Madison Medical Center

All Charges

Charge

Type

Setting

Price

CYCLOBENZAPRINE 10MG TAB EMP

Facility

$22.00

Service Code	NDC 5.9746E+10
Hospital Charge Code	2619906
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

CYCLOBENZAPRINE 5MG TAB EMP

Facility

$22.00

Service Code	NDC 2.93E+10
Hospital Charge Code	2624516
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

CYCLOBENZAPRINE 5MG TAB EMP

Facility

$22.00

Service Code	NDC 2.93E+10
Hospital Charge Code	2624516
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

CYCLOBENZAPRINE (FLEXERIL) 10MG TAB UD

Facility

$22.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2654690
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

CYCLOBENZAPRINE (FLEXERIL) 10MG TAB UD

Facility

$22.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2654690
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

CYCLOSPORA

Facility

$195.00

Service Code	CPT 87015
Hospital Charge Code	3087015
Hospital Revenue Code	306
Min. Negotiated Rate	$6.01
Max. Negotiated Rate	$139.23
Rate for Payer: Aetna Better Health Medicaid/QHP	$6.01
Rate for Payer: Aetna Medicare Advantage	$6.68
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: Cash Price	$175.50
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial HMO & PPO	$6.68
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6.01
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.43
Rate for Payer: Home State Health Plan Medicare Advantage	$6.68
Rate for Payer: Humana Commercial	$13.36
Rate for Payer: Humana Medicare Advantage	$6.68
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$70.20

CYCLOSPORA

Facility

$195.00

Service Code	CPT 87015
Hospital Charge Code	3087015
Hospital Revenue Code	306
Rate for Payer: Cash Price	$175.50

CYCLOSPORINE

Facility

$210.00

Service Code	CPT 80158
Hospital Charge Code	223906
Hospital Revenue Code	301
Min. Negotiated Rate	$16.25
Max. Negotiated Rate	$149.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.25
Rate for Payer: Aetna Medicare Advantage	$18.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$124.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$149.94
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cigna Commercial HMO & PPO	$18.05
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.25
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.39
Rate for Payer: Home State Health Plan Medicare Advantage	$18.05
Rate for Payer: Humana Commercial	$36.10
Rate for Payer: Humana Medicare Advantage	$18.05
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.25
Rate for Payer: UnitedHealthcare Medicare Advantage	$75.60

CYCLOSPORINE

Facility

$210.00

Service Code	CPT 80158
Hospital Charge Code	223906
Hospital Revenue Code	301
Rate for Payer: Cash Price	$189.00

CYCLOSPORINE (RESTASIS) OP SOL 0.4ML

Facility

$45.00

Service Code	NDC 378876058
Hospital Charge Code	2626433
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

CYCLOSPORINE (RESTASIS) OP SOL 0.4ML

Facility

$45.00

Service Code	NDC 378876058
Hospital Charge Code	2626433
Hospital Revenue Code	250
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

CYCLOSPORINE (RESTASIS) OP SOL EMP 30

Facility

$45.00

Service Code	NDC 23916330
Hospital Charge Code	2623390
Hospital Revenue Code	250
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

CYCLOSPORINE (RESTASIS) OP SOL EMP 30

Facility

$45.00

Service Code	NDC 23916330
Hospital Charge Code	2623390
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

CYCLOSPORINE (RESTASIS) OP SOL EMP 60

Facility

$45.00

Service Code	NDC 23916360
Hospital Charge Code	2627041
Hospital Revenue Code	250
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

CYCLOSPORINE (RESTASIS) OP SOL EMP 60

Facility

$45.00

Service Code	NDC 23916360
Hospital Charge Code	2627041
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

CYPROHEPTADINE 4MG TAB

Facility

$13.00

Service Code	NDC 1E+11
Hospital Charge Code	2619419
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.70

CYPROHEPTADINE 4MG TAB

Facility

$13.00

Service Code	NDC 1E+11
Hospital Charge Code	2619419
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

CYSTATIN C

Facility

$79.00

Service Code	CPT 82610
Hospital Charge Code	227281
Hospital Revenue Code	301
Min. Negotiated Rate	$16.67
Max. Negotiated Rate	$56.41
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.67
Rate for Payer: Aetna Medicare Advantage	$18.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$46.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$56.41
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial HMO & PPO	$18.52
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.67
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.84
Rate for Payer: Home State Health Plan Medicare Advantage	$18.52
Rate for Payer: Humana Commercial	$37.04
Rate for Payer: Humana Medicare Advantage	$18.52
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.44

CYSTATIN C

Facility

$79.00

Service Code	CPT 82610
Hospital Charge Code	227281
Hospital Revenue Code	301
Rate for Payer: Cash Price	$71.10

CYSTIC FIBROSIS DNA

Facility

$333.00

Service Code	CPT 81220
Hospital Charge Code	2281220
Hospital Revenue Code	305
Rate for Payer: Cash Price	$299.70

CYSTIC FIBROSIS DNA

Facility

$333.00

Service Code	CPT 81220
Hospital Charge Code	2281220
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$1,113.20
Rate for Payer: Aetna Better Health Medicaid/QHP	$500.94
Rate for Payer: Aetna Medicare Advantage	$556.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$197.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$237.76
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cigna Commercial HMO & PPO	$556.60
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$500.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$536.01
Rate for Payer: Home State Health Plan Medicare Advantage	$556.60
Rate for Payer: Humana Commercial	$1,113.20
Rate for Payer: Humana Medicare Advantage	$556.60
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$500.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$119.88

CYSTIC FIBROSIS PROFILE

Facility

$385.00

Service Code	CPT 81220
Hospital Charge Code	2282110
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$1,113.20
Rate for Payer: Aetna Better Health Medicaid/QHP	$500.94
Rate for Payer: Aetna Medicare Advantage	$556.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$227.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$274.89
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cigna Commercial HMO & PPO	$556.60
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$500.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$536.01
Rate for Payer: Home State Health Plan Medicare Advantage	$556.60
Rate for Payer: Humana Commercial	$1,113.20
Rate for Payer: Humana Medicare Advantage	$556.60
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$500.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$138.60

CYSTIC FIBROSIS PROFILE

Facility

$385.00

Service Code	CPT 81220
Hospital Charge Code	2282110
Hospital Revenue Code	301
Rate for Payer: Cash Price	$346.50

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$23,219.59

Service Code	APR-DRG 1312
Min. Negotiated Rate	$23,219.59
Max. Negotiated Rate	$23,219.59
Rate for Payer: Aetna Better Health Medicaid/QHP	$23,219.59
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$23,219.59
Rate for Payer: Home State Health Plan Medicaid Managed Care	$23,219.59
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$23,219.59

CYSTIC FIBROSIS - PULMONARY DISEASE

Facility

$34,215.35

Service Code	APR-DRG 1314
Min. Negotiated Rate	$34,215.35
Max. Negotiated Rate	$34,215.35
Rate for Payer: Aetna Better Health Medicaid/QHP	$34,215.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$34,215.35
Rate for Payer: Home State Health Plan Medicaid Managed Care	$34,215.35
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$34,215.35

Know your out-of-pocket cost for care.

All Charges