Madison Medical Center

All Charges

Charge

Type

Setting

Price

DOXEPIN 3MG TAB EMP

Facility

$45.00

Service Code	NDC 4.4183E+10
Hospital Charge Code	2623646
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

DOXYCYCLINE 100MG CAP EMP

Facility

$16.00

Service Code	NDC 6.9238E+10
Hospital Charge Code	2622411
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

DOXYCYCLINE 100MG CAP EMP

Facility

$16.00

Service Code	NDC 6.9238E+10
Hospital Charge Code	2622411
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

DOXYCYCLINE 50MG CAP EMP

Facility

$16.00

Service Code	NDC 6.2135E+10
Hospital Charge Code	2619979
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

DOXYCYCLINE 50MG CAP EMP

Facility

$16.00

Service Code	NDC 6.2135E+10
Hospital Charge Code	2619979
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

DOXYCYCLINE HYCLATE 100MG TAB

Facility

$21.00

Service Code	NDC 904043006
Hospital Charge Code	2654925
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Cash Price	$18.90
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: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

DOXYCYCLINE HYCLATE 100MG TAB

Facility

$21.00

Service Code	NDC 904043006
Hospital Charge Code	2654925
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

DOXYCYCLINE HYCLATE 100MG TAB EMP

Facility

$21.00

Service Code	NDC 5.3489E+10
Hospital Charge Code	2627304
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

DOXYCYCLINE HYCLATE 100MG TAB EMP

Facility

$21.00

Service Code	NDC 5.3489E+10
Hospital Charge Code	2627304
Hospital Revenue Code	250
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

DOXYCYCLINE HYCLATE 20MG TAB

Facility

$21.00

Service Code	NDC 527133601
Hospital Charge Code	2626550
Hospital Revenue Code	250
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

DOXYCYCLINE HYCLATE 20MG TAB

Facility

$21.00

Service Code	NDC 527133601
Hospital Charge Code	2626550
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

DOXYCYCLINE (VIBRAMYCIN) 100MG INJ

Facility

$293.00

Service Code	NDC 6.6794E+10
Hospital Charge Code	2654930
Hospital Revenue Code	250
Rate for Payer: Cash Price	$263.70

DOXYCYCLINE (VIBRAMYCIN) 100MG INJ

Facility

$293.00

Service Code	NDC 6.6794E+10
Hospital Charge Code	2654930
Hospital Revenue Code	250
Min. Negotiated Rate	$105.48
Max. Negotiated Rate	$209.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$173.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$209.20
Rate for Payer: Cash Price	$263.70
Rate for Payer: UnitedHealthcare Commercial	$195.43
Rate for Payer: UnitedHealthcare Medicare Advantage	$105.48

DRAIN ABDOMINAL ABSESS

Professional

Both

$1,628.00

Service Code	CPT 49020 51
Hospital Charge Code	4149020
Hospital Revenue Code	975
Min. Negotiated Rate	$569.80
Max. Negotiated Rate	$569.80
Rate for Payer: Cash Price	$1,465.20
Rate for Payer: Optum Medicare Advantage	$569.80

DRAINAGE/EVACUATION OF SUBUNGUAL HEMATOM

Professional

Both

$83.00

Service Code	CPT 11740
Hospital Charge Code	4111740
Hospital Revenue Code	975
Min. Negotiated Rate	$28.84
Max. Negotiated Rate	$47.53
Rate for Payer: Aetna Commercial/Medicare Advantage	$28.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$43.21
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Commercial HMO & PPO	$28.84
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$43.21
Rate for Payer: Home State Health Plan Medicaid Managed Care	$47.53
Rate for Payer: Home State Health Plan Medicare Advantage	$28.84
Rate for Payer: Optum Medicare Advantage	$29.05
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$43.21

DRAINAGE OF ABCESS

Facility

$537.00

Service Code	CPT 23931
Hospital Charge Code	4423931
Hospital Revenue Code	521
Rate for Payer: Cash Price	$483.30

DRAINAGE OF ABCESS

Facility

$537.00

Service Code	CPT 23931
Hospital Charge Code	4423931
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$3,374.74
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,488.83
Rate for Payer: Aetna Medicare Advantage	$1,687.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$317.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$383.42
Rate for Payer: Cash Price	$483.30
Rate for Payer: Cash Price	$483.30
Rate for Payer: Cash Price	$483.30
Rate for Payer: Cash Price	$483.30
Rate for Payer: Cigna Commercial HMO & PPO	$1,687.37
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,339.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,593.05
Rate for Payer: Home State Health Plan Medicare Advantage	$1,687.37
Rate for Payer: Humana Commercial	$3,374.74
Rate for Payer: Humana Medicare Advantage	$1,687.37
Rate for Payer: UnitedHealthcare Commercial	$358.18
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,488.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DRAINAGE OF ABCESS - EYELID

Facility

$140.00

Service Code	CPT 67700
Hospital Charge Code	4467700
Hospital Revenue Code	521
Rate for Payer: Cash Price	$126.00

DRAINAGE OF ABCESS - EYELID

Facility

$140.00

Service Code	CPT 67700
Hospital Charge Code	4467700
Hospital Revenue Code	521
Min. Negotiated Rate	$82.88
Max. Negotiated Rate	$648.56
Rate for Payer: Aetna Better Health Medicaid/QHP	$286.12
Rate for Payer: Aetna Medicare Advantage	$324.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$82.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$99.96
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cigna Commercial HMO & PPO	$324.28
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$257.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$306.15
Rate for Payer: Home State Health Plan Medicare Advantage	$324.28
Rate for Payer: Humana Commercial	$648.56
Rate for Payer: Humana Medicare Advantage	$324.28
Rate for Payer: UnitedHealthcare Commercial	$93.38
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$286.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DRAINAGE OF ABSCESS VESTIBULE OF MOUTH

Facility

$169.00

Service Code	CPT 40800
Hospital Charge Code	4140800
Hospital Revenue Code	521
Min. Negotiated Rate	$100.05
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$100.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$120.67
Rate for Payer: Cash Price	$152.10
Rate for Payer: Cash Price	$152.10
Rate for Payer: Cash Price	$152.10
Rate for Payer: Cash Price	$152.10
Rate for Payer: Cigna Commercial HMO & PPO	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$112.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DRAINAGE OF ABSCESS VESTIBULE OF MOUTH

Facility

$169.00

Service Code	CPT 40800
Hospital Charge Code	4140800
Hospital Revenue Code	521
Rate for Payer: Cash Price	$152.10

DRAINAGE OF OVARIAN CYST ABD APPROACH

Professional

Both

$1,924.00

Service Code	CPT 58805
Hospital Charge Code	4158805
Hospital Revenue Code	975
Min. Negotiated Rate	$325.90
Max. Negotiated Rate	$673.40
Rate for Payer: Aetna Commercial/Medicare Advantage	$361.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$325.90
Rate for Payer: Cash Price	$1,731.60
Rate for Payer: Cash Price	$1,731.60
Rate for Payer: Cigna Commercial HMO & PPO	$361.48
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$325.90
Rate for Payer: Home State Health Plan Medicaid Managed Care	$358.49
Rate for Payer: Home State Health Plan Medicare Advantage	$361.48
Rate for Payer: Optum Medicare Advantage	$673.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$325.90

DRAINAGE OF OVARIAN CYST, UNIL OR BIL VA

Professional

Both

$1,544.00

Service Code	CPT 58800
Hospital Charge Code	4158800
Hospital Revenue Code	975
Min. Negotiated Rate	$266.41
Max. Negotiated Rate	$540.40
Rate for Payer: Aetna Commercial/Medicare Advantage	$266.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$278.04
Rate for Payer: Cash Price	$1,389.60
Rate for Payer: Cash Price	$1,389.60
Rate for Payer: Cigna Commercial HMO & PPO	$266.41
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$278.04
Rate for Payer: Home State Health Plan Medicaid Managed Care	$305.84
Rate for Payer: Home State Health Plan Medicare Advantage	$266.41
Rate for Payer: Optum Medicare Advantage	$540.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$278.04

DRAINAGE OF SEROMA

Professional

Both

$110.00

Service Code	CPT 10140
Hospital Charge Code	4110140
Hospital Revenue Code	975
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$141.83
Rate for Payer: Aetna Commercial/Medicare Advantage	$107.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$128.94
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial HMO & PPO	$107.50
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$128.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$141.83
Rate for Payer: Home State Health Plan Medicare Advantage	$107.50
Rate for Payer: Optum Medicare Advantage	$38.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$128.94

DRAIN FLAT

Facility

$119.00

Hospital Charge Code	284718
Hospital Revenue Code	271
Rate for Payer: Cash Price	$107.10

Know your out-of-pocket cost for care.

All Charges