Madison Medical Center

All Charges

Charge

Type

Setting

Price

ETHOSUXIMIDE

Facility

$65.00

Service Code	CPT 80168
Hospital Charge Code	2280168
Hospital Revenue Code	301
Min. Negotiated Rate	$14.71
Max. Negotiated Rate	$46.41
Rate for Payer: Aetna Better Health Medicaid/QHP	$14.71
Rate for Payer: Aetna Medicare Advantage	$16.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$38.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$46.41
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial HMO & PPO	$16.34
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14.71
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15.74
Rate for Payer: Home State Health Plan Medicare Advantage	$16.34
Rate for Payer: Humana Commercial	$32.68
Rate for Payer: Humana Medicare Advantage	$16.34
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$23.40

ETHOSUXIMIDE

Facility

$65.00

Service Code	CPT 80168
Hospital Charge Code	2280168
Hospital Revenue Code	301
Rate for Payer: Cash Price	$58.50

ETHYL CHLORIDE

Facility

$13.00

Hospital Charge Code	122475
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.70

ETHYL CHLORIDE

Facility

$13.00

Hospital Charge Code	122475
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

ETHYL CHLORIDE FINE SPRAY 5ML DOSE

Facility

$32.00

Service Code	NDC 386000104
Hospital Charge Code	2697305
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$22.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$18.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$22.85
Rate for Payer: Cash Price	$28.80
Rate for Payer: UnitedHealthcare Commercial	$21.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.52

ETHYL CHLORIDE FINE SPRAY 5ML DOSE

Facility

$32.00

Service Code	NDC 386000104
Hospital Charge Code	2697305
Hospital Revenue Code	250
Rate for Payer: Cash Price	$28.80

ETHYLENE GLYCOL URINE

Facility

$317.00

Service Code	CPT 82693
Hospital Charge Code	2282693
Hospital Revenue Code	307
Rate for Payer: Cash Price	$285.30

ETHYLENE GLYCOL URINE

Facility

$317.00

Service Code	CPT 82693
Hospital Charge Code	2282693
Hospital Revenue Code	307
Min. Negotiated Rate	$13.41
Max. Negotiated Rate	$226.34
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.41
Rate for Payer: Aetna Medicare Advantage	$14.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$187.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$226.34
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cigna Commercial HMO & PPO	$14.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.41
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.35
Rate for Payer: Home State Health Plan Medicare Advantage	$14.90
Rate for Payer: Humana Commercial	$29.80
Rate for Payer: Humana Medicare Advantage	$14.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$114.12

ETOPOSIDE (VEPESID) 20MG/ML25ML IVP

Facility

$437.00

Service Code	HCPCS J9181
Hospital Charge Code	2626586
Hospital Revenue Code	335
Rate for Payer: Cash Price	$393.30

ETOPOSIDE (VEPESID) 20MG/ML25ML IVP

Facility

$437.00

Service Code	HCPCS J9181
Hospital Charge Code	2626586
Hospital Revenue Code	335
Min. Negotiated Rate	$157.32
Max. Negotiated Rate	$312.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$258.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$312.02
Rate for Payer: Cash Price	$393.30
Rate for Payer: UnitedHealthcare Commercial	$291.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$157.32

ETOPOSIDE (VEPESID)20MG/ML 5ML IVP

Facility

$171.00

Service Code	HCPCS J9181
Hospital Charge Code	2626583
Hospital Revenue Code	335
Rate for Payer: Cash Price	$153.90

ETOPOSIDE (VEPESID)20MG/ML 5ML IVP

Facility

$171.00

Service Code	HCPCS J9181
Hospital Charge Code	2626583
Hospital Revenue Code	335
Min. Negotiated Rate	$61.56
Max. Negotiated Rate	$122.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$101.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$122.09
Rate for Payer: Cash Price	$153.90
Rate for Payer: UnitedHealthcare Commercial	$114.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$61.56

EVAC HANDPIECE

Facility

$223.00

Hospital Charge Code	1251114
Hospital Revenue Code	271
Rate for Payer: Cash Price	$200.70

EVAC HANDPIECE

Facility

$223.00

Hospital Charge Code	1251114
Hospital Revenue Code	271
Min. Negotiated Rate	$80.28
Max. Negotiated Rate	$159.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$132.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$159.22
Rate for Payer: Cash Price	$200.70
Rate for Payer: UnitedHealthcare Commercial	$148.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$80.28

EVAL. & MGMT. (BRIEF)

Facility

$91.00

Service Code	CPT 99304
Hospital Charge Code	4499301
Hospital Revenue Code	525
Rate for Payer: Cash Price	$81.90

EVAL. & MGMT. (BRIEF)

Facility

$91.00

Service Code	CPT 99304
Hospital Charge Code	4499301
Hospital Revenue Code	525
Min. Negotiated Rate	$53.87
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$53.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$64.97
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: UnitedHealthcare Commercial	$60.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EVAL. & MGMT. (INTER)

Facility

$169.50

Service Code	CPT 99306
Hospital Charge Code	4499303
Hospital Revenue Code	525
Rate for Payer: Cash Price	$152.55

EVAL. & MGMT. (INTER)

Facility

$169.50

Service Code	CPT 99306
Hospital Charge Code	4499303
Hospital Revenue Code	525
Min. Negotiated Rate	$100.34
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$100.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$121.02
Rate for Payer: Cash Price	$152.55
Rate for Payer: Cash Price	$152.55
Rate for Payer: UnitedHealthcare Commercial	$113.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EVAL. & MGMT. (LIMITED)

Facility

$121.50

Service Code	CPT 99305
Hospital Charge Code	4499302
Hospital Revenue Code	525
Min. Negotiated Rate	$71.93
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$71.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$86.75
Rate for Payer: Cash Price	$109.35
Rate for Payer: Cash Price	$109.35
Rate for Payer: UnitedHealthcare Commercial	$81.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EVAL. & MGMT. (LIMITED)

Facility

$121.50

Service Code	CPT 99305
Hospital Charge Code	4499302
Hospital Revenue Code	525
Rate for Payer: Cash Price	$109.35

EVENT MONITOR, HOOK-UP, 30 DAY

Facility

$591.00

Service Code	CPT 93270
Hospital Charge Code	4593270
Hospital Revenue Code	410
Min. Negotiated Rate	$33.64
Max. Negotiated Rate	$421.97
Rate for Payer: Aetna Better Health Medicaid/QHP	$33.64
Rate for Payer: Aetna Medicare Advantage	$38.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$349.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$421.97
Rate for Payer: Cash Price	$531.90
Rate for Payer: Cash Price	$531.90
Rate for Payer: Cash Price	$531.90
Rate for Payer: Cigna Commercial HMO & PPO	$38.13
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$33.64
Rate for Payer: Home State Health Plan Medicaid Managed Care	$35.99
Rate for Payer: Home State Health Plan Medicare Advantage	$38.13
Rate for Payer: Humana Commercial	$76.26
Rate for Payer: Humana Medicare Advantage	$38.13
Rate for Payer: UnitedHealthcare Commercial	$394.20
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$33.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$212.76

EVENT MONITOR, HOOK-UP, 30 DAY

Facility

$591.00

Service Code	CPT 93270
Hospital Charge Code	4593270
Hospital Revenue Code	410
Rate for Payer: Cash Price	$531.90

EVENT MONITOR HOOK UP AND DISCONNECT

Facility

$263.00

Service Code	CPT 93225
Hospital Charge Code	3993270
Hospital Revenue Code	521
Rate for Payer: Cash Price	$236.70

EVENT MONITOR HOOK UP AND DISCONNECT

Facility

$263.00

Service Code	CPT 93225
Hospital Charge Code	3993270
Hospital Revenue Code	521
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$271.86
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$155.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$187.78
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$107.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$175.42
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EVENT MONITOR HOOK UP & DISCONNECT

Facility

$263.00

Service Code	CPT 93270
Hospital Charge Code	9693270
Hospital Revenue Code	521
Rate for Payer: Cash Price	$236.70

Know your out-of-pocket cost for care.

All Charges