Madison Medical Center

All Charges

Charge

Type

Setting

Price

ALPRAZOLAM 0.5MG TAB EMP C4

Facility

$21.00

Service Code	NDC 6.7253E+10
Hospital Charge Code	2619231
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

ALPRAZOLAM 1MG TAB EMP C4

Facility

$21.00

Service Code	NDC 6.7253E+10
Hospital Charge Code	2621265
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

ALPRAZOLAM 1MG TAB EMP C4

Facility

$21.00

Service Code	NDC 6.7253E+10
Hospital Charge Code	2621265
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

ALPRAZOLAM 2MG TAB EMP C4

Facility

$21.00

Service Code	NDC 228203910
Hospital Charge Code	2624918
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

ALPRAZOLAM 2MG TAB EMP C4

Facility

$21.00

Service Code	NDC 228203910
Hospital Charge Code	2624918
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

ALPRAZOLAM (XANAX) 0.25MG TAB C4

Facility

$21.00

Service Code	NDC 781106101
Hospital Charge Code	2654070
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

ALPRAZOLAM (XANAX) 0.25MG TAB C4

Facility

$21.00

Service Code	NDC 781106101
Hospital Charge Code	2654070
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

ALPRAZOLAM (XANAX) 0.5MG TAB C4

Facility

$21.00

Service Code	NDC 5.1991E+10
Hospital Charge Code	2654075
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

ALPRAZOLAM (XANAX) 0.5MG TAB C4

Facility

$21.00

Service Code	NDC 5.1991E+10
Hospital Charge Code	2654075
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

.ALT CPT 84460

Facility

$55.00

Service Code	CPT 84460
Hospital Charge Code	22284460
Hospital Revenue Code	307
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$39.27
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.77
Rate for Payer: Aetna Medicare Advantage	$5.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial HMO & PPO	$5.30
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.10
Rate for Payer: Home State Health Plan Medicare Advantage	$5.30
Rate for Payer: Humana Commercial	$10.60
Rate for Payer: Humana Medicare Advantage	$5.30
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.77
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

.ALT CPT 84460

Facility

$55.00

Service Code	CPT 84460
Hospital Charge Code	22284460
Hospital Revenue Code	307
Rate for Payer: Cash Price	$49.50

ALTEPLASE(CATHFLO ACTIVASE) 2MG INJ

Facility

$762.00

Service Code	HCPCS J2997
Hospital Charge Code	2626454
Hospital Revenue Code	250
Min. Negotiated Rate	$98.59
Max. Negotiated Rate	$544.07
Rate for Payer: Aetna Medicare Advantage	$98.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$451.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$544.07
Rate for Payer: Cash Price	$685.80
Rate for Payer: Cash Price	$685.80
Rate for Payer: Cigna Commercial HMO & PPO	$98.59
Rate for Payer: Home State Health Plan Medicare Advantage	$98.59
Rate for Payer: Humana Commercial	$197.18
Rate for Payer: Humana Medicare Advantage	$98.59
Rate for Payer: UnitedHealthcare Commercial	$508.25
Rate for Payer: UnitedHealthcare Medicare Advantage	$274.32

ALTEPLASE(CATHFLO ACTIVASE) 2MG INJ

Facility

$762.00

Service Code	HCPCS J2997
Hospital Charge Code	2626454
Hospital Revenue Code	250
Rate for Payer: Cash Price	$685.80

ALTERATION IN CONSCIOUSNESS

Facility

$21,770.57

Service Code	APR-DRG 0524
Min. Negotiated Rate	$21,770.57
Max. Negotiated Rate	$21,770.57
Rate for Payer: Aetna Better Health Medicaid/QHP	$21,770.57
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$21,770.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$21,770.57
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$21,770.57

ALTERATION IN CONSCIOUSNESS

Facility

$6,956.08

Service Code	APR-DRG 0522
Min. Negotiated Rate	$6,956.08
Max. Negotiated Rate	$6,956.08
Rate for Payer: Aetna Better Health Medicaid/QHP	$6,956.08
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6,956.08
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6,956.08
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6,956.08

ALTERATION IN CONSCIOUSNESS

Facility

$5,767.15

Service Code	APR-DRG 0521
Min. Negotiated Rate	$5,767.15
Max. Negotiated Rate	$5,767.15
Rate for Payer: Aetna Better Health Medicaid/QHP	$5,767.15
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5,767.15
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5,767.15
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5,767.15

ALTERATION IN CONSCIOUSNESS

Facility

$11,495.47

Service Code	APR-DRG 0523
Min. Negotiated Rate	$11,495.47
Max. Negotiated Rate	$11,495.47
Rate for Payer: Aetna Better Health Medicaid/QHP	$11,495.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11,495.47
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11,495.47
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11,495.47

ALT / SGPT

Facility

$124.00

Service Code	CPT 84460
Hospital Charge Code	2219127
Hospital Revenue Code	301
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$88.54
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.77
Rate for Payer: Aetna Medicare Advantage	$5.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$73.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$88.54
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial HMO & PPO	$5.30
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.10
Rate for Payer: Home State Health Plan Medicare Advantage	$5.30
Rate for Payer: Humana Commercial	$10.60
Rate for Payer: Humana Medicare Advantage	$5.30
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.77
Rate for Payer: UnitedHealthcare Medicare Advantage	$44.64

ALT / SGPT

Facility

$124.00

Service Code	CPT 84460
Hospital Charge Code	2219127
Hospital Revenue Code	301
Rate for Payer: Cash Price	$111.60

ALUMINUM

Facility

$135.00

Service Code	CPT 82108
Hospital Charge Code	2282108
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$96.39
Rate for Payer: Aetna Better Health Medicaid/QHP	$22.93
Rate for Payer: Aetna Medicare Advantage	$25.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$79.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$96.39
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial HMO & PPO	$25.48
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$22.93
Rate for Payer: Home State Health Plan Medicaid Managed Care	$24.54
Rate for Payer: Home State Health Plan Medicare Advantage	$25.48
Rate for Payer: Humana Commercial	$50.96
Rate for Payer: Humana Medicare Advantage	$25.48
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$22.93
Rate for Payer: UnitedHealthcare Medicare Advantage	$48.60

ALUMINUM

Facility

$135.00

Service Code	CPT 82108
Hospital Charge Code	2282108
Hospital Revenue Code	301
Rate for Payer: Cash Price	$121.50

ALUM SULF TET/CALC ACE MON PWDR PKT

Facility

$24.00

Service Code	NDC 1.65E+10
Hospital Charge Code	2697818
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

ALUM SULF TET/CALC ACE MON PWDR PKT

Facility

$24.00

Service Code	NDC 1.65E+10
Hospital Charge Code	2697818
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.14
Rate for Payer: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

AMIKACIN, PEAK

Facility

$102.00

Service Code	CPT 80150
Hospital Charge Code	2280150
Hospital Revenue Code	301
Min. Negotiated Rate	$13.57
Max. Negotiated Rate	$72.83
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.57
Rate for Payer: Aetna Medicare Advantage	$15.08
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	$15.08
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.52
Rate for Payer: Home State Health Plan Medicare Advantage	$15.08
Rate for Payer: Humana Commercial	$30.16
Rate for Payer: Humana Medicare Advantage	$15.08
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.57
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.72

AMIKACIN, PEAK

Facility

$102.00

Service Code	CPT 80150
Hospital Charge Code	2280150
Hospital Revenue Code	301
Rate for Payer: Cash Price	$91.80

Know your out-of-pocket cost for care.

All Charges