Madison Medical Center

All Charges

Charge

Type

Setting

Price

IUD INSERTION

Facility

$314.00

Service Code	CPT 58300
Hospital Charge Code	4258300
Hospital Revenue Code	521
Rate for Payer: Cash Price	$282.60

IUD REMOVAL

Facility

$104.00

Service Code	CPT 58301
Hospital Charge Code	5258301
Hospital Revenue Code	521
Min. Negotiated Rate	$61.57
Max. Negotiated Rate	$622.66
Rate for Payer: Aetna Better Health Medicaid/QHP	$274.70
Rate for Payer: Aetna Medicare Advantage	$311.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$61.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$74.26
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cigna Commercial HMO & PPO	$311.33
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$247.23
Rate for Payer: Home State Health Plan Medicaid Managed Care	$293.93
Rate for Payer: Home State Health Plan Medicare Advantage	$311.33
Rate for Payer: Humana Commercial	$622.66
Rate for Payer: Humana Medicare Advantage	$311.33
Rate for Payer: UnitedHealthcare Commercial	$69.37
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$274.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

IUD REMOVAL

Facility

$104.00

Service Code	CPT 58301
Hospital Charge Code	5258301
Hospital Revenue Code	521
Rate for Payer: Cash Price	$93.60

IUD REMOVAL

Facility

$93.00

Service Code	CPT 58301
Hospital Charge Code	4258301
Hospital Revenue Code	521
Rate for Payer: Cash Price	$83.70

IUD REMOVAL

Facility

$93.00

Service Code	CPT 58301
Hospital Charge Code	4258301
Hospital Revenue Code	521
Min. Negotiated Rate	$55.06
Max. Negotiated Rate	$622.66
Rate for Payer: Aetna Better Health Medicaid/QHP	$274.70
Rate for Payer: Aetna Medicare Advantage	$311.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$55.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$66.40
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial HMO & PPO	$311.33
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$247.23
Rate for Payer: Home State Health Plan Medicaid Managed Care	$293.93
Rate for Payer: Home State Health Plan Medicare Advantage	$311.33
Rate for Payer: Humana Commercial	$622.66
Rate for Payer: Humana Medicare Advantage	$311.33
Rate for Payer: UnitedHealthcare Commercial	$62.03
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$274.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

IVABRADINE 5MG TAB EMP

Facility

$31.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2627290
Hospital Revenue Code	250
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$22.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$18.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$22.13
Rate for Payer: Cash Price	$27.90
Rate for Payer: UnitedHealthcare Commercial	$20.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.16

IVABRADINE 5MG TAB EMP

Facility

$31.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2627290
Hospital Revenue Code	250
Rate for Payer: Cash Price	$27.90

IVAC CONTROLLER

Facility

$91.00

Service Code	NDC 1E+11
Hospital Charge Code	2656565
Hospital Revenue Code	250
Rate for Payer: Cash Price	$81.90

IVAC CONTROLLER

Facility

$106.00

Service Code	NDC 1E+11
Hospital Charge Code	2696417
Hospital Revenue Code	250
Rate for Payer: Cash Price	$95.40

IVAC CONTROLLER

Facility

$106.00

Service Code	NDC 1E+11
Hospital Charge Code	2696417
Hospital Revenue Code	250
Min. Negotiated Rate	$38.16
Max. Negotiated Rate	$75.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$62.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$75.68
Rate for Payer: Cash Price	$95.40
Rate for Payer: UnitedHealthcare Commercial	$70.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.16

IVAC CONTROLLER

Facility

$91.00

Service Code	NDC 1E+11
Hospital Charge Code	2656565
Hospital Revenue Code	250
Min. Negotiated Rate	$32.76
Max. Negotiated Rate	$64.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$53.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$64.97
Rate for Payer: Cash Price	$81.90
Rate for Payer: UnitedHealthcare Commercial	$60.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$32.76

IVAC PIGGYBACK SET

Facility

$22.00

Hospital Charge Code	281023
Hospital Revenue Code	271
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

IVAC PIGGYBACK SET

Facility

$22.00

Hospital Charge Code	281023
Hospital Revenue Code	271
Rate for Payer: Cash Price	$19.80

IVAC PUMP

Facility

$121.00

Service Code	NDC 1E+11
Hospital Charge Code	2696418
Hospital Revenue Code	250
Rate for Payer: Cash Price	$108.90

IVAC PUMP

Facility

$121.00

Service Code	NDC 1E+11
Hospital Charge Code	2696418
Hospital Revenue Code	250
Min. Negotiated Rate	$43.56
Max. Negotiated Rate	$86.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$71.63
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$86.39
Rate for Payer: Cash Price	$108.90
Rate for Payer: UnitedHealthcare Commercial	$80.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$43.56

IVAC UNINVERSAL SET c LOW SORBING TUBING

Facility

$140.00

Service Code	NDC 1E+11
Hospital Charge Code	2655722
Hospital Revenue Code	250
Rate for Payer: Cash Price	$126.00

IVAC UNINVERSAL SET c LOW SORBING TUBING

Facility

$140.00

Service Code	NDC 1E+11
Hospital Charge Code	2655722
Hospital Revenue Code	250
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$99.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$82.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$99.96
Rate for Payer: Cash Price	$126.00
Rate for Payer: UnitedHealthcare Commercial	$93.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$50.40

IVERMECTIN 3MG TAB

Facility

$39.00

Service Code	NDC 4.2799E+10
Hospital Charge Code	2620312
Hospital Revenue Code	250
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

IVERMECTIN 3MG TAB

Facility

$39.00

Service Code	NDC 4.2799E+10
Hospital Charge Code	2620312
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.10

IV EXTENSION FILTER SET/HIGH VOLUME

Facility

$21.00

Hospital Charge Code	288671
Hospital Revenue Code	271
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

IV EXTENSION FILTER SET/HIGH VOLUME

Facility

$21.00

Hospital Charge Code	2622606
Hospital Revenue Code	271
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

IV EXTENSION FILTER SET/HIGH VOLUME

Facility

$21.00

Hospital Charge Code	288671
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

IV EXTENSION FILTER SET/HIGH VOLUME

Facility

$21.00

Hospital Charge Code	2622606
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

IV FLUIDS & OP-SITE

Facility

$106.00

Hospital Charge Code	2058094
Hospital Revenue Code	370
Min. Negotiated Rate	$38.16
Max. Negotiated Rate	$75.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$62.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$75.68
Rate for Payer: Cash Price	$95.40
Rate for Payer: UnitedHealthcare Commercial	$70.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.16

IV FLUIDS & OP-SITE

Facility

$106.00

Hospital Charge Code	2058094
Hospital Revenue Code	370
Rate for Payer: Cash Price	$95.40

Know your out-of-pocket cost for care.

All Charges