Madison Medical Center

All Charges

Charge

Type

Setting

Price

CLOSED TX PHALANGEAL SHAFT FX W/O MANIPU

Facility

$935.00

Service Code	CPT 26720
Hospital Charge Code	9326720
Hospital Revenue Code	521
Rate for Payer: Cash Price	$841.50

CLOSED TX PROX HUMERAL FX W/O MANI

Facility

$1,112.00

Service Code	CPT 23600
Hospital Charge Code	9323600
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$793.97
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$658.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$793.97
Rate for Payer: Cash Price	$1,000.80
Rate for Payer: Cash Price	$1,000.80
Rate for Payer: Cash Price	$1,000.80
Rate for Payer: Cash Price	$1,000.80
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$741.70
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CLOSED TX PROX HUMERAL FX W/O MANI

Facility

$1,112.00

Service Code	CPT 23600
Hospital Charge Code	9323600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$1,000.80

CLOSED TX RADIAL HEAD FX W/O MANI

Facility

$930.00

Service Code	CPT 24650
Hospital Charge Code	9324650
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$664.02
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$550.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$664.02
Rate for Payer: Cash Price	$837.00
Rate for Payer: Cash Price	$837.00
Rate for Payer: Cash Price	$837.00
Rate for Payer: Cash Price	$837.00
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$620.31
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CLOSED TX RADIAL HEAD FX W/O MANI

Facility

$930.00

Service Code	CPT 24650
Hospital Charge Code	9324650
Hospital Revenue Code	521
Rate for Payer: Cash Price	$837.00

CLOSED TX SCAPULAR FX W/O MANI

Facility

$830.00

Service Code	CPT 23570
Hospital Charge Code	9323570
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$592.62
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$491.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$592.62
Rate for Payer: Cash Price	$747.00
Rate for Payer: Cash Price	$747.00
Rate for Payer: Cash Price	$747.00
Rate for Payer: Cash Price	$747.00
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$553.61
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CLOSED TX SCAPULAR FX W/O MANI

Facility

$830.00

Service Code	CPT 23570
Hospital Charge Code	9323570
Hospital Revenue Code	521
Rate for Payer: Cash Price	$747.00

CLOSED TX SHOULDER DISLOCATION W/O ANEST

Facility

$800.00

Service Code	CPT 23650
Hospital Charge Code	5423650
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$571.20
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$473.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$571.20
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$533.60
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CLOSED TX SHOULDER DISLOCATION W/O ANEST

Facility

$800.00

Service Code	CPT 23650
Hospital Charge Code	5423650
Hospital Revenue Code	521
Rate for Payer: Cash Price	$720.00

CLOSE FACE,EARS 2.66 TO 5.0CM

Professional

Both

$1,161.00

Service Code	CPT 12052
Hospital Charge Code	1812052
Hospital Revenue Code	981
Min. Negotiated Rate	$163.03
Max. Negotiated Rate	$406.35
Rate for Payer: Aetna Commercial/Medicare Advantage	$163.03
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$239.90
Rate for Payer: Cash Price	$1,044.90
Rate for Payer: Cash Price	$1,044.90
Rate for Payer: Cigna Commercial HMO & PPO	$163.03
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$239.90
Rate for Payer: Home State Health Plan Medicaid Managed Care	$263.89
Rate for Payer: Home State Health Plan Medicare Advantage	$163.03
Rate for Payer: Optum Medicare Advantage	$406.35
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$239.90

CLOSE FACE,EARS-ETC.7.6-12.5CM

Professional

Both

$1,349.00

Service Code	CPT 12054
Hospital Charge Code	1812054
Hospital Revenue Code	981
Min. Negotiated Rate	$187.50
Max. Negotiated Rate	$472.15
Rate for Payer: Aetna Commercial/Medicare Advantage	$187.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$293.75
Rate for Payer: Cash Price	$1,214.10
Rate for Payer: Cash Price	$1,214.10
Rate for Payer: Cigna Commercial HMO & PPO	$187.50
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$293.75
Rate for Payer: Home State Health Plan Medicaid Managed Care	$323.12
Rate for Payer: Home State Health Plan Medicare Advantage	$187.50
Rate for Payer: Optum Medicare Advantage	$472.15
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$293.75

CLOSE-NECK,HAND 2.6 TO 7.5CM

Professional

Both

$996.00

Service Code	CPT 12042
Hospital Charge Code	1812042
Hospital Revenue Code	981
Min. Negotiated Rate	$158.77
Max. Negotiated Rate	$348.60
Rate for Payer: Aetna Commercial/Medicare Advantage	$158.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$235.84
Rate for Payer: Cash Price	$896.40
Rate for Payer: Cash Price	$896.40
Rate for Payer: Cigna Commercial HMO & PPO	$158.77
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$235.84
Rate for Payer: Home State Health Plan Medicaid Managed Care	$259.42
Rate for Payer: Home State Health Plan Medicare Advantage	$158.77
Rate for Payer: Optum Medicare Advantage	$348.60
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$235.84

CLOSE-NECK,HAND FEET TO 2.5CM

Professional

Both

$849.00

Service Code	CPT 12041
Hospital Charge Code	1812041
Hospital Revenue Code	981
Min. Negotiated Rate	$121.81
Max. Negotiated Rate	$297.15
Rate for Payer: Aetna Commercial/Medicare Advantage	$121.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$201.62
Rate for Payer: Cash Price	$764.10
Rate for Payer: Cash Price	$764.10
Rate for Payer: Cigna Commercial HMO & PPO	$121.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$201.62
Rate for Payer: Home State Health Plan Medicaid Managed Care	$221.78
Rate for Payer: Home State Health Plan Medicare Advantage	$121.81
Rate for Payer: Optum Medicare Advantage	$297.15
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$201.62

CLOSE SHLDR,W/MANUP-WO/ANESTH

Professional

Both

$1,710.00

Service Code	CPT 23650
Hospital Charge Code	1823650
Hospital Revenue Code	981
Min. Negotiated Rate	$249.82
Max. Negotiated Rate	$598.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$335.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$249.82
Rate for Payer: Cash Price	$1,539.00
Rate for Payer: Cash Price	$1,539.00
Rate for Payer: Cigna Commercial HMO & PPO	$335.92
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$249.82
Rate for Payer: Home State Health Plan Medicaid Managed Care	$274.80
Rate for Payer: Home State Health Plan Medicare Advantage	$335.92
Rate for Payer: Optum Medicare Advantage	$598.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$249.82

CLOSURE LAYER, 12.6-20.0CM

Professional

Both

$1,509.00

Service Code	CPT 12035
Hospital Charge Code	1812035
Hospital Revenue Code	981
Min. Negotiated Rate	$211.52
Max. Negotiated Rate	$528.15
Rate for Payer: Aetna Commercial/Medicare Advantage	$211.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$295.85
Rate for Payer: Cash Price	$1,358.10
Rate for Payer: Cash Price	$1,358.10
Rate for Payer: Cigna Commercial HMO & PPO	$211.52
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$295.85
Rate for Payer: Home State Health Plan Medicaid Managed Care	$325.44
Rate for Payer: Home State Health Plan Medicare Advantage	$211.52
Rate for Payer: Optum Medicare Advantage	$528.15
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$295.85

CLOSURE OF LACERTAION,VEST MOUTH UND 2.5

Facility

$244.00

Service Code	CPT 40830
Hospital Charge Code	4140830
Hospital Revenue Code	521
Min. Negotiated Rate	$144.45
Max. Negotiated Rate	$483.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$213.51
Rate for Payer: Aetna Medicare Advantage	$241.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$144.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$174.22
Rate for Payer: Cash Price	$219.60
Rate for Payer: Cash Price	$219.60
Rate for Payer: Cash Price	$219.60
Rate for Payer: Cash Price	$219.60
Rate for Payer: Cigna Commercial HMO & PPO	$241.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$192.16
Rate for Payer: Home State Health Plan Medicaid Managed Care	$228.46
Rate for Payer: Home State Health Plan Medicare Advantage	$241.98
Rate for Payer: Humana Commercial	$483.96
Rate for Payer: Humana Medicare Advantage	$241.98
Rate for Payer: UnitedHealthcare Commercial	$162.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$213.51
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CLOSURE OF LACERTAION,VEST MOUTH UND 2.5

Facility

$244.00

Service Code	CPT 40830
Hospital Charge Code	4140830
Hospital Revenue Code	521
Rate for Payer: Cash Price	$219.60

CLOTEST

Facility

$125.00

Hospital Charge Code	1219014
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

CLOTEST

Facility

$125.00

Hospital Charge Code	1219014
Hospital Revenue Code	271
Rate for Payer: Cash Price	$112.50

CLOTR/BETA DIP CREAM 15GM EMP

Facility

$273.00

Service Code	NDC 6.8462E+10
Hospital Charge Code	2623221
Hospital Revenue Code	250
Min. Negotiated Rate	$98.28
Max. Negotiated Rate	$194.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$161.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$194.92
Rate for Payer: Cash Price	$245.70
Rate for Payer: UnitedHealthcare Commercial	$182.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$98.28

CLOTR/BETA DIP CREAM 15GM EMP

Facility

$273.00

Service Code	NDC 6.8462E+10
Hospital Charge Code	2623221
Hospital Revenue Code	250
Rate for Payer: Cash Price	$245.70

CLOTRIMAZOLE (LOTRIMIN) 1% CRM 28.35GM

Facility

$171.00

Service Code	NDC 904782231
Hospital Charge Code	2655447
Hospital Revenue Code	250
Rate for Payer: Cash Price	$153.90

CLOTRIMAZOLE (LOTRIMIN) 1% CRM 28.35GM

Facility

$171.00

Service Code	NDC 904782231
Hospital Charge Code	2655447
Hospital Revenue Code	250
Min. Negotiated Rate	$61.56
Max. Negotiated Rate	$122.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$101.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$122.09
Rate for Payer: Cash Price	$153.90
Rate for Payer: UnitedHealthcare Commercial	$114.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$61.56

CLOTRIMAZOLE (MYCELEX) 10MG LOZENGE

Facility

$67.00

Service Code	NDC 574010770
Hospital Charge Code	2697070
Hospital Revenue Code	250
Rate for Payer: Cash Price	$60.30

CLOTRIMAZOLE (MYCELEX) 10MG LOZENGE

Facility

$67.00

Service Code	NDC 574010770
Hospital Charge Code	2697070
Hospital Revenue Code	250
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$47.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.84
Rate for Payer: Cash Price	$60.30
Rate for Payer: UnitedHealthcare Commercial	$44.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.12

Know your out-of-pocket cost for care.

All Charges