Madison Medical Center

All Charges

Charge

Type

Setting

Price

SUTURE VICRYL 3.0, SH #J416H

Facility

$13.00

Hospital Charge Code	2819080
Hospital Revenue Code	272
Rate for Payer: Cash Price	$11.70

SUTURE VICRYL 3.0, SH #J416H

Facility

$13.00

Hospital Charge Code	2819080
Hospital Revenue Code	272
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

SUTURE VICRYL 4.0, PS-2: J496G

Facility

$21.00

Hospital Charge Code	2819042
Hospital Revenue Code	272
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

SUTURE VICRYL 4.0, PS-2: J496G

Facility

$21.00

Hospital Charge Code	2819042
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.90

SUTURE VICRYL 4.0, RB-1: J214H

Facility

$12.00

Hospital Charge Code	2819043
Hospital Revenue Code	272
Rate for Payer: Cash Price	$10.80

SUTURE VICRYL 4.0, RB-1: J214H

Facility

$12.00

Hospital Charge Code	2819043
Hospital Revenue Code	272
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

SUTURE VICRYL 5.0, P-1: J490G

Facility

$21.00

Hospital Charge Code	2819044
Hospital Revenue Code	272
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

SUTURE VICRYL 5.0, P-1: J490G

Facility

$21.00

Hospital Charge Code	2819044
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.90

SWAB GLYCERINE

Facility

$15.00

Hospital Charge Code	2819451
Hospital Revenue Code	271
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$10.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.71
Rate for Payer: Cash Price	$13.50
Rate for Payer: UnitedHealthcare Commercial	$10.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.40

SWAB GLYCERINE

Facility

$15.00

Hospital Charge Code	2819451
Hospital Revenue Code	271
Rate for Payer: Cash Price	$13.50

SYNCOPE AND COLLAPSE

Facility

$17,284.50

Service Code	MSDRG 312
Min. Negotiated Rate	$8,642.25
Max. Negotiated Rate	$17,284.50
Rate for Payer: Aetna Medicare Advantage	$8,642.25
Rate for Payer: Cigna Commercial HMO & PPO	$8,642.25
Rate for Payer: Home State Health Plan Medicare Advantage	$8,642.25
Rate for Payer: Humana Commercial	$17,284.50
Rate for Payer: Humana Medicare Advantage	$8,642.25

SYNCOPE AND COLLAPSE

Facility

$21,022.62

Service Code	APR-DRG 2044
Min. Negotiated Rate	$21,022.62
Max. Negotiated Rate	$21,022.62
Rate for Payer: Aetna Better Health Medicaid/QHP	$21,022.62
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$21,022.62
Rate for Payer: Home State Health Plan Medicaid Managed Care	$21,022.62
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$21,022.62

SYNCOPE AND COLLAPSE

Facility

$11,862.92

Service Code	APR-DRG 2043
Min. Negotiated Rate	$11,862.92
Max. Negotiated Rate	$11,862.92
Rate for Payer: Aetna Better Health Medicaid/QHP	$11,862.92
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11,862.92
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11,862.92
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11,862.92

SYNCOPE AND COLLAPSE

Facility

$7,574.34

Service Code	APR-DRG 2042
Min. Negotiated Rate	$7,574.34
Max. Negotiated Rate	$7,574.34
Rate for Payer: Aetna Better Health Medicaid/QHP	$7,574.34
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$7,574.34
Rate for Payer: Home State Health Plan Medicaid Managed Care	$7,574.34
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$7,574.34

SYNCOPE AND COLLAPSE

Facility

$5,178.75

Service Code	APR-DRG 2041
Min. Negotiated Rate	$5,178.75
Max. Negotiated Rate	$5,178.75
Rate for Payer: Aetna Better Health Medicaid/QHP	$5,178.75
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5,178.75
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5,178.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5,178.75

SYNJARDY 12.5/1000MG TAB EMP

Facility

$39.00

Service Code	NDC 597016818
Hospital Charge Code	2627094
Hospital Revenue Code	250
Rate for Payer: Cash Price	$35.10

SYNJARDY 12.5/1000MG TAB EMP

Facility

$39.00

Service Code	NDC 597016818
Hospital Charge Code	2627094
Hospital Revenue Code	250
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

SYNTHROID 112MCG TAB EMP

Facility

$45.00

Service Code	NDC 74706890
Hospital Charge Code	2619490
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

SYNTHROID 112MCG TAB EMP

Facility

$45.00

Service Code	NDC 74706890
Hospital Charge Code	2619490
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

SYNVISC 1 MG

Facility

$818.00

Service Code	CPT J7325
Hospital Charge Code	4107325
Hospital Revenue Code	636
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$584.05
Rate for Payer: Aetna Medicare Advantage	$6.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$484.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$584.05
Rate for Payer: Cash Price	$736.20
Rate for Payer: Cash Price	$736.20
Rate for Payer: Cigna Commercial HMO & PPO	$6.02
Rate for Payer: Home State Health Plan Medicare Advantage	$6.02
Rate for Payer: Humana Commercial	$12.04
Rate for Payer: Humana Medicare Advantage	$6.02
Rate for Payer: UnitedHealthcare Commercial	$6.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$294.48

SYNVISC 1 MG

Facility

$818.00

Service Code	CPT J7325
Hospital Charge Code	4107325
Hospital Revenue Code	636
Min. Negotiated Rate	$545.61
Max. Negotiated Rate	$545.61
Rate for Payer: Cash Price	$736.20
Rate for Payer: UnitedHealthcare Commercial	$545.61

SYNVISC-ONE 48MG/6ML PFS INJ

Facility

$8,009.00

Service Code	HCPCS J7325
Hospital Charge Code	2697612
Hospital Revenue Code	250
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$5,718.43
Rate for Payer: Humana Medicare Advantage	$6.02
Rate for Payer: Aetna Medicare Advantage	$6.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$4,741.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$5,718.43
Rate for Payer: Cash Price	$7,208.10
Rate for Payer: Cash Price	$7,208.10
Rate for Payer: Cigna Commercial HMO & PPO	$6.02
Rate for Payer: Home State Health Plan Medicare Advantage	$6.02
Rate for Payer: Humana Commercial	$12.04
Rate for Payer: UnitedHealthcare Commercial	$5,342.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$2,883.24

SYNVISC-ONE 48MG/6ML PFS INJ

Facility

$8,009.00

Service Code	HCPCS J7325
Hospital Charge Code	2697612
Hospital Revenue Code	250
Rate for Payer: Cash Price	$7,208.10

SYRINGE 10CC

Facility

$20.00

Hospital Charge Code	2824444
Hospital Revenue Code	272
Rate for Payer: Cash Price	$18.00

SYRINGE 10CC

Facility

$20.00

Hospital Charge Code	2824444
Hospital Revenue Code	272
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

Know your out-of-pocket cost for care.

All Charges