Madison Medical Center

All Charges

Charge

Type

Setting

Price

LEVALBUT (XOPENEX) 0.63MG NEB SOL 3ML UD

Facility

$62.00

Service Code	HCPCS J7608
Hospital Charge Code	2623418
Hospital Revenue Code	250
Min. Negotiated Rate	$22.32
Max. Negotiated Rate	$44.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$36.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$44.27
Rate for Payer: Cash Price	$55.80
Rate for Payer: UnitedHealthcare Commercial	$41.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$22.32

LEVALBUT (XOPENEX) 0.63MG NEB SOL 3ML UD

Facility

$62.00

Service Code	HCPCS J7608
Hospital Charge Code	2623418
Hospital Revenue Code	250
Rate for Payer: Cash Price	$55.80

LEVALBUT (XOPENEX) 1.25MG NEB SOL 3ML

Facility

$62.00

Service Code	HCPCS J7608
Hospital Charge Code	2626543
Hospital Revenue Code	250
Rate for Payer: Cash Price	$55.80

LEVALBUT (XOPENEX) 1.25MG NEB SOL 3ML

Facility

$62.00

Service Code	HCPCS J7608
Hospital Charge Code	2626543
Hospital Revenue Code	250
Min. Negotiated Rate	$22.32
Max. Negotiated Rate	$44.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$36.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$44.27
Rate for Payer: Cash Price	$55.80
Rate for Payer: UnitedHealthcare Commercial	$41.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$22.32

LEVALBUT (XOPENEX) 1.25MG SOL 3ML EMP

Facility

$51.00

Service Code	HCPCS J7608
Hospital Charge Code	2625550
Hospital Revenue Code	250
Min. Negotiated Rate	$18.36
Max. Negotiated Rate	$36.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$30.19
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$36.41
Rate for Payer: Cash Price	$45.90
Rate for Payer: UnitedHealthcare Commercial	$34.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.36

LEVALBUT (XOPENEX) 1.25MG SOL 3ML EMP

Facility

$51.00

Service Code	HCPCS J7608
Hospital Charge Code	2625550
Hospital Revenue Code	250
Rate for Payer: Cash Price	$45.90

LEVALBUT (XOPENEX) HFA INHALER EMP

Facility

$215.00

Service Code	NDC 6.3402E+10
Hospital Charge Code	2622984
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

LEVALBUT (XOPENEX) HFA INHALER EMP

Facility

$215.00

Service Code	NDC 6.3402E+10
Hospital Charge Code	2622984
Hospital Revenue Code	250
Rate for Payer: Cash Price	$193.50

LEVEL 1 SURG. PATH. GROSS EXAM.

Facility

$199.00

Service Code	CPT 88300
Hospital Charge Code	2288300
Hospital Revenue Code	305
Rate for Payer: Cash Price	$179.10

LEVEL 1 SURG. PATH. GROSS EXAM.

Facility

$199.00

Service Code	CPT 88300
Hospital Charge Code	2288300
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$142.09
Rate for Payer: Cash Price	$179.10
Rate for Payer: Aetna Better Health Medicaid/QHP	$26.07
Rate for Payer: Aetna Medicare Advantage	$29.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$117.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$142.09
Rate for Payer: Cash Price	$179.10
Rate for Payer: Cash Price	$179.10
Rate for Payer: Cigna Commercial HMO & PPO	$29.55
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$26.07
Rate for Payer: Home State Health Plan Medicaid Managed Care	$27.89
Rate for Payer: Home State Health Plan Medicare Advantage	$29.55
Rate for Payer: Humana Commercial	$59.10
Rate for Payer: Humana Medicare Advantage	$29.55
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$26.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$71.64

LEVEL 2 SURG. PATH. GROSS & MICRO.

Facility

$357.00

Service Code	CPT 88302
Hospital Charge Code	2288302
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$254.90
Rate for Payer: Aetna Better Health Medicaid/QHP	$33.67
Rate for Payer: Aetna Medicare Advantage	$38.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$211.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$254.90
Rate for Payer: Cash Price	$321.30
Rate for Payer: Cash Price	$321.30
Rate for Payer: Cash Price	$321.30
Rate for Payer: Cigna Commercial HMO & PPO	$38.16
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$33.67
Rate for Payer: Home State Health Plan Medicaid Managed Care	$36.03
Rate for Payer: Home State Health Plan Medicare Advantage	$38.16
Rate for Payer: Humana Commercial	$76.32
Rate for Payer: Humana Medicare Advantage	$38.16
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$33.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$128.52

LEVEL 2 SURG. PATH. GROSS & MICRO.

Facility

$357.00

Service Code	CPT 88302
Hospital Charge Code	2288302
Hospital Revenue Code	305
Rate for Payer: Cash Price	$321.30

LEVEL 3 SURG. PATH GROSS & MICRO.

Facility

$233.00

Service Code	CPT 88304
Hospital Charge Code	2288304
Hospital Revenue Code	305
Rate for Payer: Cash Price	$209.70

LEVEL 3 SURG. PATH GROSS & MICRO.

Facility

$233.00

Service Code	CPT 88304
Hospital Charge Code	2288304
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$166.36
Rate for Payer: Aetna Better Health Medicaid/QHP	$46.98
Rate for Payer: Aetna Medicare Advantage	$53.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$137.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$166.36
Rate for Payer: Cash Price	$209.70
Rate for Payer: Cash Price	$209.70
Rate for Payer: Cash Price	$209.70
Rate for Payer: Cigna Commercial HMO & PPO	$53.24
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$46.98
Rate for Payer: Home State Health Plan Medicaid Managed Care	$50.27
Rate for Payer: Home State Health Plan Medicare Advantage	$53.24
Rate for Payer: Humana Commercial	$106.48
Rate for Payer: Humana Medicare Advantage	$53.24
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$46.98
Rate for Payer: UnitedHealthcare Medicare Advantage	$83.88

LEVEL 5 SURG. PATH GROSS & MICRO

Facility

$566.00

Service Code	CPT 88307
Hospital Charge Code	2288307
Hospital Revenue Code	305
Rate for Payer: Cash Price	$509.40

LEVEL 5 SURG. PATH GROSS & MICRO

Facility

$566.00

Service Code	CPT 88307
Hospital Charge Code	2288307
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$732.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$323.12
Rate for Payer: Aetna Medicare Advantage	$366.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$335.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$404.12
Rate for Payer: Cash Price	$509.40
Rate for Payer: Cash Price	$509.40
Rate for Payer: Cash Price	$509.40
Rate for Payer: Cigna Commercial HMO & PPO	$366.21
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$323.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$345.74
Rate for Payer: Home State Health Plan Medicare Advantage	$366.21
Rate for Payer: Humana Commercial	$732.42
Rate for Payer: Humana Medicare Advantage	$366.21
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$323.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$203.76

LEVEL 6 SURG. PATH GROSS & MICRO

Facility

$707.00

Service Code	CPT 88309
Hospital Charge Code	2288309
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$1,646.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$726.28
Rate for Payer: Aetna Medicare Advantage	$823.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$418.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$504.80
Rate for Payer: Cash Price	$636.30
Rate for Payer: Cash Price	$636.30
Rate for Payer: Cash Price	$636.30
Rate for Payer: Cigna Commercial HMO & PPO	$823.13
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$726.28
Rate for Payer: Home State Health Plan Medicaid Managed Care	$777.12
Rate for Payer: Home State Health Plan Medicare Advantage	$823.13
Rate for Payer: Humana Commercial	$1,646.26
Rate for Payer: Humana Medicare Advantage	$823.13
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$726.28
Rate for Payer: UnitedHealthcare Medicare Advantage	$254.52

LEVEL 6 SURG. PATH GROSS & MICRO

Facility

$707.00

Service Code	CPT 88309
Hospital Charge Code	2288309
Hospital Revenue Code	305
Rate for Payer: Cash Price	$636.30

LEVETIRACETAM

Facility

$251.00

Service Code	CPT 80177
Hospital Charge Code	2280294
Hospital Revenue Code	301
Rate for Payer: Cash Price	$225.90

LEVETIRACETAM

Facility

$251.00

Service Code	CPT 80177
Hospital Charge Code	2280294
Hospital Revenue Code	301
Min. Negotiated Rate	$11.93
Max. Negotiated Rate	$179.21
Rate for Payer: Aetna Better Health Medicaid/QHP	$11.93
Rate for Payer: Aetna Medicare Advantage	$13.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$148.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$179.21
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial HMO & PPO	$13.25
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11.93
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12.77
Rate for Payer: Home State Health Plan Medicare Advantage	$13.25
Rate for Payer: Humana Commercial	$26.50
Rate for Payer: Humana Medicare Advantage	$13.25
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11.93
Rate for Payer: UnitedHealthcare Medicare Advantage	$90.36

LEVETIRACETAM 500MG INJ 5ML SDV

Facility

$57.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2622532
Hospital Revenue Code	250
Rate for Payer: Cash Price	$51.30

LEVETIRACETAM 500MG INJ 5ML SDV

Facility

$57.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2622532
Hospital Revenue Code	250
Min. Negotiated Rate	$20.52
Max. Negotiated Rate	$40.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$33.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$40.70
Rate for Payer: Cash Price	$51.30
Rate for Payer: UnitedHealthcare Commercial	$38.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.52

LEVETIRACETAM (KEPPRA) 500MG TAB EMP

Facility

$32.00

Service Code	NDC 5.0268E+10
Hospital Charge Code	2626033
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$22.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$18.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$22.85
Rate for Payer: Cash Price	$28.80
Rate for Payer: UnitedHealthcare Commercial	$21.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.52

LEVETIRACETAM (KEPPRA) 500MG TAB EMP

Facility

$32.00

Service Code	NDC 5.0268E+10
Hospital Charge Code	2626033
Hospital Revenue Code	250
Rate for Payer: Cash Price	$28.80

LEVETIRACETAM (KEPPRA) 500MG TAB UD

Facility

$32.00

Service Code	NDC 904712461
Hospital Charge Code	2626499
Hospital Revenue Code	250
Rate for Payer: Cash Price	$28.80

Know your out-of-pocket cost for care.

All Charges