Madison Medical Center

All Charges

Charge

Type

Setting

Price

NORGES/ETH-ESTRAD TAB 3X28 TAB EMP

Facility

$113.00

Service Code	NDC 6.818E+10
Hospital Charge Code	2626908
Hospital Revenue Code	250
Rate for Payer: Cash Price	$101.70

NORGES/ETH-ESTRAD TAB 3X28 TAB EMP

Facility

$113.00

Service Code	NDC 6.818E+10
Hospital Charge Code	2626908
Hospital Revenue Code	250
Min. Negotiated Rate	$40.68
Max. Negotiated Rate	$80.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$66.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$80.68
Rate for Payer: Cash Price	$101.70
Rate for Payer: UnitedHealthcare Commercial	$75.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.68

NORGES/ETH-ESTRAD TAB 6X28 TAB EMP

Facility

$113.00

Service Code	NDC 6.818E+10
Hospital Charge Code	2627243
Hospital Revenue Code	250
Min. Negotiated Rate	$40.68
Max. Negotiated Rate	$80.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$66.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$80.68
Rate for Payer: Cash Price	$101.70
Rate for Payer: UnitedHealthcare Commercial	$75.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.68

NORGES/ETH-ESTRAD TAB 6X28 TAB EMP

Facility

$113.00

Service Code	NDC 6.818E+10
Hospital Charge Code	2627243
Hospital Revenue Code	250
Rate for Payer: Cash Price	$101.70

NORMAL NEWBORN

Facility

$6,918.12

Service Code	MSDRG 795
Min. Negotiated Rate	$351.00
Max. Negotiated Rate	$6,918.12
Rate for Payer: Aetna Medicare Advantage	$3,459.06
Rate for Payer: Cigna Commercial HMO & PPO	$3,459.06
Rate for Payer: Home State Health Plan Medicare Advantage	$3,459.06
Rate for Payer: Humana Commercial	$6,918.12
Rate for Payer: Humana Medicare Advantage	$3,459.06
Rate for Payer: UnitedHealthcare Commercial	$351.00

NORPACE

Facility

$79.00

Service Code	CPT 80299
Hospital Charge Code	2280200
Hospital Revenue Code	301
Min. Negotiated Rate	$16.78
Max. Negotiated Rate	$56.41
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.78
Rate for Payer: Aetna Medicare Advantage	$18.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$46.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$56.41
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial HMO & PPO	$18.64
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.78
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.95
Rate for Payer: Home State Health Plan Medicare Advantage	$18.64
Rate for Payer: Humana Commercial	$37.28
Rate for Payer: Humana Medicare Advantage	$18.64
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.44

NORPACE

Facility

$79.00

Service Code	CPT 80299
Hospital Charge Code	2280200
Hospital Revenue Code	301
Rate for Payer: Cash Price	$71.10

NORPLANT REMOVAL

Facility

$365.00

Service Code	CPT 11976
Hospital Charge Code	4211976
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$216.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$260.61
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cigna Commercial HMO & PPO	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$243.46
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

NORPLANT REMOVAL

Facility

$365.00

Service Code	CPT 11976
Hospital Charge Code	4211976
Hospital Revenue Code	521
Rate for Payer: Cash Price	$328.50

NORTRIPTYLINE

Facility

$185.00

Service Code	CPT 80335
Hospital Charge Code	2214203
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$132.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$109.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$132.09
Rate for Payer: Cash Price	$166.50
Rate for Payer: Cash Price	$166.50
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$66.60

NORTRIPTYLINE

Facility

$185.00

Service Code	CPT 80335
Hospital Charge Code	2214203
Hospital Revenue Code	301
Rate for Payer: Cash Price	$166.50

NORTRIPTYLINE 25MG CAP EMP

Facility

$16.00

Service Code	NDC 406991103
Hospital Charge Code	2697262
Hospital Revenue Code	250
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

NORTRIPTYLINE 25MG CAP EMP

Facility

$16.00

Service Code	NDC 406991103
Hospital Charge Code	2697262
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

NORTRIPTYLINE 50MG CAP EMP

Facility

$16.00

Service Code	NDC 93081201
Hospital Charge Code	2625755
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

NORTRIPTYLINE 50MG CAP EMP

Facility

$16.00

Service Code	NDC 93081201
Hospital Charge Code	2625755
Hospital Revenue Code	250
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

NORTRIPTYLINE (PAMELOR) 10MG CAP

Facility

$20.00

Service Code	NDC 93081001
Hospital Charge Code	2655732
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

NORTRIPTYLINE (PAMELOR) 10MG CAP

Facility

$20.00

Service Code	NDC 93081001
Hospital Charge Code	2655732
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$11.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.28
Rate for Payer: Cash Price	$18.00
Rate for Payer: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

NOTROPRUSSIDE INJ

Facility

$149.00

Hospital Charge Code	2058038
Hospital Revenue Code	370
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$106.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$88.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$106.39
Rate for Payer: Cash Price	$134.10
Rate for Payer: UnitedHealthcare Commercial	$99.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$53.64

NOTROPRUSSIDE INJ

Facility

$149.00

Hospital Charge Code	2058038
Hospital Revenue Code	370
Rate for Payer: Cash Price	$134.10

NOVOLIN-N INSULIN NPH 10ML VIAL EMP

Facility

$245.00

Service Code	HCPCS J1815
Hospital Charge Code	2622027
Hospital Revenue Code	250
Rate for Payer: Cash Price	$220.50

NOVOLIN-N INSULIN NPH 10ML VIAL EMP

Facility

$245.00

Service Code	HCPCS J1815
Hospital Charge Code	2622027
Hospital Revenue Code	250
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$174.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$145.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$174.93
Rate for Payer: Cash Price	$220.50
Rate for Payer: UnitedHealthcare Commercial	$163.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$88.20

Novolin REGULAR INSULIN 10ML VL

Facility

$245.00

Service Code	HCPCS J1815
Hospital Charge Code	2621890
Hospital Revenue Code	250
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$174.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$145.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$174.93
Rate for Payer: Cash Price	$220.50
Rate for Payer: UnitedHealthcare Commercial	$163.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$88.20

Novolin REGULAR INSULIN 10ML VL

Facility

$245.00

Service Code	HCPCS J1815
Hospital Charge Code	2621890
Hospital Revenue Code	250
Rate for Payer: Cash Price	$220.50

NOVOLOG FLEX PEN 5X3ML EMP

Facility

$648.00

Service Code	HCPCS J1817
Hospital Charge Code	2624543
Hospital Revenue Code	250
Rate for Payer: Cash Price	$583.20

NOVOLOG FLEX PEN 5X3ML EMP

Facility

$648.00

Service Code	HCPCS J1817
Hospital Charge Code	2624543
Hospital Revenue Code	250
Min. Negotiated Rate	$233.28
Max. Negotiated Rate	$462.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$383.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$462.67
Rate for Payer: Cash Price	$583.20
Rate for Payer: UnitedHealthcare Commercial	$432.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$233.28

Know your out-of-pocket cost for care.

All Charges