Madison Medical Center

All Charges

Charge

Type

Setting

Price

POTASSIUM PHOS 45MM/66MEQ 15ML INJ

Facility

$56.00

Service Code	NDC 469860030
Hospital Charge Code	2655980
Hospital Revenue Code	250
Rate for Payer: Cash Price	$50.40

POTASSIUM PHOS 45MM/66MEQ 15ML INJ

Facility

$56.00

Service Code	NDC 469860030
Hospital Charge Code	2655980
Hospital Revenue Code	250
Min. Negotiated Rate	$20.16
Max. Negotiated Rate	$39.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$33.15
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.98
Rate for Payer: Cash Price	$50.40
Rate for Payer: UnitedHealthcare Commercial	$37.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.16

POTASSIUM STOOL

Facility

$110.00

Service Code	CPT 84311
Hospital Charge Code	2284311
Hospital Revenue Code	301
Rate for Payer: Cash Price	$99.00

POTASSIUM STOOL

Facility

$110.00

Service Code	CPT 84311
Hospital Charge Code	2284311
Hospital Revenue Code	301
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$78.54
Rate for Payer: Aetna Better Health Medicaid/QHP	$7.29
Rate for Payer: Aetna Medicare Advantage	$8.10
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: Cash Price	$99.00
Rate for Payer: Cigna Commercial HMO & PPO	$8.10
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$7.29
Rate for Payer: Home State Health Plan Medicaid Managed Care	$7.80
Rate for Payer: Home State Health Plan Medicare Advantage	$8.10
Rate for Payer: Humana Commercial	$16.20
Rate for Payer: Humana Medicare Advantage	$8.10
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$7.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.60

POTASSIUM URINE RANDOM

Facility

$32.00

Service Code	CPT 84133
Hospital Charge Code	2221210
Hospital Revenue Code	307
Min. Negotiated Rate	$4.26
Max. Negotiated Rate	$22.85
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.26
Rate for Payer: Aetna Medicare Advantage	$4.73
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: Cigna Commercial HMO & PPO	$4.73
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.26
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4.56
Rate for Payer: Home State Health Plan Medicare Advantage	$4.73
Rate for Payer: Humana Commercial	$9.46
Rate for Payer: Humana Medicare Advantage	$4.73
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.26
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.52

POTASSIUM URINE RANDOM

Facility

$32.00

Service Code	CPT 84133
Hospital Charge Code	2221210
Hospital Revenue Code	307
Rate for Payer: Cash Price	$28.80

POUCH, DRAINABLE STOMA

Facility

$10.00

Hospital Charge Code	2819406
Hospital Revenue Code	271
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$7.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$5.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$7.14
Rate for Payer: Cash Price	$9.00
Rate for Payer: UnitedHealthcare Commercial	$6.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.60

POUCH, DRAINABLE STOMA

Facility

$10.00

Hospital Charge Code	2819406
Hospital Revenue Code	271
Rate for Payer: Cash Price	$9.00

POUCH, ONE PIECE DRAINABLE 1 1/2 #022770

Facility

$12.00

Hospital Charge Code	80000355
Hospital Revenue Code	271
Rate for Payer: Cash Price	$10.80

POUCH, ONE PIECE DRAINABLE 1 1/2 #022770

Facility

$12.00

Hospital Charge Code	80000355
Hospital Revenue Code	271
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$8.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$8.57
Rate for Payer: Cash Price	$10.80
Rate for Payer: UnitedHealthcare Commercial	$8.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.32

POUCH,OSTOMY

Facility

$45.00

Hospital Charge Code	288392
Hospital Revenue Code	271
Rate for Payer: Cash Price	$40.50

POUCH,OSTOMY

Facility

$45.00

Hospital Charge Code	288392
Hospital Revenue Code	271
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.13
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

PPN AA/ELEC/GLY (PROCALAMI) 1000ML

Facility

$214.00

Service Code	NDC 264191507
Hospital Charge Code	2626486
Hospital Revenue Code	250
Rate for Payer: Cash Price	$192.60

PPN AA/ELEC/GLY (PROCALAMI) 1000ML

Facility

$214.00

Service Code	NDC 264191507
Hospital Charge Code	2626486
Hospital Revenue Code	250
Min. Negotiated Rate	$77.04
Max. Negotiated Rate	$152.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$126.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$152.80
Rate for Payer: Cash Price	$192.60
Rate for Payer: UnitedHealthcare Commercial	$142.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$77.04

PRAMIPEXOLE (MIRAPEX) 0.125MG TAB EMP

Facility

$25.00

Service Code	NDC 6.8382E+10
Hospital Charge Code	2622515
Hospital Revenue Code	250
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

PRAMIPEXOLE (MIRAPEX) 0.125MG TAB EMP

Facility

$25.00

Service Code	NDC 6.8382E+10
Hospital Charge Code	2622515
Hospital Revenue Code	250
Rate for Payer: Cash Price	$22.50

PRAMIPEXOLE (MIRAPEX) 0.25MG TAB

Facility

$25.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2626479
Hospital Revenue Code	250
Rate for Payer: Cash Price	$22.50

PRAMIPEXOLE (MIRAPEX) 0.25MG TAB

Facility

$25.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2626479
Hospital Revenue Code	250
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

PRAMIPEXOLE (MIRAPEX) 0.25MG TAB EMP

Facility

$25.00

Service Code	NDC 6.8382E+10
Hospital Charge Code	2622504
Hospital Revenue Code	250
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

PRAMIPEXOLE (MIRAPEX) 0.25MG TAB EMP

Facility

$25.00

Service Code	NDC 6.8382E+10
Hospital Charge Code	2622504
Hospital Revenue Code	250
Rate for Payer: Cash Price	$22.50

PRAMIPEXOLE (MIRAPEX) 0.5MG TAB EMP

Facility

$28.00

Service Code	NDC 6.8462E+10
Hospital Charge Code	2623378
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

PRAMIPEXOLE (MIRAPEX) 0.5MG TAB EMP

Facility

$28.00

Service Code	NDC 6.8462E+10
Hospital Charge Code	2623378
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.20

PRAMIPEXOLE (MIRAPEX) 0.75MG TAB EMP

Facility

$28.00

Service Code	NDC 5.7237E+10
Hospital Charge Code	2624890
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

PRAMIPEXOLE (MIRAPEX) 0.75MG TAB EMP

Facility

$28.00

Service Code	NDC 5.7237E+10
Hospital Charge Code	2624890
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.20

PRAMIPEXOLE (MIRAPEX) 1MG TAB EMP

Facility

$28.00

Service Code	NDC 555061414
Hospital Charge Code	2626500
Hospital Revenue Code	250
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

Know your out-of-pocket cost for care.

All Charges