Madison Medical Center

All Charges

Charge

Type

Setting

Price

TOPIRAMATE 50MG TAB EMP

Facility

$24.00

Service Code	NDC 4.7335E+10
Hospital Charge Code	2624130
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
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: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

TOPIRAMATE 50MG TAB EMP

Facility

$24.00

Service Code	NDC 4.7335E+10
Hospital Charge Code	2624130
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

TOPIRAMATE (TOPAMAX) 25MG TAB

Facility

$24.00

Service Code	NDC 6.8462E+10
Hospital Charge Code	2626502
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

TOPIRAMATE (TOPAMAX) 25MG TAB

Facility

$24.00

Service Code	NDC 6.8462E+10
Hospital Charge Code	2626502
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
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: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

TORADOL 30 MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9601885
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$67.83
Rate for Payer: Aetna Medicare Advantage	$0.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$56.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$67.83
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial HMO & PPO	$0.29
Rate for Payer: Home State Health Plan Medicare Advantage	$0.29
Rate for Payer: Humana Commercial	$0.58
Rate for Payer: Humana Medicare Advantage	$0.29
Rate for Payer: UnitedHealthcare Commercial	$0.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$34.20

TORADOL 30 MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9601885
Hospital Revenue Code	636
Min. Negotiated Rate	$63.37
Max. Negotiated Rate	$63.37
Rate for Payer: Cash Price	$85.50
Rate for Payer: UnitedHealthcare Commercial	$63.37

TORADOL KETORALAC 30MG

Facility

$95.00

Service Code	CPT J1885
Hospital Charge Code	4101885
Hospital Revenue Code	636
Min. Negotiated Rate	$63.37
Max. Negotiated Rate	$63.37
Rate for Payer: Cash Price	$85.50
Rate for Payer: UnitedHealthcare Commercial	$63.37

TORADOL KETORALAC 30MG

Facility

$95.00

Service Code	CPT J1885
Hospital Charge Code	4101885
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$67.83
Rate for Payer: Aetna Medicare Advantage	$0.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$56.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$67.83
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial HMO & PPO	$0.29
Rate for Payer: Home State Health Plan Medicare Advantage	$0.29
Rate for Payer: Humana Commercial	$0.58
Rate for Payer: Humana Medicare Advantage	$0.29
Rate for Payer: UnitedHealthcare Commercial	$0.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$34.20

TORADOL KETORALAC 30 MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9101885
Hospital Revenue Code	521
Rate for Payer: Cash Price	$85.50

TORADOL KETORALAC 30 MG

Facility

$95.00

Service Code	HCPCS J1885
Hospital Charge Code	9101885
Hospital Revenue Code	521
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Medicare Advantage	$0.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$56.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$67.83
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial HMO & PPO	$0.29
Rate for Payer: Home State Health Plan Medicare Advantage	$0.29
Rate for Payer: Humana Commercial	$0.58
Rate for Payer: Humana Medicare Advantage	$0.29
Rate for Payer: UnitedHealthcare Commercial	$63.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

TORSEMIDE (DEMADEX) 20MG TAB

Facility

$20.00

Service Code	NDC 5.0268E+10
Hospital Charge Code	2697072
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

TORSEMIDE (DEMADEX) 20MG TAB

Facility

$20.00

Service Code	NDC 5.0268E+10
Hospital Charge Code	2697072
Hospital Revenue Code	250
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

TORSEMIDE (DEMADEX) 20MG TAB EMP

Facility

$20.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2697438
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

TORSEMIDE (DEMADEX) 20MG TAB EMP

Facility

$20.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2697438
Hospital Revenue Code	250
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

.TOTAL PROTEIN URINE (CHARGE)

Facility

$30.00

Service Code	CPT 84156
Hospital Charge Code	221957
Hospital Revenue Code	301
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$21.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$3.30
Rate for Payer: Aetna Medicare Advantage	$3.67
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: Cash Price	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial HMO & PPO	$3.67
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$3.30
Rate for Payer: Home State Health Plan Medicaid Managed Care	$3.53
Rate for Payer: Home State Health Plan Medicare Advantage	$3.67
Rate for Payer: Humana Commercial	$7.34
Rate for Payer: Humana Medicare Advantage	$3.67
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$3.30
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.80

.TOTAL PROTEIN URINE (CHARGE)

Facility

$30.00

Service Code	CPT 84156
Hospital Charge Code	221957
Hospital Revenue Code	301
Rate for Payer: Cash Price	$27.00

TOTAL TESTOSTERONE

Facility

$93.00

Service Code	CPT 84403
Hospital Charge Code	4284403
Hospital Revenue Code	636
Min. Negotiated Rate	$23.23
Max. Negotiated Rate	$66.40
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	$55.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$66.40
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cash Price	$83.70
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	$25.81
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$23.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$33.48

TOTAL TESTOSTERONE

Facility

$93.00

Service Code	CPT 84403
Hospital Charge Code	4284403
Hospital Revenue Code	636
Min. Negotiated Rate	$62.03
Max. Negotiated Rate	$62.03
Rate for Payer: Cash Price	$83.70
Rate for Payer: UnitedHealthcare Commercial	$62.03

TOTAL THYROID LOBECTOMY;UNILAT

Professional

Both

$3,045.00

Service Code	CPT 60220
Hospital Charge Code	5460220
Hospital Revenue Code	975
Min. Negotiated Rate	$534.17
Max. Negotiated Rate	$1,065.75
Rate for Payer: Aetna Commercial/Medicare Advantage	$610.19
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$534.17
Rate for Payer: Cash Price	$2,740.50
Rate for Payer: Cash Price	$2,740.50
Rate for Payer: Cigna Commercial HMO & PPO	$610.19
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$534.17
Rate for Payer: Home State Health Plan Medicaid Managed Care	$587.59
Rate for Payer: Home State Health Plan Medicare Advantage	$610.19
Rate for Payer: Optum Medicare Advantage	$1,065.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$534.17

TOTAL THYROID LOBECTOMY UNI W OR W/O IST

Professional

Both

$2,536.00

Service Code	CPT 60220
Hospital Charge Code	4160220
Hospital Revenue Code	975
Min. Negotiated Rate	$534.17
Max. Negotiated Rate	$887.60
Rate for Payer: Aetna Commercial/Medicare Advantage	$610.19
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$534.17
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Cash Price	$2,282.40
Rate for Payer: Cigna Commercial HMO & PPO	$610.19
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$534.17
Rate for Payer: Home State Health Plan Medicaid Managed Care	$587.59
Rate for Payer: Home State Health Plan Medicare Advantage	$610.19
Rate for Payer: Optum Medicare Advantage	$887.60
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$534.17

TOUJEO SOLOSTAR INSULIN PEN EMP 3-PEN BX

Facility

$1,330.00

Service Code	NDC 24586903
Hospital Charge Code	2623376
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,197.00

TOUJEO SOLOSTAR INSULIN PEN EMP 3-PEN BX

Facility

$1,330.00

Service Code	NDC 24586903
Hospital Charge Code	2623376
Hospital Revenue Code	250
Min. Negotiated Rate	$478.80
Max. Negotiated Rate	$949.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$787.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$949.62
Rate for Payer: Cash Price	$1,197.00
Rate for Payer: UnitedHealthcare Commercial	$887.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$478.80

TOURNIQUET 12 CUFF

Facility

$125.00

Hospital Charge Code	2822248
Hospital Revenue Code	271
Rate for Payer: Cash Price	$112.50

TOURNIQUET 12 CUFF

Facility

$125.00

Hospital Charge Code	2822248
Hospital Revenue Code	271
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$89.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.00

TOURNIQUET 18

Facility

$125.00

Hospital Charge Code	2822247
Hospital Revenue Code	271
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$89.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$45.00

Know your out-of-pocket cost for care.

All Charges