Madison Medical Center

All Charges

Charge

Type

Setting

Price

AMLODIPINE (NORVASC) 5MG TAB UD

Facility

$24.00

Service Code	NDC 904637061
Hospital Charge Code	2654161
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

AMLODIPINE (NORVASC) 5MG TAB UD

Facility

$24.00

Service Code	NDC 904637061
Hospital Charge Code	2654161
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

AMLOD/OLMESART 5/20MG TAB EMP

Facility

$16.00

Service Code	NDC 3.3342E+10
Hospital Charge Code	2627309
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

AMLOD/OLMESART 5/20MG TAB EMP

Facility

$16.00

Service Code	NDC 3.3342E+10
Hospital Charge Code	2627309
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

AMLOD/OLMESART 5/40MG TAB EMP

Facility

$16.00

Service Code	NDC 4.2571E+10
Hospital Charge Code	2627313
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

AMLOD/OLMESART 5/40MG TAB EMP

Facility

$16.00

Service Code	NDC 4.2571E+10
Hospital Charge Code	2627313
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

AMMIOCENTISIS N

Facility

$135.00

Service Code	CPT 59000
Hospital Charge Code	4259000
Hospital Revenue Code	521
Min. Negotiated Rate	$79.92
Max. Negotiated Rate	$1,882.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$830.28
Rate for Payer: Aetna Medicare Advantage	$941.00
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: Cash Price	$121.50
Rate for Payer: Cigna Commercial HMO & PPO	$941.00
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$747.25
Rate for Payer: Home State Health Plan Medicaid Managed Care	$888.40
Rate for Payer: Home State Health Plan Medicare Advantage	$941.00
Rate for Payer: Humana Commercial	$1,882.00
Rate for Payer: Humana Medicare Advantage	$941.00
Rate for Payer: UnitedHealthcare Commercial	$90.05
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$830.28
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

AMMIOCENTISIS N

Facility

$135.00

Service Code	CPT 59000
Hospital Charge Code	4259000
Hospital Revenue Code	521
Rate for Payer: Cash Price	$121.50

AMMONIA

Facility

$131.00

Service Code	CPT 82140
Hospital Charge Code	221905
Hospital Revenue Code	301
Min. Negotiated Rate	$13.11
Max. Negotiated Rate	$93.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.11
Rate for Payer: Aetna Medicare Advantage	$14.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$77.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$93.53
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cigna Commercial HMO & PPO	$14.57
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.11
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.03
Rate for Payer: Home State Health Plan Medicare Advantage	$14.57
Rate for Payer: Humana Commercial	$29.14
Rate for Payer: Humana Medicare Advantage	$14.57
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$47.16

AMMONIA

Facility

$131.00

Service Code	CPT 82140
Hospital Charge Code	221905
Hospital Revenue Code	301
Rate for Payer: Cash Price	$117.90

AMMONIA INHALANT 0.33ML

Facility

$20.00

Service Code	NDC 3.9823E+10
Hospital Charge Code	2626396
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

AMMONIA INHALANT 0.33ML

Facility

$20.00

Service Code	NDC 3.9823E+10
Hospital Charge Code	2626396
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

AMMONIUM LACTATE 12% CRM 385GM EMP

Facility

$44.00

Service Code	NDC 5.1672E+10
Hospital Charge Code	2624329
Hospital Revenue Code	250
Rate for Payer: Cash Price	$39.60

AMMONIUM LACTATE 12% CRM 385GM EMP

Facility

$44.00

Service Code	NDC 5.1672E+10
Hospital Charge Code	2624329
Hospital Revenue Code	250
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$31.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$31.42
Rate for Payer: Cash Price	$39.60
Rate for Payer: UnitedHealthcare Commercial	$29.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.84

AMMONIUM LACTATE 12% LTN 225GM (8OZ) EMP

Facility

$44.00

Service Code	NDC 1E+11
Hospital Charge Code	2621232
Hospital Revenue Code	250
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$31.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$31.42
Rate for Payer: Cash Price	$39.60
Rate for Payer: UnitedHealthcare Commercial	$29.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.84

AMMONIUM LACTATE 12% LTN 225GM (8OZ) EMP

Facility

$44.00

Service Code	NDC 1E+11
Hospital Charge Code	2621232
Hospital Revenue Code	250
Rate for Payer: Cash Price	$39.60

AMOX 125MG/5ML SUSP 80ML

Facility

$21.00

Service Code	NDC 781603958
Hospital Charge Code	2654170
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

AMOX 125MG/5ML SUSP 80ML

Facility

$21.00

Service Code	NDC 781603958
Hospital Charge Code	2654170
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

AMOX 125MG/5ML SUSP 80ML EMP

Facility

$21.00

Service Code	NDC 781603958
Hospital Charge Code	2626986
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

AMOX 125MG/5ML SUSP 80ML EMP

Facility

$21.00

Service Code	NDC 781603958
Hospital Charge Code	2626986
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

AMOX 200MG/5ML SUSP 50ML

Facility

$24.00

Service Code	NDC 143988650
Hospital Charge Code	2697583
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

AMOX 200MG/5ML SUSP 50ML

Facility

$24.00

Service Code	NDC 143988650
Hospital Charge Code	2697583
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

AMOX 250MG/5ML SUSP 150ML EMP

Facility

$55.00

Service Code	NDC 781604155
Hospital Charge Code	2623082
Hospital Revenue Code	250
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
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: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

AMOX 250MG/5ML SUSP 150ML EMP

Facility

$55.00

Service Code	NDC 781604155
Hospital Charge Code	2623082
Hospital Revenue Code	250
Rate for Payer: Cash Price	$49.50

AMOX 400MG/5ML SUSP 100ML EMP

Facility

$55.00

Service Code	NDC 143988880
Hospital Charge Code	2697584
Hospital Revenue Code	250
Rate for Payer: Cash Price	$49.50

Know your out-of-pocket cost for care.

All Charges