Madison Medical Center

All Charges

Charge

Type

Setting

Price

*AMOXICILLIN SUSP 200MG (AMOXIL)

Facility

$12.00

Service Code	NDC 143988650
Hospital Charge Code	260642
Hospital Revenue Code	250
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$8.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$8.57
Rate for Payer: Cash Price	$10.80
Rate for Payer: UnitedHealthcare Commercial	$8.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.32

*AMOXICILLIN SUSP 200MG (AMOXIL)

Facility

$12.00

Service Code	NDC 143988650
Hospital Charge Code	260642
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.80

AMPHETAMINES CONFIRMATION

Facility

$226.00

Service Code	CPT 80324
Hospital Charge Code	2282145
Hospital Revenue Code	301
Rate for Payer: Cash Price	$203.40

AMPHETAMINES CONFIRMATION

Facility

$226.00

Service Code	CPT 80324
Hospital Charge Code	2282145
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$161.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$133.79
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$161.36
Rate for Payer: Cash Price	$203.40
Rate for Payer: Cash Price	$203.40
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$81.36

.AMPHETAMINES REFLEX CONFIRMATION

Facility

$110.00

Service Code	CPT 80359
Hospital Charge Code	221947
Hospital Revenue Code	301
Rate for Payer: Cash Price	$99.00

.AMPHETAMINES REFLEX CONFIRMATION

Facility

$110.00

Service Code	CPT 80359
Hospital Charge Code	221947
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$78.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$78.54
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.60

AMPHETAMINES SCR (LABCORP)

Facility

$94.00

Service Code	CPT 80307
Hospital Charge Code	2282148
Hospital Revenue Code	301
Rate for Payer: Cash Price	$84.60

AMPHETAMINES SCR (LABCORP)

Facility

$94.00

Service Code	CPT 80307
Hospital Charge Code	2282148
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$124.28
Rate for Payer: Aetna Better Health Medicaid/QHP	$55.93
Rate for Payer: Aetna Medicare Advantage	$62.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$55.65
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$67.12
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial HMO & PPO	$62.14
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$55.93
Rate for Payer: Home State Health Plan Medicaid Managed Care	$59.85
Rate for Payer: Home State Health Plan Medicare Advantage	$62.14
Rate for Payer: Humana Commercial	$124.28
Rate for Payer: Humana Medicare Advantage	$62.14
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$55.93
Rate for Payer: UnitedHealthcare Medicare Advantage	$33.84

AMPHETAMINES SERUM

Facility

$318.00

Service Code	CPT 80307
Hospital Charge Code	2280310
Hospital Revenue Code	301
Rate for Payer: Cash Price	$286.20

AMPHETAMINES SERUM

Facility

$318.00

Service Code	CPT 80307
Hospital Charge Code	2280310
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$227.05
Rate for Payer: Aetna Better Health Medicaid/QHP	$55.93
Rate for Payer: Aetna Medicare Advantage	$62.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$188.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$227.05
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial HMO & PPO	$62.14
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$55.93
Rate for Payer: Home State Health Plan Medicaid Managed Care	$59.85
Rate for Payer: Home State Health Plan Medicare Advantage	$62.14
Rate for Payer: Humana Commercial	$124.28
Rate for Payer: Humana Medicare Advantage	$62.14
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$55.93
Rate for Payer: UnitedHealthcare Medicare Advantage	$114.48

AMPHOTERICIN-B 50MG VIAL

Facility

$155.00

Service Code	NDC 3.9822E+10
Hospital Charge Code	2697140
Hospital Revenue Code	250
Rate for Payer: Cash Price	$139.50

AMPHOTERICIN-B 50MG VIAL

Facility

$155.00

Service Code	NDC 3.9822E+10
Hospital Charge Code	2697140
Hospital Revenue Code	250
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$110.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$91.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$110.67
Rate for Payer: Cash Price	$139.50
Rate for Payer: UnitedHealthcare Commercial	$103.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$55.80

AMPICILLIN 500MG CAP EMP

Facility

$21.00

Service Code	NDC 6.7253E+10
Hospital Charge Code	2654205
Hospital Revenue Code	250
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

AMPICILLIN 500MG CAP EMP

Facility

$21.00

Service Code	NDC 6.7253E+10
Hospital Charge Code	2654205
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

AMPICILLIN + NS : 2GM + 100ML MINIBAG

Facility

$142.00

Service Code	HCPCS J0290
Hospital Charge Code	2654221
Hospital Revenue Code	250
Rate for Payer: Cash Price	$127.80

AMPICILLIN + NS : 2GM + 100ML MINIBAG

Facility

$142.00

Service Code	HCPCS J0290
Hospital Charge Code	2654221
Hospital Revenue Code	250
Min. Negotiated Rate	$51.12
Max. Negotiated Rate	$101.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$84.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$101.39
Rate for Payer: Cash Price	$127.80
Rate for Payer: UnitedHealthcare Commercial	$94.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$51.12

AMPICILLIN / NS IVPB : 2GM / 100ML

Facility

$76.00

Service Code	HCPCS J0290
Hospital Charge Code	2697145
Hospital Revenue Code	250
Rate for Payer: Cash Price	$68.40

AMPICILLIN / NS IVPB : 2GM / 100ML

Facility

$76.00

Service Code	HCPCS J0290
Hospital Charge Code	2697145
Hospital Revenue Code	250
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$54.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$54.26
Rate for Payer: Cash Price	$68.40
Rate for Payer: UnitedHealthcare Commercial	$50.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.36

AMPICIL/SULBACT (UNASYN) 1.5GM VIAL IVPB

Facility

$156.00

Service Code	NDC 49001381
Hospital Charge Code	2656002
Hospital Revenue Code	250
Rate for Payer: Cash Price	$140.40

AMPICIL/SULBACT (UNASYN) 1.5GM VIAL IVPB

Facility

$156.00

Service Code	NDC 49001381
Hospital Charge Code	2656002
Hospital Revenue Code	250
Min. Negotiated Rate	$56.16
Max. Negotiated Rate	$111.38
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: UnitedHealthcare Commercial	$104.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$56.16

AMPICIL/SULBACT (UNASYN) 3GM VIAL IVPB

Facility

$223.00

Service Code	NDC 49001483
Hospital Charge Code	2656003
Hospital Revenue Code	250
Min. Negotiated Rate	$80.28
Max. Negotiated Rate	$159.22
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: UnitedHealthcare Commercial	$148.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$80.28

AMPICIL/SULBACT (UNASYN) 3GM VIAL IVPB

Facility

$223.00

Service Code	NDC 49001483
Hospital Charge Code	2656003
Hospital Revenue Code	250
Rate for Payer: Cash Price	$200.70

AMPICIL/SULBAC (UNASYN) 1.5GM IM INJ

Facility

$91.00

Service Code	HCPCS J0295
Hospital Charge Code	2656516
Hospital Revenue Code	250
Rate for Payer: Cash Price	$81.90

AMPICIL/SULBAC (UNASYN) 1.5GM IM INJ

Facility

$91.00

Service Code	HCPCS J0295
Hospital Charge Code	2656516
Hospital Revenue Code	250
Min. Negotiated Rate	$32.76
Max. Negotiated Rate	$64.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$53.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$64.97
Rate for Payer: Cash Price	$81.90
Rate for Payer: UnitedHealthcare Commercial	$60.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$32.76

AMPICIL/SULBAC (UNASYN) 3GM IM INJ

Facility

$141.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2656517
Hospital Revenue Code	250
Min. Negotiated Rate	$50.76
Max. Negotiated Rate	$100.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$83.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$100.67
Rate for Payer: Cash Price	$126.90
Rate for Payer: UnitedHealthcare Commercial	$94.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$50.76

Know your out-of-pocket cost for care.

All Charges