Madison Medical Center

All Charges

Charge

Type

Setting

Price

POISONING OF MEDICINAL AGENTS

Facility

$5,932.07

Service Code	APR-DRG 8122
Min. Negotiated Rate	$5,932.07
Max. Negotiated Rate	$5,932.07
Rate for Payer: Aetna Better Health Medicaid/QHP	$5,932.07
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5,932.07
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5,932.07
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5,932.07

POISONING OF MEDICINAL AGENTS

Facility

$22,841.72

Service Code	APR-DRG 8124
Min. Negotiated Rate	$22,841.72
Max. Negotiated Rate	$22,841.72
Rate for Payer: Aetna Better Health Medicaid/QHP	$22,841.72
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$22,841.72
Rate for Payer: Home State Health Plan Medicaid Managed Care	$22,841.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$22,841.72

POLYAXIAL LOCKING PLATE LATERAL COL 10MM

Facility

$3,831.00

Hospital Charge Code	123413
Hospital Revenue Code	271
Rate for Payer: Cash Price	$3,447.90

POLYAXIAL LOCKING PLATE LATERAL COL 10MM

Facility

$3,831.00

Hospital Charge Code	123413
Hospital Revenue Code	271
Min. Negotiated Rate	$1,379.16
Max. Negotiated Rate	$2,735.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$2,267.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,735.33
Rate for Payer: Cash Price	$3,447.90
Rate for Payer: UnitedHealthcare Commercial	$2,555.28
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,379.16

POLYAXIAL LOCKING PLATE MID(STRYKER)

Facility

$5,154.00

Hospital Charge Code	123406
Hospital Revenue Code	271
Min. Negotiated Rate	$1,855.44
Max. Negotiated Rate	$3,679.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$3,051.17
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$3,679.96
Rate for Payer: Cash Price	$4,638.60
Rate for Payer: UnitedHealthcare Commercial	$3,437.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,855.44

POLYAXIAL LOCKING PLATE MID(STRYKER)

Facility

$5,154.00

Hospital Charge Code	123406
Hospital Revenue Code	271
Rate for Payer: Cash Price	$4,638.60

POLYAXIAL LOCK PLATE NAVICULAR CUNEIF

Facility

$3,644.00

Hospital Charge Code	123412
Hospital Revenue Code	271
Rate for Payer: Cash Price	$3,279.60

POLYAXIAL LOCK PLATE NAVICULAR CUNEIF

Facility

$3,644.00

Hospital Charge Code	123412
Hospital Revenue Code	271
Min. Negotiated Rate	$1,311.84
Max. Negotiated Rate	$2,601.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$2,157.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,601.82
Rate for Payer: Cash Price	$3,279.60
Rate for Payer: UnitedHealthcare Commercial	$2,430.55
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,311.84

POLY-IRON (FERREX) 150MG CAP

Facility

$35.00

Service Code	NDC 9044539561
Hospital Charge Code	2626386
Hospital Revenue Code	250
Rate for Payer: Cash Price	$31.50

POLY-IRON (FERREX) 150MG CAP

Facility

$35.00

Service Code	NDC 9044539561
Hospital Charge Code	2626386
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$24.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24.99
Rate for Payer: Cash Price	$31.50
Rate for Payer: UnitedHealthcare Commercial	$23.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.60

POLYMEM MAX SILVER 4X4 DRESSING

Facility

$34.00

Hospital Charge Code	281045
Hospital Revenue Code	271
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$24.28
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: UnitedHealthcare Commercial	$22.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.24

POLYMEM MAX SILVER 4X4 DRESSING

Facility

$34.00

Hospital Charge Code	281045
Hospital Revenue Code	271
Rate for Payer: Cash Price	$30.60

POLYMEM, NON-ADHESIVE, DRESSING 4X4

Facility

$25.00

Hospital Charge Code	284838
Hospital Revenue Code	271
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$17.85
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: UnitedHealthcare Commercial	$16.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$9.00

POLYMEM, NON-ADHESIVE, DRESSING 4X4

Facility

$25.00

Hospital Charge Code	284838
Hospital Revenue Code	271
Rate for Payer: Cash Price	$22.50

POLYMIX/BAC (POLYSPORIN) OP OINT 3.5GM

Facility

$124.00

Service Code	NDC 2.4208E+10
Hospital Charge Code	2655948
Hospital Revenue Code	250
Min. Negotiated Rate	$44.64
Max. Negotiated Rate	$88.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$73.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$88.54
Rate for Payer: Cash Price	$111.60
Rate for Payer: UnitedHealthcare Commercial	$82.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$44.64

POLYMIX/BAC (POLYSPORIN) OP OINT 3.5GM

Facility

$124.00

Service Code	NDC 2.4208E+10
Hospital Charge Code	2655948
Hospital Revenue Code	250
Rate for Payer: Cash Price	$111.60

POLYMYX B /TRIMETH OP SOL 10ML

Facility

$55.00

Service Code	NDC 6.0758E+10
Hospital Charge Code	2697082
Hospital Revenue Code	250
Rate for Payer: Cash Price	$49.50

POLYMYX B /TRIMETH OP SOL 10ML

Facility

$55.00

Service Code	NDC 6.0758E+10
Hospital Charge Code	2697082
Hospital Revenue Code	250
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

POLYMYX B /TRIMETH OP SOL 10ML EMP

Facility

$55.00

Service Code	NDC 6.0758E+10
Hospital Charge Code	2624434
Hospital Revenue Code	250
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

POLYMYX B /TRIMETH OP SOL 10ML EMP

Facility

$55.00

Service Code	NDC 6.0758E+10
Hospital Charge Code	2624434
Hospital Revenue Code	250
Rate for Payer: Cash Price	$49.50

POLYSPORIN POWDER 10GM

Facility

$124.00

Hospital Charge Code	2655946
Hospital Revenue Code	250
Rate for Payer: Cash Price	$111.60

POLYSPORIN POWDER 10GM

Facility

$124.00

Hospital Charge Code	2655946
Hospital Revenue Code	250
Min. Negotiated Rate	$44.64
Max. Negotiated Rate	$88.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$73.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$88.54
Rate for Payer: Cash Price	$111.60
Rate for Payer: UnitedHealthcare Commercial	$82.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$44.64

PORPHOBILINOGEN DEAMINASE (PBGD)

Facility

$401.00

Service Code	CPT 82657
Hospital Charge Code	222493
Hospital Revenue Code	307
Rate for Payer: Cash Price	$360.90

PORPHOBILINOGEN DEAMINASE (PBGD)

Facility

$401.00

Service Code	CPT 82657
Hospital Charge Code	222493
Hospital Revenue Code	307
Min. Negotiated Rate	$19.95
Max. Negotiated Rate	$286.31
Rate for Payer: Aetna Better Health Medicaid/QHP	$19.95
Rate for Payer: Aetna Medicare Advantage	$22.17
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$237.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$286.31
Rate for Payer: Cash Price	$360.90
Rate for Payer: Cash Price	$360.90
Rate for Payer: Cash Price	$360.90
Rate for Payer: Cigna Commercial HMO & PPO	$22.17
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$19.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$21.35
Rate for Payer: Home State Health Plan Medicare Advantage	$22.17
Rate for Payer: Humana Commercial	$44.34
Rate for Payer: Humana Medicare Advantage	$22.17
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$19.95
Rate for Payer: UnitedHealthcare Medicare Advantage	$144.36

PORPHOBILINOGEN URINE 24 HOUR

Facility

$153.00

Service Code	CPT 84110
Hospital Charge Code	223177
Hospital Revenue Code	301
Min. Negotiated Rate	$7.60
Max. Negotiated Rate	$109.24
Rate for Payer: Aetna Better Health Medicaid/QHP	$7.60
Rate for Payer: Aetna Medicare Advantage	$8.44
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: Cash Price	$137.70
Rate for Payer: Cash Price	$137.70
Rate for Payer: Cigna Commercial HMO & PPO	$8.44
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$7.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8.13
Rate for Payer: Home State Health Plan Medicare Advantage	$8.44
Rate for Payer: Humana Commercial	$16.88
Rate for Payer: Humana Medicare Advantage	$8.44
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$7.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$55.08

Know your out-of-pocket cost for care.

All Charges