Madison Medical Center

All Charges

Charge

Type

Setting

Price

FUROSEMIDE 20MG TAB HE

Facility

$20.00

Service Code	NDC 4.2291E+10
Hospital Charge Code	2625492
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

FUROSEMIDE 20MG TAB HE

Facility

$20.00

Service Code	NDC 4.2291E+10
Hospital Charge Code	2625492
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$11.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.28
Rate for Payer: Cash Price	$18.00
Rate for Payer: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

FUROSEMIDE 40MG TAB EMP

Facility

$20.00

Service Code	NDC 54429925
Hospital Charge Code	2621905
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$11.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.28
Rate for Payer: Cash Price	$18.00
Rate for Payer: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

FUROSEMIDE 40MG TAB EMP

Facility

$20.00

Service Code	NDC 54429925
Hospital Charge Code	2621905
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

FUROSEMIDE INJ

Facility

$75.00

Service Code	HCPCS J1940
Hospital Charge Code	2058028
Hospital Revenue Code	370
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

FUROSEMIDE INJ

Facility

$75.00

Service Code	HCPCS J1940
Hospital Charge Code	2058028
Hospital Revenue Code	370
Rate for Payer: Cash Price	$67.50

FUROSEMIDE (LASIX) 100MG/10ML INJ

Facility

$65.00

Service Code	HCPCS J1940
Hospital Charge Code	2626577
Hospital Revenue Code	250
Rate for Payer: Cash Price	$58.50

FUROSEMIDE (LASIX) 100MG/10ML INJ

Facility

$65.00

Service Code	HCPCS J1940
Hospital Charge Code	2626577
Hospital Revenue Code	250
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$46.41
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: UnitedHealthcare Commercial	$43.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$23.40

FUROSEMIDE (LASIX) 20MG INJ 2ML VL

Facility

$60.00

Service Code	HCPCS J1941
Hospital Charge Code	2655060
Hospital Revenue Code	250
Rate for Payer: Cash Price	$54.00

FUROSEMIDE (LASIX) 20MG INJ 2ML VL

Facility

$60.00

Service Code	HCPCS J1941
Hospital Charge Code	2655060
Hospital Revenue Code	250
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

FUROSEMIDE (LASIX) 20MG TAB UD

Facility

$20.00

Service Code	NDC 54829725
Hospital Charge Code	2655050
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

FUROSEMIDE (LASIX) 20MG TAB UD

Facility

$20.00

Service Code	NDC 54829725
Hospital Charge Code	2655050
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$11.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.28
Rate for Payer: Cash Price	$18.00
Rate for Payer: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

FUROSEMIDE (LASIX) 40MG INJ 4ML VL

Facility

$95.00

Service Code	HCPCS J1941
Hospital Charge Code	2655070
Hospital Revenue Code	250
Rate for Payer: Cash Price	$85.50

FUROSEMIDE (LASIX) 40MG INJ 4ML VL

Facility

$95.00

Service Code	HCPCS J1941
Hospital Charge Code	2655070
Hospital Revenue Code	250
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$67.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$56.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$67.83
Rate for Payer: Cash Price	$85.50
Rate for Payer: UnitedHealthcare Commercial	$63.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$34.20

FUROSEMIDE (LASIX) 40MG TAB

Facility

$20.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2655055
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$11.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.28
Rate for Payer: Cash Price	$18.00
Rate for Payer: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

FUROSEMIDE (LASIX) 40MG TAB

Facility

$20.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2655055
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

FX CARE/CAST NONDISPLACED FX OF TOE

Facility

$263.00

Service Code	CPT 28510
Hospital Charge Code	4428510
Hospital Revenue Code	521
Rate for Payer: Cash Price	$236.70

FX CARE/CAST NONDISPLACED FX OF TOE

Facility

$263.00

Service Code	CPT 28510
Hospital Charge Code	4428510
Hospital Revenue Code	521
Min. Negotiated Rate	$155.70
Max. Negotiated Rate	$504.02
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
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	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$175.42
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FX CARE CLOSED DISTAL RADIAL FX W/O MANI

Facility

$800.00

Service Code	CPT 25600
Hospital Charge Code	4225600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$720.00

FX CARE CLOSED DISTAL RADIAL FX W/O MANI

Facility

$800.00

Service Code	CPT 25600
Hospital Charge Code	4225600
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$571.20
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$473.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$571.20
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$533.60
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FX CARE LATERAL MALLEOLUS (ANKLE)

Facility

$368.00

Service Code	CPT 27786
Hospital Charge Code	4427786
Hospital Revenue Code	521
Rate for Payer: Cash Price	$331.20

FX CARE LATERAL MALLEOLUS (ANKLE)

Facility

$368.00

Service Code	CPT 27786
Hospital Charge Code	4427786
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$504.02
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$217.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$262.75
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$245.46
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FX CLOSED EPICONDYLAR LATERAL

Facility

$955.00

Service Code	CPT 24560
Hospital Charge Code	9824560
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$681.87
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$565.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$681.87
Rate for Payer: Cash Price	$859.50
Rate for Payer: Cash Price	$859.50
Rate for Payer: Cash Price	$859.50
Rate for Payer: Cash Price	$859.50
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$636.99
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FX CLOSED EPICONDYLAR LATERAL

Facility

$955.00

Service Code	CPT 24560
Hospital Charge Code	9824560
Hospital Revenue Code	521
Rate for Payer: Cash Price	$859.50

FX CLOSED FINGER

Facility

$350.00

Service Code	CPT 26720
Hospital Charge Code	9826720
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$504.02
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$207.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$249.90
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$233.45
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Know your out-of-pocket cost for care.

All Charges