Madison Medical Center

All Charges

Charge

Type

Setting

Price

FACTOR VII ACTIVITY

Facility

$118.00

Service Code	CPT 85230
Hospital Charge Code	226143
Hospital Revenue Code	301
Rate for Payer: Cash Price	$106.20

FACTOR VIII ACTIVITY

Facility

$233.00

Service Code	CPT 85240
Hospital Charge Code	226142
Hospital Revenue Code	301
Rate for Payer: Cash Price	$209.70

FACTOR VIII ACTIVITY

Facility

$233.00

Service Code	CPT 85240
Hospital Charge Code	226142
Hospital Revenue Code	301
Min. Negotiated Rate	$16.11
Max. Negotiated Rate	$166.36
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.11
Rate for Payer: Aetna Medicare Advantage	$17.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$137.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$166.36
Rate for Payer: Cash Price	$209.70
Rate for Payer: Cash Price	$209.70
Rate for Payer: Cash Price	$209.70
Rate for Payer: Cigna Commercial HMO & PPO	$17.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.11
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.24
Rate for Payer: Home State Health Plan Medicare Advantage	$17.90
Rate for Payer: Humana Commercial	$35.80
Rate for Payer: Humana Medicare Advantage	$17.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$83.88

FACTOR V LEIDEN

Facility

$416.00

Service Code	CPT 81241
Hospital Charge Code	2283800
Hospital Revenue Code	302
Rate for Payer: Cash Price	$374.40

FACTOR V LEIDEN

Facility

$416.00

Service Code	CPT 81241
Hospital Charge Code	2283800
Hospital Revenue Code	302
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$297.02
Rate for Payer: Aetna Better Health Medicaid/QHP	$66.03
Rate for Payer: Aetna Medicare Advantage	$73.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$246.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$297.02
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cigna Commercial HMO & PPO	$73.37
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$66.03
Rate for Payer: Home State Health Plan Medicaid Managed Care	$70.65
Rate for Payer: Home State Health Plan Medicare Advantage	$73.37
Rate for Payer: Humana Commercial	$146.74
Rate for Payer: Humana Medicare Advantage	$73.37
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$66.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$149.76

FACTOR X ACTIVITY

Facility

$161.00

Service Code	CPT 85260
Hospital Charge Code	2285260
Hospital Revenue Code	305
Rate for Payer: Cash Price	$144.90

FACTOR X ACTIVITY

Facility

$161.00

Service Code	CPT 85260
Hospital Charge Code	2285260
Hospital Revenue Code	305
Min. Negotiated Rate	$16.11
Max. Negotiated Rate	$114.95
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.11
Rate for Payer: Aetna Medicare Advantage	$17.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$95.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$114.95
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial HMO & PPO	$17.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.11
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.24
Rate for Payer: Home State Health Plan Medicare Advantage	$17.90
Rate for Payer: Humana Commercial	$35.80
Rate for Payer: Humana Medicare Advantage	$17.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$57.96

FACTOR XI ACTIVITY

Facility

$364.00

Service Code	CPT 85270
Hospital Charge Code	2285270
Hospital Revenue Code	301
Min. Negotiated Rate	$16.11
Max. Negotiated Rate	$259.90
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.11
Rate for Payer: Aetna Medicare Advantage	$17.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$215.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$259.90
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cigna Commercial HMO & PPO	$17.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.11
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.24
Rate for Payer: Home State Health Plan Medicare Advantage	$17.90
Rate for Payer: Humana Commercial	$35.80
Rate for Payer: Humana Medicare Advantage	$17.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$131.04

FACTOR XI ACTIVITY

Facility

$364.00

Service Code	CPT 85270
Hospital Charge Code	2285270
Hospital Revenue Code	301
Rate for Payer: Cash Price	$327.60

FACTOR XII ACTIVITY

Facility

$502.00

Service Code	CPT 85280
Hospital Charge Code	2285280
Hospital Revenue Code	301
Min. Negotiated Rate	$17.42
Max. Negotiated Rate	$358.43
Rate for Payer: Aetna Better Health Medicaid/QHP	$17.42
Rate for Payer: Aetna Medicare Advantage	$19.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$297.18
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$358.43
Rate for Payer: Cash Price	$451.80
Rate for Payer: Cash Price	$451.80
Rate for Payer: Cash Price	$451.80
Rate for Payer: Cigna Commercial HMO & PPO	$19.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$17.42
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18.64
Rate for Payer: Home State Health Plan Medicare Advantage	$19.35
Rate for Payer: Humana Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$19.35
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$180.72

FACTOR XII ACTIVITY

Facility

$502.00

Service Code	CPT 85280
Hospital Charge Code	2285280
Hospital Revenue Code	301
Rate for Payer: Cash Price	$451.80

FALMINA 0.02/0.1MG 6X28 TAB PAKS EMP

Facility

$113.00

Service Code	NDC 1.6714E+10
Hospital Charge Code	2623263
Hospital Revenue Code	250
Min. Negotiated Rate	$40.68
Max. Negotiated Rate	$80.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$66.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$80.68
Rate for Payer: Cash Price	$101.70
Rate for Payer: UnitedHealthcare Commercial	$75.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.68

FALMINA 0.02/0.1MG 6X28 TAB PAKS EMP

Facility

$113.00

Service Code	NDC 1.6714E+10
Hospital Charge Code	2623263
Hospital Revenue Code	250
Rate for Payer: Cash Price	$101.70

FAMOTIDINE (PEPCID) 10MG TAB

Facility

$15.00

Service Code	NDC 93274894
Hospital Charge Code	2623088
Hospital Revenue Code	250
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$10.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.71
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.40

FAMOTIDINE (PEPCID) 10MG TAB

Facility

$15.00

Service Code	NDC 93274894
Hospital Charge Code	2623088
Hospital Revenue Code	250
Rate for Payer: Cash Price	$13.50

FAMOTIDINE (PEPCID) 10MG TAB EMP

Facility

$16.00

Service Code	NDC 904552952
Hospital Charge Code	2625863
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

FAMOTIDINE (PEPCID) 10MG TAB EMP

Facility

$16.00

Service Code	NDC 904552952
Hospital Charge Code	2625863
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

FAMOTIDINE (PEPCID) 20MG INJ 2ML

Facility

$251.00

Service Code	HCPCS J1308
Hospital Charge Code	2626555
Hospital Revenue Code	250
Min. Negotiated Rate	$90.36
Max. Negotiated Rate	$179.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$148.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$179.21
Rate for Payer: Cash Price	$225.90
Rate for Payer: UnitedHealthcare Commercial	$167.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$90.36

FAMOTIDINE (PEPCID) 20MG INJ 2ML

Facility

$251.00

Service Code	HCPCS J1308
Hospital Charge Code	2626555
Hospital Revenue Code	250
Rate for Payer: Cash Price	$225.90

FAMOTIDINE (PEPCID) 20MG TAB EMP

Facility

$16.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2624013
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

FAMOTIDINE (PEPCID) 20MG TAB EMP

Facility

$16.00

Service Code	NDC 6.5862E+10
Hospital Charge Code	2624013
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

FAMOTIDINE (PEPCID) 20MG TAB UD

Facility

$16.00

Service Code	NDC 904719306
Hospital Charge Code	2623601
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

FAMOTIDINE (PEPCID) 20MG TAB UD

Facility

$16.00

Service Code	NDC 904719306
Hospital Charge Code	2623601
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

FAMOTIDINE (PEPCID) 40MG TAB EMP

Facility

$16.00

Service Code	NDC 172572960
Hospital Charge Code	2623973
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

FAMOTIDINE (PEPCID) 40MG TAB EMP

Facility

$16.00

Service Code	NDC 172572960
Hospital Charge Code	2623973
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

Know your out-of-pocket cost for care.

All Charges