Madison Medical Center

All Charges

Charge

Type

Setting

Price

CL- ZOOSTER SHINGLES VACCINE OLIVERO

Facility

$600.00

Service Code	HCPCS 90750
Hospital Charge Code	5490750
Hospital Revenue Code	636
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$428.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$355.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$428.40
Rate for Payer: Cash Price	$540.00
Rate for Payer: UnitedHealthcare Commercial	$400.20
Rate for Payer: UnitedHealthcare Medicare Advantage	$216.00

CL - ZOSTAVAX

Facility

$200.00

Service Code	HCPCS 90736
Hospital Charge Code	9490736
Hospital Revenue Code	636
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$142.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$118.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$142.80
Rate for Payer: Cash Price	$180.00
Rate for Payer: UnitedHealthcare Commercial	$133.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$72.00

CL - ZOSTAVAX

Facility

$200.00

Service Code	HCPCS 90736
Hospital Charge Code	9490736
Hospital Revenue Code	636
Min. Negotiated Rate	$133.40
Max. Negotiated Rate	$133.40
Rate for Payer: Cash Price	$180.00
Rate for Payer: UnitedHealthcare Commercial	$133.40

CL-ZOSTAVAX OLIVERO

Facility

$200.00

Service Code	HCPCS 90736
Hospital Charge Code	5490736
Hospital Revenue Code	636
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$142.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$118.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$142.80
Rate for Payer: Cash Price	$180.00
Rate for Payer: UnitedHealthcare Commercial	$133.40
Rate for Payer: UnitedHealthcare Medicare Advantage	$72.00

CL-ZOSTAVAX OLIVERO

Facility

$200.00

Service Code	HCPCS 90736
Hospital Charge Code	5490736
Hospital Revenue Code	636
Min. Negotiated Rate	$133.40
Max. Negotiated Rate	$133.40
Rate for Payer: Cash Price	$180.00
Rate for Payer: UnitedHealthcare Commercial	$133.40

CMP COMPREHENSIVE MET PROFILE

Facility

$381.00

Service Code	CPT 80053
Hospital Charge Code	221552
Hospital Revenue Code	301
Rate for Payer: Cash Price	$342.90

CMP COMPREHENSIVE MET PROFILE

Facility

$381.00

Service Code	CPT 80053
Hospital Charge Code	221552
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$272.03
Rate for Payer: Aetna Better Health Medicaid/QHP	$9.50
Rate for Payer: Aetna Medicare Advantage	$10.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$225.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$272.03
Rate for Payer: Cash Price	$342.90
Rate for Payer: Cash Price	$342.90
Rate for Payer: Cash Price	$342.90
Rate for Payer: Cigna Commercial HMO & PPO	$10.56
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$9.50
Rate for Payer: Home State Health Plan Medicaid Managed Care	$10.16
Rate for Payer: Home State Health Plan Medicare Advantage	$10.56
Rate for Payer: Humana Commercial	$21.12
Rate for Payer: Humana Medicare Advantage	$10.56
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$9.50
Rate for Payer: UnitedHealthcare Medicare Advantage	$137.16

CMP-PICCOLO

Facility

$381.00

Service Code	CPT 80053
Hospital Charge Code	221553
Hospital Revenue Code	301
Rate for Payer: Cash Price	$342.90

CMP-PICCOLO

Facility

$381.00

Service Code	CPT 80053
Hospital Charge Code	221553
Hospital Revenue Code	301
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$272.03
Rate for Payer: Aetna Better Health Medicaid/QHP	$9.50
Rate for Payer: Aetna Medicare Advantage	$10.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$225.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$272.03
Rate for Payer: Cash Price	$342.90
Rate for Payer: Cash Price	$342.90
Rate for Payer: Cash Price	$342.90
Rate for Payer: Cigna Commercial HMO & PPO	$10.56
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$9.50
Rate for Payer: Home State Health Plan Medicaid Managed Care	$10.16
Rate for Payer: Home State Health Plan Medicare Advantage	$10.56
Rate for Payer: Humana Commercial	$21.12
Rate for Payer: Humana Medicare Advantage	$10.56
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$9.50
Rate for Payer: UnitedHealthcare Medicare Advantage	$137.16

CMV BY PCR - QUANTITATIVE

Facility

$422.00

Service Code	CPT 87497
Hospital Charge Code	2287497
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$301.31
Rate for Payer: Aetna Better Health Medicaid/QHP	$38.56
Rate for Payer: Aetna Medicare Advantage	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$249.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$301.31
Rate for Payer: Cash Price	$379.80
Rate for Payer: Cash Price	$379.80
Rate for Payer: Cash Price	$379.80
Rate for Payer: Cigna Commercial HMO & PPO	$42.84
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$38.56
Rate for Payer: Home State Health Plan Medicaid Managed Care	$41.26
Rate for Payer: Home State Health Plan Medicare Advantage	$42.84
Rate for Payer: Humana Commercial	$85.68
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$38.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$151.92

CMV BY PCR - QUANTITATIVE

Facility

$422.00

Service Code	CPT 87497
Hospital Charge Code	2287497
Hospital Revenue Code	301
Rate for Payer: Cash Price	$379.80

CMV, CULTURE

Facility

$214.00

Service Code	CPT 87252
Hospital Charge Code	2287252
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$152.80
Rate for Payer: Aetna Better Health Medicaid/QHP	$23.46
Rate for Payer: Aetna Medicare Advantage	$26.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$126.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$152.80
Rate for Payer: Cash Price	$192.60
Rate for Payer: Cash Price	$192.60
Rate for Payer: Cash Price	$192.60
Rate for Payer: Cigna Commercial HMO & PPO	$26.07
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$23.46
Rate for Payer: Home State Health Plan Medicaid Managed Care	$25.10
Rate for Payer: Home State Health Plan Medicare Advantage	$26.07
Rate for Payer: Humana Commercial	$52.14
Rate for Payer: Humana Medicare Advantage	$26.07
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$23.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$77.04

CMV, CULTURE

Facility

$214.00

Service Code	CPT 87252
Hospital Charge Code	2287252
Hospital Revenue Code	301
Rate for Payer: Cash Price	$192.60

CMV IGG

Facility

$138.00

Service Code	CPT 86644
Hospital Charge Code	223961
Hospital Revenue Code	301
Min. Negotiated Rate	$12.95
Max. Negotiated Rate	$98.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$12.95
Rate for Payer: Aetna Medicare Advantage	$14.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$98.53
Rate for Payer: Cash Price	$124.20
Rate for Payer: Cash Price	$124.20
Rate for Payer: Cash Price	$124.20
Rate for Payer: Cigna Commercial HMO & PPO	$14.39
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.86
Rate for Payer: Home State Health Plan Medicare Advantage	$14.39
Rate for Payer: Humana Commercial	$28.78
Rate for Payer: Humana Medicare Advantage	$14.39
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12.95
Rate for Payer: UnitedHealthcare Medicare Advantage	$49.68

CMV IGG

Facility

$138.00

Service Code	CPT 86644
Hospital Charge Code	223961
Hospital Revenue Code	301
Rate for Payer: Cash Price	$124.20

CMV IGM

Facility

$138.00

Service Code	CPT 86645
Hospital Charge Code	2286645
Hospital Revenue Code	301
Min. Negotiated Rate	$15.17
Max. Negotiated Rate	$98.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.17
Rate for Payer: Aetna Medicare Advantage	$16.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$98.53
Rate for Payer: Cash Price	$124.20
Rate for Payer: Cash Price	$124.20
Rate for Payer: Cash Price	$124.20
Rate for Payer: Cigna Commercial HMO & PPO	$16.85
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.17
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16.23
Rate for Payer: Home State Health Plan Medicare Advantage	$16.85
Rate for Payer: Humana Commercial	$33.70
Rate for Payer: Humana Medicare Advantage	$16.85
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.17
Rate for Payer: UnitedHealthcare Medicare Advantage	$49.68

CMV IGM

Facility

$138.00

Service Code	CPT 86645
Hospital Charge Code	2286645
Hospital Revenue Code	301
Rate for Payer: Cash Price	$124.20

CO2 LASER

Facility

$4,430.00

Hospital Charge Code	12150000
Hospital Revenue Code	360
Min. Negotiated Rate	$1,594.80
Max. Negotiated Rate	$2,954.81
Rate for Payer: Cash Price	$3,987.00
Rate for Payer: UnitedHealthcare Commercial	$2,954.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,594.80

CO2 LASER

Facility

$4,430.00

Hospital Charge Code	12150000
Hospital Revenue Code	360
Rate for Payer: Cash Price	$3,987.00

CO2 MONITORING CANNULA

Facility

$104.00

Hospital Charge Code	1299114
Hospital Revenue Code	271
Min. Negotiated Rate	$37.44
Max. Negotiated Rate	$74.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$61.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$74.26
Rate for Payer: Cash Price	$93.60
Rate for Payer: UnitedHealthcare Commercial	$69.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$37.44

CO2 MONITORING CANNULA

Facility

$104.00

Hospital Charge Code	1299114
Hospital Revenue Code	271
Rate for Payer: Cash Price	$93.60

COAGULATION AND PLATELET DISORDERS

Facility

$28,152.48

Service Code	APR-DRG 6613
Min. Negotiated Rate	$28,152.48
Max. Negotiated Rate	$28,152.48
Rate for Payer: Aetna Better Health Medicaid/QHP	$28,152.48
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$28,152.48
Rate for Payer: Home State Health Plan Medicaid Managed Care	$28,152.48
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$28,152.48

COAGULATION AND PLATELET DISORDERS

Facility

$37,793.00

Service Code	APR-DRG 6614
Min. Negotiated Rate	$37,793.00
Max. Negotiated Rate	$37,793.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$37,793.00
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$37,793.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$37,793.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$37,793.00

COAGULATION AND PLATELET DISORDERS

Facility

$8,831.49

Service Code	APR-DRG 6612
Min. Negotiated Rate	$8,831.49
Max. Negotiated Rate	$8,831.49
Rate for Payer: Aetna Better Health Medicaid/QHP	$8,831.49
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8,831.49
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8,831.49
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8,831.49

COAGULATION AND PLATELET DISORDERS

Facility

$7,204.95

Service Code	APR-DRG 6611
Min. Negotiated Rate	$7,204.95
Max. Negotiated Rate	$7,204.95
Rate for Payer: Aetna Better Health Medicaid/QHP	$7,204.95
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$7,204.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$7,204.95
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$7,204.95

Know your out-of-pocket cost for care.

All Charges