Madison Medical Center

All Charges

Charge

Type

Setting

Price

STERILE GLOVE SZ 6

Facility

$10.00

Hospital Charge Code	2819030
Hospital Revenue Code	272
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

STERILE GLOVE SZ 6

Facility

$10.00

Hospital Charge Code	2819030
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.00

STERILE GLOVE SZ 7

Facility

$10.00

Hospital Charge Code	2819031
Hospital Revenue Code	272
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

STERILE GLOVE SZ 7

Facility

$10.00

Hospital Charge Code	2819031
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.00

STERILE GLOVE SZ 7-1/2

Facility

$22.00

Hospital Charge Code	2698386
Hospital Revenue Code	272
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

STERILE GLOVE SZ 7-1/2

Facility

$10.00

Hospital Charge Code	287271
Hospital Revenue Code	272
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

STERILE GLOVE SZ 7-1/2

Facility

$22.00

Hospital Charge Code	2698386
Hospital Revenue Code	272
Rate for Payer: Cash Price	$19.80

STERILE GLOVE SZ 7-1/2

Facility

$10.00

Hospital Charge Code	287271
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.00

STERILE GLOVE SZ 8

Facility

$10.00

Hospital Charge Code	2819032
Hospital Revenue Code	272
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

STERILE GLOVE SZ 8

Facility

$10.00

Hospital Charge Code	2819032
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.00

STERILE GLOVE SZ 8-1/2

Facility

$10.00

Hospital Charge Code	2819065
Hospital Revenue Code	272
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

STERILE GLOVE SZ 8-1/2

Facility

$10.00

Hospital Charge Code	2819065
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.00

STERILE GLOVE SZ 9

Facility

$10.00

Hospital Charge Code	2819034
Hospital Revenue Code	272
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

STERILE GLOVE SZ 9

Facility

$10.00

Hospital Charge Code	2819034
Hospital Revenue Code	272
Rate for Payer: Cash Price	$9.00

STERILE INST EA

Facility

$16.00

Hospital Charge Code	2819300
Hospital Revenue Code	271
Rate for Payer: Cash Price	$14.40

STERILE INST EA

Facility

$16.00

Hospital Charge Code	2819300
Hospital Revenue Code	271
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

STERILE VIAL 10ML

Facility

$35.00

Service Code	NDC 1E+11
Hospital Charge Code	2698389
Hospital Revenue Code	272
Rate for Payer: Cash Price	$31.50

STERILE VIAL 10ML

Facility

$35.00

Service Code	NDC 1E+11
Hospital Charge Code	2698389
Hospital Revenue Code	272
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

STERILE WATER FOR INJECTION 10ML (SWFI)

Facility

$58.00

Service Code	HCPCS A4216
Hospital Charge Code	2626363
Hospital Revenue Code	250
Rate for Payer: Cash Price	$52.20

STERILE WATER FOR INJECTION 10ML (SWFI)

Facility

$58.00

Service Code	HCPCS A4216
Hospital Charge Code	2626363
Hospital Revenue Code	250
Min. Negotiated Rate	$20.88
Max. Negotiated Rate	$41.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$34.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$41.41
Rate for Payer: Cash Price	$52.20
Rate for Payer: UnitedHealthcare Commercial	$38.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.88

STERILE WATER FOR INJECTION 50ML (SWFI)

Facility

$35.00

Service Code	HCPCS A4216
Hospital Charge Code	2621454
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

STERILE WATER FOR INJECTION 50ML (SWFI)

Facility

$35.00

Service Code	HCPCS A4216
Hospital Charge Code	2621454
Hospital Revenue Code	250
Rate for Payer: Cash Price	$31.50

STERILE WATER INJECTION

Facility

$58.00

Hospital Charge Code	260279
Hospital Revenue Code	370
Min. Negotiated Rate	$20.88
Max. Negotiated Rate	$41.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$34.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$41.41
Rate for Payer: Cash Price	$52.20
Rate for Payer: UnitedHealthcare Commercial	$38.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.88

STERILE WATER INJECTION

Facility

$58.00

Hospital Charge Code	260279
Hospital Revenue Code	370
Rate for Payer: Cash Price	$52.20

STERI STRIP 1/2 X 4

Facility

$55.00

Hospital Charge Code	2819293
Hospital Revenue Code	271
Rate for Payer: Cash Price	$49.50

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All Charges