Madison Medical Center

All Charges

Charge

Type

Setting

Price

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
Rate for Payer: Cash Price	$140.40

OLANZAPINE + SWFI : 10MG + 2.1ML IM INJ

Facility

$350.00

Service Code	NDC 781315972
Hospital Charge Code	2626537
Hospital Revenue Code	250
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$249.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$207.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$249.90
Rate for Payer: Cash Price	$315.00
Rate for Payer: UnitedHealthcare Commercial	$233.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$126.00

OLANZAPINE + SWFI : 10MG + 2.1ML IM INJ

Facility

$350.00

Service Code	NDC 781315972
Hospital Charge Code	2626537
Hospital Revenue Code	250
Rate for Payer: Cash Price	$315.00

OLANZAPINE (ZYPREXA) 10MG TAB

Facility

$75.00

Service Code	NDC 904637661
Hospital Charge Code	2626298
Hospital Revenue Code	250
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$53.55
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: UnitedHealthcare Commercial	$50.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

OLANZAPINE (ZYPREXA) 10MG TAB

Facility

$75.00

Service Code	NDC 904637661
Hospital Charge Code	2626298
Hospital Revenue Code	250
Rate for Payer: Cash Price	$67.50

OLANZAPINE (ZYPREXA) 2.5MG TAB

Facility

$48.00

Service Code	NDC 93576756
Hospital Charge Code	2654117
Hospital Revenue Code	250
Rate for Payer: Cash Price	$43.20

OLANZAPINE (ZYPREXA) 2.5MG TAB

Facility

$48.00

Service Code	NDC 93576756
Hospital Charge Code	2654117
Hospital Revenue Code	250
Min. Negotiated Rate	$17.28
Max. Negotiated Rate	$34.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$28.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$34.27
Rate for Payer: Cash Price	$43.20
Rate for Payer: UnitedHealthcare Commercial	$32.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.28

OLANZAPINE (ZYPREXA) 5MG TAB EMP

Facility

$48.00

Service Code	NDC 3.3342E+10
Hospital Charge Code	2627072
Hospital Revenue Code	250
Rate for Payer: Cash Price	$43.20

OLANZAPINE (ZYPREXA) 5MG TAB EMP

Facility

$48.00

Service Code	NDC 3.3342E+10
Hospital Charge Code	2627072
Hospital Revenue Code	250
Min. Negotiated Rate	$17.28
Max. Negotiated Rate	$34.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$28.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$34.27
Rate for Payer: Cash Price	$43.20
Rate for Payer: UnitedHealthcare Commercial	$32.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.28

OLIVERO GLUCOSE BY MONITOR

Facility

$30.00

Service Code	CPT 82962
Hospital Charge Code	5482962
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

OLIVERO GLUCOSE BY MONITOR

Facility

$30.00

Service Code	CPT 82962
Hospital Charge Code	5482962
Hospital Revenue Code	301
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$2.95
Rate for Payer: Aetna Medicare Advantage	$3.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$3.28
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$2.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$3.16
Rate for Payer: Home State Health Plan Medicare Advantage	$3.28
Rate for Payer: Humana Commercial	$6.56
Rate for Payer: Humana Medicare Advantage	$3.28
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$2.95
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

OLIVERO INFLUENZA A & B CLIA WAVED

Facility

$71.00

Service Code	CPT 87804
Hospital Charge Code	5487804
Hospital Revenue Code	301
Rate for Payer: Cash Price	$63.90

OLIVERO INFLUENZA A & B CLIA WAVED

Facility

$71.00

Service Code	CPT 87804
Hospital Charge Code	5487804
Hospital Revenue Code	301
Min. Negotiated Rate	$14.90
Max. Negotiated Rate	$50.69
Rate for Payer: Aetna Better Health Medicaid/QHP	$14.90
Rate for Payer: Aetna Medicare Advantage	$16.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$42.03
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$50.69
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial HMO & PPO	$16.55
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14.90
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15.94
Rate for Payer: Home State Health Plan Medicare Advantage	$16.55
Rate for Payer: Humana Commercial	$33.10
Rate for Payer: Humana Medicare Advantage	$16.55
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.56

OLIVERO INFLUENZA A&B TEST

Facility

$123.00

Service Code	CPT 87502
Hospital Charge Code	5487502
Hospital Revenue Code	301
Rate for Payer: Cash Price	$110.70

OLIVERO INFLUENZA A&B TEST

Facility

$123.00

Service Code	CPT 87502
Hospital Charge Code	5487502
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$191.60
Rate for Payer: Aetna Better Health Medicaid/QHP	$86.22
Rate for Payer: Aetna Medicare Advantage	$95.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$72.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$87.82
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cigna Commercial HMO & PPO	$95.80
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$86.22
Rate for Payer: Home State Health Plan Medicaid Managed Care	$92.26
Rate for Payer: Home State Health Plan Medicare Advantage	$95.80
Rate for Payer: Humana Commercial	$191.60
Rate for Payer: Humana Medicare Advantage	$95.80
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$86.22
Rate for Payer: UnitedHealthcare Medicare Advantage	$44.28

OLIVERO KOH WET MOUNT

Facility

$40.00

Service Code	CPT 87210
Hospital Charge Code	5487210
Hospital Revenue Code	301
Rate for Payer: Cash Price	$36.00

OLIVERO KOH WET MOUNT

Facility

$40.00

Service Code	CPT 87210
Hospital Charge Code	5487210
Hospital Revenue Code	301
Min. Negotiated Rate	$5.24
Max. Negotiated Rate	$28.56
Rate for Payer: Aetna Better Health Medicaid/QHP	$5.24
Rate for Payer: Aetna Medicare Advantage	$5.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$28.56
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial HMO & PPO	$5.82
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5.24
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.61
Rate for Payer: Home State Health Plan Medicare Advantage	$5.82
Rate for Payer: Humana Commercial	$11.64
Rate for Payer: Humana Medicare Advantage	$5.82
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

OLIVERO OCCULT BLOOD

Facility

$25.00

Service Code	CPT 82270
Hospital Charge Code	5482270
Hospital Revenue Code	301
Rate for Payer: Cash Price	$22.50

OLIVERO OCCULT BLOOD

Facility

$25.00

Service Code	CPT 82270
Hospital Charge Code	5482270
Hospital Revenue Code	301
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$3.94
Rate for Payer: Aetna Medicare Advantage	$4.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.85
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial HMO & PPO	$4.38
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$3.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4.22
Rate for Payer: Home State Health Plan Medicare Advantage	$4.38
Rate for Payer: Humana Commercial	$8.76
Rate for Payer: Humana Medicare Advantage	$4.38
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$3.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.00

OLIVERO RAPID STREP

Facility

$75.00

Service Code	CPT 87880
Hospital Charge Code	5487880
Hospital Revenue Code	301
Rate for Payer: Cash Price	$67.50

OLIVERO RAPID STREP

Facility

$75.00

Service Code	CPT 87880
Hospital Charge Code	5487880
Hospital Revenue Code	301
Min. Negotiated Rate	$14.88
Max. Negotiated Rate	$53.55
Rate for Payer: Aetna Better Health Medicaid/QHP	$14.88
Rate for Payer: Aetna Medicare Advantage	$16.53
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	$16.53
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14.88
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15.92
Rate for Payer: Home State Health Plan Medicare Advantage	$16.53
Rate for Payer: Humana Commercial	$33.06
Rate for Payer: Humana Medicare Advantage	$16.53
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14.88
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

OLIVERO RSV TEST

Facility

$123.00

Service Code	CPT 87634
Hospital Charge Code	5487634
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$140.40
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	$72.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$87.82
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cash Price	$110.70
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	$44.28

OLIVERO RSV TEST

Facility

$123.00

Service Code	CPT 87634
Hospital Charge Code	5487634
Hospital Revenue Code	301
Rate for Payer: Cash Price	$110.70

OLIVERO STREP

Facility

$75.00

Service Code	CPT 87651
Hospital Charge Code	5487651
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$70.18
Rate for Payer: Aetna Better Health Medicaid/QHP	$31.58
Rate for Payer: Aetna Medicare Advantage	$35.09
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	$35.09
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$31.58
Rate for Payer: Home State Health Plan Medicaid Managed Care	$33.79
Rate for Payer: Home State Health Plan Medicare Advantage	$35.09
Rate for Payer: Humana Commercial	$70.18
Rate for Payer: Humana Medicare Advantage	$35.09
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$31.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

OLIVERO STREP

Facility

$75.00

Service Code	CPT 87651
Hospital Charge Code	5487651
Hospital Revenue Code	301
Rate for Payer: Cash Price	$67.50

Know your out-of-pocket cost for care.

All Charges