Madison Medical Center

All Charges

Charge

Type

Setting

Price

LUBRICANT EYE DROPS 15ML

Facility

$58.00

Service Code	NDC 23079815
Hospital Charge Code	2654235
Hospital Revenue Code	250
Min. Negotiated Rate	$20.88
Max. Negotiated Rate	$41.41
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: UnitedHealthcare Commercial	$38.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.88

LUBRICANT (LACRI-LUBE) OP OINT

Facility

$60.00

Service Code	NDC 23031204
Hospital Charge Code	2654236
Hospital Revenue Code	250
Rate for Payer: Cash Price	$54.00

LUBRICANT (LACRI-LUBE) OP OINT

Facility

$60.00

Service Code	NDC 23031204
Hospital Charge Code	2654236
Hospital Revenue Code	250
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

LUMBAR PUNCTURE SET

Facility

$153.00

Hospital Charge Code	2812539
Hospital Revenue Code	271
Min. Negotiated Rate	$55.08
Max. Negotiated Rate	$109.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$90.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$109.24
Rate for Payer: Cash Price	$137.70
Rate for Payer: UnitedHealthcare Commercial	$102.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$55.08

LUMBAR PUNCTURE SET

Facility

$153.00

Hospital Charge Code	2812539
Hospital Revenue Code	271
Rate for Payer: Cash Price	$137.70

LUNG TRANSPLANT

Facility

$208,714.56

Service Code	MSDRG 007
Min. Negotiated Rate	$104,357.28
Max. Negotiated Rate	$208,714.56
Rate for Payer: Aetna Medicare Advantage	$104,357.28
Rate for Payer: Cigna Commercial HMO & PPO	$104,357.28
Rate for Payer: Home State Health Plan Medicare Advantage	$104,357.28
Rate for Payer: Humana Commercial	$208,714.56
Rate for Payer: Humana Medicare Advantage	$104,357.28

LUPRON DEPOT 45MG 6MTH INJ

Facility

$46,422.00

Service Code	HCPCS J9217
Hospital Charge Code	2624093
Hospital Revenue Code	335
Rate for Payer: Cash Price	$41,779.80

LUPRON DEPOT 45MG 6MTH INJ

Facility

$46,422.00

Service Code	HCPCS J9217
Hospital Charge Code	2624093
Hospital Revenue Code	335
Min. Negotiated Rate	$160.34
Max. Negotiated Rate	$33,145.31
Rate for Payer: Aetna Medicare Advantage	$160.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$27,481.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$33,145.31
Rate for Payer: Cash Price	$41,779.80
Rate for Payer: Cash Price	$41,779.80
Rate for Payer: Cigna Commercial HMO & PPO	$160.34
Rate for Payer: Home State Health Plan Medicare Advantage	$160.34
Rate for Payer: Humana Commercial	$320.68
Rate for Payer: Humana Medicare Advantage	$160.34
Rate for Payer: UnitedHealthcare Commercial	$30,963.47
Rate for Payer: UnitedHealthcare Medicare Advantage	$16,711.92

LUTENIZING HORMONE

Facility

$168.00

Service Code	CPT 83002
Hospital Charge Code	2212601
Hospital Revenue Code	301
Rate for Payer: Cash Price	$151.20

LUTENIZING HORMONE

Facility

$168.00

Service Code	CPT 83002
Hospital Charge Code	2212601
Hospital Revenue Code	301
Min. Negotiated Rate	$16.67
Max. Negotiated Rate	$119.95
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	$99.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$119.95
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cigna Commercial HMO & PPO	$18.52
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.67
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	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$60.48

LYME DISEASE AB/RFX

Facility

$86.00

Service Code	CPT 86618
Hospital Charge Code	2259112
Hospital Revenue Code	302
Min. Negotiated Rate	$15.33
Max. Negotiated Rate	$61.40
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.33
Rate for Payer: Aetna Medicare Advantage	$17.03
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$50.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$61.40
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cigna Commercial HMO & PPO	$17.03
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.33
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.40
Rate for Payer: Home State Health Plan Medicare Advantage	$17.03
Rate for Payer: Humana Commercial	$34.06
Rate for Payer: Humana Medicare Advantage	$17.03
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.33
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.96

LYME DISEASE AB/RFX

Facility

$86.00

Service Code	CPT 86618
Hospital Charge Code	2259112
Hospital Revenue Code	302
Rate for Payer: Cash Price	$77.40

LYMES DNA

Facility

$857.00

Service Code	CPT 87801
Hospital Charge Code	2287476
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$611.90
Rate for Payer: Aetna Better Health Medicaid/QHP	$63.18
Rate for Payer: Aetna Medicare Advantage	$70.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$507.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$611.90
Rate for Payer: Cash Price	$771.30
Rate for Payer: Cash Price	$771.30
Rate for Payer: Cash Price	$771.30
Rate for Payer: Cigna Commercial HMO & PPO	$70.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$63.18
Rate for Payer: Home State Health Plan Medicaid Managed Care	$67.60
Rate for Payer: Home State Health Plan Medicare Advantage	$70.20
Rate for Payer: Humana Commercial	$140.40
Rate for Payer: Humana Medicare Advantage	$70.20
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$63.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$308.52

LYMES DNA

Facility

$857.00

Service Code	CPT 87801
Hospital Charge Code	2287476
Hospital Revenue Code	301
Rate for Payer: Cash Price	$771.30

LYMES IMMUNOBLOT IGM

Facility

$65.00

Service Code	CPT 86617
Hospital Charge Code	3059116
Hospital Revenue Code	302
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$46.41
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.94
Rate for Payer: Aetna Medicare Advantage	$15.49
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	$15.49
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.92
Rate for Payer: Home State Health Plan Medicare Advantage	$15.49
Rate for Payer: Humana Commercial	$30.98
Rate for Payer: Humana Medicare Advantage	$15.49
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$23.40

LYMES IMMUNOBLOT IGM

Facility

$65.00

Service Code	CPT 86617
Hospital Charge Code	3059116
Hospital Revenue Code	302
Rate for Payer: Cash Price	$58.50

LYME WESTERN BLOT

Facility

$93.00

Service Code	CPT 86617
Hospital Charge Code	2259115
Hospital Revenue Code	302
Rate for Payer: Cash Price	$83.70

LYME WESTERN BLOT

Facility

$93.00

Service Code	CPT 86617
Hospital Charge Code	2259115
Hospital Revenue Code	302
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$66.40
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.94
Rate for Payer: Aetna Medicare Advantage	$15.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$55.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$66.40
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial HMO & PPO	$15.49
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.92
Rate for Payer: Home State Health Plan Medicare Advantage	$15.49
Rate for Payer: Humana Commercial	$30.98
Rate for Payer: Humana Medicare Advantage	$15.49
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$33.48

LYME WESTERN BLOT IGG

Facility

$75.00

Service Code	CPT 86617
Hospital Charge Code	2259116
Hospital Revenue Code	302
Rate for Payer: Cash Price	$67.50

LYME WESTERN BLOT IGG

Facility

$75.00

Service Code	CPT 86617
Hospital Charge Code	2259116
Hospital Revenue Code	302
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$53.55
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.94
Rate for Payer: Aetna Medicare Advantage	$15.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$53.55
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial HMO & PPO	$15.49
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.92
Rate for Payer: Home State Health Plan Medicare Advantage	$15.49
Rate for Payer: Humana Commercial	$30.98
Rate for Payer: Humana Medicare Advantage	$15.49
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

LYMPHADENECTOMY INC EXT ILIAC,NODE ETC

Professional

Both

$4,725.00

Service Code	CPT 38770
Hospital Charge Code	5438770
Hospital Revenue Code	975
Min. Negotiated Rate	$603.44
Max. Negotiated Rate	$1,653.75
Rate for Payer: Aetna Commercial/Medicare Advantage	$708.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$603.44
Rate for Payer: Cash Price	$4,252.50
Rate for Payer: Cash Price	$4,252.50
Rate for Payer: Cigna Commercial HMO & PPO	$708.99
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$603.44
Rate for Payer: Home State Health Plan Medicaid Managed Care	$663.78
Rate for Payer: Home State Health Plan Medicare Advantage	$708.99
Rate for Payer: Optum Medicare Advantage	$1,653.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$603.44

LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$14,355.01

Service Code	APR-DRG 6943
Min. Negotiated Rate	$14,355.01
Max. Negotiated Rate	$14,355.01
Rate for Payer: Aetna Better Health Medicaid/QHP	$14,355.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14,355.01
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14,355.01
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14,355.01

LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$10,355.54

Service Code	APR-DRG 6942
Min. Negotiated Rate	$10,355.54
Max. Negotiated Rate	$10,355.54
Rate for Payer: Aetna Better Health Medicaid/QHP	$10,355.54
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$10,355.54
Rate for Payer: Home State Health Plan Medicaid Managed Care	$10,355.54
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$10,355.54

LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$28,110.00

Service Code	APR-DRG 6944
Min. Negotiated Rate	$28,110.00
Max. Negotiated Rate	$28,110.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$28,110.00
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$28,110.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$28,110.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$28,110.00

LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR

Facility

$7,429.43

Service Code	APR-DRG 6941
Min. Negotiated Rate	$7,429.43
Max. Negotiated Rate	$7,429.43
Rate for Payer: Aetna Better Health Medicaid/QHP	$7,429.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$7,429.43
Rate for Payer: Home State Health Plan Medicaid Managed Care	$7,429.43
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$7,429.43

Know your out-of-pocket cost for care.

All Charges