Madison Medical Center

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 75MCG TAB EMP

Facility

$20.00

Service Code	NDC 74518290
Hospital Charge Code	2618988
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LEVOTHYROXINE 88MCG TAB EMP

Facility

$20.00

Service Code	NDC 74659490
Hospital Charge Code	2619430
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LEVOTHYROXINE 88MCG TAB EMP

Facility

$20.00

Service Code	NDC 74659490
Hospital Charge Code	2619430
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

LEVOTHYROXINE 88MCG TAB HE

Facility

$20.00

Service Code	NDC 378180777
Hospital Charge Code	2655384
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

LEVOTHYROXINE 88MCG TAB HE

Facility

$20.00

Service Code	NDC 378180777
Hospital Charge Code	2655384
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LEVOTHYROXINE (SYNTHROID) 100MCG TAB

Facility

$20.00

Service Code	NDC 904695361
Hospital Charge Code	2655390
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LEVOTHYROXINE (SYNTHROID) 100MCG TAB

Facility

$20.00

Service Code	NDC 904695361
Hospital Charge Code	2655390
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

LEVOTHYROXINE (SYNTHROID) 112MCG TAB EMP

Facility

$18.00

Service Code	NDC 6.0846E+10
Hospital Charge Code	2622563
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

LEVOTHYROXINE (SYNTHROID) 112MCG TAB EMP

Facility

$18.00

Service Code	NDC 6.0846E+10
Hospital Charge Code	2622563
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

LEVOTHYROXINE (SYNTHROID) 137MCG TAB EMP

Facility

$45.00

Service Code	NDC 74372790
Hospital Charge Code	2697251
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

LEVOTHYROXINE (SYNTHROID) 137MCG TAB EMP

Facility

$45.00

Service Code	NDC 74372790
Hospital Charge Code	2697251
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.13
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

LEVOTHYROXINE (SYNTHROID) 25MCG TAB UD

Facility

$20.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2655382
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

LEVOTHYROXINE (SYNTHROID) 25MCG TAB UD

Facility

$20.00

Service Code	NDC 6.0687E+10
Hospital Charge Code	2655382
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LEVOTHYROXINE (SYNTHROID) 500MCG INJ

Facility

$1,060.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2697047
Hospital Revenue Code	250
Min. Negotiated Rate	$381.60
Max. Negotiated Rate	$756.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$627.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$756.84
Rate for Payer: Cash Price	$954.00
Rate for Payer: UnitedHealthcare Commercial	$707.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$381.60

LEVOTHYROXINE (SYNTHROID) 500MCG INJ

Facility

$1,060.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2697047
Hospital Revenue Code	250
Rate for Payer: Cash Price	$954.00

LEVOTHYROXINE (SYNTHROID)50MCG TAB

Facility

$20.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2626613
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LEVOTHYROXINE (SYNTHROID)50MCG TAB

Facility

$20.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2626613
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

LEVOTHYROXINE (SYNTHROID)75MCG TAB

Facility

$20.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2626605
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LEVOTHYROXINE (SYNTHROID)75MCG TAB

Facility

$20.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2626605
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

LEXI/STRESS EKG PHYSICIAN SUPERVISION

Professional

Both

$288.00

Service Code	CPT 93016
Hospital Charge Code	4593016
Hospital Revenue Code	976
Min. Negotiated Rate	$19.92
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna Commercial/Medicare Advantage	$19.92
Rate for Payer: Cash Price	$259.20
Rate for Payer: Cash Price	$259.20
Rate for Payer: Cigna Commercial HMO & PPO	$19.92
Rate for Payer: Home State Health Plan Medicare Advantage	$19.92
Rate for Payer: Optum Medicare Advantage	$100.80

LG VOLUME NEBULIZER

Facility

$6.00

Hospital Charge Code	4500481
Hospital Revenue Code	271
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$4.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$3.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$4.28
Rate for Payer: Cash Price	$5.40
Rate for Payer: UnitedHealthcare Commercial	$4.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$2.16

LG VOLUME NEBULIZER

Facility

$6.00

Hospital Charge Code	4500481
Hospital Revenue Code	271
Rate for Payer: Cash Price	$5.40

Facility

$58.00

Service Code	CPT 83002
Hospital Charge Code	4283002
Hospital Revenue Code	521
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.67
Rate for Payer: Aetna Medicare Advantage	$18.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$34.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$41.41
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial HMO & PPO	$18.52
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.84
Rate for Payer: Home State Health Plan Medicare Advantage	$18.52
Rate for Payer: Humana Commercial	$37.04
Rate for Payer: Humana Medicare Advantage	$18.52
Rate for Payer: UnitedHealthcare Commercial	$38.69
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Facility

$58.00

Service Code	CPT 83002
Hospital Charge Code	4283002
Hospital Revenue Code	521
Rate for Payer: Cash Price	$52.20

LICOCAINE (LIDODERM) 5% PATCH #30 EMP

Facility

$58.00

Service Code	NDC 603188016
Hospital Charge Code	2623393
Hospital Revenue Code	250
Rate for Payer: Cash Price	$52.20

Know your out-of-pocket cost for care.

All Charges