Madison Medical Center

All Charges

Charge

Type

Setting

Price

IV INFUSION REGEN-COV ADMINISTRATION

Facility

$839.00

Service Code	CPT M0243
Hospital Charge Code	126877
Hospital Revenue Code	260
Rate for Payer: Cash Price	$755.10

IV INFUSION REGEN-COV ADMINISTRATION

Facility

$839.00

Service Code	CPT M0243
Hospital Charge Code	126877
Hospital Revenue Code	260
Min. Negotiated Rate	$302.04
Max. Negotiated Rate	$599.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$496.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$599.05
Rate for Payer: Cash Price	$755.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$302.04

IV INFUSION SOTROVIMAB ADMINISTRATION

Facility

$839.00

Service Code	CPT M0247
Hospital Charge Code	126878
Hospital Revenue Code	260
Rate for Payer: Cash Price	$755.10

IV INFUSION SOTROVIMAB ADMINISTRATION

Facility

$839.00

Service Code	CPT M0247
Hospital Charge Code	126878
Hospital Revenue Code	260
Min. Negotiated Rate	$302.04
Max. Negotiated Rate	$599.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$496.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$599.05
Rate for Payer: Cash Price	$755.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$302.04

IVP ADMIN PAK

Facility

$156.00

Hospital Charge Code	2800121
Hospital Revenue Code	271
Min. Negotiated Rate	$56.16
Max. Negotiated Rate	$111.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$92.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$111.38
Rate for Payer: Cash Price	$140.40
Rate for Payer: UnitedHealthcare Commercial	$104.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$56.16

IVP ADMIN PAK

Facility

$156.00

Hospital Charge Code	2800121
Hospital Revenue Code	271
Rate for Payer: Cash Price	$140.40

IVP ADMIN PAK

Facility

$153.00

Hospital Charge Code	3200121
Hospital Revenue Code	271
Rate for Payer: Cash Price	$137.70

IVP ADMIN PAK

Facility

$153.00

Hospital Charge Code	3200121
Hospital Revenue Code	271
Min. Negotiated Rate	$55.08
Max. Negotiated Rate	$109.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$90.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$109.24
Rate for Payer: Cash Price	$137.70
Rate for Payer: UnitedHealthcare Commercial	$102.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$55.08

IVP-NEPHROTOMOGRAM

Facility

$1,150.00

Service Code	CPT 74415
Hospital Charge Code	3274415
Hospital Revenue Code	320
Rate for Payer: Cash Price	$1,035.00

IVP-NEPHROTOMOGRAM

Facility

$1,150.00

Service Code	CPT 74415
Hospital Charge Code	3274415
Hospital Revenue Code	320
Min. Negotiated Rate	$158.12
Max. Negotiated Rate	$821.10
Rate for Payer: Aetna Better Health Medicaid/QHP	$158.12
Rate for Payer: Aetna Medicare Advantage	$179.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$680.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$821.10
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Cash Price	$1,035.00
Rate for Payer: Cigna Commercial HMO & PPO	$179.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$158.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$169.19
Rate for Payer: Home State Health Plan Medicare Advantage	$179.20
Rate for Payer: Humana Commercial	$358.40
Rate for Payer: Humana Medicare Advantage	$179.20
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$158.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$414.00

IV PUMP SET

Facility

$39.00

Hospital Charge Code	281020
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

IV PUMP SET

Facility

$39.00

Hospital Charge Code	281020
Hospital Revenue Code	271
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

IVP X-RAY

Facility

$1,010.00

Service Code	CPT 74400
Hospital Charge Code	3216159
Hospital Revenue Code	320
Min. Negotiated Rate	$158.12
Max. Negotiated Rate	$721.14
Rate for Payer: Aetna Better Health Medicaid/QHP	$158.12
Rate for Payer: Aetna Medicare Advantage	$179.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$597.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$721.14
Rate for Payer: Cash Price	$909.00
Rate for Payer: Cash Price	$909.00
Rate for Payer: Cash Price	$909.00
Rate for Payer: Cigna Commercial HMO & PPO	$179.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$158.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$169.19
Rate for Payer: Home State Health Plan Medicare Advantage	$179.20
Rate for Payer: Humana Commercial	$358.40
Rate for Payer: Humana Medicare Advantage	$179.20
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$158.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$363.60

IVP X-RAY

Facility

$1,010.00

Service Code	CPT 74400
Hospital Charge Code	3216159
Hospital Revenue Code	320
Rate for Payer: Cash Price	$909.00

IV SET 10 DROP

Facility

$39.00

Hospital Charge Code	289804
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

IV SET 10 DROP

Facility

$39.00

Hospital Charge Code	289804
Hospital Revenue Code	271
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

IV SET, VENTED

Facility

$39.00

Hospital Charge Code	2622607
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

IV SET, VENTED

Facility

$39.00

Hospital Charge Code	289803
Hospital Revenue Code	271
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

IV SET, VENTED

Facility

$39.00

Hospital Charge Code	2622607
Hospital Revenue Code	271
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

IV SET, VENTED

Facility

$39.00

Hospital Charge Code	289803
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

IV START KIT

Facility

$39.00

Hospital Charge Code	289802
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

IV START KIT

Facility

$39.00

Hospital Charge Code	289802
Hospital Revenue Code	271
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

J.AK2 EXON 12 MUTATION

Facility

$862.00

Service Code	CPT 81403
Hospital Charge Code	2281403
Hospital Revenue Code	301
Rate for Payer: Cash Price	$775.80

J.AK2 EXON 12 MUTATION

Facility

$862.00

Service Code	CPT 81403
Hospital Charge Code	2281403
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$615.47
Rate for Payer: Aetna Better Health Medicaid/QHP	$166.68
Rate for Payer: Aetna Medicare Advantage	$185.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$510.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$615.47
Rate for Payer: Cash Price	$775.80
Rate for Payer: Cash Price	$775.80
Rate for Payer: Cash Price	$775.80
Rate for Payer: Cigna Commercial HMO & PPO	$185.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$166.68
Rate for Payer: Home State Health Plan Medicaid Managed Care	$178.35
Rate for Payer: Home State Health Plan Medicare Advantage	$185.20
Rate for Payer: Humana Commercial	$370.40
Rate for Payer: Humana Medicare Advantage	$185.20
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$166.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$310.32

JAK2 MUTATION

Facility

$846.00

Service Code	CPT 81270
Hospital Charge Code	2281270
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$604.04
Rate for Payer: Aetna Better Health Medicaid/QHP	$82.49
Rate for Payer: Aetna Medicare Advantage	$91.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$500.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$604.04
Rate for Payer: Cash Price	$761.40
Rate for Payer: Cash Price	$761.40
Rate for Payer: Cash Price	$761.40
Rate for Payer: Cigna Commercial HMO & PPO	$91.66
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$82.49
Rate for Payer: Home State Health Plan Medicaid Managed Care	$88.26
Rate for Payer: Home State Health Plan Medicare Advantage	$91.66
Rate for Payer: Humana Commercial	$183.32
Rate for Payer: Humana Medicare Advantage	$91.66
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$82.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$304.56

Know your out-of-pocket cost for care.

All Charges