Madison Medical Center

All Charges

Charge

Type

Setting

Price

NASAL HEMORRHAGE CONTROL

Professional

Both

$610.00

Service Code	CPT 30901
Hospital Charge Code	1819012
Hospital Revenue Code	981
Min. Negotiated Rate	$48.54
Max. Negotiated Rate	$213.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$48.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$120.83
Rate for Payer: Cash Price	$549.00
Rate for Payer: Cash Price	$549.00
Rate for Payer: Cigna Commercial HMO & PPO	$48.54
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$120.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$132.91
Rate for Payer: Home State Health Plan Medicare Advantage	$48.54
Rate for Payer: Optum Medicare Advantage	$213.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$120.83

NASAL PACKING/CAUTERY

Professional

Both

$610.00

Service Code	CPT 30901
Hospital Charge Code	1830901
Hospital Revenue Code	981
Min. Negotiated Rate	$48.54
Max. Negotiated Rate	$213.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$48.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$120.83
Rate for Payer: Cash Price	$549.00
Rate for Payer: Cash Price	$549.00
Rate for Payer: Cigna Commercial HMO & PPO	$48.54
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$120.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$132.91
Rate for Payer: Home State Health Plan Medicare Advantage	$48.54
Rate for Payer: Optum Medicare Advantage	$213.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$120.83

NASAL/SINUS ENDO SURG; DILATION OF MAX S

Professional

Both

$780.00

Service Code	CPT 31295
Hospital Charge Code	9331295
Hospital Revenue Code	975
Min. Negotiated Rate	$129.90
Max. Negotiated Rate	$1,450.34
Rate for Payer: Aetna Commercial/Medicare Advantage	$129.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$1,318.49
Rate for Payer: Cash Price	$702.00
Rate for Payer: Cash Price	$702.00
Rate for Payer: Cigna Commercial HMO & PPO	$129.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,318.49
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,450.34
Rate for Payer: Home State Health Plan Medicare Advantage	$129.90
Rate for Payer: Optum Medicare Advantage	$273.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,318.49

NASAL/SINUS ENDO W/DILATION OF FRONTAL S

Professional

Both

$890.00

Service Code	CPT 31296
Hospital Charge Code	9331296
Hospital Revenue Code	975
Min. Negotiated Rate	$146.82
Max. Negotiated Rate	$2,635.32
Rate for Payer: Aetna Commercial/Medicare Advantage	$146.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$2,395.75
Rate for Payer: Cash Price	$801.00
Rate for Payer: Cash Price	$801.00
Rate for Payer: Cigna Commercial HMO & PPO	$146.82
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$2,395.75
Rate for Payer: Home State Health Plan Medicaid Managed Care	$2,635.32
Rate for Payer: Home State Health Plan Medicare Advantage	$146.82
Rate for Payer: Optum Medicare Advantage	$311.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$2,395.75

NASAL/SINUS ENDO W/ETHMOIDECTOMY PARTIAL

Professional

Both

$2,210.00

Service Code	CPT 31254
Hospital Charge Code	9331254
Hospital Revenue Code	975
Min. Negotiated Rate	$198.78
Max. Negotiated Rate	$773.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$198.78
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$335.18
Rate for Payer: Cash Price	$1,989.00
Rate for Payer: Cash Price	$1,989.00
Rate for Payer: Cigna Commercial HMO & PPO	$198.78
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$335.18
Rate for Payer: Home State Health Plan Medicaid Managed Care	$368.70
Rate for Payer: Home State Health Plan Medicare Advantage	$198.78
Rate for Payer: Optum Medicare Advantage	$773.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$335.18

NASAL SPLINT

Facility

$45.00

Hospital Charge Code	2814013
Hospital Revenue Code	271
Rate for Payer: Cash Price	$40.50

NASAL SPLINT

Facility

$45.00

Hospital Charge Code	2814013
Hospital Revenue Code	271
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.13
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

NASAL TRAY

Facility

$62.00

Hospital Charge Code	2814003
Hospital Revenue Code	271
Rate for Payer: Cash Price	$55.80

NASAL TRAY

Facility

$62.00

Hospital Charge Code	2814003
Hospital Revenue Code	271
Min. Negotiated Rate	$22.32
Max. Negotiated Rate	$44.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$36.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$44.27
Rate for Payer: Cash Price	$55.80
Rate for Payer: UnitedHealthcare Commercial	$41.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$22.32

NASCOBAL NASAL SPRAY 500MCG EMP

Facility

$282.00

Service Code	NDC 4.9884E+10
Hospital Charge Code	2622498
Hospital Revenue Code	250
Rate for Payer: Cash Price	$253.80

NASCOBAL NASAL SPRAY 500MCG EMP

Facility

$282.00

Service Code	NDC 4.9884E+10
Hospital Charge Code	2622498
Hospital Revenue Code	250
Min. Negotiated Rate	$101.52
Max. Negotiated Rate	$201.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$166.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$201.35
Rate for Payer: Cash Price	$253.80
Rate for Payer: UnitedHealthcare Commercial	$188.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$101.52

NEBIVOLOL (BYSTOLIC) 10MG TAB EMP

Facility

$32.00

Service Code	NDC 456141030
Hospital Charge Code	2622919
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$22.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$18.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$22.85
Rate for Payer: Cash Price	$28.80
Rate for Payer: UnitedHealthcare Commercial	$21.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.52

NEBIVOLOL (BYSTOLIC) 10MG TAB EMP

Facility

$32.00

Service Code	NDC 456141030
Hospital Charge Code	2622919
Hospital Revenue Code	250
Rate for Payer: Cash Price	$28.80

NEBIVOLOL (BYSTOLIC) 20MG TAB

Facility

$32.00

Service Code	NDC 456142030
Hospital Charge Code	2626541
Hospital Revenue Code	250
Rate for Payer: Cash Price	$28.80

NEBIVOLOL (BYSTOLIC) 20MG TAB

Facility

$32.00

Service Code	NDC 456142030
Hospital Charge Code	2626541
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$22.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$18.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$22.85
Rate for Payer: Cash Price	$28.80
Rate for Payer: UnitedHealthcare Commercial	$21.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.52

NEBIVOLOL (BYSTOLIC) 20MG TAB EMP

Facility

$32.00

Service Code	NDC 456142030
Hospital Charge Code	2622477
Hospital Revenue Code	250
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$22.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$18.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$22.85
Rate for Payer: Cash Price	$28.80
Rate for Payer: UnitedHealthcare Commercial	$21.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.52

NEBIVOLOL (BYSTOLIC) 20MG TAB EMP

Facility

$32.00

Service Code	NDC 456142030
Hospital Charge Code	2622477
Hospital Revenue Code	250
Rate for Payer: Cash Price	$28.80

NEBIVOLOL (BYSTOLIC) 2.5MG TAB EMP

Facility

$24.00

Service Code	NDC 456140230
Hospital Charge Code	2624803
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

NEBIVOLOL (BYSTOLIC) 2.5MG TAB EMP

Facility

$24.00

Service Code	NDC 456140230
Hospital Charge Code	2624803
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.14
Rate for Payer: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

NEBIVOLOL (BYSTOLIC) 5MG TAB EMP

Facility

$24.00

Service Code	NDC 456140590
Hospital Charge Code	2621959
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

NEBIVOLOL (BYSTOLIC) 5MG TAB EMP

Facility

$24.00

Service Code	NDC 456140590
Hospital Charge Code	2621959
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.14
Rate for Payer: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

NEBULIZER-1ST. TIME

Facility

$70.00

Service Code	CPT 94664
Hospital Charge Code	4494664
Hospital Revenue Code	412
Rate for Payer: Cash Price	$63.00

NEBULIZER-1ST. TIME

Facility

$70.00

Service Code	CPT 94664
Hospital Charge Code	4494664
Hospital Revenue Code	412
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$447.44
Rate for Payer: Aetna Better Health Medicaid/QHP	$197.40
Rate for Payer: Aetna Medicare Advantage	$223.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$41.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$49.98
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial HMO & PPO	$223.72
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$197.40
Rate for Payer: Home State Health Plan Medicaid Managed Care	$211.22
Rate for Payer: Home State Health Plan Medicare Advantage	$223.72
Rate for Payer: Humana Commercial	$447.44
Rate for Payer: Humana Medicare Advantage	$223.72
Rate for Payer: UnitedHealthcare Commercial	$46.69
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$197.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.20

NEBULIZER CONTINUOUS-1 HR

Facility

$156.00

Service Code	CPT 94644
Hospital Charge Code	4501205
Hospital Revenue Code	412
Rate for Payer: Cash Price	$140.40

NEBULIZER CONTINUOUS-1 HR

Facility

$156.00

Service Code	CPT 94644
Hospital Charge Code	4501205
Hospital Revenue Code	412
Min. Negotiated Rate	$56.16
Max. Negotiated Rate	$271.86
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
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	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$119.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$104.05
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$56.16

Know your out-of-pocket cost for care.

All Charges