Madison Medical Center

All Charges

Charge

Type

Setting

Price

SULFACETAMIDE 10% OP SOL 15ML

Facility

$196.00

Service Code	NDC 2.4208E+10
Hospital Charge Code	2626289
Hospital Revenue Code	250
Min. Negotiated Rate	$70.56
Max. Negotiated Rate	$139.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$116.03
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$139.94
Rate for Payer: Cash Price	$176.40
Rate for Payer: UnitedHealthcare Commercial	$130.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$70.56

SULFASALAZINE 500MG TAB EMP

Facility

$16.00

Service Code	NDC 5.9763E+10
Hospital Charge Code	2626504
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

SULFASALAZINE 500MG TAB EMP

Facility

$16.00

Service Code	NDC 5.9763E+10
Hospital Charge Code	2626504
Hospital Revenue Code	250
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

SULFATE

Facility

$147.00

Service Code	CPT 84392
Hospital Charge Code	2284392
Hospital Revenue Code	307
Rate for Payer: Cash Price	$132.30

SULFATE

Facility

$147.00

Service Code	CPT 84392
Hospital Charge Code	2284392
Hospital Revenue Code	307
Min. Negotiated Rate	$4.94
Max. Negotiated Rate	$104.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.94
Rate for Payer: Aetna Medicare Advantage	$5.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$87.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$104.96
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cigna Commercial HMO & PPO	$5.49
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.29
Rate for Payer: Home State Health Plan Medicare Advantage	$5.49
Rate for Payer: Humana Commercial	$10.98
Rate for Payer: Humana Medicare Advantage	$5.49
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$52.92

SULFATIDE Ab,IgG

Facility

$496.00

Service Code	CPT 83520
Hospital Charge Code	223520
Hospital Revenue Code	302
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$354.14
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.54
Rate for Payer: Aetna Medicare Advantage	$17.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$293.63
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$354.14
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cigna Commercial HMO & PPO	$17.27
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.54
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.63
Rate for Payer: Home State Health Plan Medicare Advantage	$17.27
Rate for Payer: Humana Commercial	$34.54
Rate for Payer: Humana Medicare Advantage	$17.27
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.54
Rate for Payer: UnitedHealthcare Medicare Advantage	$178.56

SULFATIDE Ab,IgG

Facility

$496.00

Service Code	CPT 83520
Hospital Charge Code	223520
Hospital Revenue Code	302
Rate for Payer: Cash Price	$446.40

SULFATIDE Ab,IgM

Facility

$496.00

Service Code	CPT 83520
Hospital Charge Code	228352
Hospital Revenue Code	302
Rate for Payer: Cash Price	$446.40

SULFATIDE Ab,IgM

Facility

$496.00

Service Code	CPT 83520
Hospital Charge Code	228352
Hospital Revenue Code	302
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$354.14
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.54
Rate for Payer: Aetna Medicare Advantage	$17.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$293.63
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$354.14
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cigna Commercial HMO & PPO	$17.27
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.54
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.63
Rate for Payer: Home State Health Plan Medicare Advantage	$17.27
Rate for Payer: Humana Commercial	$34.54
Rate for Payer: Humana Medicare Advantage	$17.27
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.54
Rate for Payer: UnitedHealthcare Medicare Advantage	$178.56

SULFA / TRIMETH 200/40 ORAL SUSP 5ML

Facility

$44.00

Service Code	NDC 5.7237E+10
Hospital Charge Code	2656486
Hospital Revenue Code	250
Rate for Payer: Cash Price	$39.60

SULFA / TRIMETH 200/40 ORAL SUSP 5ML

Facility

$44.00

Service Code	NDC 5.7237E+10
Hospital Charge Code	2656486
Hospital Revenue Code	250
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$31.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$31.42
Rate for Payer: Cash Price	$39.60
Rate for Payer: UnitedHealthcare Commercial	$29.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.84

SULFA / TRIMETH 200/40 ORAL SUSP EMP

Facility

$44.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2624190
Hospital Revenue Code	250
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$31.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$31.42
Rate for Payer: Cash Price	$39.60
Rate for Payer: UnitedHealthcare Commercial	$29.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.84

SULFA / TRIMETH 200/40 ORAL SUSP EMP

Facility

$44.00

Service Code	NDC 5.0383E+10
Hospital Charge Code	2624190
Hospital Revenue Code	250
Rate for Payer: Cash Price	$39.60

SULFA / TRIMETH DS 800/160 TAB EMP

Facility

$28.00

Service Code	NDC 5.3489E+10
Hospital Charge Code	2697038
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

SULFA / TRIMETH DS 800/160 TAB EMP

Facility

$28.00

Service Code	NDC 5.3489E+10
Hospital Charge Code	2697038
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.20

SULFA / TRIMETH DS 800/160 U/D TAB

Facility

$28.00

Service Code	NDC 5.7237E+10
Hospital Charge Code	2656485
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

SULFA / TRIMETH DS 800/160 U/D TAB

Facility

$28.00

Service Code	NDC 5.7237E+10
Hospital Charge Code	2656485
Hospital Revenue Code	250
Rate for Payer: Cash Price	$25.20

SULFONYLUREA SCR

Facility

$431.00

Service Code	CPT 80377
Hospital Charge Code	2280377
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$307.73
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$255.15
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$307.73
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cash Price	$387.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$155.16

SULFONYLUREA SCR

Facility

$431.00

Service Code	CPT 80377
Hospital Charge Code	2280377
Hospital Revenue Code	301
Rate for Payer: Cash Price	$387.90

SUMATRIPTAN 100MG TAB EMP

Facility

$147.00

Service Code	NDC 6.3304E+10
Hospital Charge Code	2698253
Hospital Revenue Code	250
Rate for Payer: Cash Price	$132.30

SUMATRIPTAN 100MG TAB EMP

Facility

$147.00

Service Code	NDC 6.3304E+10
Hospital Charge Code	2698253
Hospital Revenue Code	250
Min. Negotiated Rate	$52.92
Max. Negotiated Rate	$104.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$87.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$104.96
Rate for Payer: Cash Price	$132.30
Rate for Payer: UnitedHealthcare Commercial	$98.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$52.92

SUMATRIPTAN 50MG TAB EMP

Facility

$147.00

Service Code	NDC 6.2756E+10
Hospital Charge Code	2624450
Hospital Revenue Code	250
Min. Negotiated Rate	$52.92
Max. Negotiated Rate	$104.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$87.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$104.96
Rate for Payer: Cash Price	$132.30
Rate for Payer: UnitedHealthcare Commercial	$98.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$52.92

SUMATRIPTAN 50MG TAB EMP

Facility

$147.00

Service Code	NDC 6.2756E+10
Hospital Charge Code	2624450
Hospital Revenue Code	250
Rate for Payer: Cash Price	$132.30

SUMATRIPTAN (IMITREX) 25MG TABS

Facility

$147.00

Service Code	NDC 6.3304E+10
Hospital Charge Code	2697261
Hospital Revenue Code	250
Min. Negotiated Rate	$52.92
Max. Negotiated Rate	$104.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$87.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$104.96
Rate for Payer: Cash Price	$132.30
Rate for Payer: UnitedHealthcare Commercial	$98.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$52.92

SUMATRIPTAN (IMITREX) 25MG TABS

Facility

$147.00

Service Code	NDC 6.3304E+10
Hospital Charge Code	2697261
Hospital Revenue Code	250
Rate for Payer: Cash Price	$132.30

Know your out-of-pocket cost for care.

All Charges