Madison Medical Center

All Charges

Charge

Type

Setting

Price

MOUNJARO 7.5MG/0.5ML INJ PEN

Facility

$3,978.00

Service Code	NDC 1E+11
Hospital Charge Code	2625925
Hospital Revenue Code	250
Rate for Payer: Cash Price	$3,580.20

MOUTH CLEAN KIT

Facility

$15.00

Hospital Charge Code	2813523
Hospital Revenue Code	271
Rate for Payer: Cash Price	$13.50

MOUTH CLEAN KIT

Facility

$15.00

Hospital Charge Code	2813523
Hospital Revenue Code	271
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

MOUTH PROCEDURES WITH CC/MCC

Facility

$27,017.54

Service Code	MSDRG 137
Min. Negotiated Rate	$13,508.77
Max. Negotiated Rate	$27,017.54
Rate for Payer: Aetna Medicare Advantage	$13,508.77
Rate for Payer: Cigna Commercial HMO & PPO	$13,508.77
Rate for Payer: Home State Health Plan Medicare Advantage	$13,508.77
Rate for Payer: Humana Commercial	$27,017.54
Rate for Payer: Humana Medicare Advantage	$13,508.77

MOUTH PROCEDURES WITHOUT CC/MCC

Facility

$17,512.98

Service Code	MSDRG 138
Min. Negotiated Rate	$8,756.49
Max. Negotiated Rate	$17,512.98
Rate for Payer: Aetna Medicare Advantage	$8,756.49
Rate for Payer: Cigna Commercial HMO & PPO	$8,756.49
Rate for Payer: Home State Health Plan Medicare Advantage	$8,756.49
Rate for Payer: Humana Commercial	$17,512.98
Rate for Payer: Humana Medicare Advantage	$8,756.49

MOUTH WASH

Facility

$16.00

Hospital Charge Code	2813839
Hospital Revenue Code	271
Rate for Payer: Cash Price	$14.40

MOUTH WASH

Facility

$16.00

Hospital Charge Code	2813839
Hospital Revenue Code	271
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

MOXIFLOXAC(AVELOX) 400MG/250ML IVPB

Facility

$139.00

Service Code	HCPCS J1956
Hospital Charge Code	2626518
Hospital Revenue Code	250
Rate for Payer: Cash Price	$125.10

MOXIFLOXAC(AVELOX) 400MG/250ML IVPB

Facility

$139.00

Service Code	HCPCS J1956
Hospital Charge Code	2626518
Hospital Revenue Code	250
Min. Negotiated Rate	$50.04
Max. Negotiated Rate	$99.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$82.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$99.25
Rate for Payer: Cash Price	$125.10
Rate for Payer: UnitedHealthcare Commercial	$92.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$50.04

MOXIFLOXACIN 0.5% OP SOL 3ML

Facility

$439.00

Service Code	NDC 781713593
Hospital Charge Code	2625886
Hospital Revenue Code	250
Min. Negotiated Rate	$158.04
Max. Negotiated Rate	$313.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$259.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$313.45
Rate for Payer: Cash Price	$395.10
Rate for Payer: UnitedHealthcare Commercial	$292.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$158.04

MOXIFLOXACIN 0.5% OP SOL 3ML

Facility

$439.00

Service Code	NDC 781713593
Hospital Charge Code	2625886
Hospital Revenue Code	250
Rate for Payer: Cash Price	$395.10

MOXIFLOXACIN 0.5% OP SOL 3ML EMP

Facility

$439.00

Service Code	NDC 378543035
Hospital Charge Code	2624004
Hospital Revenue Code	250
Min. Negotiated Rate	$158.04
Max. Negotiated Rate	$313.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$259.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$313.45
Rate for Payer: Cash Price	$395.10
Rate for Payer: UnitedHealthcare Commercial	$292.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$158.04

MOXIFLOXACIN 0.5% OP SOL 3ML EMP

Facility

$439.00

Service Code	NDC 378543035
Hospital Charge Code	2624004
Hospital Revenue Code	250
Rate for Payer: Cash Price	$395.10

MOXIFLOXACIN (AVELOX) 400MG TAB

Facility

$85.00

Hospital Charge Code	2626410
Hospital Revenue Code	250
Rate for Payer: Cash Price	$76.50

MOXIFLOXACIN (AVELOX) 400MG TAB

Facility

$85.00

Hospital Charge Code	2626410
Hospital Revenue Code	250
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$60.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$50.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$60.69
Rate for Payer: Cash Price	$76.50
Rate for Payer: UnitedHealthcare Commercial	$56.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.60

MRA ABDOMEN

Facility

$4,072.00

Service Code	CPT 74185
Hospital Charge Code	3374185
Hospital Revenue Code	610
Min. Negotiated Rate	$1,465.92
Max. Negotiated Rate	$2,907.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,555.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,907.41
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: Cash Price	$3,664.80
Rate for Payer: UnitedHealthcare Commercial	$2,716.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,465.92

MRA ABDOMEN

Facility

$4,072.00

Service Code	CPT 74185
Hospital Charge Code	3374185
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,664.80

MR ABDOMEN W CONTRAST

Facility

$4,131.00

Service Code	CPT 74182
Hospital Charge Code	3374182
Hospital Revenue Code	610
Min. Negotiated Rate	$314.49
Max. Negotiated Rate	$2,949.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$314.49
Rate for Payer: Aetna Medicare Advantage	$356.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,555.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,949.53
Rate for Payer: Cash Price	$3,717.90
Rate for Payer: Cash Price	$3,717.90
Rate for Payer: Cash Price	$3,717.90
Rate for Payer: Cigna Commercial HMO & PPO	$356.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$314.49
Rate for Payer: Home State Health Plan Medicaid Managed Care	$336.50
Rate for Payer: Home State Health Plan Medicare Advantage	$356.43
Rate for Payer: Humana Commercial	$712.86
Rate for Payer: Humana Medicare Advantage	$356.43
Rate for Payer: UnitedHealthcare Commercial	$2,755.38
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$314.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,487.16

MR ABDOMEN W CONTRAST

Facility

$4,131.00

Service Code	CPT 74182
Hospital Charge Code	3374182
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,717.90

MR ABDOMEN WO CONTRAST

Facility

$3,577.00

Service Code	CPT 74181
Hospital Charge Code	3374181
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,219.30

MR ABDOMEN WO CONTRAST

Facility

$3,577.00

Service Code	CPT 74181
Hospital Charge Code	3374181
Hospital Revenue Code	610
Min. Negotiated Rate	$215.09
Max. Negotiated Rate	$2,553.98
Rate for Payer: Aetna Better Health Medicaid/QHP	$215.09
Rate for Payer: Aetna Medicare Advantage	$243.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,555.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,553.98
Rate for Payer: Cash Price	$3,219.30
Rate for Payer: Cash Price	$3,219.30
Rate for Payer: Cash Price	$3,219.30
Rate for Payer: Cigna Commercial HMO & PPO	$243.77
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$215.09
Rate for Payer: Home State Health Plan Medicaid Managed Care	$230.15
Rate for Payer: Home State Health Plan Medicare Advantage	$243.77
Rate for Payer: Humana Commercial	$487.54
Rate for Payer: Humana Medicare Advantage	$243.77
Rate for Payer: UnitedHealthcare Commercial	$2,385.86
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$215.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,287.72

MR ABDOMEN W WO CONTRAST

Facility

$4,190.00

Service Code	CPT 74183
Hospital Charge Code	3374183
Hospital Revenue Code	610
Min. Negotiated Rate	$314.49
Max. Negotiated Rate	$2,991.66
Rate for Payer: Aetna Better Health Medicaid/QHP	$314.49
Rate for Payer: Aetna Medicare Advantage	$356.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,555.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,991.66
Rate for Payer: Cash Price	$3,771.00
Rate for Payer: Cash Price	$3,771.00
Rate for Payer: Cash Price	$3,771.00
Rate for Payer: Cigna Commercial HMO & PPO	$356.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$314.49
Rate for Payer: Home State Health Plan Medicaid Managed Care	$336.50
Rate for Payer: Home State Health Plan Medicare Advantage	$356.43
Rate for Payer: Humana Commercial	$712.86
Rate for Payer: Humana Medicare Advantage	$356.43
Rate for Payer: UnitedHealthcare Commercial	$2,794.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$314.49
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,508.40

MR ABDOMEN W WO CONTRAST

Facility

$4,190.00

Service Code	CPT 74183
Hospital Charge Code	3374183
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,771.00

MRA BRAIN WO

Facility

$3,700.00

Service Code	CPT 70544
Hospital Charge Code	3370544
Hospital Revenue Code	610
Min. Negotiated Rate	$215.09
Max. Negotiated Rate	$2,641.80
Rate for Payer: Aetna Better Health Medicaid/QHP	$215.09
Rate for Payer: Aetna Medicare Advantage	$243.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,555.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,641.80
Rate for Payer: Cash Price	$3,330.00
Rate for Payer: Cash Price	$3,330.00
Rate for Payer: Cash Price	$3,330.00
Rate for Payer: Cigna Commercial HMO & PPO	$243.77
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$215.09
Rate for Payer: Home State Health Plan Medicaid Managed Care	$230.15
Rate for Payer: Home State Health Plan Medicare Advantage	$243.77
Rate for Payer: Humana Commercial	$487.54
Rate for Payer: Humana Medicare Advantage	$243.77
Rate for Payer: UnitedHealthcare Commercial	$2,467.90
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$215.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,332.00

MRA BRAIN WO

Facility

$3,700.00

Service Code	CPT 70544
Hospital Charge Code	3370544
Hospital Revenue Code	610
Rate for Payer: Cash Price	$3,330.00

Know your out-of-pocket cost for care.

All Charges