Madison Medical Center

All Charges

Charge

Type

Setting

Price

T3 TOTAL

Facility

$113.00

Service Code	CPT 84480
Hospital Charge Code	2284480
Hospital Revenue Code	301
Rate for Payer: Cash Price	$101.70

T3 TOTAL (LABCORP)

Facility

$113.00

Service Code	CPT 84480
Hospital Charge Code	2284485
Hospital Revenue Code	301
Rate for Payer: Cash Price	$101.70

T3 TOTAL (LABCORP)

Facility

$113.00

Service Code	CPT 84480
Hospital Charge Code	2284485
Hospital Revenue Code	301
Min. Negotiated Rate	$12.76
Max. Negotiated Rate	$80.68
Rate for Payer: Aetna Better Health Medicaid/QHP	$12.76
Rate for Payer: Aetna Medicare Advantage	$14.18
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	$14.18
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12.76
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.65
Rate for Payer: Home State Health Plan Medicare Advantage	$14.18
Rate for Payer: Humana Commercial	$28.36
Rate for Payer: Humana Medicare Advantage	$14.18
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12.76
Rate for Payer: UnitedHealthcare Medicare Advantage	$40.68

T3 UPTAKE

Facility

$178.00

Service Code	CPT 84479
Hospital Charge Code	2220120
Hospital Revenue Code	301
Rate for Payer: Cash Price	$160.20

T3 UPTAKE

Facility

$178.00

Service Code	CPT 84479
Hospital Charge Code	2220120
Hospital Revenue Code	301
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$127.09
Rate for Payer: Aetna Better Health Medicaid/QHP	$5.82
Rate for Payer: Aetna Medicare Advantage	$6.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$105.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$127.09
Rate for Payer: Cash Price	$160.20
Rate for Payer: Cash Price	$160.20
Rate for Payer: Cash Price	$160.20
Rate for Payer: Cigna Commercial HMO & PPO	$6.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5.82
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.23
Rate for Payer: Home State Health Plan Medicare Advantage	$6.47
Rate for Payer: Humana Commercial	$12.94
Rate for Payer: Humana Medicare Advantage	$6.47
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5.82
Rate for Payer: UnitedHealthcare Medicare Advantage	$64.08

T4 TOTAL

Facility

$131.00

Service Code	CPT 84436
Hospital Charge Code	2220162
Hospital Revenue Code	301
Rate for Payer: Cash Price	$117.90

T4 TOTAL

Facility

$131.00

Service Code	CPT 84436
Hospital Charge Code	2220162
Hospital Revenue Code	301
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$93.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$6.18
Rate for Payer: Aetna Medicare Advantage	$6.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$77.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$93.53
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cigna Commercial HMO & PPO	$6.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6.18
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.61
Rate for Payer: Home State Health Plan Medicare Advantage	$6.87
Rate for Payer: Humana Commercial	$13.74
Rate for Payer: Humana Medicare Advantage	$6.87
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$47.16

T4 TOTAL (LABCORP)

Facility

$14.00

Service Code	CPT 84436
Hospital Charge Code	2284436
Hospital Revenue Code	301
Rate for Payer: Cash Price	$12.60

T4 TOTAL (LABCORP)

Facility

$14.00

Service Code	CPT 84436
Hospital Charge Code	2284436
Hospital Revenue Code	301
Min. Negotiated Rate	$5.04
Max. Negotiated Rate	$21.00
Rate for Payer: Humana Commercial	$13.74
Rate for Payer: Aetna Better Health Medicaid/QHP	$6.18
Rate for Payer: Aetna Medicare Advantage	$6.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$8.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$10.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial HMO & PPO	$6.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6.18
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.61
Rate for Payer: Home State Health Plan Medicare Advantage	$6.87
Rate for Payer: Humana Medicare Advantage	$6.87
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.04

T A

Facility

$159.00

Hospital Charge Code	2820003
Hospital Revenue Code	271
Min. Negotiated Rate	$57.24
Max. Negotiated Rate	$113.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$94.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$113.53
Rate for Payer: Cash Price	$143.10
Rate for Payer: UnitedHealthcare Commercial	$106.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$57.24

T A

Facility

$159.00

Hospital Charge Code	2820003
Hospital Revenue Code	271
Rate for Payer: Cash Price	$143.10

T A-90

Facility

$1,076.00

Hospital Charge Code	2820002
Hospital Revenue Code	271
Min. Negotiated Rate	$387.36
Max. Negotiated Rate	$768.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$636.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$768.26
Rate for Payer: Cash Price	$968.40
Rate for Payer: UnitedHealthcare Commercial	$717.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$387.36

T A-90

Facility

$1,076.00

Hospital Charge Code	2820002
Hospital Revenue Code	271
Rate for Payer: Cash Price	$968.40

TACROLIMUS

Facility

$336.00

Service Code	CPT 80197
Hospital Charge Code	2280197
Hospital Revenue Code	301
Rate for Payer: Cash Price	$302.40

TACROLIMUS

Facility

$336.00

Service Code	CPT 80197
Hospital Charge Code	2280197
Hospital Revenue Code	301
Min. Negotiated Rate	$12.36
Max. Negotiated Rate	$239.90
Rate for Payer: Aetna Better Health Medicaid/QHP	$12.36
Rate for Payer: Aetna Medicare Advantage	$13.73
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$198.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$239.90
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna Commercial HMO & PPO	$13.73
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12.36
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.23
Rate for Payer: Home State Health Plan Medicare Advantage	$13.73
Rate for Payer: Humana Commercial	$27.46
Rate for Payer: Humana Medicare Advantage	$13.73
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$120.96

TAC SHEILD MESH

Facility

$1,387.00

Hospital Charge Code	1219125
Hospital Revenue Code	272
Rate for Payer: Cash Price	$1,248.30

TAC SHEILD MESH

Facility

$1,387.00

Hospital Charge Code	1219125
Hospital Revenue Code	272
Min. Negotiated Rate	$499.32
Max. Negotiated Rate	$990.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$821.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$990.32
Rate for Payer: Cash Price	$1,248.30
Rate for Payer: UnitedHealthcare Commercial	$925.13
Rate for Payer: UnitedHealthcare Medicare Advantage	$499.32

TADALAFIL 10MG TAB EMP

Facility

$40.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2625950
Hospital Revenue Code	250
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$28.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$28.56
Rate for Payer: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

TADALAFIL 10MG TAB EMP

Facility

$40.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2625950
Hospital Revenue Code	250
Rate for Payer: Cash Price	$36.00

TADALAFIL (CIALIS) 20MG TAB EMP

Facility

$40.00

Service Code	NDC 6.9238E+10
Hospital Charge Code	2624290
Hospital Revenue Code	250
Rate for Payer: Cash Price	$36.00

TADALAFIL (CIALIS) 20MG TAB EMP

Facility

$40.00

Service Code	NDC 6.9238E+10
Hospital Charge Code	2624290
Hospital Revenue Code	250
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$28.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$28.56
Rate for Payer: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

TADALAFIL (CIALIS) 2.5MG TAB EMP

Facility

$40.00

Service Code	NDC 1E+11
Hospital Charge Code	2623571
Hospital Revenue Code	250
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$28.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$28.56
Rate for Payer: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

TADALAFIL (CIALIS) 2.5MG TAB EMP

Facility

$40.00

Service Code	NDC 1E+11
Hospital Charge Code	2623571
Hospital Revenue Code	250
Rate for Payer: Cash Price	$36.00

TADALAFIL (CIALIS) 5MG TAB EMP

Facility

$40.00

Service Code	NDC 93301765
Hospital Charge Code	2624052
Hospital Revenue Code	250
Rate for Payer: Cash Price	$36.00

TADALAFIL (CIALIS) 5MG TAB EMP

Facility

$40.00

Service Code	NDC 93301765
Hospital Charge Code	2624052
Hospital Revenue Code	250
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$28.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$28.56
Rate for Payer: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

Know your out-of-pocket cost for care.

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