Madison Medical Center

All Charges

Charge

Type

Setting

Price

DERMA CARE PAD 30 40

Facility

$119.00

Hospital Charge Code	284424
Hospital Revenue Code	271
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$84.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$70.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$84.97
Rate for Payer: Cash Price	$107.10
Rate for Payer: UnitedHealthcare Commercial	$79.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$42.84

DERMA GEL WOUND DRESSING

Facility

$45.00

Hospital Charge Code	288000
Hospital Revenue Code	271
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.13
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

DERMA GEL WOUND DRESSING

Facility

$45.00

Hospital Charge Code	288000
Hospital Revenue Code	271
Rate for Payer: Cash Price	$40.50

DESIPRAMINE

Facility

$152.00

Service Code	CPT 80335
Hospital Charge Code	224302
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$108.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$89.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$108.53
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cash Price	$136.80
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$54.72

DESIPRAMINE

Facility

$152.00

Service Code	CPT 80335
Hospital Charge Code	224302
Hospital Revenue Code	301
Rate for Payer: Cash Price	$136.80

DESITIN OINTMENT/CREAMY 4OZ

Facility

$18.00

Hospital Charge Code	2800301
Hospital Revenue Code	271
Rate for Payer: Cash Price	$16.20

DESITIN OINTMENT/CREAMY 4OZ

Facility

$18.00

Hospital Charge Code	2800301
Hospital Revenue Code	271
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

DESMOGLEIN 1&3

Facility

$402.00

Hospital Charge Code	2280003
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$287.03
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$237.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$287.03
Rate for Payer: Cash Price	$361.80
Rate for Payer: Cash Price	$361.80
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$144.72

DESMOGLEIN 1&3

Facility

$402.00

Hospital Charge Code	2280003
Hospital Revenue Code	305
Rate for Payer: Cash Price	$361.80

DESMOPRESSIN 0.2MG TAB

Facility

$16.00

Service Code	NDC 6.9918E+10
Hospital Charge Code	2619804
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

DESMOPRESSIN 0.2MG TAB

Facility

$16.00

Service Code	NDC 6.9918E+10
Hospital Charge Code	2619804
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

DEST BY NEURO AGENT FACET JT NERVE EA A

Professional

Both

$800.00

Service Code	CPT 64636
Hospital Charge Code	4164636
Hospital Revenue Code	975
Min. Negotiated Rate	$49.38
Max. Negotiated Rate	$280.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$49.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$188.18
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cigna Commercial HMO & PPO	$49.38
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$188.18
Rate for Payer: Home State Health Plan Medicaid Managed Care	$207.00
Rate for Payer: Home State Health Plan Medicare Advantage	$49.38
Rate for Payer: Optum Medicare Advantage	$280.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$188.18

DEST BY NEURO AGENT FACET JT NERVE LUMBA

Professional

Both

$1,900.00

Service Code	CPT 64635
Hospital Charge Code	4164635
Hospital Revenue Code	975
Min. Negotiated Rate	$165.16
Max. Negotiated Rate	$665.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$165.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$340.28
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Cigna Commercial HMO & PPO	$165.16
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$340.28
Rate for Payer: Home State Health Plan Medicaid Managed Care	$374.31
Rate for Payer: Home State Health Plan Medicare Advantage	$165.16
Rate for Payer: Optum Medicare Advantage	$665.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$340.28

DEST BY NEUROLYTIC AGENT, EA ADDL FACET

Professional

Both

$880.00

Service Code	CPT 64634
Hospital Charge Code	4164634
Hospital Revenue Code	975
Min. Negotiated Rate	$56.20
Max. Negotiated Rate	$308.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$56.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$199.40
Rate for Payer: Cash Price	$792.00
Rate for Payer: Cash Price	$792.00
Rate for Payer: Cigna Commercial HMO & PPO	$56.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$199.40
Rate for Payer: Home State Health Plan Medicaid Managed Care	$219.34
Rate for Payer: Home State Health Plan Medicare Advantage	$56.20
Rate for Payer: Optum Medicare Advantage	$308.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$199.40

DEST BY NEUROLYTIC AGENT, OTHER PERI NER

Professional

Both

$1,000.00

Service Code	CPT 64624
Hospital Charge Code	4164624
Hospital Revenue Code	975
Min. Negotiated Rate	$126.95
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$126.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$300.44
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial HMO & PPO	$126.95
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$300.44
Rate for Payer: Home State Health Plan Medicaid Managed Care	$330.48
Rate for Payer: Home State Health Plan Medicare Advantage	$126.95
Rate for Payer: Optum Medicare Advantage	$350.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$300.44

DEST BY NEUROLYTIC AGENT, OTHER PERI NER

Professional

Both

$700.00

Service Code	CPT 64640
Hospital Charge Code	4164640
Hospital Revenue Code	975
Min. Negotiated Rate	$105.88
Max. Negotiated Rate	$245.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$105.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$189.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cigna Commercial HMO & PPO	$105.88
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$189.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$207.90
Rate for Payer: Home State Health Plan Medicare Advantage	$105.88
Rate for Payer: Optum Medicare Advantage	$245.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$189.00

DEST BY NEUROLYTIC AGENT, PARAVERTEBRAL

Professional

Both

$1,900.00

Service Code	CPT 64633
Hospital Charge Code	4164633
Hospital Revenue Code	975
Min. Negotiated Rate	$164.91
Max. Negotiated Rate	$665.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$164.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$337.22
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Cash Price	$1,710.00
Rate for Payer: Cigna Commercial HMO & PPO	$164.91
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$337.22
Rate for Payer: Home State Health Plan Medicaid Managed Care	$370.94
Rate for Payer: Home State Health Plan Medicare Advantage	$164.91
Rate for Payer: Optum Medicare Advantage	$665.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$337.22

DEST MALIG LES .5 CM OR LESS

Facility

$350.00

Service Code	CPT 17280
Hospital Charge Code	9817280
Hospital Revenue Code	521
Min. Negotiated Rate	$162.77
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	$207.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$249.90
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
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	$233.45
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DEST MALIG LES .5 CM OR LESS

Facility

$350.00

Service Code	CPT 17280
Hospital Charge Code	9817280
Hospital Revenue Code	521
Rate for Payer: Cash Price	$315.00

DEST MAL LES .6 TO 1 CM FACE EARS EYELID

Facility

$400.00

Service Code	CPT 17281
Hospital Charge Code	9817281
Hospital Revenue Code	521
Min. Negotiated Rate	$162.77
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	$236.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$285.60
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
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	$266.80
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DEST MAL LES .6 TO 1 CM FACE EARS EYELID

Facility

$400.00

Service Code	CPT 17281
Hospital Charge Code	9817281
Hospital Revenue Code	521
Rate for Payer: Cash Price	$360.00

DEST MAL LES .6 TO 1 CM TRUNK ARMS LEGS

Facility

$400.00

Service Code	CPT 17261
Hospital Charge Code	9817261
Hospital Revenue Code	521
Rate for Payer: Cash Price	$360.00

DEST MAL LES .6 TO 1 CM TRUNK ARMS LEGS

Facility

$400.00

Service Code	CPT 17261
Hospital Charge Code	9817261
Hospital Revenue Code	521
Min. Negotiated Rate	$162.77
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	$236.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$285.60
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
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	$266.80
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DEST MAL LES CRYO CURET SCALP NECK .5 CM

Facility

$400.00

Service Code	CPT 17270
Hospital Charge Code	9817270
Hospital Revenue Code	521
Min. Negotiated Rate	$162.77
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	$236.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$285.60
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
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	$266.80
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DEST MAL LES CRYO CURET SCALP NECK .5 CM

Facility

$400.00

Service Code	CPT 17270
Hospital Charge Code	9817270
Hospital Revenue Code	521
Rate for Payer: Cash Price	$360.00

Know your out-of-pocket cost for care.

All Charges