Madison Medical Center

All Charges

Charge

Type

Setting

Price

TOLTERODINE (DETROL LA) 4MG CAP EMP

Facility

$48.00

Service Code	NDC 9519102
Hospital Charge Code	2623123
Hospital Revenue Code	250
Min. Negotiated Rate	$17.28
Max. Negotiated Rate	$34.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$28.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$34.27
Rate for Payer: Cash Price	$43.20
Rate for Payer: UnitedHealthcare Commercial	$32.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.28

TOLVAPTAN (SAMSCA) 15MG TAB

Facility

$1,693.00

Service Code	NDC 5.9148E+10
Hospital Charge Code	2626588
Hospital Revenue Code	250
Min. Negotiated Rate	$609.48
Max. Negotiated Rate	$1,208.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,002.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,208.80
Rate for Payer: Cash Price	$1,523.70
Rate for Payer: UnitedHealthcare Commercial	$1,129.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$609.48

TOLVAPTAN (SAMSCA) 15MG TAB

Facility

$1,693.00

Service Code	NDC 5.9148E+10
Hospital Charge Code	2626588
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,523.70

TOM CAT SHAVER BLADE F-SERIES 4.0

Facility

$142.00

Hospital Charge Code	1220847
Hospital Revenue Code	271
Min. Negotiated Rate	$51.12
Max. Negotiated Rate	$101.39
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: UnitedHealthcare Commercial	$94.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$51.12

TOM CAT SHAVER BLADE F-SERIES 4.0

Facility

$142.00

Hospital Charge Code	1220847
Hospital Revenue Code	271
Rate for Payer: Cash Price	$127.80

TONGUE LACERATION/REPAIR

Professional

Both

$1,007.00

Service Code	CPT 41250
Hospital Charge Code	1841250
Hospital Revenue Code	981
Min. Negotiated Rate	$154.04
Max. Negotiated Rate	$352.45
Rate for Payer: Aetna Commercial/Medicare Advantage	$154.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$216.47
Rate for Payer: Cash Price	$906.30
Rate for Payer: Cash Price	$906.30
Rate for Payer: Cigna Commercial HMO & PPO	$154.04
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$216.47
Rate for Payer: Home State Health Plan Medicaid Managed Care	$238.12
Rate for Payer: Home State Health Plan Medicare Advantage	$154.04
Rate for Payer: Optum Medicare Advantage	$352.45
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$216.47

TONSIL AND ADENOID PROCEDURES

Facility

$2,828.10

Service Code	APR-DRG 0971
Min. Negotiated Rate	$2,828.10
Max. Negotiated Rate	$2,828.10
Rate for Payer: Aetna Better Health Medicaid/QHP	$2,828.10
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$2,828.10
Rate for Payer: Home State Health Plan Medicaid Managed Care	$2,828.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$2,828.10

TONSIL AND ADENOID PROCEDURES

Facility

$13,059.76

Service Code	APR-DRG 0972
Min. Negotiated Rate	$13,059.76
Max. Negotiated Rate	$13,059.76
Rate for Payer: Aetna Better Health Medicaid/QHP	$13,059.76
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13,059.76
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13,059.76
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13,059.76

TONSIL AND ADENOID PROCEDURES

Facility

$14,773.81

Service Code	APR-DRG 0973
Min. Negotiated Rate	$14,773.81
Max. Negotiated Rate	$14,773.81
Rate for Payer: Aetna Better Health Medicaid/QHP	$14,773.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14,773.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14,773.81
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14,773.81

TONSIL AND ADENOID PROCEDURES

Facility

$25,775.59

Service Code	APR-DRG 0974
Min. Negotiated Rate	$25,775.59
Max. Negotiated Rate	$25,775.59
Rate for Payer: Aetna Better Health Medicaid/QHP	$25,775.59
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$25,775.59
Rate for Payer: Home State Health Plan Medicaid Managed Care	$25,775.59
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$25,775.59

TONSILLECTOMY > 12 YRS OLD

Professional

Both

$1,200.00

Service Code	CPT 42826
Hospital Charge Code	9342826
Hospital Revenue Code	975
Min. Negotiated Rate	$215.07
Max. Negotiated Rate	$420.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$216.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$215.07
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Cigna Commercial HMO & PPO	$216.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$215.07
Rate for Payer: Home State Health Plan Medicaid Managed Care	$236.58
Rate for Payer: Home State Health Plan Medicare Advantage	$216.81
Rate for Payer: Optum Medicare Advantage	$420.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$215.07

TONSILLECTOMY & ADENOID < 12 YRS OLD

Professional

Both

$1,400.00

Service Code	CPT 42820
Hospital Charge Code	9342820
Hospital Revenue Code	975
Min. Negotiated Rate	$226.54
Max. Negotiated Rate	$490.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$246.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$226.54
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Cigna Commercial HMO & PPO	$246.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$226.54
Rate for Payer: Home State Health Plan Medicaid Managed Care	$249.19
Rate for Payer: Home State Health Plan Medicare Advantage	$246.01
Rate for Payer: Optum Medicare Advantage	$490.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$226.54

TONSILLECTOMY & ADENOID < 12 YRS OLD

Professional

Both

$1,200.00

Service Code	CPT 42825
Hospital Charge Code	9342825
Hospital Revenue Code	975
Min. Negotiated Rate	$211.83
Max. Negotiated Rate	$420.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$227.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$211.83
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Cash Price	$1,080.00
Rate for Payer: Cigna Commercial HMO & PPO	$227.45
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$211.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$233.01
Rate for Payer: Home State Health Plan Medicare Advantage	$227.45
Rate for Payer: Optum Medicare Advantage	$420.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$211.83

TONSILLECTOMY & ADENOID > 12 YRS OLD

Professional

Both

$1,400.00

Service Code	CPT 42821
Hospital Charge Code	9342821
Hospital Revenue Code	975
Min. Negotiated Rate	$253.61
Max. Negotiated Rate	$490.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$256.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$253.61
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Cigna Commercial HMO & PPO	$256.52
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$253.61
Rate for Payer: Home State Health Plan Medicaid Managed Care	$278.97
Rate for Payer: Home State Health Plan Medicare Advantage	$256.52
Rate for Payer: Optum Medicare Advantage	$490.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$253.61

TONSILLECTOMY & ADENOID > 12 YRS OLD

Professional

Both

$1,300.00

Service Code	CPT 42821
Hospital Charge Code	9442820
Hospital Revenue Code	975
Min. Negotiated Rate	$253.61
Max. Negotiated Rate	$455.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$256.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$253.61
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Cigna Commercial HMO & PPO	$256.52
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$253.61
Rate for Payer: Home State Health Plan Medicaid Managed Care	$278.97
Rate for Payer: Home State Health Plan Medicare Advantage	$256.52
Rate for Payer: Optum Medicare Advantage	$455.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$253.61

TONSIL SPONGE

Facility

$21.00

Hospital Charge Code	1224442
Hospital Revenue Code	271
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

TONSIL SPONGE

Facility

$21.00

Hospital Charge Code	1224442
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

TOPIRAMATE

Facility

$251.00

Service Code	CPT 80201
Hospital Charge Code	2280201
Hospital Revenue Code	301
Min. Negotiated Rate	$10.73
Max. Negotiated Rate	$179.21
Rate for Payer: Aetna Better Health Medicaid/QHP	$10.73
Rate for Payer: Aetna Medicare Advantage	$11.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$148.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$179.21
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial HMO & PPO	$11.92
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$10.73
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11.48
Rate for Payer: Home State Health Plan Medicare Advantage	$11.92
Rate for Payer: Humana Commercial	$23.84
Rate for Payer: Humana Medicare Advantage	$11.92
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$10.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$90.36

TOPIRAMATE

Facility

$251.00

Service Code	CPT 80201
Hospital Charge Code	2280201
Hospital Revenue Code	301
Rate for Payer: Cash Price	$225.90

TOPIRAMATE 100MG TAB

Facility

$40.00

Service Code	NDC 6.9097E+10
Hospital Charge Code	2623777
Hospital Revenue Code	250
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$28.56
Rate for Payer: Cash Price	$36.00
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: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

TOPIRAMATE 100MG TAB

Facility

$40.00

Service Code	NDC 6.9097E+10
Hospital Charge Code	2623777
Hospital Revenue Code	250
Rate for Payer: Cash Price	$36.00

TOPIRAMATE 100MG TAB EMP

Facility

$40.00

Service Code	NDC 6.8382E+10
Hospital Charge Code	2619150
Hospital Revenue Code	250
Rate for Payer: Cash Price	$36.00

TOPIRAMATE 100MG TAB EMP

Facility

$40.00

Service Code	NDC 6.8382E+10
Hospital Charge Code	2619150
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

TOPIRAMATE 25MG TAB EMP

Facility

$24.00

Service Code	NDC 2.93E+10
Hospital Charge Code	2622892
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

TOPIRAMATE 25MG TAB EMP

Facility

$24.00

Service Code	NDC 2.93E+10
Hospital Charge Code	2622892
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
Rate for Payer: Cash Price	$21.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.14
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

Know your out-of-pocket cost for care.

All Charges