Madison Medical Center

All Charges

Charge

Type

Setting

Price

IBUPROFEN (MOTRIN) 100MG/5ML SUSP

Facility

$20.00

Service Code	NDC 121183605
Hospital Charge Code	2601517
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

IBUPROFEN (MOTRIN) 100MG/5ML SUSP

Facility

$20.00

Service Code	NDC 121183605
Hospital Charge Code	2601517
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

IBUPROFEN (MOTRIN) 200MG TAB UD

Facility

$20.00

Service Code	HCPCS Q0144
Hospital Charge Code	2627003
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

IBUPROFEN (MOTRIN) 200MG TAB UD

Facility

$20.00

Service Code	HCPCS Q0144
Hospital Charge Code	2627003
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

IBUPROFEN (MOTRIN) 400MG TAB

Facility

$20.00

Service Code	HCPCS Q0144
Hospital Charge Code	2655300
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

IBUPROFEN (MOTRIN) 400MG TAB

Facility

$20.00

Service Code	HCPCS Q0144
Hospital Charge Code	2655300
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

IBUPROFEN (MOTRIN) 600MG TAB

Facility

$20.00

Service Code	HCPCS Q0144
Hospital Charge Code	2655305
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

IBUPROFEN (MOTRIN) 600MG TAB

Facility

$20.00

Service Code	HCPCS Q0144
Hospital Charge Code	2655305
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

IBUPROFEN (MOTRIN) 600MG TAB EMP

Facility

$20.00

Service Code	HCPCS Q0144
Hospital Charge Code	2697474
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

IBUPROFEN (MOTRIN) 600MG TAB EMP

Facility

$20.00

Service Code	HCPCS Q0144
Hospital Charge Code	2697474
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

IBUPROFEN (MOTRIN) 800MG TAB UD

Facility

$20.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2657130
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

IBUPROFEN (MOTRIN) 800MG TAB UD

Facility

$20.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2657130
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

IBUTILIDE FUM (CORVERT) 1MG/ML 10ML

Facility

$1,056.00

Service Code	HCPCS J1742
Hospital Charge Code	2654617
Hospital Revenue Code	250
Rate for Payer: Cash Price	$950.40

IBUTILIDE FUM (CORVERT) 1MG/ML 10ML

Facility

$1,056.00

Service Code	HCPCS J1742
Hospital Charge Code	2654617
Hospital Revenue Code	250
Min. Negotiated Rate	$175.89
Max. Negotiated Rate	$753.98
Rate for Payer: Aetna Medicare Advantage	$175.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$625.15
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$753.98
Rate for Payer: Cash Price	$950.40
Rate for Payer: Cash Price	$950.40
Rate for Payer: Cigna Commercial HMO & PPO	$175.89
Rate for Payer: Home State Health Plan Medicare Advantage	$175.89
Rate for Payer: Humana Commercial	$351.78
Rate for Payer: Humana Medicare Advantage	$175.89
Rate for Payer: UnitedHealthcare Commercial	$704.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$380.16

ICE PACK CONSTANT

Facility

$42.00

Hospital Charge Code	289010
Hospital Revenue Code	271
Rate for Payer: Cash Price	$37.80

ICE PACK CONSTANT

Facility

$42.00

Hospital Charge Code	289010
Hospital Revenue Code	271
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$29.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$24.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$29.99
Rate for Payer: Cash Price	$37.80
Rate for Payer: UnitedHealthcare Commercial	$28.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.12

ICOSAPENT (VASCEPA) 1GM CAP EMP

Facility

$20.00

Service Code	NDC 54050823
Hospital Charge Code	2627236
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

ICOSAPENT (VASCEPA) 1GM CAP EMP

Facility

$20.00

Service Code	NDC 54050823
Hospital Charge Code	2627236
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

I&D

Facility

$141.00

Service Code	CPT 10080
Hospital Charge Code	4110080
Hospital Revenue Code	521
Min. Negotiated Rate	$83.47
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$83.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$100.67
Rate for Payer: Cash Price	$126.90
Rate for Payer: Cash Price	$126.90
Rate for Payer: Cash Price	$126.90
Rate for Payer: Cash Price	$126.90
Rate for Payer: Cigna Commercial HMO & PPO	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$94.05
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

I&D

Facility

$141.00

Service Code	CPT 10080
Hospital Charge Code	4110080
Hospital Revenue Code	521
Rate for Payer: Cash Price	$126.90

I&D BARTHOLIN CYST

Facility

$182.00

Service Code	CPT 56420
Hospital Charge Code	4256420
Hospital Revenue Code	521
Min. Negotiated Rate	$107.74
Max. Negotiated Rate	$413.10
Rate for Payer: Aetna Better Health Medicaid/QHP	$182.25
Rate for Payer: Aetna Medicare Advantage	$206.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$107.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$129.95
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial HMO & PPO	$206.55
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$164.03
Rate for Payer: Home State Health Plan Medicaid Managed Care	$195.01
Rate for Payer: Home State Health Plan Medicare Advantage	$206.55
Rate for Payer: Humana Commercial	$413.10
Rate for Payer: Humana Medicare Advantage	$206.55
Rate for Payer: UnitedHealthcare Commercial	$121.39
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$182.25
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

I&D BARTHOLIN CYST

Facility

$182.00

Service Code	CPT 56420
Hospital Charge Code	4256420
Hospital Revenue Code	521
Rate for Payer: Cash Price	$163.80

I&D COMPLICATED

Professional

Both

$811.00

Service Code	CPT 10061
Hospital Charge Code	1810061
Hospital Revenue Code	981
Min. Negotiated Rate	$160.90
Max. Negotiated Rate	$283.85
Rate for Payer: Aetna Commercial/Medicare Advantage	$161.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$160.90
Rate for Payer: Cash Price	$729.90
Rate for Payer: Cash Price	$729.90
Rate for Payer: Cigna Commercial HMO & PPO	$161.68
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$160.90
Rate for Payer: Home State Health Plan Medicaid Managed Care	$176.99
Rate for Payer: Home State Health Plan Medicare Advantage	$161.68
Rate for Payer: Optum Medicare Advantage	$283.85
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$160.90

IDH1, 2

Facility

$731.00

Hospital Charge Code	2281123
Hospital Revenue Code	305
Rate for Payer: Cash Price	$657.90

IDH1, 2

Facility

$731.00

Hospital Charge Code	2281123
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$521.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$432.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$521.93
Rate for Payer: Cash Price	$657.90
Rate for Payer: Cash Price	$657.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$263.16

Know your out-of-pocket cost for care.

All Charges