Madison Medical Center

All Charges

Charge

Type

Setting

Price

02 BUBBLE JET HUMIDIFICATION

Facility

$42.00

Hospital Charge Code	4500480
Hospital Revenue Code	412
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$29.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$24.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$29.99
Rate for Payer: Cash Price	$37.80
Rate for Payer: UnitedHealthcare Commercial	$28.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.12

02 BUBBLE JET HUMIDIFICATION

Facility

$42.00

Hospital Charge Code	4500480
Hospital Revenue Code	412
Rate for Payer: Cash Price	$37.80

02 REBR. MASK SETUP #1059

Facility

$70.00

Hospital Charge Code	4500460
Hospital Revenue Code	271
Rate for Payer: Cash Price	$63.00

02 REBR. MASK SETUP #1059

Facility

$70.00

Hospital Charge Code	4500460
Hospital Revenue Code	271
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$49.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$41.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$49.98
Rate for Payer: Cash Price	$63.00
Rate for Payer: UnitedHealthcare Commercial	$46.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.20

02 VENTI-MASK SETUP

Facility

$70.00

Hospital Charge Code	4500470
Hospital Revenue Code	271
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$49.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$41.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$49.98
Rate for Payer: Cash Price	$63.00
Rate for Payer: UnitedHealthcare Commercial	$46.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.20

02 VENTI-MASK SETUP

Facility

$70.00

Hospital Charge Code	4500470
Hospital Revenue Code	271
Rate for Payer: Cash Price	$63.00

1000CC STERIL H2 0

Facility

$43.00

Hospital Charge Code	289367
Hospital Revenue Code	271
Rate for Payer: Cash Price	$38.70

1000CC STERIL H2 0

Facility

$52.00

Hospital Charge Code	129367
Hospital Revenue Code	271
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$37.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$30.78
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$37.13
Rate for Payer: Cash Price	$46.80
Rate for Payer: UnitedHealthcare Commercial	$34.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.72

1000CC STERIL H2 0

Facility

$43.00

Hospital Charge Code	289367
Hospital Revenue Code	271
Min. Negotiated Rate	$15.48
Max. Negotiated Rate	$30.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$25.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$30.70
Rate for Payer: Cash Price	$38.70
Rate for Payer: UnitedHealthcare Commercial	$28.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.48

1000CC STERIL H2 0

Facility

$52.00

Hospital Charge Code	129367
Hospital Revenue Code	271
Rate for Payer: Cash Price	$46.80

1010 DRAPE 3M1010

Facility

$106.00

Hospital Charge Code	124700
Hospital Revenue Code	271
Rate for Payer: Cash Price	$95.40

1010 DRAPE 3M1010

Facility

$106.00

Hospital Charge Code	124700
Hospital Revenue Code	271
Min. Negotiated Rate	$38.16
Max. Negotiated Rate	$75.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$62.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$75.68
Rate for Payer: Cash Price	$95.40
Rate for Payer: UnitedHealthcare Commercial	$70.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$38.16

10+ LESIONS, REMOVAL

Facility

$61.00

Service Code	CPT 11201
Hospital Charge Code	4111201
Hospital Revenue Code	521
Min. Negotiated Rate	$36.11
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$36.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$43.55
Rate for Payer: Cash Price	$54.90
Rate for Payer: Cash Price	$54.90
Rate for Payer: UnitedHealthcare Commercial	$40.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

10+ LESIONS, REMOVAL

Facility

$61.00

Service Code	CPT 11201
Hospital Charge Code	4111201
Hospital Revenue Code	521
Rate for Payer: Cash Price	$54.90

10X10 MM KIT

Facility

$2,512.00

Hospital Charge Code	123330
Hospital Revenue Code	271
Rate for Payer: Cash Price	$2,260.80

10X10 MM KIT

Facility

$2,512.00

Hospital Charge Code	123330
Hospital Revenue Code	271
Min. Negotiated Rate	$904.32
Max. Negotiated Rate	$1,793.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,487.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,793.57
Rate for Payer: Cash Price	$2,260.80
Rate for Payer: UnitedHealthcare Commercial	$1,675.50
Rate for Payer: UnitedHealthcare Medicare Advantage	$904.32

10X10X1.5 SCREW

Facility

$1,952.00

Hospital Charge Code	123320
Hospital Revenue Code	271
Min. Negotiated Rate	$702.72
Max. Negotiated Rate	$1,393.73
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,155.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,393.73
Rate for Payer: Cash Price	$1,756.80
Rate for Payer: UnitedHealthcare Commercial	$1,301.98
Rate for Payer: UnitedHealthcare Medicare Advantage	$702.72

10X10X1.5 SCREW

Facility

$1,952.00

Hospital Charge Code	123320
Hospital Revenue Code	271
Rate for Payer: Cash Price	$1,756.80

11 BETA-PROSTAGLANDIN F2 ALPHA, UR (AEL)

Facility

$227.00

Service Code	CPT 82570
Hospital Charge Code	22282570
Hospital Revenue Code	301
Rate for Payer: Cash Price	$204.30

11 BETA-PROSTAGLANDIN F2 ALPHA, UR (AEL)

Facility

$227.00

Service Code	CPT 82570
Hospital Charge Code	22282570
Hospital Revenue Code	301
Min. Negotiated Rate	$4.66
Max. Negotiated Rate	$162.08
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.66
Rate for Payer: Aetna Medicare Advantage	$5.18
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$134.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$162.08
Rate for Payer: Cash Price	$204.30
Rate for Payer: Cash Price	$204.30
Rate for Payer: Cash Price	$204.30
Rate for Payer: Cigna Commercial HMO & PPO	$5.18
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.66
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4.99
Rate for Payer: Home State Health Plan Medicare Advantage	$5.18
Rate for Payer: Humana Commercial	$10.36
Rate for Payer: Humana Medicare Advantage	$5.18
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.66
Rate for Payer: UnitedHealthcare Medicare Advantage	$81.72

12FR STOMACH TUBE/LEVIN TYPE

Facility

$28.00

Hospital Charge Code	2819470
Hospital Revenue Code	271
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

12FR STOMACH TUBE/LEVIN TYPE

Facility

$28.00

Hospital Charge Code	2819470
Hospital Revenue Code	271
Rate for Payer: Cash Price	$25.20

14FR SALEM SUMP

Facility

$42.00

Hospital Charge Code	2819063
Hospital Revenue Code	270
Rate for Payer: Cash Price	$37.80

14FR SALEM SUMP

Facility

$42.00

Hospital Charge Code	2819063
Hospital Revenue Code	270
Min. Negotiated Rate	$15.12
Max. Negotiated Rate	$29.99
Rate for Payer: UnitedHealthcare Commercial	$28.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$24.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$29.99
Rate for Payer: Cash Price	$37.80
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.12

14FR STOMACH TUBE/LEVIN TYPE

Facility

$28.00

Hospital Charge Code	2819471
Hospital Revenue Code	271
Rate for Payer: Cash Price	$25.20

Know your out-of-pocket cost for care.

All Charges