Madison Medical Center

All Charges

Charge

Type

Setting

Price

OUTREACH-URINALYSIS

Facility

$16.00

Service Code	CPT 81000
Hospital Charge Code	2481000
Hospital Revenue Code	301
Rate for Payer: Cash Price	$14.40

OUTREACH-URINALYSIS

Facility

$16.00

Service Code	CPT 81000
Hospital Charge Code	2481000
Hospital Revenue Code	301
Min. Negotiated Rate	$3.62
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$3.62
Rate for Payer: Aetna Medicare Advantage	$4.02
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: Cash Price	$14.40
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial HMO & PPO	$4.02
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$3.62
Rate for Payer: Home State Health Plan Medicaid Managed Care	$3.87
Rate for Payer: Home State Health Plan Medicare Advantage	$4.02
Rate for Payer: Humana Commercial	$8.04
Rate for Payer: Humana Medicare Advantage	$4.02
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$3.62
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

OVA1

Facility

$1,364.00

Service Code	CPT 84999
Hospital Charge Code	22849990
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$973.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$807.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$973.90
Rate for Payer: Cash Price	$1,227.60
Rate for Payer: Cash Price	$1,227.60
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$491.04

OVA1

Facility

$1,364.00

Service Code	CPT 84999
Hospital Charge Code	22849990
Hospital Revenue Code	301
Rate for Payer: Cash Price	$1,227.60

.OVA AND PARASITES STOOL SMEAR

Facility

$34.00

Service Code	CPT 87177
Hospital Charge Code	3012006
Hospital Revenue Code	306
Rate for Payer: Cash Price	$30.60

.OVA AND PARASITES STOOL SMEAR

Facility

$34.00

Service Code	CPT 87177
Hospital Charge Code	3012006
Hospital Revenue Code	306
Min. Negotiated Rate	$8.01
Max. Negotiated Rate	$24.28
Rate for Payer: Aetna Better Health Medicaid/QHP	$8.01
Rate for Payer: Aetna Medicare Advantage	$8.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24.28
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna Commercial HMO & PPO	$8.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8.01
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8.57
Rate for Payer: Home State Health Plan Medicare Advantage	$8.90
Rate for Payer: Humana Commercial	$17.80
Rate for Payer: Humana Medicare Advantage	$8.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.24

.OVA AND PARASITES STOOL STAIN

Facility

$37.00

Service Code	CPT 87209
Hospital Charge Code	3012005
Hospital Revenue Code	306
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$35.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.18
Rate for Payer: Aetna Medicare Advantage	$17.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$21.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$26.42
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cigna Commercial HMO & PPO	$17.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.18
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.31
Rate for Payer: Home State Health Plan Medicare Advantage	$17.98
Rate for Payer: Humana Commercial	$35.96
Rate for Payer: Humana Medicare Advantage	$17.98
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.32

.OVA AND PARASITES STOOL STAIN

Facility

$37.00

Service Code	CPT 87209
Hospital Charge Code	3012005
Hospital Revenue Code	306
Rate for Payer: Cash Price	$33.30

OVAL CARBIDE BURR 4.0

Facility

$215.00

Hospital Charge Code	127777
Hospital Revenue Code	271
Min. Negotiated Rate	$77.40
Max. Negotiated Rate	$153.51
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$127.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$153.51
Rate for Payer: Cash Price	$193.50
Rate for Payer: UnitedHealthcare Commercial	$143.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$77.40

OVAL CARBIDE BURR 4.0

Facility

$215.00

Hospital Charge Code	127777
Hospital Revenue Code	271
Rate for Payer: Cash Price	$193.50

OVARIAN CYSTECTOMY

Professional

Both

$2,315.00

Service Code	CPT 58925
Hospital Charge Code	4158925
Hospital Revenue Code	975
Min. Negotiated Rate	$582.62
Max. Negotiated Rate	$810.25
Rate for Payer: Aetna Commercial/Medicare Advantage	$666.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$582.62
Rate for Payer: Cash Price	$2,083.50
Rate for Payer: Cash Price	$2,083.50
Rate for Payer: Cigna Commercial HMO & PPO	$666.62
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$582.62
Rate for Payer: Home State Health Plan Medicaid Managed Care	$640.88
Rate for Payer: Home State Health Plan Medicare Advantage	$666.62
Rate for Payer: Optum Medicare Advantage	$810.25
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$582.62

OVARIAN CYSTECTOMY, UNILATERAL OR BILAT

Facility

$2,940.00

Service Code	CPT 58925
Hospital Charge Code	5458925
Rate for Payer: Cash Price	$2,646.00

OVERIAN CYSTOSTOMY

Professional

Both

$1,624.00

Service Code	CPT 58662
Hospital Charge Code	4156303
Hospital Revenue Code	975
Min. Negotiated Rate	$568.40
Max. Negotiated Rate	$704.05
Rate for Payer: Aetna Commercial/Medicare Advantage	$620.63
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$640.05
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cash Price	$1,461.60
Rate for Payer: Cigna Commercial HMO & PPO	$620.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$640.05
Rate for Payer: Home State Health Plan Medicaid Managed Care	$704.05
Rate for Payer: Home State Health Plan Medicare Advantage	$620.63
Rate for Payer: Optum Medicare Advantage	$568.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$640.05

OVIDREL 250MCG INJ 0.5ML EMP

Facility

$776.00

Service Code	NDC 4.4087E+10
Hospital Charge Code	2623111
Hospital Revenue Code	250
Min. Negotiated Rate	$279.36
Max. Negotiated Rate	$554.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$459.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$554.06
Rate for Payer: Cash Price	$698.40
Rate for Payer: UnitedHealthcare Commercial	$517.59
Rate for Payer: UnitedHealthcare Medicare Advantage	$279.36

OVIDREL 250MCG INJ 0.5ML EMP

Facility

$776.00

Service Code	NDC 4.4087E+10
Hospital Charge Code	2623111
Hospital Revenue Code	250
Rate for Payer: Cash Price	$698.40

OXACILLIN 2GM INJ VIAL

Facility

$86.00

Service Code	HCPCS J2700
Hospital Charge Code	2627261
Hospital Revenue Code	250
Rate for Payer: Cash Price	$77.40

OXACILLIN 2GM INJ VIAL

Facility

$86.00

Service Code	HCPCS J2700
Hospital Charge Code	2627261
Hospital Revenue Code	250
Min. Negotiated Rate	$30.96
Max. Negotiated Rate	$61.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$50.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$61.40
Rate for Payer: Cash Price	$77.40
Rate for Payer: UnitedHealthcare Commercial	$57.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.96

OXACILLIN + NS : 2GM + 100ML MINIBAG

Facility

$86.00

Service Code	HCPCS J2700
Hospital Charge Code	2627262
Hospital Revenue Code	250
Min. Negotiated Rate	$30.96
Max. Negotiated Rate	$61.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$50.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$61.40
Rate for Payer: Cash Price	$77.40
Rate for Payer: UnitedHealthcare Commercial	$57.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.96

OXACILLIN + NS : 2GM + 100ML MINIBAG

Facility

$86.00

Service Code	HCPCS J2700
Hospital Charge Code	2627262
Hospital Revenue Code	250
Rate for Payer: Cash Price	$77.40

OXALATE, 24 HR URINE

Facility

$147.00

Service Code	CPT 83945
Hospital Charge Code	2221301
Hospital Revenue Code	307
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$104.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.01
Rate for Payer: Aetna Medicare Advantage	$14.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$87.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$104.96
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cigna Commercial HMO & PPO	$14.45
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.01
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.92
Rate for Payer: Home State Health Plan Medicare Advantage	$14.45
Rate for Payer: Humana Commercial	$28.90
Rate for Payer: Humana Medicare Advantage	$14.45
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$52.92

OXALATE, 24 HR URINE

Facility

$147.00

Service Code	CPT 83945
Hospital Charge Code	2221301
Hospital Revenue Code	307
Rate for Payer: Cash Price	$132.30

OXALATE, PLASMA

Facility

$360.00

Service Code	CPT 83945
Hospital Charge Code	2221302
Hospital Revenue Code	307
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$257.04
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.01
Rate for Payer: Aetna Medicare Advantage	$14.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$213.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$257.04
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial HMO & PPO	$14.45
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.01
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.92
Rate for Payer: Home State Health Plan Medicare Advantage	$14.45
Rate for Payer: Humana Commercial	$28.90
Rate for Payer: Humana Medicare Advantage	$14.45
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$129.60

OXALATE, PLASMA

Facility

$360.00

Service Code	CPT 83945
Hospital Charge Code	2221302
Hospital Revenue Code	307
Rate for Payer: Cash Price	$324.00

OXALTE, QUANT 24HR URINE

Facility

$48.00

Service Code	CPT 83945
Hospital Charge Code	223953
Hospital Revenue Code	301
Min. Negotiated Rate	$13.01
Max. Negotiated Rate	$34.27
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.01
Rate for Payer: Aetna Medicare Advantage	$14.45
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: Cash Price	$43.20
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial HMO & PPO	$14.45
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.01
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.92
Rate for Payer: Home State Health Plan Medicare Advantage	$14.45
Rate for Payer: Humana Commercial	$28.90
Rate for Payer: Humana Medicare Advantage	$14.45
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.28

OXALTE, QUANT 24HR URINE

Facility

$48.00

Service Code	CPT 83945
Hospital Charge Code	223953
Hospital Revenue Code	301
Rate for Payer: Cash Price	$43.20

Know your out-of-pocket cost for care.

All Charges