Madison Medical Center

All Charges

Charge

Type

Setting

Price

.LITHOLINK CITRATE

Facility

$30.00

Service Code	CPT 82507
Hospital Charge Code	221329
Hospital Revenue Code	301
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$55.60
Rate for Payer: Aetna Better Health Medicaid/QHP	$25.02
Rate for Payer: Aetna Medicare Advantage	$27.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$27.80
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$25.02
Rate for Payer: Home State Health Plan Medicaid Managed Care	$26.77
Rate for Payer: Home State Health Plan Medicare Advantage	$27.80
Rate for Payer: Humana Commercial	$55.60
Rate for Payer: Humana Medicare Advantage	$27.80
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$25.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK CREATININE

Facility

$30.00

Service Code	CPT 82570
Hospital Charge Code	221330
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

.LITHOLINK CREATININE

Facility

$30.00

Service Code	CPT 82570
Hospital Charge Code	221330
Hospital Revenue Code	301
Min. Negotiated Rate	$4.66
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.66
Rate for Payer: Aetna Medicare Advantage	$5.18
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$5.18
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.66
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4.99
Rate for Payer: Home State Health Plan Medicare Advantage	$5.18
Rate for Payer: Humana Commercial	$10.36
Rate for Payer: Humana Medicare Advantage	$5.18
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK CYSTINE

Facility

$30.00

Service Code	CPT 82615
Hospital Charge Code	221331
Hospital Revenue Code	301
Min. Negotiated Rate	$8.60
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$8.60
Rate for Payer: Aetna Medicare Advantage	$9.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$9.55
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9.20
Rate for Payer: Home State Health Plan Medicare Advantage	$9.55
Rate for Payer: Humana Commercial	$19.10
Rate for Payer: Humana Medicare Advantage	$9.55
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK CYSTINE

Facility

$30.00

Service Code	CPT 82615
Hospital Charge Code	221331
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

.LITHOLINK MAGNESIUM

Facility

$30.00

Service Code	CPT 83735
Hospital Charge Code	221332
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

.LITHOLINK MAGNESIUM

Facility

$30.00

Service Code	CPT 83735
Hospital Charge Code	221332
Hospital Revenue Code	301
Min. Negotiated Rate	$6.03
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$6.03
Rate for Payer: Aetna Medicare Advantage	$6.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$6.70
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6.03
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.45
Rate for Payer: Home State Health Plan Medicare Advantage	$6.70
Rate for Payer: Humana Commercial	$13.40
Rate for Payer: Humana Medicare Advantage	$6.70
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK OXALATE

Facility

$30.00

Service Code	CPT 83945
Hospital Charge Code	221333
Hospital Revenue Code	301
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$28.90
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.01
Rate for Payer: Aetna Medicare Advantage	$14.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$14.45
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.01
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.92
Rate for Payer: Home State Health Plan Medicare Advantage	$14.45
Rate for Payer: Humana Commercial	$28.90
Rate for Payer: Humana Medicare Advantage	$14.45
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK OXALATE

Facility

$30.00

Service Code	CPT 83945
Hospital Charge Code	221333
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

.LITHOLINK PH

Facility

$30.00

Service Code	CPT 83986
Hospital Charge Code	221341
Hospital Revenue Code	301
Min. Negotiated Rate	$3.22
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$3.22
Rate for Payer: Aetna Medicare Advantage	$3.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$3.58
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$3.22
Rate for Payer: Home State Health Plan Medicaid Managed Care	$3.45
Rate for Payer: Home State Health Plan Medicare Advantage	$3.58
Rate for Payer: Humana Commercial	$7.16
Rate for Payer: Humana Medicare Advantage	$3.58
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$3.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK PH

Facility

$30.00

Service Code	CPT 83986
Hospital Charge Code	221341
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

.LITHOLINK PHOSPHORUS

Facility

$30.00

Service Code	CPT 84105
Hospital Charge Code	221334
Hospital Revenue Code	301
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$5.20
Rate for Payer: Aetna Medicare Advantage	$5.78
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$5.78
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5.20
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.56
Rate for Payer: Home State Health Plan Medicare Advantage	$5.78
Rate for Payer: Humana Commercial	$11.56
Rate for Payer: Humana Medicare Advantage	$5.78
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK PHOSPHORUS

Facility

$30.00

Service Code	CPT 84105
Hospital Charge Code	221334
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

.LITHOLINK POTASSIUM

Facility

$30.00

Service Code	CPT 84133
Hospital Charge Code	221335
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

.LITHOLINK POTASSIUM

Facility

$30.00

Service Code	CPT 84133
Hospital Charge Code	221335
Hospital Revenue Code	301
Min. Negotiated Rate	$4.26
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.26
Rate for Payer: Aetna Medicare Advantage	$4.73
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$4.73
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.26
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4.56
Rate for Payer: Home State Health Plan Medicare Advantage	$4.73
Rate for Payer: Humana Commercial	$9.46
Rate for Payer: Humana Medicare Advantage	$4.73
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.26
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK SODIUM

Facility

$30.00

Service Code	CPT 84300
Hospital Charge Code	221336
Hospital Revenue Code	301
Min. Negotiated Rate	$4.55
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.55
Rate for Payer: Aetna Medicare Advantage	$5.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$5.06
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.55
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4.87
Rate for Payer: Home State Health Plan Medicare Advantage	$5.06
Rate for Payer: Humana Commercial	$10.12
Rate for Payer: Humana Medicare Advantage	$5.06
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK SODIUM

Facility

$30.00

Service Code	CPT 84300
Hospital Charge Code	221336
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

LITHOLINK STONE ANA (LC910245)

Facility

$65.00

Service Code	CPT 82365
Hospital Charge Code	22910245
Hospital Revenue Code	307
Rate for Payer: Cash Price	$58.50

LITHOLINK STONE ANA (LC910245)

Facility

$65.00

Service Code	CPT 82365
Hospital Charge Code	22910245
Hospital Revenue Code	307
Min. Negotiated Rate	$11.61
Max. Negotiated Rate	$46.41
Rate for Payer: Aetna Better Health Medicaid/QHP	$11.61
Rate for Payer: Aetna Medicare Advantage	$12.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$38.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$46.41
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial HMO & PPO	$12.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11.61
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12.42
Rate for Payer: Home State Health Plan Medicare Advantage	$12.90
Rate for Payer: Humana Commercial	$25.80
Rate for Payer: Humana Medicare Advantage	$12.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11.61
Rate for Payer: UnitedHealthcare Medicare Advantage	$23.40

.LITHOLINK SULFATE

Facility

$30.00

Service Code	CPT 84392
Hospital Charge Code	221337
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

.LITHOLINK SULFATE

Facility

$30.00

Service Code	CPT 84392
Hospital Charge Code	221337
Hospital Revenue Code	301
Min. Negotiated Rate	$4.94
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.94
Rate for Payer: Aetna Medicare Advantage	$5.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$5.49
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.29
Rate for Payer: Home State Health Plan Medicare Advantage	$5.49
Rate for Payer: Humana Commercial	$10.98
Rate for Payer: Humana Medicare Advantage	$5.49
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK UREA NITROGEN

Facility

$30.00

Service Code	CPT 84540
Hospital Charge Code	221338
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

.LITHOLINK UREA NITROGEN

Facility

$30.00

Service Code	CPT 84540
Hospital Charge Code	221338
Hospital Revenue Code	301
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$5.00
Rate for Payer: Aetna Medicare Advantage	$5.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$5.56
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.35
Rate for Payer: Home State Health Plan Medicare Advantage	$5.56
Rate for Payer: Humana Commercial	$11.12
Rate for Payer: Humana Medicare Advantage	$5.56
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.LITHOLINK URIC ACID

Facility

$30.00

Service Code	CPT 84560
Hospital Charge Code	221339
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

.LITHOLINK URIC ACID

Facility

$30.00

Service Code	CPT 84560
Hospital Charge Code	221339
Hospital Revenue Code	301
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.57
Rate for Payer: Aetna Medicare Advantage	$5.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$5.08
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4.89
Rate for Payer: Home State Health Plan Medicare Advantage	$5.08
Rate for Payer: Humana Commercial	$10.16
Rate for Payer: Humana Medicare Advantage	$5.08
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.57
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

Know your out-of-pocket cost for care.

All Charges