Madison Medical Center

All Charges

Charge

Type

Setting

Price

ERGOCALCIFEROL (VIT D2) 50,000IU CAP

Facility

$21.00

Service Code	NDC 6.438E+10
Hospital Charge Code	2626435
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

ERGOCALCIFEROL (VIT D2) 50,000IU CAP

Facility

$21.00

Service Code	NDC 6.438E+10
Hospital Charge Code	2626435
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

ERGOCALCIFEROL (VIT D2) 50,000IU CAP EMP

Facility

$21.00

Service Code	NDC 5.7664E+10
Hospital Charge Code	2622121
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

ERGOCALCIFEROL (VIT D2) 50,000IU CAP EMP

Facility

$21.00

Service Code	NDC 5.7664E+10
Hospital Charge Code	2622121
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

ER INSTRUMENT SET

Facility

$86.00

Hospital Charge Code	289007
Hospital Revenue Code	271
Min. Negotiated Rate	$30.96
Max. Negotiated Rate	$61.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$50.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$61.40
Rate for Payer: Cash Price	$77.40
Rate for Payer: UnitedHealthcare Commercial	$57.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.96

ER INSTRUMENT SET

Facility

$86.00

Hospital Charge Code	289007
Hospital Revenue Code	271
Rate for Payer: Cash Price	$77.40

ER INST SET (DISPOSABLE)

Facility

$67.00

Hospital Charge Code	284018
Hospital Revenue Code	271
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$47.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.84
Rate for Payer: Cash Price	$60.30
Rate for Payer: UnitedHealthcare Commercial	$44.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.12

ER INST SET (DISPOSABLE)

Facility

$67.00

Hospital Charge Code	284018
Hospital Revenue Code	271
Rate for Payer: Cash Price	$60.30

ER INTERMEDIATE

Facility

$389.00

Hospital Charge Code	1819010
Hospital Revenue Code	450
Min. Negotiated Rate	$140.04
Max. Negotiated Rate	$140.04
Rate for Payer: Cash Price	$350.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$140.04

ER INTERMEDIATE

Facility

$389.00

Hospital Charge Code	1819010
Hospital Revenue Code	450
Rate for Payer: Cash Price	$350.10

ER PHYSICIAN/LEVEL 1

Professional

Both

$250.00

Service Code	CPT 99281
Hospital Charge Code	1899281
Hospital Revenue Code	981
Min. Negotiated Rate	$10.77
Max. Negotiated Rate	$87.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$10.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$18.83
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial HMO & PPO	$10.77
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$18.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$20.71
Rate for Payer: Home State Health Plan Medicare Advantage	$10.77
Rate for Payer: Optum Medicare Advantage	$87.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$18.83

ER PHYSICIAN/LEVEL 2

Professional

Both

$372.00

Service Code	CPT 99282
Hospital Charge Code	1899282
Hospital Revenue Code	981
Min. Negotiated Rate	$35.15
Max. Negotiated Rate	$130.20
Rate for Payer: Aetna Commercial/Medicare Advantage	$39.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$35.15
Rate for Payer: Cash Price	$334.80
Rate for Payer: Cash Price	$334.80
Rate for Payer: Cigna Commercial HMO & PPO	$39.54
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$35.15
Rate for Payer: Home State Health Plan Medicaid Managed Care	$38.66
Rate for Payer: Home State Health Plan Medicare Advantage	$39.54
Rate for Payer: Optum Medicare Advantage	$130.20
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$35.15

ER PHYSICIAN/LEVEL 3

Professional

Both

$594.00

Service Code	CPT 99283
Hospital Charge Code	1899283
Hospital Revenue Code	981
Min. Negotiated Rate	$59.80
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna Commercial/Medicare Advantage	$68.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$59.80
Rate for Payer: Cash Price	$534.60
Rate for Payer: Cash Price	$534.60
Rate for Payer: Cigna Commercial HMO & PPO	$68.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$59.80
Rate for Payer: Home State Health Plan Medicaid Managed Care	$65.78
Rate for Payer: Home State Health Plan Medicare Advantage	$68.01
Rate for Payer: Optum Medicare Advantage	$207.90
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$59.80

ER PHYSICIAN/LEVEL 4

Professional

Both

$863.00

Service Code	CPT 99284
Hospital Charge Code	1899284
Hospital Revenue Code	981
Min. Negotiated Rate	$100.99
Max. Negotiated Rate	$302.05
Rate for Payer: Aetna Commercial/Medicare Advantage	$115.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$100.99
Rate for Payer: Cash Price	$776.70
Rate for Payer: Cash Price	$776.70
Rate for Payer: Cigna Commercial HMO & PPO	$115.86
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$100.99
Rate for Payer: Home State Health Plan Medicaid Managed Care	$111.09
Rate for Payer: Home State Health Plan Medicare Advantage	$115.86
Rate for Payer: Optum Medicare Advantage	$302.05
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$100.99

ER PHYSICIAN/LEVEL 5

Professional

Both

$1,341.00

Service Code	CPT 99285
Hospital Charge Code	1899285
Hospital Revenue Code	981
Min. Negotiated Rate	$146.64
Max. Negotiated Rate	$469.35
Rate for Payer: Aetna Commercial/Medicare Advantage	$167.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$146.64
Rate for Payer: Cash Price	$1,206.90
Rate for Payer: Cash Price	$1,206.90
Rate for Payer: Cigna Commercial HMO & PPO	$167.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$146.64
Rate for Payer: Home State Health Plan Medicaid Managed Care	$161.30
Rate for Payer: Home State Health Plan Medicare Advantage	$167.93
Rate for Payer: Optum Medicare Advantage	$469.35
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$146.64

ERTAPENEM (INVANZ) 1GM VIAL

Facility

$717.00

Service Code	HCPCS J1335
Hospital Charge Code	2626342
Hospital Revenue Code	250
Rate for Payer: Cash Price	$645.30

ERTAPENEM (INVANZ) 1GM VIAL

Facility

$717.00

Service Code	HCPCS J1335
Hospital Charge Code	2626342
Hospital Revenue Code	250
Min. Negotiated Rate	$258.12
Max. Negotiated Rate	$511.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$424.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$511.94
Rate for Payer: Cash Price	$645.30
Rate for Payer: UnitedHealthcare Commercial	$478.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$258.12

ER TREATMENT

Facility

$268.00

Hospital Charge Code	1819011
Hospital Revenue Code	450
Min. Negotiated Rate	$96.48
Max. Negotiated Rate	$96.48
Rate for Payer: Cash Price	$241.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$96.48

ER TREATMENT

Facility

$268.00

Hospital Charge Code	1819011
Hospital Revenue Code	450
Rate for Payer: Cash Price	$241.20

E/R VISIT-COMPRE HIST. HIGH COMPLEX

Facility

$307.00

Service Code	CPT 99285
Hospital Charge Code	4199285
Hospital Revenue Code	521
Rate for Payer: Cash Price	$276.30

E/R VISIT-COMPRE HIST. HIGH COMPLEX

Facility

$307.00

Service Code	CPT 99285
Hospital Charge Code	4199285
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$1,216.86
Rate for Payer: Aetna Better Health Medicaid/QHP	$536.84
Rate for Payer: Aetna Medicare Advantage	$608.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$181.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$219.20
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial HMO & PPO	$608.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$483.16
Rate for Payer: Home State Health Plan Medicaid Managed Care	$574.42
Rate for Payer: Home State Health Plan Medicare Advantage	$608.43
Rate for Payer: Humana Commercial	$1,216.86
Rate for Payer: Humana Medicare Advantage	$608.43
Rate for Payer: UnitedHealthcare Commercial	$204.77
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$536.84
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

E/R VISIT-DETAIL HIST. MOD COMPLEX

Facility

$212.00

Service Code	CPT 99284
Hospital Charge Code	4199284
Hospital Revenue Code	521
Rate for Payer: Cash Price	$190.80

E/R VISIT-DETAIL HIST. MOD COMPLEX

Facility

$212.00

Service Code	CPT 99284
Hospital Charge Code	4199284
Hospital Revenue Code	521
Min. Negotiated Rate	$125.50
Max. Negotiated Rate	$852.60
Rate for Payer: Aetna Better Health Medicaid/QHP	$376.14
Rate for Payer: Aetna Medicare Advantage	$426.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$125.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$151.37
Rate for Payer: Cash Price	$190.80
Rate for Payer: Cash Price	$190.80
Rate for Payer: Cash Price	$190.80
Rate for Payer: Cash Price	$190.80
Rate for Payer: Cigna Commercial HMO & PPO	$426.30
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$338.53
Rate for Payer: Home State Health Plan Medicaid Managed Care	$402.47
Rate for Payer: Home State Health Plan Medicare Advantage	$426.30
Rate for Payer: Humana Commercial	$852.60
Rate for Payer: Humana Medicare Advantage	$426.30
Rate for Payer: UnitedHealthcare Commercial	$141.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$376.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

E/R VISIT-EXAM & HIST. LOW COMPLEX

Facility

$93.00

Service Code	CPT 99282
Hospital Charge Code	4199282
Hospital Revenue Code	521
Rate for Payer: Cash Price	$83.70

E/R VISIT-EXAM & HIST. LOW COMPLEX

Facility

$93.00

Service Code	CPT 99282
Hospital Charge Code	4199282
Hospital Revenue Code	521
Min. Negotiated Rate	$55.06
Max. Negotiated Rate	$313.74
Rate for Payer: Cash Price	$83.70
Rate for Payer: Aetna Better Health Medicaid/QHP	$138.41
Rate for Payer: Aetna Medicare Advantage	$156.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$55.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$66.40
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial HMO & PPO	$156.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$124.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$148.10
Rate for Payer: Home State Health Plan Medicare Advantage	$156.87
Rate for Payer: Humana Commercial	$313.74
Rate for Payer: Humana Medicare Advantage	$156.87
Rate for Payer: UnitedHealthcare Commercial	$62.03
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$138.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Know your out-of-pocket cost for care.

All Charges