Madison Medical Center

All Charges

Charge

Type

Setting

Price

BRINZOLAMIDE(AZOPT) 1% OP SUSP 10ML

Facility

$410.00

Service Code	NDC 65027510
Hospital Charge Code	2697081
Hospital Revenue Code	250
Min. Negotiated Rate	$147.60
Max. Negotiated Rate	$292.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$242.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$292.74
Rate for Payer: Cash Price	$369.00
Rate for Payer: UnitedHealthcare Commercial	$273.47
Rate for Payer: UnitedHealthcare Medicare Advantage	$147.60

BRINZOLAMIDE(AZOPT) 1% OP SUSP 10ML

Facility

$410.00

Service Code	NDC 65027510
Hospital Charge Code	2697081
Hospital Revenue Code	250
Rate for Payer: Cash Price	$369.00

BRINZOLAMIDE(AZOPT) 1% OP SUSP 15ML EMP

Facility

$439.00

Service Code	NDC 65027515
Hospital Charge Code	2622730
Hospital Revenue Code	250
Min. Negotiated Rate	$158.04
Max. Negotiated Rate	$313.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$259.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$313.45
Rate for Payer: Cash Price	$395.10
Rate for Payer: UnitedHealthcare Commercial	$292.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$158.04

BRINZOLAMIDE(AZOPT) 1% OP SUSP 15ML EMP

Facility

$439.00

Service Code	NDC 65027515
Hospital Charge Code	2622730
Hospital Revenue Code	250
Rate for Payer: Cash Price	$395.10

BRONCHIOLITIS AND RSV PNEUMONIA

Facility

$4,469.03

Service Code	APR-DRG 1381
Min. Negotiated Rate	$4,469.03
Max. Negotiated Rate	$4,469.03
Rate for Payer: Aetna Better Health Medicaid/QHP	$4,469.03
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4,469.03
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4,469.03
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4,469.03

BRONCHIOLITIS AND RSV PNEUMONIA

Facility

$22,313.67

Service Code	APR-DRG 1384
Min. Negotiated Rate	$22,313.67
Max. Negotiated Rate	$22,313.67
Rate for Payer: Aetna Better Health Medicaid/QHP	$22,313.67
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$22,313.67
Rate for Payer: Home State Health Plan Medicaid Managed Care	$22,313.67
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$22,313.67

BRONCHIOLITIS AND RSV PNEUMONIA

Facility

$16,050.97

Service Code	APR-DRG 1383
Min. Negotiated Rate	$16,050.97
Max. Negotiated Rate	$16,050.97
Rate for Payer: Aetna Better Health Medicaid/QHP	$16,050.97
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16,050.97
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16,050.97
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16,050.97

BRONCHIOLITIS AND RSV PNEUMONIA

Facility

$7,990.97

Service Code	APR-DRG 1382
Min. Negotiated Rate	$7,990.97
Max. Negotiated Rate	$7,990.97
Rate for Payer: Aetna Better Health Medicaid/QHP	$7,990.97
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$7,990.97
Rate for Payer: Home State Health Plan Medicaid Managed Care	$7,990.97
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$7,990.97

BRONCHITIS AND ASTHMA WITH CC/MCC

Facility

$18,843.18

Service Code	MSDRG 202
Min. Negotiated Rate	$9,421.59
Max. Negotiated Rate	$18,843.18
Rate for Payer: Aetna Medicare Advantage	$9,421.59
Rate for Payer: Cigna Commercial HMO & PPO	$9,421.59
Rate for Payer: Home State Health Plan Medicare Advantage	$9,421.59
Rate for Payer: Humana Commercial	$18,843.18
Rate for Payer: Humana Medicare Advantage	$9,421.59

BRONCHITIS AND ASTHMA WITHOUT CC/MCC

Facility

$14,134.30

Service Code	MSDRG 203
Min. Negotiated Rate	$7,067.15
Max. Negotiated Rate	$14,134.30
Rate for Payer: Aetna Medicare Advantage	$7,067.15
Rate for Payer: Cigna Commercial HMO & PPO	$7,067.15
Rate for Payer: Home State Health Plan Medicare Advantage	$7,067.15
Rate for Payer: Humana Commercial	$14,134.30
Rate for Payer: Humana Medicare Advantage	$7,067.15

BRONCHODILATION RESPONSIVENESS

Facility

$630.00

Service Code	CPT 94060
Hospital Charge Code	4594060
Hospital Revenue Code	460
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$762.48
Rate for Payer: Aetna Better Health Medicaid/QHP	$336.38
Rate for Payer: Aetna Medicare Advantage	$381.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$372.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$449.82
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial HMO & PPO	$381.24
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$336.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$359.93
Rate for Payer: Home State Health Plan Medicare Advantage	$381.24
Rate for Payer: Humana Commercial	$762.48
Rate for Payer: Humana Medicare Advantage	$381.24
Rate for Payer: UnitedHealthcare Commercial	$420.21
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$336.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$226.80

BRONCHODILATION RESPONSIVENESS

Facility

$630.00

Service Code	CPT 94060
Hospital Charge Code	4594060
Hospital Revenue Code	460
Rate for Payer: Cash Price	$567.00

BRUCELLA IGG

Facility

$195.00

Service Code	CPT 86622
Hospital Charge Code	222151
Hospital Revenue Code	302
Min. Negotiated Rate	$8.04
Max. Negotiated Rate	$139.23
Rate for Payer: Aetna Better Health Medicaid/QHP	$8.04
Rate for Payer: Aetna Medicare Advantage	$8.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$115.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$139.23
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial HMO & PPO	$8.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8.04
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8.60
Rate for Payer: Home State Health Plan Medicare Advantage	$8.93
Rate for Payer: Humana Commercial	$17.86
Rate for Payer: Humana Medicare Advantage	$8.93
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$70.20

BRUCELLA IGG

Facility

$195.00

Service Code	CPT 86622
Hospital Charge Code	222151
Hospital Revenue Code	302
Rate for Payer: Cash Price	$175.50

BUCKY CHEST

Facility

$360.00

Service Code	CPT 71045
Hospital Charge Code	323140
Hospital Revenue Code	320
Rate for Payer: Cash Price	$324.00

BUCKY CHEST

Facility

$360.00

Service Code	CPT 71045
Hospital Charge Code	323140
Hospital Revenue Code	320
Min. Negotiated Rate	$78.45
Max. Negotiated Rate	$257.04
Rate for Payer: Aetna Better Health Medicaid/QHP	$78.45
Rate for Payer: Aetna Medicare Advantage	$88.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$213.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$257.04
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial HMO & PPO	$88.91
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$78.45
Rate for Payer: Home State Health Plan Medicaid Managed Care	$83.94
Rate for Payer: Home State Health Plan Medicare Advantage	$88.91
Rate for Payer: Humana Commercial	$177.82
Rate for Payer: Humana Medicare Advantage	$88.91
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$78.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$129.60

BUDES/FORMOT (SYMBICORT)160/4.5 INH 6GM

Facility

$661.00

Service Code	NDC 186037028
Hospital Charge Code	2626591
Hospital Revenue Code	250
Rate for Payer: Cash Price	$594.90

BUDES/FORMOT (SYMBICORT)160/4.5 INH 6GM

Facility

$661.00

Service Code	NDC 186037028
Hospital Charge Code	2626591
Hospital Revenue Code	250
Min. Negotiated Rate	$237.96
Max. Negotiated Rate	$471.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$391.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$471.95
Rate for Payer: Cash Price	$594.90
Rate for Payer: UnitedHealthcare Commercial	$440.89
Rate for Payer: UnitedHealthcare Medicare Advantage	$237.96

BUDES/FORMOT (SYMBICORT)160/4.5 INH EMP

Facility

$661.00

Service Code	NDC 186037020
Hospital Charge Code	2624895
Hospital Revenue Code	250
Min. Negotiated Rate	$237.96
Max. Negotiated Rate	$471.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$391.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$471.95
Rate for Payer: Cash Price	$594.90
Rate for Payer: UnitedHealthcare Commercial	$440.89
Rate for Payer: UnitedHealthcare Medicare Advantage	$237.96

BUDES/FORMOT (SYMBICORT)160/4.5 INH EMP

Facility

$661.00

Service Code	NDC 186037020
Hospital Charge Code	2624895
Hospital Revenue Code	250
Rate for Payer: Cash Price	$594.90

BUDES/FORMOT (SYMBICORT)80/4.5 INH

Facility

$643.00

Service Code	NDC 186037028
Hospital Charge Code	2619174
Hospital Revenue Code	250
Rate for Payer: Cash Price	$578.70

BUDES/FORMOT (SYMBICORT)80/4.5 INH

Facility

$643.00

Service Code	NDC 186037028
Hospital Charge Code	2619174
Hospital Revenue Code	250
Min. Negotiated Rate	$231.48
Max. Negotiated Rate	$459.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$380.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$459.10
Rate for Payer: Cash Price	$578.70
Rate for Payer: UnitedHealthcare Commercial	$428.88
Rate for Payer: UnitedHealthcare Medicare Advantage	$231.48

BUDES/FORMOT (SYMBICORT) 80/4.5 INH EMP

Facility

$840.00

Service Code	NDC 186037220
Hospital Charge Code	2622618
Hospital Revenue Code	250
Rate for Payer: Cash Price	$756.00

BUDES/FORMOT (SYMBICORT) 80/4.5 INH EMP

Facility

$840.00

Service Code	NDC 186037220
Hospital Charge Code	2622618
Hospital Revenue Code	250
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$599.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$497.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$599.76
Rate for Payer: Cash Price	$756.00
Rate for Payer: UnitedHealthcare Commercial	$560.28
Rate for Payer: UnitedHealthcare Medicare Advantage	$302.40

BUDESONIDE 0.5MG INH SUSP 2ML UD

Facility

$60.00

Service Code	NDC 591376830
Hospital Charge Code	2626448
Hospital Revenue Code	250
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

Know your out-of-pocket cost for care.

All Charges