Madison Medical Center

All Charges

Charge

Type

Setting

Price

Fospropofol disodium 1050mg/30ml Lusedra

Facility

$234.00

Hospital Charge Code	2058100
Hospital Revenue Code	370
Rate for Payer: Cash Price	$210.60

Fospropofol disodium 1050mg/30ml Lusedra

Facility

$234.00

Hospital Charge Code	2058100
Hospital Revenue Code	370
Min. Negotiated Rate	$84.24
Max. Negotiated Rate	$167.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$138.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$167.08
Rate for Payer: Cash Price	$210.60
Rate for Payer: UnitedHealthcare Commercial	$156.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$84.24

FOUNDAYO 0.8MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627244
Hospital Revenue Code	250
Rate for Payer: Cash Price	$123.30

FOUNDAYO 0.8MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627244
Hospital Revenue Code	250
Min. Negotiated Rate	$49.32
Max. Negotiated Rate	$97.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$97.82
Rate for Payer: Cash Price	$123.30
Rate for Payer: UnitedHealthcare Commercial	$91.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$49.32

FOUNDAYO 14.5MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627248
Hospital Revenue Code	250
Min. Negotiated Rate	$49.32
Max. Negotiated Rate	$97.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$97.82
Rate for Payer: Cash Price	$123.30
Rate for Payer: UnitedHealthcare Commercial	$91.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$49.32

FOUNDAYO 14.5MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627248
Hospital Revenue Code	250
Rate for Payer: Cash Price	$123.30

FOUNDAYO 17.2MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627249
Hospital Revenue Code	250
Min. Negotiated Rate	$49.32
Max. Negotiated Rate	$97.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$97.82
Rate for Payer: Cash Price	$123.30
Rate for Payer: UnitedHealthcare Commercial	$91.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$49.32

FOUNDAYO 17.2MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627249
Hospital Revenue Code	250
Rate for Payer: Cash Price	$123.30

FOUNDAYO 2.5MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627245
Hospital Revenue Code	250
Rate for Payer: Cash Price	$123.30

FOUNDAYO 2.5MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627245
Hospital Revenue Code	250
Min. Negotiated Rate	$49.32
Max. Negotiated Rate	$97.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$97.82
Rate for Payer: Cash Price	$123.30
Rate for Payer: UnitedHealthcare Commercial	$91.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$49.32

FOUNDAYO 5.5MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627246
Hospital Revenue Code	250
Min. Negotiated Rate	$49.32
Max. Negotiated Rate	$97.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$97.82
Rate for Payer: Cash Price	$123.30
Rate for Payer: UnitedHealthcare Commercial	$91.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$49.32

FOUNDAYO 5.5MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627246
Hospital Revenue Code	250
Rate for Payer: Cash Price	$123.30

FOUNDAYO 9MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627247
Hospital Revenue Code	250
Min. Negotiated Rate	$49.32
Max. Negotiated Rate	$97.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$97.82
Rate for Payer: Cash Price	$123.30
Rate for Payer: UnitedHealthcare Commercial	$91.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$49.32

FOUNDAYO 9MG TAB

Facility

$137.00

Service Code	NDC 1E+11
Hospital Charge Code	2627247
Hospital Revenue Code	250
Rate for Payer: Cash Price	$123.30

FRACTURE OF FEMUR

Facility

$10,108.69

Service Code	APR-DRG 3403
Min. Negotiated Rate	$10,108.69
Max. Negotiated Rate	$10,108.69
Rate for Payer: Aetna Better Health Medicaid/QHP	$10,108.69
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$10,108.69
Rate for Payer: Home State Health Plan Medicaid Managed Care	$10,108.69
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$10,108.69

FRACTURE OF FEMUR

Facility

$10,108.69

Service Code	APR-DRG 3402
Min. Negotiated Rate	$10,108.69
Max. Negotiated Rate	$10,108.69
Rate for Payer: Aetna Better Health Medicaid/QHP	$10,108.69
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$10,108.69
Rate for Payer: Home State Health Plan Medicaid Managed Care	$10,108.69
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$10,108.69

FRACTURE OF FEMUR

Facility

$8,981.70

Service Code	APR-DRG 3401
Min. Negotiated Rate	$8,981.70
Max. Negotiated Rate	$8,981.70
Rate for Payer: Aetna Better Health Medicaid/QHP	$8,981.70
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8,981.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8,981.70
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8,981.70

FRACTURE OF FEMUR

Facility

$15,384.00

Service Code	APR-DRG 3404
Min. Negotiated Rate	$15,384.00
Max. Negotiated Rate	$15,384.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$15,384.00
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15,384.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15,384.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15,384.00

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$9,003.89

Service Code	APR-DRG 3413
Min. Negotiated Rate	$9,003.89
Max. Negotiated Rate	$9,003.89
Rate for Payer: Aetna Better Health Medicaid/QHP	$9,003.89
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$9,003.89
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9,003.89
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$9,003.89

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$5,573.93

Service Code	APR-DRG 3411
Min. Negotiated Rate	$5,573.93
Max. Negotiated Rate	$5,573.93
Rate for Payer: Aetna Better Health Medicaid/QHP	$5,573.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5,573.93
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5,573.93
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5,573.93

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$15,873.99

Service Code	APR-DRG 3414
Min. Negotiated Rate	$15,873.99
Max. Negotiated Rate	$15,873.99
Rate for Payer: Aetna Better Health Medicaid/QHP	$15,873.99
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15,873.99
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15,873.99
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15,873.99

FRACTURE OF PELVIS OR DISLOCATION OF HIP

Facility

$8,007.26

Service Code	APR-DRG 3412
Min. Negotiated Rate	$8,007.26
Max. Negotiated Rate	$8,007.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$8,007.26
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8,007.26
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8,007.26
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8,007.26

FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK

Facility

$8,078.45

Service Code	APR-DRG 3421
Min. Negotiated Rate	$8,078.45
Max. Negotiated Rate	$8,078.45
Rate for Payer: Aetna Better Health Medicaid/QHP	$8,078.45
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8,078.45
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8,078.45
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8,078.45

FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK

Facility

$20,860.85

Service Code	APR-DRG 3424
Min. Negotiated Rate	$20,860.85
Max. Negotiated Rate	$20,860.85
Rate for Payer: Aetna Better Health Medicaid/QHP	$20,860.85
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$20,860.85
Rate for Payer: Home State Health Plan Medicaid Managed Care	$20,860.85
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$20,860.85

FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK

Facility

$11,518.58

Service Code	APR-DRG 3423
Min. Negotiated Rate	$11,518.58
Max. Negotiated Rate	$11,518.58
Rate for Payer: Aetna Better Health Medicaid/QHP	$11,518.58
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11,518.58
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11,518.58
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11,518.58

Know your out-of-pocket cost for care.

All Charges