Madison Medical Center

All Charges

Charge

Type

Setting

Price

CRYOFREEZE 2 - 14 LESIONS

Facility

$55.00

Service Code	CPT 17003
Hospital Charge Code	5217003
Hospital Revenue Code	521
Min. Negotiated Rate	$32.56
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE 2 - 14 LESIONS

Facility

$55.00

Service Code	CPT 17003
Hospital Charge Code	9517003
Hospital Revenue Code	521
Min. Negotiated Rate	$32.56
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE 2ND THRU 14 LESIONS

Facility

$55.00

Service Code	CPT 17003
Hospital Charge Code	4217003
Hospital Revenue Code	521
Min. Negotiated Rate	$32.56
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE 2ND THRU 14 LESIONS

Facility

$55.00

Service Code	CPT 17003
Hospital Charge Code	5417003
Hospital Revenue Code	521
Min. Negotiated Rate	$32.56
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE 2ND THRU 14 LESIONS

Facility

$55.00

Service Code	CPT 17003
Hospital Charge Code	4217003
Hospital Revenue Code	521
Rate for Payer: Cash Price	$49.50

CRYOFREEZE 2ND THRU 14 LESIONS

Facility

$55.00

Service Code	CPT 17003
Hospital Charge Code	5417003
Hospital Revenue Code	521
Rate for Payer: Cash Price	$49.50

CRYOFREEZE BENIGN UP TO 14 LESIONS

Facility

$125.00

Service Code	CPT 17110
Hospital Charge Code	9817110
Hospital Revenue Code	521
Min. Negotiated Rate	$74.00
Max. Negotiated Rate	$409.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$180.86
Rate for Payer: Aetna Medicare Advantage	$204.98
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: Cash Price	$112.50
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$193.52
Rate for Payer: Home State Health Plan Medicare Advantage	$204.98
Rate for Payer: Humana Commercial	$409.96
Rate for Payer: Humana Medicare Advantage	$204.98
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE BENIGN UP TO 14 LESIONS

Facility

$110.00

Service Code	CPT 17110
Hospital Charge Code	4217110
Hospital Revenue Code	521
Rate for Payer: Cash Price	$99.00

CRYOFREEZE BENIGN UP TO 14 LESIONS

Facility

$125.00

Service Code	CPT 17110
Hospital Charge Code	9817110
Hospital Revenue Code	521
Rate for Payer: Cash Price	$112.50

CRYOFREEZE BENIGN UP TO 14 LESIONS

Facility

$110.00

Service Code	CPT 17110
Hospital Charge Code	4217110
Hospital Revenue Code	521
Min. Negotiated Rate	$65.12
Max. Negotiated Rate	$409.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$180.86
Rate for Payer: Aetna Medicare Advantage	$204.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$78.54
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$193.52
Rate for Payer: Home State Health Plan Medicare Advantage	$204.98
Rate for Payer: Humana Commercial	$409.96
Rate for Payer: Humana Medicare Advantage	$204.98
Rate for Payer: UnitedHealthcare Commercial	$73.37
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE BEN UP TO 14 LESIONS

Facility

$110.00

Service Code	CPT 17110
Hospital Charge Code	9617110
Hospital Revenue Code	521
Min. Negotiated Rate	$65.12
Max. Negotiated Rate	$409.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$180.86
Rate for Payer: Aetna Medicare Advantage	$204.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$78.54
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$193.52
Rate for Payer: Home State Health Plan Medicare Advantage	$204.98
Rate for Payer: Humana Commercial	$409.96
Rate for Payer: Humana Medicare Advantage	$204.98
Rate for Payer: UnitedHealthcare Commercial	$73.37
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE BEN UP TO 14 LESIONS

Facility

$110.00

Service Code	CPT 17110
Hospital Charge Code	9617110
Hospital Revenue Code	521
Rate for Payer: Cash Price	$99.00

CRYOFREEZE FIFTEEN OR MORE LESIONS

Facility

$198.00

Service Code	CPT 17004
Hospital Charge Code	9817004
Hospital Revenue Code	521
Min. Negotiated Rate	$117.22
Max. Negotiated Rate	$830.64
Rate for Payer: Aetna Better Health Medicaid/QHP	$366.45
Rate for Payer: Aetna Medicare Advantage	$415.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$117.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$141.37
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cigna Commercial HMO & PPO	$415.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$329.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$392.10
Rate for Payer: Home State Health Plan Medicare Advantage	$415.32
Rate for Payer: Humana Commercial	$830.64
Rate for Payer: Humana Medicare Advantage	$415.32
Rate for Payer: UnitedHealthcare Commercial	$132.07
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE FIFTEEN OR MORE LESIONS

Facility

$198.00

Service Code	CPT 17004
Hospital Charge Code	9817004
Hospital Revenue Code	521
Rate for Payer: Cash Price	$178.20

CRYOFREEZE FIRST LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	9817000
Hospital Revenue Code	521
Rate for Payer: Cash Price	$130.50

CRYOFREEZE FIRST LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	9817000
Hospital Revenue Code	521
Min. Negotiated Rate	$85.84
Max. Negotiated Rate	$409.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$180.86
Rate for Payer: Aetna Medicare Advantage	$204.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$85.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$103.53
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$193.52
Rate for Payer: Home State Health Plan Medicare Advantage	$204.98
Rate for Payer: Humana Commercial	$409.96
Rate for Payer: Humana Medicare Advantage	$204.98
Rate for Payer: UnitedHealthcare Commercial	$96.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE FIRST LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	4217000
Hospital Revenue Code	521
Rate for Payer: Cash Price	$130.50

CRYOFREEZE FIRST LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	4217000
Hospital Revenue Code	521
Min. Negotiated Rate	$85.84
Max. Negotiated Rate	$409.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$180.86
Rate for Payer: Aetna Medicare Advantage	$204.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$85.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$103.53
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$193.52
Rate for Payer: Home State Health Plan Medicare Advantage	$204.98
Rate for Payer: Humana Commercial	$409.96
Rate for Payer: Humana Medicare Advantage	$204.98
Rate for Payer: UnitedHealthcare Commercial	$96.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE FIRST LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	5417000
Hospital Revenue Code	521
Rate for Payer: Cash Price	$130.50

CRYOFREEZE FIRST LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	9517000
Hospital Revenue Code	521
Rate for Payer: Cash Price	$130.50

CRYOFREEZE FIRST LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	9517000
Hospital Revenue Code	521
Min. Negotiated Rate	$85.84
Max. Negotiated Rate	$409.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$180.86
Rate for Payer: Aetna Medicare Advantage	$204.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$85.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$103.53
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$193.52
Rate for Payer: Home State Health Plan Medicare Advantage	$204.98
Rate for Payer: Humana Commercial	$409.96
Rate for Payer: Humana Medicare Advantage	$204.98
Rate for Payer: UnitedHealthcare Commercial	$96.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE FIRST LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	3917000
Hospital Revenue Code	521
Min. Negotiated Rate	$85.84
Max. Negotiated Rate	$409.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$180.86
Rate for Payer: Aetna Medicare Advantage	$204.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$85.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$103.53
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$193.52
Rate for Payer: Home State Health Plan Medicare Advantage	$204.98
Rate for Payer: Humana Commercial	$409.96
Rate for Payer: Humana Medicare Advantage	$204.98
Rate for Payer: UnitedHealthcare Commercial	$96.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE FIRST LESION

Facility

$45.00

Service Code	CPT 17000
Hospital Charge Code	9617000
Hospital Revenue Code	521
Rate for Payer: Cash Price	$40.50

CRYOFREEZE FIRST LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	5417000
Hospital Revenue Code	521
Min. Negotiated Rate	$85.84
Max. Negotiated Rate	$409.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$180.86
Rate for Payer: Aetna Medicare Advantage	$204.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$85.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$103.53
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$193.52
Rate for Payer: Home State Health Plan Medicare Advantage	$204.98
Rate for Payer: Humana Commercial	$409.96
Rate for Payer: Humana Medicare Advantage	$204.98
Rate for Payer: UnitedHealthcare Commercial	$96.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CRYOFREEZE FIRST LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	9217000
Hospital Revenue Code	521
Min. Negotiated Rate	$85.84
Max. Negotiated Rate	$409.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$180.86
Rate for Payer: Aetna Medicare Advantage	$204.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$85.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$103.53
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$193.52
Rate for Payer: Home State Health Plan Medicare Advantage	$204.98
Rate for Payer: Humana Commercial	$409.96
Rate for Payer: Humana Medicare Advantage	$204.98
Rate for Payer: UnitedHealthcare Commercial	$96.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Know your out-of-pocket cost for care.

All Charges