Madison Medical Center

All Charges

Charge

Type

Setting

Price

FIBOBLAST GROWTH FACTOR 23

Facility

$520.00

Service Code	CPT 83520
Hospital Charge Code	2283528
Hospital Revenue Code	301
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$371.28
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.54
Rate for Payer: Aetna Medicare Advantage	$17.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$307.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$371.28
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cigna Commercial HMO & PPO	$17.27
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.54
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.63
Rate for Payer: Home State Health Plan Medicare Advantage	$17.27
Rate for Payer: Humana Commercial	$34.54
Rate for Payer: Humana Medicare Advantage	$17.27
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.54
Rate for Payer: UnitedHealthcare Medicare Advantage	$187.20

FIBRACOL PLUS 4 X 4 DRESSING

Facility

$75.00

Hospital Charge Code	286215
Hospital Revenue Code	271
Rate for Payer: Cash Price	$67.50

FIBRACOL PLUS 4 X 4 DRESSING

Facility

$75.00

Hospital Charge Code	286215
Hospital Revenue Code	271
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$53.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$53.55
Rate for Payer: Cash Price	$67.50
Rate for Payer: UnitedHealthcare Commercial	$50.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

FIBRIN MONOMER

Facility

$240.00

Service Code	CPT 85362
Hospital Charge Code	2285362
Hospital Revenue Code	301
Rate for Payer: Cash Price	$216.00

FIBRIN MONOMER

Facility

$240.00

Service Code	CPT 85362
Hospital Charge Code	2285362
Hospital Revenue Code	301
Min. Negotiated Rate	$6.20
Max. Negotiated Rate	$171.36
Rate for Payer: Aetna Better Health Medicaid/QHP	$6.20
Rate for Payer: Aetna Medicare Advantage	$6.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna Commercial HMO & PPO	$6.89
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6.20
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.63
Rate for Payer: Home State Health Plan Medicare Advantage	$6.89
Rate for Payer: Humana Commercial	$13.78
Rate for Payer: Humana Medicare Advantage	$6.89
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$86.40

FIBRINOGEN ACTIVITY

Facility

$102.00

Service Code	CPT 85384
Hospital Charge Code	226500
Hospital Revenue Code	301
Rate for Payer: Cash Price	$91.80

FIBRINOGEN ACTIVITY

Facility

$102.00

Service Code	CPT 85384
Hospital Charge Code	226500
Hospital Revenue Code	301
Min. Negotiated Rate	$8.75
Max. Negotiated Rate	$72.83
Rate for Payer: Aetna Better Health Medicaid/QHP	$8.75
Rate for Payer: Aetna Medicare Advantage	$9.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$60.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$72.83
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna Commercial HMO & PPO	$9.72
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8.75
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9.36
Rate for Payer: Home State Health Plan Medicare Advantage	$9.72
Rate for Payer: Humana Commercial	$19.44
Rate for Payer: Humana Medicare Advantage	$9.72
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.72

FILEFORMS & FOLLOWERS

Facility

$452.00

Service Code	CPT 53620
Hospital Charge Code	286681
Hospital Revenue Code	271
Min. Negotiated Rate	$162.72
Max. Negotiated Rate	$1,424.80
Rate for Payer: Aetna Better Health Medicaid/QHP	$628.57
Rate for Payer: Aetna Medicare Advantage	$712.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$267.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$322.73
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial HMO & PPO	$712.40
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$628.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$672.57
Rate for Payer: Home State Health Plan Medicare Advantage	$712.40
Rate for Payer: Humana Commercial	$1,424.80
Rate for Payer: Humana Medicare Advantage	$712.40
Rate for Payer: UnitedHealthcare Commercial	$301.48
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$628.57
Rate for Payer: UnitedHealthcare Medicare Advantage	$162.72

FILEFORMS & FOLLOWERS

Facility

$452.00

Service Code	CPT 53620
Hospital Charge Code	286681
Hospital Revenue Code	271
Rate for Payer: Cash Price	$406.80

FILGRASTIM 300MCG INJ (NEUPOGEN)

Facility

$3,580.00

Service Code	NDC 5.5513E+10
Hospital Charge Code	2698104
Hospital Revenue Code	335
Rate for Payer: Cash Price	$3,222.00

FILGRASTIM 300MCG INJ (NEUPOGEN)

Facility

$3,580.00

Service Code	NDC 5.5513E+10
Hospital Charge Code	2698104
Hospital Revenue Code	335
Min. Negotiated Rate	$1,288.80
Max. Negotiated Rate	$2,556.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$2,119.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,556.12
Rate for Payer: Cash Price	$3,222.00
Rate for Payer: UnitedHealthcare Commercial	$2,387.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,288.80

FILGRASTIM 480MCG INJ (NEUPOGEN) 0.8ML

Facility

$4,149.00

Service Code	HCPCS J1442
Hospital Charge Code	2621553
Hospital Revenue Code	250
Rate for Payer: Cash Price	$3,734.10

FILGRASTIM 480MCG INJ (NEUPOGEN) 0.8ML

Facility

$4,149.00

Service Code	HCPCS J1442
Hospital Charge Code	2621553
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$2,962.39
Rate for Payer: Aetna Medicare Advantage	$1.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$2,456.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,962.39
Rate for Payer: Cash Price	$3,734.10
Rate for Payer: Cash Price	$3,734.10
Rate for Payer: Cigna Commercial HMO & PPO	$1.01
Rate for Payer: Home State Health Plan Medicare Advantage	$1.01
Rate for Payer: Humana Commercial	$2.02
Rate for Payer: Humana Medicare Advantage	$1.01
Rate for Payer: UnitedHealthcare Commercial	$2,767.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,493.64

FILTER FLO EXTEN SET

Facility

$39.00

Hospital Charge Code	286816
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

FILTER FLO EXTEN SET

Facility

$39.00

Hospital Charge Code	286816
Hospital Revenue Code	271
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

FILTER, ISO GUARD HEPA

Facility

$13.00

Hospital Charge Code	28251795
Hospital Revenue Code	271
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

FILTER, ISO GUARD HEPA

Facility

$13.00

Hospital Charge Code	28251795
Hospital Revenue Code	271
Rate for Payer: Cash Price	$11.70

FILTER. I.V.

Facility

$28.00

Hospital Charge Code	286679
Hospital Revenue Code	271
Rate for Payer: Cash Price	$25.20

FILTER. I.V.

Facility

$28.00

Hospital Charge Code	286679
Hospital Revenue Code	271
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

FILTER, KIDNEY STONE

Facility

$16.00

Hospital Charge Code	286220
Hospital Revenue Code	271
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

FILTER, KIDNEY STONE

Facility

$16.00

Hospital Charge Code	286220
Hospital Revenue Code	271
Rate for Payer: Cash Price	$14.40

FILTER NEEDLE 5 MICRON

Facility

$22.00

Service Code	NDC 8881305018
Hospital Charge Code	2621331
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

FILTER NEEDLE 5 MICRON

Facility

$22.00

Service Code	NDC 8881305018
Hospital Charge Code	2621331
Hospital Revenue Code	250
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

FILTER NEEDLE (CHEMO) 0.22 MICRON

Facility

$22.00

Service Code	NDC 8290305200
Hospital Charge Code	2698054
Hospital Revenue Code	250
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

FILTER NEEDLE (CHEMO) 0.22 MICRON

Facility

$22.00

Service Code	NDC 8290305200
Hospital Charge Code	2698054
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

Know your out-of-pocket cost for care.

All Charges