Madison Medical Center

All Charges

Charge

Type

Setting

Price

CYSTOURETHROSCOPY

Facility

$261.00

Service Code	CPT 520000
Hospital Charge Code	5252000
Hospital Revenue Code	521
Min. Negotiated Rate	$154.51
Max. Negotiated Rate	$186.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$154.51
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$186.35
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cash Price	$234.90
Rate for Payer: UnitedHealthcare Commercial	$174.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CYSTOURETHROSCOPY

Professional

Both

$695.00

Service Code	CPT 52005-80
Hospital Charge Code	4152005
Hospital Revenue Code	975
Min. Negotiated Rate	$243.25
Max. Negotiated Rate	$243.25
Rate for Payer: Cash Price	$625.50
Rate for Payer: Optum Medicare Advantage	$243.25

Cystourethroscopy (separate procedure)

Facility

$1,424.80

Service Code	CPT 52000
Hospital Revenue Code	490
Min. Negotiated Rate	$628.57
Max. Negotiated Rate	$1,424.80
Rate for Payer: Aetna Better Health Medicaid/QHP	$628.57
Rate for Payer: Aetna Medicare Advantage	$712.40
Rate for Payer: Cigna Commercial HMO & PPO	$712.40
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$628.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$672.57
Rate for Payer: Home State Health Plan Medicare Advantage	$712.40
Rate for Payer: Humana Commercial	$1,424.80
Rate for Payer: Humana Medicare Advantage	$712.40
Rate for Payer: UnitedHealthcare Commercial	$947.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$628.57

Cystourethroscopy (separate procedure)

Facility

$1,424.80

Service Code	CPT 52000
Hospital Revenue Code	360
Min. Negotiated Rate	$628.57
Max. Negotiated Rate	$1,424.80
Rate for Payer: Aetna Better Health Medicaid/QHP	$628.57
Rate for Payer: Aetna Medicare Advantage	$712.40
Rate for Payer: Cigna Commercial HMO & PPO	$712.40
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$628.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$672.57
Rate for Payer: Home State Health Plan Medicare Advantage	$712.40
Rate for Payer: Humana Commercial	$1,424.80
Rate for Payer: Humana Medicare Advantage	$712.40
Rate for Payer: UnitedHealthcare Commercial	$947.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$628.57

CYSTOURETHROSCOPY W/INS EA ADD'L IMPLANT

Professional

Both

$500.00

Service Code	CPT 52442
Hospital Charge Code	9352442
Hospital Revenue Code	975
Min. Negotiated Rate	$43.01
Max. Negotiated Rate	$752.21
Rate for Payer: Aetna Commercial/Medicare Advantage	$43.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$683.83
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cigna Commercial HMO & PPO	$43.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$683.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$752.21
Rate for Payer: Home State Health Plan Medicare Advantage	$43.01
Rate for Payer: Optum Medicare Advantage	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$683.83

CYSTOURETHROSCOPY W/INS SINGLE IMPLANT

Professional

Both

$1,400.00

Service Code	CPT 52441
Hospital Charge Code	9352441
Hospital Revenue Code	975
Min. Negotiated Rate	$178.41
Max. Negotiated Rate	$1,095.27
Rate for Payer: Aetna Commercial/Medicare Advantage	$178.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$995.70
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Cigna Commercial HMO & PPO	$178.41
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$995.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,095.27
Rate for Payer: Home State Health Plan Medicare Advantage	$178.41
Rate for Payer: Optum Medicare Advantage	$490.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$995.70

CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA

Facility

$4,271.32

Service Code	CPT 52260
Hospital Revenue Code	360
Min. Negotiated Rate	$1,462.00
Max. Negotiated Rate	$4,271.32
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,884.38
Rate for Payer: Aetna Medicare Advantage	$2,135.66
Rate for Payer: Cigna Commercial HMO & PPO	$2,135.66
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,884.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$2,016.29
Rate for Payer: Home State Health Plan Medicare Advantage	$2,135.66
Rate for Payer: Humana Commercial	$4,271.32
Rate for Payer: Humana Medicare Advantage	$2,135.66
Rate for Payer: UnitedHealthcare Commercial	$1,462.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,884.38

Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple

Facility

$4,271.32

Service Code	CPT 52310
Hospital Revenue Code	490
Min. Negotiated Rate	$1,462.00
Max. Negotiated Rate	$4,271.32
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,884.38
Rate for Payer: Aetna Medicare Advantage	$2,135.66
Rate for Payer: Cigna Commercial HMO & PPO	$2,135.66
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,884.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$2,016.29
Rate for Payer: Home State Health Plan Medicare Advantage	$2,135.66
Rate for Payer: Humana Commercial	$4,271.32
Rate for Payer: Humana Medicare Advantage	$2,135.66
Rate for Payer: UnitedHealthcare Commercial	$1,462.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,884.38

CYSTOURETHROSCOPY, WITH URETERAL CATH

Facility

$695.00

Service Code	CPT 52005
Hospital Charge Code	5252005
Hospital Revenue Code	521
Rate for Payer: Cash Price	$625.50

CYSTOURETHROSCOPY, WITH URETERAL CATH

Facility

$695.00

Service Code	CPT 52005
Hospital Charge Code	5252005
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$4,271.32
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,884.38
Rate for Payer: Aetna Medicare Advantage	$2,135.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$411.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$496.23
Rate for Payer: Cash Price	$625.50
Rate for Payer: Cash Price	$625.50
Rate for Payer: Cash Price	$625.50
Rate for Payer: Cash Price	$625.50
Rate for Payer: Cigna Commercial HMO & PPO	$2,135.66
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,695.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$2,016.29
Rate for Payer: Home State Health Plan Medicare Advantage	$2,135.66
Rate for Payer: Humana Commercial	$4,271.32
Rate for Payer: Humana Medicare Advantage	$2,135.66
Rate for Payer: UnitedHealthcare Commercial	$463.56
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,884.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CYSTOURETHROSCOPY W REMOVAL OF STENT

Professional

Both

$1,300.00

Service Code	CPT 52310
Hospital Charge Code	9352310
Hospital Revenue Code	975
Min. Negotiated Rate	$130.01
Max. Negotiated Rate	$455.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$130.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$244.17
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Cigna Commercial HMO & PPO	$130.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$244.17
Rate for Payer: Home State Health Plan Medicaid Managed Care	$268.59
Rate for Payer: Home State Health Plan Medicare Advantage	$130.01
Rate for Payer: Optum Medicare Advantage	$455.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$244.17

CYSTOURETHROSCOPY W/SINGLE IMPLANT

Professional

Both

$1,400.00

Service Code	CPT 52441
Hospital Charge Code	9392441
Hospital Revenue Code	975
Min. Negotiated Rate	$178.41
Max. Negotiated Rate	$1,095.27
Rate for Payer: Aetna Commercial/Medicare Advantage	$178.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$995.70
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Cash Price	$1,260.00
Rate for Payer: Cigna Commercial HMO & PPO	$178.41
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$995.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,095.27
Rate for Payer: Home State Health Plan Medicare Advantage	$178.41
Rate for Payer: Optum Medicare Advantage	$490.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$995.70

CYTOLOGY

Facility

$62.00

Service Code	CPT 88104
Hospital Charge Code	4288104
Hospital Revenue Code	521
Min. Negotiated Rate	$30.30
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$33.67
Rate for Payer: Aetna Medicare Advantage	$38.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$36.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$44.27
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial HMO & PPO	$38.16
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$30.30
Rate for Payer: Home State Health Plan Medicaid Managed Care	$36.03
Rate for Payer: Home State Health Plan Medicare Advantage	$38.16
Rate for Payer: Humana Commercial	$76.32
Rate for Payer: Humana Medicare Advantage	$38.16
Rate for Payer: UnitedHealthcare Commercial	$41.35
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$33.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

CYTOLOGY

Facility

$62.00

Service Code	CPT 88104
Hospital Charge Code	4288104
Hospital Revenue Code	521
Rate for Payer: Cash Price	$55.80

CYTOLOGY

Facility

$339.00

Service Code	CPT 88108
Hospital Charge Code	2288104
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$242.05
Rate for Payer: Aetna Better Health Medicaid/QHP	$33.67
Rate for Payer: Aetna Medicare Advantage	$38.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$200.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$242.05
Rate for Payer: Cash Price	$305.10
Rate for Payer: Cash Price	$305.10
Rate for Payer: Cash Price	$305.10
Rate for Payer: Cigna Commercial HMO & PPO	$38.16
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$33.67
Rate for Payer: Home State Health Plan Medicaid Managed Care	$36.03
Rate for Payer: Home State Health Plan Medicare Advantage	$38.16
Rate for Payer: Humana Commercial	$76.32
Rate for Payer: Humana Medicare Advantage	$38.16
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$33.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$122.04

CYTOLOGY

Facility

$339.00

Service Code	CPT 88108
Hospital Charge Code	2288104
Hospital Revenue Code	301
Rate for Payer: Cash Price	$305.10

CYTOLOGY BRUSH

Facility

$437.00

Hospital Charge Code	1231202
Hospital Revenue Code	271
Min. Negotiated Rate	$157.32
Max. Negotiated Rate	$312.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$258.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$312.02
Rate for Payer: Cash Price	$393.30
Rate for Payer: UnitedHealthcare Commercial	$291.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$157.32

CYTOLOGY BRUSH

Facility

$437.00

Hospital Charge Code	1231202
Hospital Revenue Code	271
Rate for Payer: Cash Price	$393.30

CYTOLOGY SPUTUM

Facility

$339.00

Service Code	CPT 88104
Hospital Charge Code	2288108
Hospital Revenue Code	305
Rate for Payer: Cash Price	$305.10

CYTOLOGY SPUTUM

Facility

$339.00

Service Code	CPT 88104
Hospital Charge Code	2288108
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$242.05
Rate for Payer: Aetna Better Health Medicaid/QHP	$33.67
Rate for Payer: Aetna Medicare Advantage	$38.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$200.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$242.05
Rate for Payer: Cash Price	$305.10
Rate for Payer: Cash Price	$305.10
Rate for Payer: Cash Price	$305.10
Rate for Payer: Cigna Commercial HMO & PPO	$38.16
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$33.67
Rate for Payer: Home State Health Plan Medicaid Managed Care	$36.03
Rate for Payer: Home State Health Plan Medicare Advantage	$38.16
Rate for Payer: Humana Commercial	$76.32
Rate for Payer: Humana Medicare Advantage	$38.16
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$33.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$122.04

CYTOLOGY URINE

Facility

$161.00

Service Code	CPT 88104
Hospital Charge Code	2288107
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$114.95
Rate for Payer: Aetna Better Health Medicaid/QHP	$33.67
Rate for Payer: Aetna Medicare Advantage	$38.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$95.31
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$114.95
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial HMO & PPO	$38.16
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$33.67
Rate for Payer: Home State Health Plan Medicaid Managed Care	$36.03
Rate for Payer: Home State Health Plan Medicare Advantage	$38.16
Rate for Payer: Humana Commercial	$76.32
Rate for Payer: Humana Medicare Advantage	$38.16
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$33.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$57.96

CYTOLOGY URINE

Facility

$161.00

Service Code	CPT 88104
Hospital Charge Code	2288107
Hospital Revenue Code	305
Rate for Payer: Cash Price	$144.90

D5 1/2NS 1000ML IV 019531

Facility

$129.00

Service Code	NDC 338008504
Hospital Charge Code	2659107
Hospital Revenue Code	258
Min. Negotiated Rate	$86.04
Max. Negotiated Rate	$86.04
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04

D5 1/2NS 1000ML IV 019531

Facility

$129.00

Service Code	NDC 338008504
Hospital Charge Code	2659107
Hospital Revenue Code	258
Min. Negotiated Rate	$46.44
Max. Negotiated Rate	$92.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.11
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$46.44

D5 1/2NS 500ML IV

Facility

$129.00

Service Code	NDC 338008503
Hospital Charge Code	2697179
Hospital Revenue Code	258
Min. Negotiated Rate	$46.44
Max. Negotiated Rate	$92.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.11
Rate for Payer: Cash Price	$116.10
Rate for Payer: UnitedHealthcare Commercial	$86.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$46.44

Know your out-of-pocket cost for care.

All Charges