Madison Medical Center

All Charges

Charge

Type

Setting

Price

OXYCODONE ORAL SOL 5MG 5ML C2

Facility

$21.00

Service Code	NDC 1E+11
Hospital Charge Code	2619354
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

OXYCODONE (OXYCONTIN) CR 10MG TAB C2

Facility

$48.00

Service Code	NDC 5.9011E+10
Hospital Charge Code	2626282
Hospital Revenue Code	250
Min. Negotiated Rate	$17.28
Max. Negotiated Rate	$34.27
Rate for Payer: Cash Price	$43.20
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: UnitedHealthcare Commercial	$32.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.28

OXYCODONE (OXYCONTIN) CR 10MG TAB C2

Facility

$48.00

Service Code	NDC 5.9011E+10
Hospital Charge Code	2626282
Hospital Revenue Code	250
Rate for Payer: Cash Price	$43.20

OXYCODONE (OXYCONTIN) CR 20MG TAB C2

Facility

$43.00

Service Code	NDC 5.9011E+10
Hospital Charge Code	2626283
Hospital Revenue Code	250
Rate for Payer: Cash Price	$38.70

OXYCODONE (OXYCONTIN) CR 20MG TAB C2

Facility

$43.00

Service Code	NDC 5.9011E+10
Hospital Charge Code	2626283
Hospital Revenue Code	250
Min. Negotiated Rate	$15.48
Max. Negotiated Rate	$30.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$25.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$30.70
Rate for Payer: Cash Price	$38.70
Rate for Payer: UnitedHealthcare Commercial	$28.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.48

OXYCODONE (OXY IR) 5MG IR TAB C2

Facility

$39.00

Service Code	NDC 4.2858E+10
Hospital Charge Code	2626453
Hospital Revenue Code	250
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

OXYCODONE (OXY IR) 5MG IR TAB C2

Facility

$39.00

Service Code	NDC 4.2858E+10
Hospital Charge Code	2626453
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.10

.OXYCODONE REFLEX CONFIRMATION

Facility

$110.00

Service Code	CPT 80365
Hospital Charge Code	221298
Hospital Revenue Code	301
Rate for Payer: Cash Price	$99.00

.OXYCODONE REFLEX CONFIRMATION

Facility

$110.00

Service Code	CPT 80365
Hospital Charge Code	221298
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$78.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$78.54
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.60

OXYGEN

Facility

$247.00

Service Code	CPT 94680
Hospital Charge Code	4500390
Hospital Revenue Code	272
Rate for Payer: Cash Price	$222.30

OXYGEN

Facility

$247.00

Service Code	CPT 94680
Hospital Charge Code	4500390
Hospital Revenue Code	272
Min. Negotiated Rate	$88.92
Max. Negotiated Rate	$262.92
Rate for Payer: Aetna Better Health Medicaid/QHP	$116.00
Rate for Payer: Aetna Medicare Advantage	$131.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$146.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$176.36
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cigna Commercial HMO & PPO	$131.46
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$116.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$124.12
Rate for Payer: Home State Health Plan Medicare Advantage	$131.46
Rate for Payer: Humana Commercial	$262.92
Rate for Payer: Humana Medicare Advantage	$131.46
Rate for Payer: UnitedHealthcare Commercial	$164.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$116.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$88.92

OXYGEN 1 CUBIC FOOT

Facility

$38.00

Service Code	CPT S8120
Hospital Charge Code	4108120
Hospital Revenue Code	521
Rate for Payer: Cash Price	$34.20

OXYGEN 1 CUBIC FOOT

Facility

$38.00

Service Code	CPT S8120
Hospital Charge Code	4108120
Hospital Revenue Code	521
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$22.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.13
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cash Price	$34.20
Rate for Payer: UnitedHealthcare Commercial	$25.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OXYGEN CANNULA

Facility

$21.00

Hospital Charge Code	4500420
Hospital Revenue Code	271
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

OXYGEN CANNULA

Facility

$21.00

Hospital Charge Code	4500420
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

OXYGEN CONN. TUBE

Facility

$18.00

Hospital Charge Code	4500450
Hospital Revenue Code	271
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

OXYGEN CONN. TUBE

Facility

$18.00

Hospital Charge Code	4500450
Hospital Revenue Code	271
Rate for Payer: Cash Price	$16.20

OXYGEN PORTABLE

Facility

$91.00

Hospital Charge Code	4500395
Hospital Revenue Code	272
Rate for Payer: Cash Price	$81.90

OXYGEN PORTABLE

Facility

$91.00

Hospital Charge Code	4500395
Hospital Revenue Code	272
Min. Negotiated Rate	$32.76
Max. Negotiated Rate	$64.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$53.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$64.97
Rate for Payer: Cash Price	$81.90
Rate for Payer: UnitedHealthcare Commercial	$60.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$32.76

OXYGEN SET

Facility

$247.00

Service Code	CPT 94680
Hospital Charge Code	450000
Hospital Revenue Code	271
Rate for Payer: Cash Price	$222.30

OXYGEN SET

Facility

$247.00

Service Code	CPT 94680
Hospital Charge Code	450000
Hospital Revenue Code	271
Min. Negotiated Rate	$88.92
Max. Negotiated Rate	$262.92
Rate for Payer: Aetna Better Health Medicaid/QHP	$116.00
Rate for Payer: Aetna Medicare Advantage	$131.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$146.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$176.36
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cigna Commercial HMO & PPO	$131.46
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$116.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$124.12
Rate for Payer: Home State Health Plan Medicare Advantage	$131.46
Rate for Payer: Humana Commercial	$262.92
Rate for Payer: Humana Medicare Advantage	$131.46
Rate for Payer: UnitedHealthcare Commercial	$164.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$116.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$88.92

OXYGEN UNIT SET-UP

Facility

$91.00

Service Code	CPT 94680
Hospital Charge Code	4500400
Hospital Revenue Code	271
Min. Negotiated Rate	$32.76
Max. Negotiated Rate	$262.92
Rate for Payer: Aetna Better Health Medicaid/QHP	$116.00
Rate for Payer: Aetna Medicare Advantage	$131.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$53.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$64.97
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cigna Commercial HMO & PPO	$131.46
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$116.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$124.12
Rate for Payer: Home State Health Plan Medicare Advantage	$131.46
Rate for Payer: Humana Commercial	$262.92
Rate for Payer: Humana Medicare Advantage	$131.46
Rate for Payer: UnitedHealthcare Commercial	$60.70
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$116.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$32.76

OXYGEN UNIT SET-UP

Facility

$91.00

Service Code	CPT 94680
Hospital Charge Code	4500400
Hospital Revenue Code	271
Rate for Payer: Cash Price	$81.90

OXYMETAZOLINE 0.5% 12HR NAS SPRY 30ML

Facility

$70.00

Service Code	NDC 904571130
Hospital Charge Code	2659103
Hospital Revenue Code	250
Rate for Payer: Cash Price	$63.00

OXYMETAZOLINE 0.5% 12HR NAS SPRY 30ML

Facility

$70.00

Service Code	NDC 904571130
Hospital Charge Code	2659103
Hospital Revenue Code	250
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$49.98
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: UnitedHealthcare Commercial	$46.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.20

Know your out-of-pocket cost for care.

All Charges