Madison Medical Center

All Charges

Charge

Type

Setting

Price

LENS, CORNEA IRRIG FLOW

Facility

$161.00

Hospital Charge Code	2812016
Hospital Revenue Code	271
Min. Negotiated Rate	$57.96
Max. Negotiated Rate	$114.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$95.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$114.95
Rate for Payer: Cash Price	$144.90
Rate for Payer: UnitedHealthcare Commercial	$107.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$57.96

LENS, CORNEA IRRIG FLOW

Facility

$161.00

Hospital Charge Code	2812016
Hospital Revenue Code	271
Rate for Payer: Cash Price	$144.90

LEPTOSPIRA ANTIBODY

Facility

$223.00

Service Code	CPT 86720
Hospital Charge Code	2212403
Hospital Revenue Code	301
Rate for Payer: Cash Price	$200.70

LEPTOSPIRA ANTIBODY

Facility

$223.00

Service Code	CPT 86720
Hospital Charge Code	2212403
Hospital Revenue Code	301
Min. Negotiated Rate	$14.58
Max. Negotiated Rate	$159.22
Rate for Payer: Aetna Better Health Medicaid/QHP	$14.58
Rate for Payer: Aetna Medicare Advantage	$16.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$132.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$159.22
Rate for Payer: Cash Price	$200.70
Rate for Payer: Cash Price	$200.70
Rate for Payer: Cash Price	$200.70
Rate for Payer: Cigna Commercial HMO & PPO	$16.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14.58
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15.60
Rate for Payer: Home State Health Plan Medicare Advantage	$16.20
Rate for Payer: Humana Commercial	$32.40
Rate for Payer: Humana Medicare Advantage	$16.20
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$80.28

LESI WITH CT FLUORO GUIDANCE

Professional

Both

$420.00

Service Code	CPT 62323
Hospital Charge Code	4162323
Hospital Revenue Code	975
Min. Negotiated Rate	$85.62
Max. Negotiated Rate	$218.38
Rate for Payer: Aetna Commercial/Medicare Advantage	$85.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$198.53
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cigna Commercial HMO & PPO	$85.62
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$198.53
Rate for Payer: Home State Health Plan Medicaid Managed Care	$218.38
Rate for Payer: Home State Health Plan Medicare Advantage	$85.62
Rate for Payer: Optum Medicare Advantage	$147.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$198.53

LESI WITH CT FLURO GUIDANCE

Professional

Both

$1,200.00

Service Code	CPT 62323
Hospital Charge Code	4162311
Hospital Revenue Code	975
Min. Negotiated Rate	$85.62
Max. Negotiated Rate	$420.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$85.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$198.53
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Cigna Commercial HMO & PPO	$85.62
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$198.53
Rate for Payer: Home State Health Plan Medicaid Managed Care	$218.38
Rate for Payer: Home State Health Plan Medicare Advantage	$85.62
Rate for Payer: Optum Medicare Advantage	$420.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$198.53

LESI WITHOUT CT FLUORO GUIDANCE

Professional

Both

$1,000.00

Service Code	CPT 62322
Hospital Charge Code	4162322
Hospital Revenue Code	975
Min. Negotiated Rate	$71.44
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$71.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$129.77
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial HMO & PPO	$71.44
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$129.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$142.75
Rate for Payer: Home State Health Plan Medicare Advantage	$71.44
Rate for Payer: Optum Medicare Advantage	$350.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$129.77

LEUKEMIA/LYMPHOMA EVAL, ADD1. MARKER

Facility

$27.00

Service Code	CPT 88185
Hospital Charge Code	223104
Hospital Revenue Code	305
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$21.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$15.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.28
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.72

LEUKEMIA/LYMPHOMA EVAL, ADD1. MARKER

Facility

$27.00

Service Code	CPT 88185
Hospital Charge Code	223104
Hospital Revenue Code	305
Rate for Payer: Cash Price	$24.30

LEUKEMIA/LYMPHOMA EVAL ADD1 MARKER OV16

Facility

$27.00

Service Code	CPT 88189
Hospital Charge Code	2288189
Hospital Revenue Code	305
Rate for Payer: Cash Price	$24.30

LEUKEMIA/LYMPHOMA EVAL ADD1 MARKER OV16

Facility

$27.00

Service Code	CPT 88189
Hospital Charge Code	2288189
Hospital Revenue Code	305
Min. Negotiated Rate	$9.72
Max. Negotiated Rate	$21.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$15.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.28
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.72

LEUPROLIDE ACE (ELIGARD) 45MG 6MTH INJ

Facility

$20,430.00

Service Code	HCPCS J9217
Hospital Charge Code	2619248
Hospital Revenue Code	335
Rate for Payer: Cash Price	$18,387.00

LEUPROLIDE ACE (ELIGARD) 45MG 6MTH INJ

Facility

$20,430.00

Service Code	HCPCS J9217
Hospital Charge Code	2619248
Hospital Revenue Code	335
Min. Negotiated Rate	$160.34
Max. Negotiated Rate	$14,587.02
Rate for Payer: Aetna Medicare Advantage	$160.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12,094.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14,587.02
Rate for Payer: Cash Price	$18,387.00
Rate for Payer: Cash Price	$18,387.00
Rate for Payer: Cigna Commercial HMO & PPO	$160.34
Rate for Payer: Home State Health Plan Medicare Advantage	$160.34
Rate for Payer: Humana Commercial	$320.68
Rate for Payer: Humana Medicare Advantage	$160.34
Rate for Payer: UnitedHealthcare Commercial	$13,626.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$7,354.80

LEUPROLIDE ACETATE 22.5MG DEPOT IM INJ

Facility

$33,888.00

Service Code	HCPCS J9217
Hospital Charge Code	2697743
Hospital Revenue Code	335
Min. Negotiated Rate	$160.34
Max. Negotiated Rate	$24,196.03
Rate for Payer: Aetna Medicare Advantage	$160.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20,061.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24,196.03
Rate for Payer: Cash Price	$30,499.20
Rate for Payer: Cash Price	$30,499.20
Rate for Payer: Cigna Commercial HMO & PPO	$160.34
Rate for Payer: Home State Health Plan Medicare Advantage	$160.34
Rate for Payer: Humana Commercial	$320.68
Rate for Payer: Humana Medicare Advantage	$160.34
Rate for Payer: UnitedHealthcare Commercial	$22,603.30
Rate for Payer: UnitedHealthcare Medicare Advantage	$12,199.68

LEUPROLIDE ACETATE 22.5MG DEPOT IM INJ

Facility

$33,888.00

Service Code	HCPCS J9217
Hospital Charge Code	2697743
Hospital Revenue Code	335
Rate for Payer: Cash Price	$30,499.20

LEUR ADAPTER

Facility

$21.00

Hospital Charge Code	289174
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

LEUR ADAPTER

Facility

$21.00

Hospital Charge Code	289174
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

LEVALBUTEROL 0.63MG INH SOL 4X3ML PAK

Facility

$56.00

Service Code	HCPCS J7614
Hospital Charge Code	2626443
Hospital Revenue Code	250
Rate for Payer: Cash Price	$50.40

LEVALBUTEROL 0.63MG INH SOL 4X3ML PAK

Facility

$56.00

Service Code	HCPCS J7614
Hospital Charge Code	2626443
Hospital Revenue Code	250
Min. Negotiated Rate	$20.16
Max. Negotiated Rate	$39.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$33.15
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.98
Rate for Payer: Cash Price	$50.40
Rate for Payer: UnitedHealthcare Commercial	$37.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.16

LEVALBUTEROL 0.63MG INH SOL 5X3ML PAK

Facility

$60.00

Service Code	HCPCS J7614
Hospital Charge Code	2623039
Hospital Revenue Code	250
Rate for Payer: Cash Price	$54.00

LEVALBUTEROL 0.63MG INH SOL 5X3ML PAK

Facility

$60.00

Service Code	HCPCS J7614
Hospital Charge Code	2623039
Hospital Revenue Code	250
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

LEVALBUTEROL / SOD CHL 1.25MG / 3ML

Facility

$81.00

Service Code	HCPCS J7608
Hospital Charge Code	2626444
Hospital Revenue Code	250
Min. Negotiated Rate	$29.16
Max. Negotiated Rate	$57.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$47.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$57.83
Rate for Payer: Cash Price	$72.90
Rate for Payer: UnitedHealthcare Commercial	$54.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$29.16

LEVALBUTEROL / SOD CHL 1.25MG / 3ML

Facility

$81.00

Service Code	HCPCS J7608
Hospital Charge Code	2626444
Hospital Revenue Code	250
Rate for Payer: Cash Price	$72.90

LEVALBUTEROL TART HFA INH 200 DOSES

Facility

$215.00

Service Code	NDC 6.3402E+10
Hospital Charge Code	2697874
Hospital Revenue Code	250
Rate for Payer: Cash Price	$193.50

LEVALBUTEROL TART HFA INH 200 DOSES

Facility

$215.00

Service Code	NDC 6.3402E+10
Hospital Charge Code	2697874
Hospital Revenue Code	250
Min. Negotiated Rate	$77.40
Max. Negotiated Rate	$153.51
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$127.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$153.51
Rate for Payer: Cash Price	$193.50
Rate for Payer: UnitedHealthcare Commercial	$143.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$77.40

Know your out-of-pocket cost for care.

All Charges