Madison Medical Center

All Charges

Charge

Type

Setting

Price

EPI PROCOLON

Facility

$421.00

Service Code	CPT 81327
Hospital Charge Code	2281327
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$384.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$172.80
Rate for Payer: Aetna Medicare Advantage	$192.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$249.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$300.59
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna Commercial HMO & PPO	$192.00
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$172.80
Rate for Payer: Home State Health Plan Medicaid Managed Care	$184.90
Rate for Payer: Home State Health Plan Medicare Advantage	$192.00
Rate for Payer: Humana Commercial	$384.00
Rate for Payer: Humana Medicare Advantage	$192.00
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$172.80
Rate for Payer: UnitedHealthcare Medicare Advantage	$151.56

EPI PROCOLON

Facility

$421.00

Service Code	CPT 81327
Hospital Charge Code	2281327
Hospital Revenue Code	301
Rate for Payer: Cash Price	$378.90

EPISTAXIS/NASAL PACK

Facility

$199.00

Hospital Charge Code	2814005
Hospital Revenue Code	271
Min. Negotiated Rate	$71.64
Max. Negotiated Rate	$142.09
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: UnitedHealthcare Commercial	$132.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$71.64

EPISTAXIS/NASAL PACK

Facility

$199.00

Hospital Charge Code	2814005
Hospital Revenue Code	271
Rate for Payer: Cash Price	$179.10

EPISTAXIS WITH MCC

Facility

$24,481.62

Service Code	MSDRG 150
Min. Negotiated Rate	$12,240.81
Max. Negotiated Rate	$24,481.62
Rate for Payer: Aetna Medicare Advantage	$12,240.81
Rate for Payer: Cigna Commercial HMO & PPO	$12,240.81
Rate for Payer: Home State Health Plan Medicare Advantage	$12,240.81
Rate for Payer: Humana Commercial	$24,481.62
Rate for Payer: Humana Medicare Advantage	$12,240.81

EPISTAXIS WITHOUT MCC

Facility

$15,131.52

Service Code	MSDRG 151
Min. Negotiated Rate	$7,565.76
Max. Negotiated Rate	$15,131.52
Rate for Payer: Aetna Medicare Advantage	$7,565.76
Rate for Payer: Cigna Commercial HMO & PPO	$7,565.76
Rate for Payer: Home State Health Plan Medicare Advantage	$7,565.76
Rate for Payer: Humana Commercial	$15,131.52
Rate for Payer: Humana Medicare Advantage	$7,565.76

EPOETIN ALFA 3,000U/ML (PROCRIT) INJ

Facility

$697.00

Service Code	NDC 5.9676E+10
Hospital Charge Code	2620698
Hospital Revenue Code	250
Rate for Payer: Cash Price	$627.30

EPOETIN ALFA 3,000U/ML (PROCRIT) INJ

Facility

$697.00

Service Code	NDC 5.9676E+10
Hospital Charge Code	2620698
Hospital Revenue Code	250
Min. Negotiated Rate	$250.92
Max. Negotiated Rate	$497.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$412.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$497.66
Rate for Payer: Cash Price	$627.30
Rate for Payer: UnitedHealthcare Commercial	$464.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$250.92

EPOETIN ALFA 4,000U/ML (PROCRIT)

Facility

$696.00

Service Code	NDC 5.9676E+10
Hospital Charge Code	2654941
Hospital Revenue Code	250
Rate for Payer: Cash Price	$626.40

EPOETIN ALFA 4,000U/ML (PROCRIT)

Facility

$696.00

Service Code	NDC 5.9676E+10
Hospital Charge Code	2654941
Hospital Revenue Code	250
Min. Negotiated Rate	$250.56
Max. Negotiated Rate	$496.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$412.03
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$496.94
Rate for Payer: Cash Price	$626.40
Rate for Payer: UnitedHealthcare Commercial	$464.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$250.56

EPOETIN ALFA (PROCRIT) 10,000U/ML 10ML I

Facility

$838.00

Service Code	HCPCS J0885
Hospital Charge Code	2626306
Hospital Revenue Code	250
Rate for Payer: Cash Price	$754.20

EPOETIN ALFA (PROCRIT) 10,000U/ML 10ML I

Facility

$838.00

Service Code	HCPCS J0885
Hospital Charge Code	2626306
Hospital Revenue Code	250
Min. Negotiated Rate	$6.88
Max. Negotiated Rate	$598.33
Rate for Payer: Aetna Medicare Advantage	$6.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$496.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$598.33
Rate for Payer: Cash Price	$754.20
Rate for Payer: Cash Price	$754.20
Rate for Payer: Cigna Commercial HMO & PPO	$6.88
Rate for Payer: Home State Health Plan Medicare Advantage	$6.88
Rate for Payer: Humana Commercial	$13.76
Rate for Payer: Humana Medicare Advantage	$6.88
Rate for Payer: UnitedHealthcare Commercial	$558.95
Rate for Payer: UnitedHealthcare Medicare Advantage	$301.68

EP PHYSICAL AGE 18 - 39

Facility

$255.00

Service Code	CPT 99395
Hospital Charge Code	4199395
Hospital Revenue Code	521
Min. Negotiated Rate	$150.96
Max. Negotiated Rate	$182.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$150.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$182.07
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cash Price	$229.50
Rate for Payer: UnitedHealthcare Commercial	$170.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EP PHYSICAL AGE 18 - 39

Facility

$255.00

Service Code	CPT 99395
Hospital Charge Code	4199395
Hospital Revenue Code	521
Rate for Payer: Cash Price	$229.50

EP PHYSICAL AGE 40-64

Facility

$285.00

Service Code	CPT 99396
Hospital Charge Code	4199396
Hospital Revenue Code	521
Min. Negotiated Rate	$168.72
Max. Negotiated Rate	$203.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$168.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$203.49
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cash Price	$256.50
Rate for Payer: UnitedHealthcare Commercial	$190.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EP PHYSICAL AGE 40-64

Facility

$285.00

Service Code	CPT 99396
Hospital Charge Code	4199396
Hospital Revenue Code	521
Rate for Payer: Cash Price	$256.50

EP PHYSICAL AGE 65 & OVER

Facility

$330.00

Service Code	CPT 99397
Hospital Charge Code	4199397
Hospital Revenue Code	521
Rate for Payer: Cash Price	$297.00

EP PHYSICAL AGE 65 & OVER

Facility

$330.00

Service Code	CPT 99397
Hospital Charge Code	4199397
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$235.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$195.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$235.62
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: UnitedHealthcare Commercial	$220.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EPSTEIN BARR DNA

Facility

$338.00

Service Code	CPT 87798
Hospital Charge Code	225183
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$241.33
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	$200.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$241.33
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cash Price	$304.20
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	$121.68

EPSTEIN BARR DNA

Facility

$338.00

Service Code	CPT 87798
Hospital Charge Code	225183
Hospital Revenue Code	301
Rate for Payer: Cash Price	$304.20

EPSTEIN BARR EARLY DET

Facility

$72.00

Service Code	CPT 86663
Hospital Charge Code	228663
Hospital Revenue Code	302
Rate for Payer: Cash Price	$64.80

EPSTEIN BARR EARLY DET

Facility

$72.00

Service Code	CPT 86663
Hospital Charge Code	228663
Hospital Revenue Code	302
Min. Negotiated Rate	$11.81
Max. Negotiated Rate	$51.41
Rate for Payer: Aetna Better Health Medicaid/QHP	$11.81
Rate for Payer: Aetna Medicare Advantage	$13.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$42.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$51.41
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial HMO & PPO	$13.12
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12.64
Rate for Payer: Home State Health Plan Medicare Advantage	$13.12
Rate for Payer: Humana Commercial	$26.24
Rate for Payer: Humana Medicare Advantage	$13.12
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.92

EPSTEIN BARR IGG

Facility

$80.00

Service Code	CPT 86665
Hospital Charge Code	2286665
Hospital Revenue Code	301
Rate for Payer: Cash Price	$72.00

EPSTEIN BARR IGG

Facility

$80.00

Service Code	CPT 86665
Hospital Charge Code	2286665
Hospital Revenue Code	301
Min. Negotiated Rate	$16.33
Max. Negotiated Rate	$57.12
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.33
Rate for Payer: Aetna Medicare Advantage	$18.14
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	$18.14
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.33
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.47
Rate for Payer: Home State Health Plan Medicare Advantage	$18.14
Rate for Payer: Humana Commercial	$36.28
Rate for Payer: Humana Medicare Advantage	$18.14
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.33
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.80

EPSTEIN BARR IGM

Facility

$80.00

Service Code	CPT 86665
Hospital Charge Code	2286664
Hospital Revenue Code	301
Min. Negotiated Rate	$16.33
Max. Negotiated Rate	$57.12
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.33
Rate for Payer: Aetna Medicare Advantage	$18.14
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	$18.14
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.33
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.47
Rate for Payer: Home State Health Plan Medicare Advantage	$18.14
Rate for Payer: Humana Commercial	$36.28
Rate for Payer: Humana Medicare Advantage	$18.14
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.33
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.80

Know your out-of-pocket cost for care.

All Charges