Madison Medical Center

All Charges

Charge

Type

Setting

Price

LIPID PROF REFLEX DLDL

Facility

$233.00

Service Code	CPT 80061
Hospital Charge Code	223200
Hospital Revenue Code	301
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$166.36
Rate for Payer: Aetna Better Health Medicaid/QHP	$12.05
Rate for Payer: Aetna Medicare Advantage	$13.39
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	$13.39
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12.05
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12.89
Rate for Payer: Home State Health Plan Medicare Advantage	$13.39
Rate for Payer: Humana Commercial	$26.78
Rate for Payer: Humana Medicare Advantage	$13.39
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$83.88

LIPOPROTEIN A

Facility

$156.00

Service Code	CPT 83695
Hospital Charge Code	2280061
Hospital Revenue Code	301
Rate for Payer: Cash Price	$140.40

LIPOPROTEIN A

Facility

$156.00

Service Code	CPT 83695
Hospital Charge Code	2280061
Hospital Revenue Code	301
Min. Negotiated Rate	$12.89
Max. Negotiated Rate	$111.38
Rate for Payer: Aetna Better Health Medicaid/QHP	$12.89
Rate for Payer: Aetna Medicare Advantage	$14.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$92.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$111.38
Rate for Payer: Cash Price	$140.40
Rate for Payer: Cash Price	$140.40
Rate for Payer: Cash Price	$140.40
Rate for Payer: Cigna Commercial HMO & PPO	$14.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12.89
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.79
Rate for Payer: Home State Health Plan Medicare Advantage	$14.32
Rate for Payer: Humana Commercial	$28.64
Rate for Payer: Humana Medicare Advantage	$14.32
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12.89
Rate for Payer: UnitedHealthcare Medicare Advantage	$56.16

LIRAGLUTIDE (VICTOZA) 2 PENS 6ML EMP

Facility

$1,073.00

Service Code	NDC 169406012
Hospital Charge Code	2625770
Hospital Revenue Code	250
Min. Negotiated Rate	$386.28
Max. Negotiated Rate	$766.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$635.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$766.12
Rate for Payer: Cash Price	$965.70
Rate for Payer: UnitedHealthcare Commercial	$715.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$386.28

LIRAGLUTIDE (VICTOZA) 2 PENS 6ML EMP

Facility

$1,073.00

Service Code	NDC 169406012
Hospital Charge Code	2625770
Hospital Revenue Code	250
Rate for Payer: Cash Price	$965.70

LIRAGLUTIDE (VICTOZA) 3 PENS 9ML EMP

Facility

$1,073.00

Service Code	NDC 169406013
Hospital Charge Code	2622507
Hospital Revenue Code	250
Min. Negotiated Rate	$386.28
Max. Negotiated Rate	$766.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$635.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$766.12
Rate for Payer: Cash Price	$965.70
Rate for Payer: UnitedHealthcare Commercial	$715.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$386.28

LIRAGLUTIDE (VICTOZA) 3 PENS 9ML EMP

Facility

$1,073.00

Service Code	NDC 169406013
Hospital Charge Code	2622507
Hospital Revenue Code	250
Rate for Payer: Cash Price	$965.70

LISINOPRIL 10MG TAB EMP

Facility

$22.00

Service Code	NDC 904580861
Hospital Charge Code	2697791
Hospital Revenue Code	250
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

LISINOPRIL 10MG TAB EMP

Facility

$22.00

Service Code	NDC 904580861
Hospital Charge Code	2697791
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

LISINOPRIL 20MG TAB EMP

Facility

$15.00

Service Code	NDC 185010201
Hospital Charge Code	2697276
Hospital Revenue Code	250
Rate for Payer: Cash Price	$13.50

LISINOPRIL 20MG TAB EMP

Facility

$15.00

Service Code	NDC 185010201
Hospital Charge Code	2697276
Hospital Revenue Code	250
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$10.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.71
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.40

LISINOPRIL 2.5MG TAB EMP

Facility

$13.00

Service Code	NDC 185002501
Hospital Charge Code	2697323
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.70

LISINOPRIL 2.5MG TAB EMP

Facility

$13.00

Service Code	NDC 185002501
Hospital Charge Code	2697323
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

LISINOPRIL 30MG TAB EMP

Facility

$15.00

Service Code	NDC 6.818E+10
Hospital Charge Code	2622250
Hospital Revenue Code	250
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$10.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.71
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.40

LISINOPRIL 30MG TAB EMP

Facility

$15.00

Service Code	NDC 6.818E+10
Hospital Charge Code	2622250
Hospital Revenue Code	250
Rate for Payer: Cash Price	$13.50

LISINOPRIL 40MG TAB EMP

Facility

$15.00

Service Code	NDC 904720061
Hospital Charge Code	2621410
Hospital Revenue Code	250
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$10.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.71
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.40

LISINOPRIL 40MG TAB EMP

Facility

$15.00

Service Code	NDC 904720061
Hospital Charge Code	2621410
Hospital Revenue Code	250
Rate for Payer: Cash Price	$13.50

LISINOPRIL 5MG TAB EMP

Facility

$20.00

Service Code	NDC 185540001
Hospital Charge Code	2698209
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

LISINOPRIL 5MG TAB EMP

Facility

$20.00

Service Code	NDC 185540001
Hospital Charge Code	2698209
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LISINOPRIL/HCTZ 10/12.5MG TAB EMP

Facility

$22.00

Service Code	NDC 6.818E+10
Hospital Charge Code	2619390
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

LISINOPRIL/HCTZ 10/12.5MG TAB EMP

Facility

$22.00

Service Code	NDC 6.818E+10
Hospital Charge Code	2619390
Hospital Revenue Code	250
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

LISINOPRIL/HCTZ 20/12.5MG TAB EMP

Facility

$13.00

Service Code	NDC 1E+11
Hospital Charge Code	2619596
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

LISINOPRIL/HCTZ 20/12.5MG TAB EMP

Facility

$13.00

Service Code	NDC 1E+11
Hospital Charge Code	2619596
Hospital Revenue Code	250
Rate for Payer: Cash Price	$11.70

LISINOPRIL/HCTZ 20/25MG TAB EMP

Facility

$22.00

Service Code	NDC 6.818E+10
Hospital Charge Code	2619399
Hospital Revenue Code	250
Rate for Payer: Cash Price	$19.80

LISINOPRIL/HCTZ 20/25MG TAB EMP

Facility

$22.00

Service Code	NDC 6.818E+10
Hospital Charge Code	2619399
Hospital Revenue Code	250
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

Know your out-of-pocket cost for care.

All Charges