: Cash Price	$290.70

.ADALIMUMAB ANTIBODY

Facility

$323.00

Service Code	CPT 86777
Hospital Charge Code	2282397
Hospital Revenue Code	302
Min. Negotiated Rate	$12.95
Max. Negotiated Rate	$230.62
Rate for Payer: Aetna Better Health Medicaid/QHP	$12.95
Rate for Payer: Aetna Medicare Advantage	$14.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$191.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$230.62
Rate for Payer: Cash Price	$290.70
Rate for Payer: Cash Price	$290.70
Rate for Payer: Cash Price	$290.70
Rate for Payer: Cigna Commercial HMO & PPO	$14.39
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.86
Rate for Payer: Home State Health Plan Medicare Advantage	$14.39
Rate for Payer: Humana Commercial	$28.78
Rate for Payer: Humana Medicare Advantage	$14.39
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12.95
Rate for Payer: UnitedHealthcare Medicare Advantage	$116.28

.ADALIMUMAB DRUG LEVEL

Facility

$323.00

Service Code	CPT 80145
Hospital Charge Code	2280145
Hospital Revenue Code	301
Rate for Payer: Cash Price	$290.70

.ADALIMUMAB DRUG LEVEL

Facility

$323.00

Service Code	CPT 80145
Hospital Charge Code	2280145
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$230.62
Rate for Payer: Aetna Better Health Medicaid/QHP	$34.71
Rate for Payer: Aetna Medicare Advantage	$38.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$191.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$230.62
Rate for Payer: Cash Price	$290.70
Rate for Payer: Cash Price	$290.70
Rate for Payer: Cash Price	$290.70
Rate for Payer: Cigna Commercial HMO & PPO	$38.57
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$34.71
Rate for Payer: Home State Health Plan Medicaid Managed Care	$37.14
Rate for Payer: Home State Health Plan Medicare Advantage	$38.57
Rate for Payer: Humana Commercial	$77.14
Rate for Payer: Humana Medicare Advantage	$38.57
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$34.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$116.28

ADAPTIC 3 X 16 NON-ADHERING DRESSING

Facility

$28.00

Hospital Charge Code	281836
Hospital Revenue Code	271
Rate for Payer: Cash Price	$25.20

ADAPTIC 3 X 16 NON-ADHERING DRESSING

Facility

$28.00

Hospital Charge Code	281836
Hospital Revenue Code	271
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

ADAPTIC 3 X 3

Facility

$21.00

Hospital Charge Code	281835
Hospital Revenue Code	271
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

ADAPTIC 3 X 3

Facility

$21.00

Hospital Charge Code	281835
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

ADDITIONAL IMMUNIZATION ADMIN

Facility

$80.00

Service Code	CPT 90471
Hospital Charge Code	90472
Hospital Revenue Code	771
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$147.12
Rate for Payer: Aetna Better Health Medicaid/QHP	$64.91
Rate for Payer: Aetna Medicare Advantage	$73.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$47.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$57.12
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial HMO & PPO	$73.56
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$64.91
Rate for Payer: Home State Health Plan Medicaid Managed Care	$69.45
Rate for Payer: Home State Health Plan Medicare Advantage	$73.56
Rate for Payer: Humana Commercial	$147.12
Rate for Payer: Humana Medicare Advantage	$73.56
Rate for Payer: UnitedHealthcare Commercial	$53.36
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$64.91
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.80

ADDITIONAL IMMUNIZATION ADMIN

Facility

$80.00

Service Code	CPT 90471
Hospital Charge Code	90472
Hospital Revenue Code	771
Rate for Payer: Cash Price	$72.00

Know your out-of-pocket cost for care.

All Charges