Madison Medical Center

All Charges

Charge

Type

Setting

Price

TIMOLOL 0.5% (TIMOPTIC XE)OP GEL 5ML EMP

Facility

$985.00

Service Code	NDC 6.2332E+10
Hospital Charge Code	2624157
Hospital Revenue Code	250
Min. Negotiated Rate	$354.60
Max. Negotiated Rate	$703.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$583.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$703.29
Rate for Payer: Cash Price	$886.50
Rate for Payer: UnitedHealthcare Commercial	$657.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$354.60

TIMOLOL MAL 0.5% OP SOL 5ML EMP

Facility

$79.00

Service Code	NDC 6.498E+10
Hospital Charge Code	2625241
Hospital Revenue Code	250
Min. Negotiated Rate	$28.44
Max. Negotiated Rate	$56.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$46.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$56.41
Rate for Payer: Cash Price	$71.10
Rate for Payer: UnitedHealthcare Commercial	$52.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.44

TIMOLOL MAL 0.5% OP SOL 5ML EMP

Facility

$79.00

Service Code	NDC 6.498E+10
Hospital Charge Code	2625241
Hospital Revenue Code	250
Rate for Payer: Cash Price	$71.10

TIMOLOL MAL (TIMOPTIC)0.5% OP SOL 5ML

Facility

$79.00

Service Code	NDC 6.498E+10
Hospital Charge Code	2697084
Hospital Revenue Code	250
Rate for Payer: Cash Price	$71.10

TIMOLOL MAL (TIMOPTIC)0.5% OP SOL 5ML

Facility

$79.00

Service Code	NDC 6.498E+10
Hospital Charge Code	2697084
Hospital Revenue Code	250
Min. Negotiated Rate	$28.44
Max. Negotiated Rate	$56.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$46.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$56.41
Rate for Payer: Cash Price	$71.10
Rate for Payer: UnitedHealthcare Commercial	$52.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.44

TIOTROPIUM (SPIRIVA) RESPIMAT 1.25MCG

Facility

$1,179.00

Service Code	NDC 597016061
Hospital Charge Code	2623717
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,061.10

TIOTROPIUM (SPIRIVA) RESPIMAT 1.25MCG

Facility

$1,179.00

Service Code	NDC 597016061
Hospital Charge Code	2623717
Hospital Revenue Code	250
Min. Negotiated Rate	$424.44
Max. Negotiated Rate	$841.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$697.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$841.81
Rate for Payer: Cash Price	$1,061.10
Rate for Payer: UnitedHealthcare Commercial	$786.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$424.44

TIROSINT 100 MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2623301
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

TIROSINT 100 MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2623301
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

TIROSINT 112 MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2623452
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

TIROSINT 112 MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2623452
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

TIROSINT 125MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2623300
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

TIROSINT 125MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2623300
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

TIROSINT 137MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2624462
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

TIROSINT 137MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2624462
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

TIROSINT 150MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2625680
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

TIROSINT 150MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2625680
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

TIROSINT 50 MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2625426
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

TIROSINT 50 MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2625426
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

TIROSINT 75 MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2625799
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

TIROSINT 75 MCG CAP EMP

Facility

$45.00

Service Code	NDC 7.1858E+10
Hospital Charge Code	2625799
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

TISSUE EXAM SINGLE/MULTIPLE

Facility

$130.00

Service Code	CPT 88305
Hospital Charge Code	4288305
Hospital Revenue Code	521
Min. Negotiated Rate	$42.28
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$46.98
Rate for Payer: Aetna Medicare Advantage	$53.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.82
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cigna Commercial HMO & PPO	$53.24
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$42.28
Rate for Payer: Home State Health Plan Medicaid Managed Care	$50.27
Rate for Payer: Home State Health Plan Medicare Advantage	$53.24
Rate for Payer: Humana Commercial	$106.48
Rate for Payer: Humana Medicare Advantage	$53.24
Rate for Payer: UnitedHealthcare Commercial	$86.71
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$46.98
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

TISSUE EXAM SINGLE/MULTIPLE

Facility

$130.00

Service Code	CPT 88305
Hospital Charge Code	4288305
Hospital Revenue Code	521
Rate for Payer: Cash Price	$117.00

TISSUE PLASMINOGEN ACTIVATOR

Facility

$461.00

Service Code	CPT 85415
Hospital Charge Code	225415
Hospital Revenue Code	301
Min. Negotiated Rate	$15.47
Max. Negotiated Rate	$329.15
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.47
Rate for Payer: Aetna Medicare Advantage	$17.19
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$272.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$329.15
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cigna Commercial HMO & PPO	$17.19
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.47
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.55
Rate for Payer: Home State Health Plan Medicare Advantage	$17.19
Rate for Payer: Humana Commercial	$34.38
Rate for Payer: Humana Medicare Advantage	$17.19
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.47
Rate for Payer: UnitedHealthcare Medicare Advantage	$165.96

TISSUE PLASMINOGEN ACTIVATOR

Facility

$461.00

Service Code	CPT 85415
Hospital Charge Code	225415
Hospital Revenue Code	301
Rate for Payer: Cash Price	$414.90

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All Charges