Madison Medical Center

All Charges

Charge

Type

Setting

Price

RIVAROXABAN (XARELTO) 10MG TAB

Facility

$70.00

Service Code	NDC 5.0458E+10
Hospital Charge Code	2626560
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

RIVAROXABAN (XARELTO) 10MG TAB

Facility

$70.00

Service Code	NDC 5.0458E+10
Hospital Charge Code	2626560
Hospital Revenue Code	250
Rate for Payer: Cash Price	$63.00

RIVAROXABAN (XARELTO) 10MG TAB EMP

Facility

$70.00

Service Code	NDC 5.0458E+10
Hospital Charge Code	2622744
Hospital Revenue Code	250
Rate for Payer: Cash Price	$63.00

RIVAROXABAN (XARELTO) 10MG TAB EMP

Facility

$70.00

Service Code	NDC 5.0458E+10
Hospital Charge Code	2622744
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

RIVAROXABAN (XARELTO) 20MG TAB EMP

Facility

$498.00

Service Code	NDC 5.0458E+10
Hospital Charge Code	2697339
Hospital Revenue Code	250
Rate for Payer: Cash Price	$448.20

RIVAROXABAN (XARELTO) 20MG TAB EMP

Facility

$498.00

Service Code	NDC 5.0458E+10
Hospital Charge Code	2697339
Hospital Revenue Code	250
Min. Negotiated Rate	$179.28
Max. Negotiated Rate	$355.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$294.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$355.57
Rate for Payer: Cash Price	$448.20
Rate for Payer: UnitedHealthcare Commercial	$332.17
Rate for Payer: UnitedHealthcare Medicare Advantage	$179.28

RIZATRIPTAN BENZ 10MG ODT EMP

Facility

$127.00

Service Code	HCPCS Q0162
Hospital Charge Code	2623726
Hospital Revenue Code	250
Min. Negotiated Rate	$45.72
Max. Negotiated Rate	$90.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$75.18
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$90.68
Rate for Payer: Cash Price	$114.30
Rate for Payer: UnitedHealthcare Commercial	$84.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.72

RIZATRIPTAN BENZ 10MG ODT EMP

Facility

$127.00

Service Code	HCPCS Q0162
Hospital Charge Code	2623726
Hospital Revenue Code	250
Rate for Payer: Cash Price	$114.30

RIZATRIPTAN BENZ 10MG TAB EMP

Facility

$127.00

Service Code	HCPCS Q0162
Hospital Charge Code	2624059
Hospital Revenue Code	250
Min. Negotiated Rate	$45.72
Max. Negotiated Rate	$90.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$75.18
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$90.68
Rate for Payer: Cash Price	$114.30
Rate for Payer: UnitedHealthcare Commercial	$84.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.72

RIZATRIPTAN BENZ 10MG TAB EMP

Facility

$127.00

Service Code	HCPCS Q0162
Hospital Charge Code	2624059
Hospital Revenue Code	250
Rate for Payer: Cash Price	$114.30

RIZATRIPTAN BENZ 5 MG TAB EMP

Facility

$127.00

Service Code	HCPCS Q0162
Hospital Charge Code	2623774
Hospital Revenue Code	250
Rate for Payer: Cash Price	$114.30

RIZATRIPTAN BENZ 5 MG TAB EMP

Facility

$127.00

Service Code	HCPCS Q0162
Hospital Charge Code	2623774
Hospital Revenue Code	250
Min. Negotiated Rate	$45.72
Max. Negotiated Rate	$90.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$75.18
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$90.68
Rate for Payer: Cash Price	$114.30
Rate for Payer: UnitedHealthcare Commercial	$84.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.72

R.K. EPI. NEEDLE

Facility

$96.00

Hospital Charge Code	2824479
Hospital Revenue Code	270
Min. Negotiated Rate	$34.56
Max. Negotiated Rate	$68.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$56.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$68.54
Rate for Payer: Cash Price	$86.40
Rate for Payer: UnitedHealthcare Commercial	$64.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$34.56

R.K. EPI. NEEDLE

Facility

$96.00

Hospital Charge Code	2824479
Hospital Revenue Code	270
Rate for Payer: Cash Price	$86.40

RMSF ANTIBODY IGG

Facility

$75.00

Service Code	CPT 86757
Hospital Charge Code	221010
Hospital Revenue Code	302
Min. Negotiated Rate	$17.42
Max. Negotiated Rate	$53.55
Rate for Payer: Aetna Better Health Medicaid/QHP	$17.42
Rate for Payer: Aetna Medicare Advantage	$19.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$53.55
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial HMO & PPO	$19.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$17.42
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18.64
Rate for Payer: Home State Health Plan Medicare Advantage	$19.35
Rate for Payer: Humana Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$19.35
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

RMSF ANTIBODY IGG

Facility

$75.00

Service Code	CPT 86757
Hospital Charge Code	221010
Hospital Revenue Code	302
Rate for Payer: Cash Price	$67.50

RMSF ANTIBODY IGM

Facility

$75.00

Service Code	CPT 86757
Hospital Charge Code	221102
Hospital Revenue Code	302
Min. Negotiated Rate	$17.42
Max. Negotiated Rate	$53.55
Rate for Payer: Aetna Better Health Medicaid/QHP	$17.42
Rate for Payer: Aetna Medicare Advantage	$19.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$53.55
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial HMO & PPO	$19.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$17.42
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18.64
Rate for Payer: Home State Health Plan Medicare Advantage	$19.35
Rate for Payer: Humana Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$19.35
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

RMSF ANTIBODY IGM

Facility

$75.00

Service Code	CPT 86757
Hospital Charge Code	221102
Hospital Revenue Code	302
Rate for Payer: Cash Price	$67.50

.RMSF IGG

Facility

$113.00

Service Code	CPT 86757
Hospital Charge Code	2219200
Hospital Revenue Code	302
Rate for Payer: Cash Price	$101.70

.RMSF IGG

Facility

$113.00

Service Code	CPT 86757
Hospital Charge Code	2219200
Hospital Revenue Code	302
Min. Negotiated Rate	$17.42
Max. Negotiated Rate	$80.68
Rate for Payer: Aetna Better Health Medicaid/QHP	$17.42
Rate for Payer: Aetna Medicare Advantage	$19.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$66.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$80.68
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial HMO & PPO	$19.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$17.42
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18.64
Rate for Payer: Home State Health Plan Medicare Advantage	$19.35
Rate for Payer: Humana Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$19.35
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.68

..RMSF IGG AEL

Facility

$113.00

Service Code	CPT 86757
Hospital Charge Code	2219204
Hospital Revenue Code	302
Min. Negotiated Rate	$17.42
Max. Negotiated Rate	$80.68
Rate for Payer: Aetna Better Health Medicaid/QHP	$17.42
Rate for Payer: Aetna Medicare Advantage	$19.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$66.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$80.68
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial HMO & PPO	$19.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$17.42
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18.64
Rate for Payer: Home State Health Plan Medicare Advantage	$19.35
Rate for Payer: Humana Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$19.35
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.68

..RMSF IGG AEL

Facility

$113.00

Service Code	CPT 86757
Hospital Charge Code	2219204
Hospital Revenue Code	302
Rate for Payer: Cash Price	$101.70

.RMSF IGG, IFA CONFIRMATORY TEST

Facility

$108.00

Service Code	CPT 86757
Hospital Charge Code	2219203
Hospital Revenue Code	302
Rate for Payer: Cash Price	$97.20

.RMSF IGG, IFA CONFIRMATORY TEST

Facility

$108.00

Service Code	CPT 86757
Hospital Charge Code	2219203
Hospital Revenue Code	302
Min. Negotiated Rate	$17.42
Max. Negotiated Rate	$77.11
Rate for Payer: Aetna Better Health Medicaid/QHP	$17.42
Rate for Payer: Aetna Medicare Advantage	$19.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$63.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$77.11
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cigna Commercial HMO & PPO	$19.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$17.42
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18.64
Rate for Payer: Home State Health Plan Medicare Advantage	$19.35
Rate for Payer: Humana Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$19.35
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.88

.RMSF IGM

Facility

$113.00

Service Code	CPT 86757
Hospital Charge Code	2219201
Hospital Revenue Code	302
Min. Negotiated Rate	$17.42
Max. Negotiated Rate	$80.68
Rate for Payer: Aetna Better Health Medicaid/QHP	$17.42
Rate for Payer: Aetna Medicare Advantage	$19.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$66.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$80.68
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial HMO & PPO	$19.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$17.42
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18.64
Rate for Payer: Home State Health Plan Medicare Advantage	$19.35
Rate for Payer: Humana Commercial	$38.70
Rate for Payer: Humana Medicare Advantage	$19.35
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.68

Know your out-of-pocket cost for care.

All Charges