Madison Medical Center

All Charges

Charge

Type

Setting

Price

ESOMEPRAZOLE 40MG CAP EMP

Facility

$10.00

Service Code	NDC 93645198
Hospital Charge Code	2622125
Hospital Revenue Code	250
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$7.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$5.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$7.14
Rate for Payer: Cash Price	$9.00
Rate for Payer: UnitedHealthcare Commercial	$6.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.60

ESOMEPRAZOLE 40MG CAP HE

Facility

$27.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2625717
Hospital Revenue Code	250
Rate for Payer: Cash Price	$24.30

ESOMEPRAZOLE 40MG CAP HE

Facility

$27.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2625717
Hospital Revenue Code	250
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$19.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$15.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.28
Rate for Payer: Cash Price	$24.30
Rate for Payer: UnitedHealthcare Commercial	$18.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.72

ESOPHAGEAL COLONIC DIALATOR 240 CM

Facility

$1,291.00

Hospital Charge Code	125848
Hospital Revenue Code	360
Min. Negotiated Rate	$464.76
Max. Negotiated Rate	$861.10
Rate for Payer: Cash Price	$1,161.90
Rate for Payer: UnitedHealthcare Commercial	$861.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$464.76

ESOPHAGEAL COLONIC DIALATOR 240 CM

Facility

$1,291.00

Hospital Charge Code	125848
Hospital Revenue Code	360
Rate for Payer: Cash Price	$1,161.90

ESOPHAGEAL STETHOSC

Facility

$159.00

Hospital Charge Code	285210
Hospital Revenue Code	271
Min. Negotiated Rate	$57.24
Max. Negotiated Rate	$113.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$94.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$113.53
Rate for Payer: Cash Price	$143.10
Rate for Payer: UnitedHealthcare Commercial	$106.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$57.24

ESOPHAGEAL STETHOSC

Facility

$159.00

Hospital Charge Code	285210
Hospital Revenue Code	271
Rate for Payer: Cash Price	$143.10

ESOPHAGES PROBS

Facility

$48.00

Hospital Charge Code	2024480
Hospital Revenue Code	271
Rate for Payer: Cash Price	$43.20

ESOPHAGES PROBS

Facility

$48.00

Hospital Charge Code	2024480
Hospital Revenue Code	271
Min. Negotiated Rate	$17.28
Max. Negotiated Rate	$34.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$28.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$34.27
Rate for Payer: Cash Price	$43.20
Rate for Payer: UnitedHealthcare Commercial	$32.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.28

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

$23,492.60

Service Code	MSDRG 391
Min. Negotiated Rate	$11,746.30
Max. Negotiated Rate	$23,492.60
Rate for Payer: Aetna Medicare Advantage	$11,746.30
Rate for Payer: Cigna Commercial HMO & PPO	$11,746.30
Rate for Payer: Home State Health Plan Medicare Advantage	$11,746.30
Rate for Payer: Humana Commercial	$23,492.60
Rate for Payer: Humana Medicare Advantage	$11,746.30

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC

Facility

$15,844.80

Service Code	MSDRG 392
Min. Negotiated Rate	$7,922.40
Max. Negotiated Rate	$15,844.80
Rate for Payer: Aetna Medicare Advantage	$7,922.40
Rate for Payer: Cigna Commercial HMO & PPO	$7,922.40
Rate for Payer: Home State Health Plan Medicare Advantage	$7,922.40
Rate for Payer: Humana Commercial	$15,844.80
Rate for Payer: Humana Medicare Advantage	$7,922.40

Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Facility

$1,853.26

Service Code	CPT 43235
Hospital Revenue Code	490
Min. Negotiated Rate	$817.60
Max. Negotiated Rate	$1,853.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$817.60
Rate for Payer: Aetna Medicare Advantage	$926.63
Rate for Payer: Cigna Commercial HMO & PPO	$926.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$817.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$874.83
Rate for Payer: Home State Health Plan Medicare Advantage	$926.63
Rate for Payer: Humana Commercial	$1,853.26
Rate for Payer: Humana Medicare Advantage	$926.63
Rate for Payer: UnitedHealthcare Commercial	$1,462.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$817.60

Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Facility

$1,853.26

Service Code	CPT 43235
Hospital Revenue Code	360
Min. Negotiated Rate	$817.60
Max. Negotiated Rate	$1,853.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$817.60
Rate for Payer: Aetna Medicare Advantage	$926.63
Rate for Payer: Cigna Commercial HMO & PPO	$926.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$817.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$874.83
Rate for Payer: Home State Health Plan Medicare Advantage	$926.63
Rate for Payer: Humana Commercial	$1,853.26
Rate for Payer: Humana Medicare Advantage	$926.63
Rate for Payer: UnitedHealthcare Commercial	$1,462.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$817.60

Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple

Facility

$1,853.26

Service Code	CPT 43239
Hospital Revenue Code	490
Min. Negotiated Rate	$817.60
Max. Negotiated Rate	$1,853.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$817.60
Rate for Payer: Aetna Medicare Advantage	$926.63
Rate for Payer: Cigna Commercial HMO & PPO	$926.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$817.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$874.83
Rate for Payer: Home State Health Plan Medicare Advantage	$926.63
Rate for Payer: Humana Commercial	$1,853.26
Rate for Payer: Humana Medicare Advantage	$926.63
Rate for Payer: UnitedHealthcare Commercial	$1,462.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$817.60

Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple

Facility

$1,853.26

Service Code	CPT 43239
Hospital Revenue Code	360
Min. Negotiated Rate	$817.60
Max. Negotiated Rate	$1,853.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$817.60
Rate for Payer: Aetna Medicare Advantage	$926.63
Rate for Payer: Cigna Commercial HMO & PPO	$926.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$817.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$874.83
Rate for Payer: Home State Health Plan Medicare Advantage	$926.63
Rate for Payer: Humana Commercial	$1,853.26
Rate for Payer: Humana Medicare Advantage	$926.63
Rate for Payer: UnitedHealthcare Commercial	$1,462.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$817.60

Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire

Facility

$1,853.26

Service Code	CPT 43248
Hospital Revenue Code	360
Min. Negotiated Rate	$817.60
Max. Negotiated Rate	$1,853.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$817.60
Rate for Payer: Aetna Medicare Advantage	$926.63
Rate for Payer: Cigna Commercial HMO & PPO	$926.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$817.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$874.83
Rate for Payer: Home State Health Plan Medicare Advantage	$926.63
Rate for Payer: Humana Commercial	$1,853.26
Rate for Payer: Humana Medicare Advantage	$926.63
Rate for Payer: UnitedHealthcare Commercial	$1,462.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$817.60

Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire

Facility

$1,853.26

Service Code	CPT 43248
Hospital Revenue Code	490
Min. Negotiated Rate	$817.60
Max. Negotiated Rate	$1,853.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$817.60
Rate for Payer: Aetna Medicare Advantage	$926.63
Rate for Payer: Cigna Commercial HMO & PPO	$926.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$817.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$874.83
Rate for Payer: Home State Health Plan Medicare Advantage	$926.63
Rate for Payer: Humana Commercial	$1,853.26
Rate for Payer: Humana Medicare Advantage	$926.63
Rate for Payer: UnitedHealthcare Commercial	$1,462.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$817.60

Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)

Facility

$3,920.94

Service Code	CPT 43249
Hospital Revenue Code	360
Min. Negotiated Rate	$1,462.00
Max. Negotiated Rate	$3,920.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,729.79
Rate for Payer: Aetna Medicare Advantage	$1,960.47
Rate for Payer: Cigna Commercial HMO & PPO	$1,960.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,729.79
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,850.88
Rate for Payer: Home State Health Plan Medicare Advantage	$1,960.47
Rate for Payer: Humana Commercial	$3,920.94
Rate for Payer: Humana Medicare Advantage	$1,960.47
Rate for Payer: UnitedHealthcare Commercial	$1,462.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,729.79

ESOPHAGOSCOPY W/BALLOON DILATION

Professional

Both

$945.00

Service Code	CPT 43220
Hospital Charge Code	5443220
Hospital Revenue Code	975
Min. Negotiated Rate	$101.23
Max. Negotiated Rate	$788.77
Rate for Payer: Aetna Commercial/Medicare Advantage	$101.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$717.06
Rate for Payer: Cash Price	$850.50
Rate for Payer: Cash Price	$850.50
Rate for Payer: Cigna Commercial HMO & PPO	$101.23
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$717.06
Rate for Payer: Home State Health Plan Medicaid Managed Care	$788.77
Rate for Payer: Home State Health Plan Medicare Advantage	$101.23
Rate for Payer: Optum Medicare Advantage	$330.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$717.06

ESOPHAGUS XRAY

Facility

$533.00

Service Code	CPT 74220
Hospital Charge Code	325151
Hospital Revenue Code	320
Rate for Payer: Cash Price	$479.70

ESOPHAGUS XRAY

Facility

$533.00

Service Code	CPT 74220
Hospital Charge Code	325151
Hospital Revenue Code	320
Min. Negotiated Rate	$158.12
Max. Negotiated Rate	$380.56
Rate for Payer: Aetna Better Health Medicaid/QHP	$158.12
Rate for Payer: Aetna Medicare Advantage	$179.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$315.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$380.56
Rate for Payer: Cash Price	$479.70
Rate for Payer: Cash Price	$479.70
Rate for Payer: Cash Price	$479.70
Rate for Payer: Cigna Commercial HMO & PPO	$179.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$158.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$169.19
Rate for Payer: Home State Health Plan Medicare Advantage	$179.20
Rate for Payer: Humana Commercial	$358.40
Rate for Payer: Humana Medicare Advantage	$179.20
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$158.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$191.88

ESOPH DILATOR

Facility

$669.00

Hospital Charge Code	125110
Hospital Revenue Code	271
Min. Negotiated Rate	$240.84
Max. Negotiated Rate	$477.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$396.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$477.67
Rate for Payer: Cash Price	$602.10
Rate for Payer: UnitedHealthcare Commercial	$446.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$240.84

ESOPH DILATOR

Facility

$669.00

Hospital Charge Code	125110
Hospital Revenue Code	271
Rate for Payer: Cash Price	$602.10

ESOPH DILATOR 15/16.5/18

Facility

$422.00

Hospital Charge Code	125109
Hospital Revenue Code	271
Min. Negotiated Rate	$151.92
Max. Negotiated Rate	$301.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$249.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$301.31
Rate for Payer: Cash Price	$379.80
Rate for Payer: UnitedHealthcare Commercial	$281.47
Rate for Payer: UnitedHealthcare Medicare Advantage	$151.92

ESOPH DILATOR 15/16.5/18

Facility

$422.00

Hospital Charge Code	125109
Hospital Revenue Code	271
Rate for Payer: Cash Price	$379.80

Know your out-of-pocket cost for care.

All Charges