Madison Medical Center

All Charges

Charge

Type

Setting

Price

PEG 3350(MIRALAX)238GM BOWELPREPSUS

Facility

$79.00

Service Code	NDC 1.1524E+10
Hospital Charge Code	2626429
Hospital Revenue Code	250
Min. Negotiated Rate	$28.44
Max. Negotiated Rate	$56.41
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: UnitedHealthcare Commercial	$52.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.44

PEG 3350(MIRALAX)238GM BOWELPREPSUS

Facility

$79.00

Service Code	NDC 1.1524E+10
Hospital Charge Code	2626429
Hospital Revenue Code	250
Rate for Payer: Cash Price	$71.10

PEG 3350 (MIRALAX) 238GM POWDER

Facility

$153.00

Service Code	NDC 3.7205E+10
Hospital Charge Code	2626371
Hospital Revenue Code	250
Min. Negotiated Rate	$55.08
Max. Negotiated Rate	$109.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$90.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$109.24
Rate for Payer: Cash Price	$137.70
Rate for Payer: UnitedHealthcare Commercial	$102.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$55.08

PEG 3350 (MIRALAX) 238GM POWDER

Facility

$153.00

Service Code	NDC 3.7205E+10
Hospital Charge Code	2626371
Hospital Revenue Code	250
Rate for Payer: Cash Price	$137.70

PEG 3350 (MIRALAX) 510GM NH USE 17.9OZ

Facility

$79.00

Service Code	NDC 1.1524E+10
Hospital Charge Code	2620396
Hospital Revenue Code	250
Min. Negotiated Rate	$28.44
Max. Negotiated Rate	$56.41
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: UnitedHealthcare Commercial	$52.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.44

PEG 3350 (MIRALAX) 510GM NH USE 17.9OZ

Facility

$79.00

Service Code	NDC 1.1524E+10
Hospital Charge Code	2620396
Hospital Revenue Code	250
Rate for Payer: Cash Price	$71.10

PEGFILGRASTIM (NEULASTA) 6MG SC INJ

Facility

$32,682.00

Service Code	HCPCS J2506
Hospital Charge Code	2626423
Hospital Revenue Code	335
Rate for Payer: Cash Price	$29,413.80

PEGFILGRASTIM (NEULASTA) 6MG SC INJ

Facility

$32,682.00

Service Code	HCPCS J2506
Hospital Charge Code	2626423
Hospital Revenue Code	335
Min. Negotiated Rate	$143.23
Max. Negotiated Rate	$23,334.95
Rate for Payer: Aetna Medicare Advantage	$143.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$19,347.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$23,334.95
Rate for Payer: Cash Price	$29,413.80
Rate for Payer: Cash Price	$29,413.80
Rate for Payer: Cigna Commercial HMO & PPO	$143.23
Rate for Payer: Home State Health Plan Medicare Advantage	$143.23
Rate for Payer: Humana Commercial	$286.46
Rate for Payer: Humana Medicare Advantage	$143.23
Rate for Payer: UnitedHealthcare Commercial	$21,798.89
Rate for Payer: UnitedHealthcare Medicare Advantage	$11,765.52

P E G TUBE

Facility

$439.00

Hospital Charge Code	127293
Hospital Revenue Code	271
Min. Negotiated Rate	$158.04
Max. Negotiated Rate	$313.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$259.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$313.45
Rate for Payer: Cash Price	$395.10
Rate for Payer: UnitedHealthcare Commercial	$292.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$158.04

P E G TUBE

Facility

$439.00

Hospital Charge Code	127293
Hospital Revenue Code	271
Rate for Payer: Cash Price	$395.10

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$37,047.42

Service Code	MSDRG 734
Min. Negotiated Rate	$18,523.71
Max. Negotiated Rate	$37,047.42
Rate for Payer: Aetna Medicare Advantage	$18,523.71
Rate for Payer: Cigna Commercial HMO & PPO	$18,523.71
Rate for Payer: Home State Health Plan Medicare Advantage	$18,523.71
Rate for Payer: Humana Commercial	$37,047.42
Rate for Payer: Humana Medicare Advantage	$18,523.71

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$24,700.72

Service Code	MSDRG 735
Min. Negotiated Rate	$12,350.36
Max. Negotiated Rate	$24,700.72
Rate for Payer: Aetna Medicare Advantage	$12,350.36
Rate for Payer: Cigna Commercial HMO & PPO	$12,350.36
Rate for Payer: Home State Health Plan Medicare Advantage	$12,350.36
Rate for Payer: Humana Commercial	$24,700.72
Rate for Payer: Humana Medicare Advantage	$12,350.36

PELVIC EXAM

Facility

$32.00

Service Code	CPT 80150
Hospital Charge Code	4480150
Hospital Revenue Code	521
Rate for Payer: Cash Price	$28.80

PELVIC EXAM

Facility

$32.00

Service Code	CPT 80150
Hospital Charge Code	4480150
Hospital Revenue Code	521
Min. Negotiated Rate	$12.21
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.57
Rate for Payer: Aetna Medicare Advantage	$15.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$18.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$22.85
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial HMO & PPO	$15.08
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12.21
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.52
Rate for Payer: Home State Health Plan Medicare Advantage	$15.08
Rate for Payer: Humana Commercial	$30.16
Rate for Payer: Humana Medicare Advantage	$15.08
Rate for Payer: UnitedHealthcare Commercial	$21.34
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.57
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

PELVIC STRAPPING DEVICE

Facility

$301.00

Hospital Charge Code	1817743
Hospital Revenue Code	271
Rate for Payer: Cash Price	$270.90

PELVIC STRAPPING DEVICE

Facility

$301.00

Hospital Charge Code	1817743
Hospital Revenue Code	271
Min. Negotiated Rate	$108.36
Max. Negotiated Rate	$214.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$178.19
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$214.91
Rate for Payer: Cash Price	$270.90
Rate for Payer: UnitedHealthcare Commercial	$200.77
Rate for Payer: UnitedHealthcare Medicare Advantage	$108.36

PELVIC,TRANS VAGINAL

Facility

$799.00

Hospital Charge Code	357089
Hospital Revenue Code	402
Min. Negotiated Rate	$269.00
Max. Negotiated Rate	$570.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$473.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$570.49
Rate for Payer: Cash Price	$719.10
Rate for Payer: Cash Price	$719.10
Rate for Payer: UnitedHealthcare Commercial	$269.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$287.64

PELVIC,TRANS VAGINAL

Facility

$799.00

Hospital Charge Code	357089
Hospital Revenue Code	402
Rate for Payer: Cash Price	$719.10

PELVIS - COMPLETE

Facility

$193.00

Service Code	CPT 72190
Hospital Charge Code	3272190
Hospital Revenue Code	320
Min. Negotiated Rate	$69.48
Max. Negotiated Rate	$213.62
Rate for Payer: Aetna Better Health Medicaid/QHP	$94.24
Rate for Payer: Aetna Medicare Advantage	$106.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$114.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$137.80
Rate for Payer: Cash Price	$173.70
Rate for Payer: Cash Price	$173.70
Rate for Payer: Cash Price	$173.70
Rate for Payer: Cigna Commercial HMO & PPO	$106.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$94.24
Rate for Payer: Home State Health Plan Medicaid Managed Care	$100.84
Rate for Payer: Home State Health Plan Medicare Advantage	$106.81
Rate for Payer: Humana Commercial	$213.62
Rate for Payer: Humana Medicare Advantage	$106.81
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$94.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$69.48

PELVIS - COMPLETE

Facility

$193.00

Service Code	CPT 72190
Hospital Charge Code	3272190
Hospital Revenue Code	320
Rate for Payer: Cash Price	$173.70

PELVIS EXAM

Facility

$63.00

Hospital Charge Code	2815360
Hospital Revenue Code	271
Rate for Payer: Cash Price	$56.70

PELVIS EXAM

Facility

$63.00

Hospital Charge Code	2815360
Hospital Revenue Code	271
Min. Negotiated Rate	$22.68
Max. Negotiated Rate	$44.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$37.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$44.98
Rate for Payer: Cash Price	$56.70
Rate for Payer: UnitedHealthcare Commercial	$42.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$22.68

PELVIS X-RAY

Facility

$465.00

Service Code	CPT 72170
Hospital Charge Code	3216114
Hospital Revenue Code	320
Rate for Payer: Cash Price	$418.50

PELVIS X-RAY

Facility

$465.00

Service Code	CPT 72170
Hospital Charge Code	3216114
Hospital Revenue Code	320
Min. Negotiated Rate	$94.24
Max. Negotiated Rate	$332.01
Rate for Payer: Aetna Better Health Medicaid/QHP	$94.24
Rate for Payer: Aetna Medicare Advantage	$106.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$275.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$332.01
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cigna Commercial HMO & PPO	$106.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$94.24
Rate for Payer: Home State Health Plan Medicaid Managed Care	$100.84
Rate for Payer: Home State Health Plan Medicare Advantage	$106.81
Rate for Payer: Humana Commercial	$213.62
Rate for Payer: Humana Medicare Advantage	$106.81
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$94.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$167.40

PENICIL G BEN LA 600 KU INJ PEDIATRIC

Facility

$576.00

Service Code	HCPCS J0561
Hospital Charge Code	2626389
Hospital Revenue Code	250
Min. Negotiated Rate	$32.59
Max. Negotiated Rate	$411.26
Rate for Payer: Aetna Medicare Advantage	$32.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$340.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$411.26
Rate for Payer: Cash Price	$518.40
Rate for Payer: Cash Price	$518.40
Rate for Payer: Cigna Commercial HMO & PPO	$32.59
Rate for Payer: Home State Health Plan Medicare Advantage	$32.59
Rate for Payer: Humana Commercial	$65.18
Rate for Payer: Humana Medicare Advantage	$32.59
Rate for Payer: UnitedHealthcare Commercial	$384.19
Rate for Payer: UnitedHealthcare Medicare Advantage	$207.36

Know your out-of-pocket cost for care.

All Charges