Madison Medical Center

All Charges

Charge

Type

Setting

Price

LATANOPROST (XALATAN) 2.5ML OPTH SOL

Facility

$297.00

Service Code	NDC 2.4208E+10
Hospital Charge Code	2626277
Hospital Revenue Code	250
Min. Negotiated Rate	$106.92
Max. Negotiated Rate	$212.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$175.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$212.06
Rate for Payer: Cash Price	$267.30
Rate for Payer: UnitedHealthcare Commercial	$198.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$106.92

LATANOPROST (XALATAN) 2.5ML OPTH SOL

Facility

$297.00

Service Code	NDC 2.4208E+10
Hospital Charge Code	2626277
Hospital Revenue Code	250
Rate for Payer: Cash Price	$267.30

LATANOPROST (XALATAN) OP SOL 2.5ML EMP

Facility

$297.00

Service Code	NDC 13830304
Hospital Charge Code	2623512
Hospital Revenue Code	250
Min. Negotiated Rate	$106.92
Max. Negotiated Rate	$212.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$175.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$212.06
Rate for Payer: Cash Price	$267.30
Rate for Payer: UnitedHealthcare Commercial	$198.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$106.92

LATANOPROST (XALATAN) OP SOL 2.5ML EMP

Facility

$297.00

Service Code	NDC 13830304
Hospital Charge Code	2623512
Hospital Revenue Code	250
Rate for Payer: Cash Price	$267.30

L A T KIT

Facility

$110.00

Hospital Charge Code	2812010
Hospital Revenue Code	270
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$78.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$78.54
Rate for Payer: Cash Price	$99.00
Rate for Payer: UnitedHealthcare Commercial	$73.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.60

L A T KIT

Facility

$110.00

Hospital Charge Code	2812010
Hospital Revenue Code	270
Rate for Payer: Cash Price	$99.00

LAVACUATOR TUBE 22

Facility

$131.00

Hospital Charge Code	2812003
Hospital Revenue Code	271
Rate for Payer: Cash Price	$117.90

LAVACUATOR TUBE 22

Facility

$131.00

Hospital Charge Code	2812003
Hospital Revenue Code	271
Min. Negotiated Rate	$47.16
Max. Negotiated Rate	$93.53
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: UnitedHealthcare Commercial	$87.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$47.16

LAVAGE, TRAY

Facility

$141.00

Hospital Charge Code	2812018
Hospital Revenue Code	271
Min. Negotiated Rate	$50.76
Max. Negotiated Rate	$100.67
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: UnitedHealthcare Commercial	$94.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$50.76

LAVAGE, TRAY

Facility

$141.00

Hospital Charge Code	2812018
Hospital Revenue Code	271
Rate for Payer: Cash Price	$126.90

LAYER CLOSURE-12.6CM TO 20.0CM

Professional

Both

$1,586.00

Service Code	CPT 12045
Hospital Charge Code	1812045
Hospital Revenue Code	981
Min. Negotiated Rate	$250.97
Max. Negotiated Rate	$555.10
Rate for Payer: Aetna Commercial/Medicare Advantage	$250.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$309.92
Rate for Payer: Cash Price	$1,427.40
Rate for Payer: Cash Price	$1,427.40
Rate for Payer: Cigna Commercial HMO & PPO	$250.97
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$309.92
Rate for Payer: Home State Health Plan Medicaid Managed Care	$340.91
Rate for Payer: Home State Health Plan Medicare Advantage	$250.97
Rate for Payer: Optum Medicare Advantage	$555.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$309.92

LAYER CLOSURE 2.6 TO 7.5 NECK,HANDS,FEET

Facility

$420.00

Service Code	CPT 12042
Hospital Charge Code	5412042
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$830.64
Rate for Payer: Aetna Better Health Medicaid/QHP	$366.45
Rate for Payer: Aetna Medicare Advantage	$415.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$248.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$299.88
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cigna Commercial HMO & PPO	$415.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$329.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$392.10
Rate for Payer: Home State Health Plan Medicare Advantage	$415.32
Rate for Payer: Humana Commercial	$830.64
Rate for Payer: Humana Medicare Advantage	$415.32
Rate for Payer: UnitedHealthcare Commercial	$280.14
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

LAYER CLOSURE 2.6 TO 7.5 NECK,HANDS,FEET

Facility

$420.00

Service Code	CPT 12042
Hospital Charge Code	5412042
Hospital Revenue Code	521
Rate for Payer: Cash Price	$378.00

LAYER CLOSURE-FACE 0 TO 2.5CM

Professional

Both

$920.00

Service Code	CPT 12051
Hospital Charge Code	1812051
Hospital Revenue Code	981
Min. Negotiated Rate	$140.25
Max. Negotiated Rate	$322.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$140.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$216.12
Rate for Payer: Cash Price	$828.00
Rate for Payer: Cash Price	$828.00
Rate for Payer: Cigna Commercial HMO & PPO	$140.25
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$216.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.73
Rate for Payer: Home State Health Plan Medicare Advantage	$140.25
Rate for Payer: Optum Medicare Advantage	$322.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$216.12

LAYER CLOSURE FR 2.6CM TO 7.5C

Professional

Both

$942.00

Service Code	CPT 12032
Hospital Charge Code	1812032
Hospital Revenue Code	981
Min. Negotiated Rate	$154.54
Max. Negotiated Rate	$329.70
Rate for Payer: Aetna Commercial/Medicare Advantage	$154.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$229.70
Rate for Payer: Cash Price	$847.80
Rate for Payer: Cash Price	$847.80
Rate for Payer: Cigna Commercial HMO & PPO	$154.54
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$229.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$252.67
Rate for Payer: Home State Health Plan Medicare Advantage	$154.54
Rate for Payer: Optum Medicare Advantage	$329.70
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$229.70

LAYER CLOSURE OF 5.1CM TO 7.5CM

Professional

Both

$1,341.00

Service Code	CPT 12053
Hospital Charge Code	1812053
Hospital Revenue Code	981
Min. Negotiated Rate	$176.93
Max. Negotiated Rate	$469.35
Rate for Payer: Aetna Commercial/Medicare Advantage	$176.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$277.19
Rate for Payer: Cash Price	$1,206.90
Rate for Payer: Cash Price	$1,206.90
Rate for Payer: Cigna Commercial HMO & PPO	$176.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$277.19
Rate for Payer: Home State Health Plan Medicaid Managed Care	$304.91
Rate for Payer: Home State Health Plan Medicare Advantage	$176.93
Rate for Payer: Optum Medicare Advantage	$469.35
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$277.19

LAYER CLOSURE OF WOUND 2.6 TO 7.5 CM

Facility

$405.00

Service Code	CPT 12042
Hospital Charge Code	4112042
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$830.64
Rate for Payer: Aetna Better Health Medicaid/QHP	$366.45
Rate for Payer: Aetna Medicare Advantage	$415.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$239.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$289.17
Rate for Payer: Cash Price	$364.50
Rate for Payer: Cash Price	$364.50
Rate for Payer: Cash Price	$364.50
Rate for Payer: Cash Price	$364.50
Rate for Payer: Cigna Commercial HMO & PPO	$415.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$329.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$392.10
Rate for Payer: Home State Health Plan Medicare Advantage	$415.32
Rate for Payer: Humana Commercial	$830.64
Rate for Payer: Humana Medicare Advantage	$415.32
Rate for Payer: UnitedHealthcare Commercial	$270.13
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

LAYER CLOSURE OF WOUND 2.6 TO 7.5 CM

Facility

$405.00

Service Code	CPT 12042
Hospital Charge Code	4112042
Hospital Revenue Code	521
Rate for Payer: Cash Price	$364.50

LAYER CLOSURE UP TO 2.5CM

Professional

Both

$729.00

Service Code	CPT 12031
Hospital Charge Code	1812031
Hospital Revenue Code	981
Min. Negotiated Rate	$124.73
Max. Negotiated Rate	$255.15
Rate for Payer: Aetna Commercial/Medicare Advantage	$124.73
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$200.81
Rate for Payer: Cash Price	$656.10
Rate for Payer: Cash Price	$656.10
Rate for Payer: Cigna Commercial HMO & PPO	$124.73
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$220.89
Rate for Payer: Home State Health Plan Medicare Advantage	$124.73
Rate for Payer: Optum Medicare Advantage	$255.15
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$200.81

.LC 138651 CPT ITEM

Facility

$106.00

Service Code	CPT 87529
Hospital Charge Code	229006
Hospital Revenue Code	307
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$75.68
Rate for Payer: Aetna Better Health Medicaid/QHP	$31.58
Rate for Payer: Aetna Medicare Advantage	$35.09
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: Cash Price	$95.40
Rate for Payer: Cash Price	$95.40
Rate for Payer: Cigna Commercial HMO & PPO	$35.09
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$31.58
Rate for Payer: Home State Health Plan Medicaid Managed Care	$33.79
Rate for Payer: Home State Health Plan Medicare Advantage	$35.09
Rate for Payer: Humana Commercial	$70.18
Rate for Payer: Humana Medicare Advantage	$35.09
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$31.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.16

.LC 138651 CPT ITEM

Facility

$106.00

Service Code	CPT 87529
Hospital Charge Code	229006
Hospital Revenue Code	307
Rate for Payer: Cash Price	$95.40

.LC 138651 CPT ITEM

Facility

$106.00

Service Code	CPT 87529
Hospital Charge Code	229007
Hospital Revenue Code	307
Rate for Payer: Cash Price	$95.40

.LC 138651 CPT ITEM

Facility

$106.00

Service Code	CPT 87529
Hospital Charge Code	229007
Hospital Revenue Code	307
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$75.68
Rate for Payer: Aetna Better Health Medicaid/QHP	$31.58
Rate for Payer: Aetna Medicare Advantage	$35.09
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: Cash Price	$95.40
Rate for Payer: Cash Price	$95.40
Rate for Payer: Cigna Commercial HMO & PPO	$35.09
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$31.58
Rate for Payer: Home State Health Plan Medicaid Managed Care	$33.79
Rate for Payer: Home State Health Plan Medicare Advantage	$35.09
Rate for Payer: Humana Commercial	$70.18
Rate for Payer: Humana Medicare Advantage	$35.09
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$31.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.16

LDH

Facility

$98.00

Service Code	CPT 83615
Hospital Charge Code	2212133
Hospital Revenue Code	301
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$69.97
Rate for Payer: Aetna Better Health Medicaid/QHP	$5.44
Rate for Payer: Aetna Medicare Advantage	$6.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$58.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$69.97
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial HMO & PPO	$6.04
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5.44
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.82
Rate for Payer: Home State Health Plan Medicare Advantage	$6.04
Rate for Payer: Humana Commercial	$12.08
Rate for Payer: Humana Medicare Advantage	$6.04
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5.44
Rate for Payer: UnitedHealthcare Medicare Advantage	$35.28

LDH

Facility

$98.00

Service Code	CPT 83615
Hospital Charge Code	2212133
Hospital Revenue Code	301
Rate for Payer: Cash Price	$88.20

Know your out-of-pocket cost for care.

All Charges