Madison Medical Center

All Charges

Charge

Type

Setting

Price

OFFICE VISIT NP INTERMEDIATE

Facility

$240.00

Service Code	CPT 99203
Hospital Charge Code	9799203
Hospital Revenue Code	521
Rate for Payer: Cash Price	$216.00

OFFICE VISIT NP INTERMEDIATE

Facility

$240.00

Service Code	CPT 99203
Hospital Charge Code	9799203
Hospital Revenue Code	521
Min. Negotiated Rate	$142.08
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: UnitedHealthcare Commercial	$160.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OFFICE VISIT NP LEVEL 1

Facility

$120.00

Service Code	CPT 99202
Hospital Charge Code	9399201
Hospital Revenue Code	521
Min. Negotiated Rate	$71.04
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$71.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$85.68
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: UnitedHealthcare Commercial	$80.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OFFICE VISIT NP LEVEL 1

Facility

$120.00

Service Code	CPT 99202
Hospital Charge Code	9399201
Hospital Revenue Code	521
Rate for Payer: Cash Price	$108.00

OFFICE VISIT NP LEVEL 2

Facility

$175.00

Service Code	CPT 99202
Hospital Charge Code	9399202
Hospital Revenue Code	521
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$103.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$124.95
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cash Price	$157.50
Rate for Payer: UnitedHealthcare Commercial	$116.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OFFICE VISIT NP LEVEL 2

Facility

$175.00

Service Code	CPT 99202
Hospital Charge Code	9399202
Hospital Revenue Code	521
Rate for Payer: Cash Price	$157.50

OFFICE VISIT NP LEVEL 3

Facility

$240.00

Service Code	CPT 99203
Hospital Charge Code	9399203
Hospital Revenue Code	521
Rate for Payer: Cash Price	$216.00

OFFICE VISIT NP LEVEL 3

Facility

$240.00

Service Code	CPT 99203
Hospital Charge Code	9399203
Hospital Revenue Code	521
Min. Negotiated Rate	$142.08
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: UnitedHealthcare Commercial	$160.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OFFICE VISIT NP LEVEL 4

Facility

$385.00

Service Code	CPT 99204
Hospital Charge Code	9399204
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$274.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$227.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$274.89
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cash Price	$346.50
Rate for Payer: UnitedHealthcare Commercial	$256.80
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OFFICE VISIT NP LEVEL 4

Facility

$385.00

Service Code	CPT 99204
Hospital Charge Code	9399204
Hospital Revenue Code	521
Rate for Payer: Cash Price	$346.50

OFFICE VISIT NP LEVEL 5

Facility

$485.00

Service Code	CPT 99205
Hospital Charge Code	9399205
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$346.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$287.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$346.29
Rate for Payer: Cash Price	$436.50
Rate for Payer: Cash Price	$436.50
Rate for Payer: UnitedHealthcare Commercial	$323.50
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OFFICE VISIT NP LEVEL 5

Facility

$485.00

Service Code	CPT 99205
Hospital Charge Code	9399205
Hospital Revenue Code	521
Rate for Payer: Cash Price	$436.50

OFFICE VISIT - NP LIMITED

Facility

$175.00

Service Code	CPT 99202
Hospital Charge Code	9699202
Hospital Revenue Code	521
Rate for Payer: Cash Price	$157.50

OFFICE VISIT - NP LIMITED

Facility

$175.00

Service Code	CPT 99202
Hospital Charge Code	9699202
Hospital Revenue Code	521
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$103.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$124.95
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cash Price	$157.50
Rate for Payer: UnitedHealthcare Commercial	$116.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OFFICE VISIT - NP - LIMITED

Facility

$175.00

Service Code	CPT 99202
Hospital Charge Code	9599202
Hospital Revenue Code	521
Rate for Payer: Cash Price	$157.50

OFFICE VISIT - NP - LIMITED

Facility

$175.00

Service Code	CPT 99202
Hospital Charge Code	9599202
Hospital Revenue Code	521
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$103.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$124.95
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cash Price	$157.50
Rate for Payer: UnitedHealthcare Commercial	$116.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OFFICE VISIT NP LIMITED

Facility

$175.00

Service Code	CPT 99202
Hospital Charge Code	9799202
Hospital Revenue Code	521
Rate for Payer: Cash Price	$157.50

OFFICE VISIT NP LIMITED

Facility

$175.00

Service Code	CPT 99202
Hospital Charge Code	9799202
Hospital Revenue Code	521
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$103.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$124.95
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cash Price	$157.50
Rate for Payer: UnitedHealthcare Commercial	$116.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OFLOXACIN (FLOXIN)0.3% OTIC SOL 10ML EMP

Facility

$235.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2623909
Hospital Revenue Code	250
Rate for Payer: Cash Price	$211.50

OFLOXACIN (FLOXIN)0.3% OTIC SOL 10ML EMP

Facility

$235.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2623909
Hospital Revenue Code	250
Min. Negotiated Rate	$84.60
Max. Negotiated Rate	$167.79
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$139.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$167.79
Rate for Payer: Cash Price	$211.50
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$84.60

OFLOXACIN (FLOXIN)0.3% OTIC SOL 5ML

Facility

$235.00

Service Code	NDC 2.4208E+10
Hospital Charge Code	2626355
Hospital Revenue Code	250
Min. Negotiated Rate	$84.60
Max. Negotiated Rate	$167.79
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$139.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$167.79
Rate for Payer: Cash Price	$211.50
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$84.60

OFLOXACIN (FLOXIN)0.3% OTIC SOL 5ML

Facility

$235.00

Service Code	NDC 2.4208E+10
Hospital Charge Code	2626355
Hospital Revenue Code	250
Rate for Payer: Cash Price	$211.50

OFLOXACIN (OCUFLOX) 0.3% OP SOL 5ML

Facility

$156.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2655747
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

OFLOXACIN (OCUFLOX) 0.3% OP SOL 5ML

Facility

$156.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2655747
Hospital Revenue Code	250
Rate for Payer: Cash Price	$140.40

OFLOXACIN (OCUFLOX) 0.3% OP SOL 5ML EMP

Facility

$156.00

Service Code	NDC 1.7478E+10
Hospital Charge Code	2622333
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

Know your out-of-pocket cost for care.

All Charges