Madison Medical Center

All Charges

Charge

Type

Setting

Price

PROLONGED EVAL AFTER FACE TO FACE 30 MIN

Facility

$150.00

Service Code	CPT 99359
Hospital Charge Code	9899359
Hospital Revenue Code	521
Rate for Payer: Cash Price	$135.00

PROLONGED SERV IN OFFICE OR OTHER SETTIN

Facility

$265.00

Service Code	CPT 99415
Hospital Charge Code	9899354
Hospital Revenue Code	521
Rate for Payer: Cash Price	$238.50

PROLONGED SERV IN OFFICE OR OTHER SETTIN

Facility

$265.00

Service Code	CPT 99415
Hospital Charge Code	9899354
Hospital Revenue Code	521
Min. Negotiated Rate	$156.88
Max. Negotiated Rate	$189.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$156.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$189.21
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cash Price	$238.50
Rate for Payer: UnitedHealthcare Commercial	$176.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

PROMETHAZINE DM COUGH SYRUP EMP

Facility

$21.00

Service Code	NDC 6.0432E+10
Hospital Charge Code	2619881
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

PROMETHAZINE DM COUGH SYRUP EMP

Facility

$21.00

Service Code	NDC 6.0432E+10
Hospital Charge Code	2619881
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

PROMETHAZINE(PHENERGAN)12.5MG SUPP

Facility

$72.00

Service Code	NDC 4.5802E+10
Hospital Charge Code	2626287
Hospital Revenue Code	250
Rate for Payer: Cash Price	$64.80

PROMETHAZINE(PHENERGAN)12.5MG SUPP

Facility

$72.00

Service Code	NDC 4.5802E+10
Hospital Charge Code	2626287
Hospital Revenue Code	250
Min. Negotiated Rate	$25.92
Max. Negotiated Rate	$51.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$42.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$51.41
Rate for Payer: Cash Price	$64.80
Rate for Payer: UnitedHealthcare Commercial	$48.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.92

PROMETHAZINE (PHENERGAN)25MG INJ 1ML

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	2656061
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

PROMETHAZINE (PHENERGAN)25MG INJ 1ML

Facility

$45.00

Service Code	HCPCS J2550
Hospital Charge Code	2656061
Hospital Revenue Code	250
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

PROMETHAZINE (PHENERGAN) 25MG TAB

Facility

$20.00

Service Code	NDC 6.5162E+10
Hospital Charge Code	2626328
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$11.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.28
Rate for Payer: Cash Price	$18.00
Rate for Payer: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

PROMETHAZINE (PHENERGAN) 25MG TAB

Facility

$20.00

Service Code	NDC 6.5162E+10
Hospital Charge Code	2626328
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

PROMETHAZINE (PHENERGAN) 50MG INJ 1ML

Facility

$60.00

Service Code	HCPCS J2550
Hospital Charge Code	2656060
Hospital Revenue Code	250
Rate for Payer: Cash Price	$54.00

PROMETHAZINE (PHENERGAN) 50MG INJ 1ML

Facility

$60.00

Service Code	HCPCS J2550
Hospital Charge Code	2656060
Hospital Revenue Code	250
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

PROMETH/COD 6.25/10MG SYP 10ML C5

Facility

$21.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2656071
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

PROMETH/COD 6.25/10MG SYP 10ML C5

Facility

$21.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2656071
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

PROPEPTIDE TYPE 1 COLLAGEN

Facility

$568.00

Service Code	CPT 82523
Hospital Charge Code	2282524
Hospital Revenue Code	301
Rate for Payer: Cash Price	$511.20

PROPEPTIDE TYPE 1 COLLAGEN

Facility

$568.00

Service Code	CPT 82523
Hospital Charge Code	2282524
Hospital Revenue Code	301
Min. Negotiated Rate	$16.81
Max. Negotiated Rate	$405.55
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.81
Rate for Payer: Aetna Medicare Advantage	$18.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$336.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$405.55
Rate for Payer: Cash Price	$511.20
Rate for Payer: Cash Price	$511.20
Rate for Payer: Cash Price	$511.20
Rate for Payer: Cigna Commercial HMO & PPO	$18.68
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.99
Rate for Payer: Home State Health Plan Medicare Advantage	$18.68
Rate for Payer: Humana Commercial	$37.36
Rate for Payer: Humana Medicare Advantage	$18.68
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$204.48

PROPOFOL 10MG/ML 10ML (SURGERY)

Facility

$43.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2623996
Hospital Revenue Code	250
Rate for Payer: Cash Price	$38.70

PROPOFOL 10MG/ML 10ML (SURGERY)

Facility

$43.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2623996
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

PROPOFOL 10MG/ML 20ML (SURGERY)

Facility

$43.00

Service Code	NDC 8290305200
Hospital Charge Code	2620869
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

PROPOFOL 10MG/ML 20ML (SURGERY)

Facility

$43.00

Service Code	NDC 8290305200
Hospital Charge Code	2620869
Hospital Revenue Code	250
Rate for Payer: Cash Price	$38.70

PROPOFOL 200MG 20ML VIAL

Facility

$171.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2058003
Hospital Revenue Code	370
Min. Negotiated Rate	$61.56
Max. Negotiated Rate	$122.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$101.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$122.09
Rate for Payer: Cash Price	$153.90
Rate for Payer: UnitedHealthcare Commercial	$114.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$61.56

PROPOFOL 200MG 20ML VIAL

Facility

$171.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2058003
Hospital Revenue Code	370
Rate for Payer: Cash Price	$153.90

PROPOXYPHENE

Facility

$236.00

Service Code	CPT 80367
Hospital Charge Code	2282206
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$168.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$139.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$168.50
Rate for Payer: Cash Price	$212.40
Rate for Payer: Cash Price	$212.40
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$84.96

PROPOXYPHENE

Facility

$236.00

Service Code	CPT 80367
Hospital Charge Code	2282206
Hospital Revenue Code	305
Rate for Payer: Cash Price	$212.40

Know your out-of-pocket cost for care.

All Charges