Madison Medical Center

All Charges

Charge

Type

Setting

Price

.TESTOSTERONE FREE

Facility

$414.00

Service Code	CPT 84403
Hospital Charge Code	2220303
Hospital Revenue Code	301
Rate for Payer: Cash Price	$372.60

TESTOSTERONE, FREE DIRECT

Facility

$31.00

Service Code	CPT 84402
Hospital Charge Code	2284406
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.90

TESTOSTERONE, FREE DIRECT

Facility

$31.00

Service Code	CPT 84402
Hospital Charge Code	2284406
Hospital Revenue Code	301
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$50.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$22.92
Rate for Payer: Aetna Medicare Advantage	$25.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$18.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$22.13
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cigna Commercial HMO & PPO	$25.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$22.92
Rate for Payer: Home State Health Plan Medicaid Managed Care	$24.52
Rate for Payer: Home State Health Plan Medicare Advantage	$25.47
Rate for Payer: Humana Commercial	$50.94
Rate for Payer: Humana Medicare Advantage	$25.47
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$22.92
Rate for Payer: UnitedHealthcare Medicare Advantage	$11.16

TESTOSTERONE FREE&TOTAL MALE

Facility

$255.00

Service Code	CPT 84402
Hospital Charge Code	2220302
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$182.07
Rate for Payer: Aetna Better Health Medicaid/QHP	$22.92
Rate for Payer: Aetna Medicare Advantage	$25.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$150.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$182.07
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cigna Commercial HMO & PPO	$25.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$22.92
Rate for Payer: Home State Health Plan Medicaid Managed Care	$24.52
Rate for Payer: Home State Health Plan Medicare Advantage	$25.47
Rate for Payer: Humana Commercial	$50.94
Rate for Payer: Humana Medicare Advantage	$25.47
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$22.92
Rate for Payer: UnitedHealthcare Medicare Advantage	$91.80

TESTOSTERONE FREE&TOTAL MALE

Facility

$255.00

Service Code	CPT 84402
Hospital Charge Code	2220302
Hospital Revenue Code	301
Rate for Payer: Cash Price	$229.50

TESTOSTERONE LCMS

Facility

$111.00

Service Code	CPT 84403
Hospital Charge Code	2220305
Hospital Revenue Code	301
Rate for Payer: Cash Price	$99.90

TESTOSTERONE LCMS

Facility

$111.00

Service Code	CPT 84403
Hospital Charge Code	2220305
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$79.25
Rate for Payer: Aetna Better Health Medicaid/QHP	$23.23
Rate for Payer: Aetna Medicare Advantage	$25.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$79.25
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial HMO & PPO	$25.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$23.23
Rate for Payer: Home State Health Plan Medicaid Managed Care	$24.86
Rate for Payer: Home State Health Plan Medicare Advantage	$25.81
Rate for Payer: Humana Commercial	$51.62
Rate for Payer: Humana Medicare Advantage	$25.81
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$23.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.96

TESTOSTERONE TOTAL(LABCORP)

Facility

$86.00

Service Code	CPT 84403
Hospital Charge Code	2284405
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$61.40
Rate for Payer: Aetna Better Health Medicaid/QHP	$23.23
Rate for Payer: Aetna Medicare Advantage	$25.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$50.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$61.40
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cigna Commercial HMO & PPO	$25.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$23.23
Rate for Payer: Home State Health Plan Medicaid Managed Care	$24.86
Rate for Payer: Home State Health Plan Medicare Advantage	$25.81
Rate for Payer: Humana Commercial	$51.62
Rate for Payer: Humana Medicare Advantage	$25.81
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$23.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.96

TESTOSTERONE TOTAL(LABCORP)

Facility

$86.00

Service Code	CPT 84403
Hospital Charge Code	2284405
Hospital Revenue Code	301
Rate for Payer: Cash Price	$77.40

TESTTOSTERONE 200 MG/ML 1CC

Facility

$7.00

Service Code	CPT J1080
Hospital Charge Code	441080
Hospital Revenue Code	636
Min. Negotiated Rate	$2.52
Max. Negotiated Rate	$5.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$4.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$5.00
Rate for Payer: Cash Price	$6.30
Rate for Payer: UnitedHealthcare Commercial	$4.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$2.52

TESTTOSTERONE 200 MG/ML 1CC

Facility

$7.00

Service Code	CPT J1080
Hospital Charge Code	441080
Hospital Revenue Code	636
Min. Negotiated Rate	$4.67
Max. Negotiated Rate	$4.67
Rate for Payer: Cash Price	$6.30
Rate for Payer: UnitedHealthcare Commercial	$4.67

TETANUS ANTIOXID

Facility

$142.00

Service Code	CPT 86774
Hospital Charge Code	2286700
Hospital Revenue Code	301
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$101.39
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.32
Rate for Payer: Aetna Medicare Advantage	$14.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$84.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$101.39
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial HMO & PPO	$14.80
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.32
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.25
Rate for Payer: Home State Health Plan Medicare Advantage	$14.80
Rate for Payer: Humana Commercial	$29.60
Rate for Payer: Humana Medicare Advantage	$14.80
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.32
Rate for Payer: UnitedHealthcare Medicare Advantage	$51.12

TETANUS ANTIOXID

Facility

$142.00

Service Code	CPT 86774
Hospital Charge Code	2286700
Hospital Revenue Code	301
Rate for Payer: Cash Price	$127.80

TETANUS, DIPTHERIA, PERTUSSIS VACCINE

Facility

$226.00

Service Code	HCPCS 90714
Hospital Charge Code	2698325
Hospital Revenue Code	250
Min. Negotiated Rate	$81.36
Max. Negotiated Rate	$161.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$133.79
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$161.36
Rate for Payer: Cash Price	$203.40
Rate for Payer: UnitedHealthcare Commercial	$150.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$81.36

TETANUS, DIPTHERIA, PERTUSSIS VACCINE

Facility

$226.00

Service Code	HCPCS 90714
Hospital Charge Code	2698325
Hospital Revenue Code	250
Rate for Payer: Cash Price	$203.40

TETANUS & DIPTH TOX 7Y+ INJ 0.5ML

Facility

$189.00

Service Code	HCPCS 90714
Hospital Charge Code	2626288
Hospital Revenue Code	250
Rate for Payer: Cash Price	$170.10

TETANUS & DIPTH TOX 7Y+ INJ 0.5ML

Facility

$189.00

Service Code	HCPCS 90714
Hospital Charge Code	2626288
Hospital Revenue Code	250
Min. Negotiated Rate	$68.04
Max. Negotiated Rate	$134.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$111.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$134.95
Rate for Payer: Cash Price	$170.10
Rate for Payer: UnitedHealthcare Commercial	$126.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$68.04

TETANUS & DIPTH TOX 7Y+ INJ 0.5ML EMP

Facility

$189.00

Service Code	HCPCS 90714
Hospital Charge Code	2626184
Hospital Revenue Code	250
Rate for Payer: Cash Price	$170.10

TETANUS & DIPTH TOX 7Y+ INJ 0.5ML EMP

Facility

$189.00

Service Code	HCPCS 90714
Hospital Charge Code	2626184
Hospital Revenue Code	250
Min. Negotiated Rate	$68.04
Max. Negotiated Rate	$134.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$111.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$134.95
Rate for Payer: Cash Price	$170.10
Rate for Payer: UnitedHealthcare Commercial	$126.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$68.04

TETANUS TOXOID INJ 0.5ML

Facility

$44.00

Service Code	HCPCS 90703
Hospital Charge Code	2656295
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

TETANUS TOXOID INJ 0.5ML

Facility

$44.00

Service Code	HCPCS 90703
Hospital Charge Code	2656295
Hospital Revenue Code	250
Rate for Payer: Cash Price	$39.60

TETRACAINE 0.5% OP SOL DROPPERETTE 2ML

Facility

$30.00

Service Code	NDC 5.8768E+10
Hospital Charge Code	2656297
Hospital Revenue Code	250
Rate for Payer: Cash Price	$27.00

TETRACAINE 0.5% OP SOL DROPPERETTE 2ML

Facility

$30.00

Service Code	NDC 5.8768E+10
Hospital Charge Code	2656297
Hospital Revenue Code	250
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$21.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$17.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$21.42
Rate for Payer: Cash Price	$27.00
Rate for Payer: UnitedHealthcare Commercial	$20.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

TETRACAINE 0.5% OP SOL DROPPERETTE 4ML

Facility

$76.00

Service Code	NDC 65074114
Hospital Charge Code	2620514
Hospital Revenue Code	250
Min. Negotiated Rate	$27.36
Max. Negotiated Rate	$54.26
Rate for Payer: Cash Price	$68.40
Rate for Payer: UnitedHealthcare Commercial	$50.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$54.26
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.36

TETRACAINE 0.5% OP SOL DROPPERETTE 4ML

Facility

$76.00

Service Code	NDC 65074114
Hospital Charge Code	2620514
Hospital Revenue Code	250
Rate for Payer: Cash Price	$68.40

Know your out-of-pocket cost for care.

All Charges