Madison Medical Center

All Charges

Charge

Type

Setting

Price

DEST OF CUTAN VASC LES < 10 SQ CM

Facility

$750.00

Service Code	CPT 17106
Hospital Charge Code	9817106
Hospital Revenue Code	521
Rate for Payer: Cash Price	$675.00

DEST OF CUTAN VASC LES < 10 SQ CM

Facility

$750.00

Service Code	CPT 17106
Hospital Charge Code	9817106
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
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	$444.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$535.50
Rate for Payer: Cash Price	$675.00
Rate for Payer: Cash Price	$675.00
Rate for Payer: Cash Price	$675.00
Rate for Payer: Cash Price	$675.00
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	$500.25
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DEST OF LES, ANUS,PAPILLOMA, MULLUSCUM,C

Professional

Both

$735.00

Service Code	CPT 46922
Hospital Charge Code	5446922
Hospital Revenue Code	975
Min. Negotiated Rate	$125.66
Max. Negotiated Rate	$266.57
Rate for Payer: Aetna Commercial/Medicare Advantage	$125.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$242.34
Rate for Payer: Cash Price	$661.50
Rate for Payer: Cash Price	$661.50
Rate for Payer: Cigna Commercial HMO & PPO	$125.66
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$242.34
Rate for Payer: Home State Health Plan Medicaid Managed Care	$266.57
Rate for Payer: Home State Health Plan Medicare Advantage	$125.66
Rate for Payer: Optum Medicare Advantage	$257.25
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$242.34

DEST. OF LESION,ANUS,EXTENS, ANY MTHD.

Professional

Both

$784.00

Service Code	CPT 46924-51
Hospital Charge Code	4146924
Hospital Revenue Code	975
Min. Negotiated Rate	$274.40
Max. Negotiated Rate	$274.40
Rate for Payer: Cash Price	$705.60
Rate for Payer: Optum Medicare Advantage	$274.40

DEST OF LESION EYELID UP TO 1 CM

Facility

$725.00

Service Code	CPT 67850
Hospital Charge Code	9867850
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$2,036.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$898.64
Rate for Payer: Aetna Medicare Advantage	$1,018.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$429.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$517.65
Rate for Payer: Cash Price	$652.50
Rate for Payer: Cash Price	$652.50
Rate for Payer: Cash Price	$652.50
Rate for Payer: Cash Price	$652.50
Rate for Payer: Cigna Commercial HMO & PPO	$1,018.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$808.78
Rate for Payer: Home State Health Plan Medicaid Managed Care	$961.54
Rate for Payer: Home State Health Plan Medicare Advantage	$1,018.47
Rate for Payer: Humana Commercial	$2,036.94
Rate for Payer: Humana Medicare Advantage	$1,018.47
Rate for Payer: UnitedHealthcare Commercial	$483.57
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$898.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DEST OF LESION EYELID UP TO 1 CM

Facility

$725.00

Service Code	CPT 67850
Hospital Charge Code	9867850
Hospital Revenue Code	521
Rate for Payer: Cash Price	$652.50

DEST OF LES PENIS EXTENSIVE

Facility

$1,160.00

Service Code	CPT 54065
Hospital Charge Code	9854065
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$4,215.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,859.94
Rate for Payer: Aetna Medicare Advantage	$2,107.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$686.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$828.24
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Cigna Commercial HMO & PPO	$2,107.97
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,673.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,990.14
Rate for Payer: Home State Health Plan Medicare Advantage	$2,107.97
Rate for Payer: Humana Commercial	$4,215.94
Rate for Payer: Humana Medicare Advantage	$2,107.97
Rate for Payer: UnitedHealthcare Commercial	$773.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,859.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DEST OF LES PENIS EXTENSIVE

Facility

$1,160.00

Service Code	CPT 54065
Hospital Charge Code	9854065
Hospital Revenue Code	521
Rate for Payer: Cash Price	$1,044.00

DESTRUCTION BENIGN LESIONS

Facility

$115.00

Service Code	CPT 17110
Hospital Charge Code	3917110
Hospital Revenue Code	521
Rate for Payer: Cash Price	$103.50

DESTRUCTION BENIGN LESIONS

Facility

$115.00

Service Code	CPT 17110
Hospital Charge Code	3917110
Hospital Revenue Code	521
Min. Negotiated Rate	$68.08
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	$68.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$82.11
Rate for Payer: Cash Price	$103.50
Rate for Payer: Cash Price	$103.50
Rate for Payer: Cash Price	$103.50
Rate for Payer: Cash Price	$103.50
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	$76.70
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DESTRUCTION BEN LES UP TO 14 LESIONS

Facility

$180.00

Service Code	CPT 17110
Hospital Charge Code	9217110
Hospital Revenue Code	521
Min. Negotiated Rate	$106.56
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	$106.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$128.52
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$162.00
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	$120.06
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DESTRUCTION BEN LES UP TO 14 LESIONS

Facility

$180.00

Service Code	CPT 17110
Hospital Charge Code	9217110
Hospital Revenue Code	521
Rate for Payer: Cash Price	$162.00

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT

Facility

$3,990.04

Service Code	CPT 64633
Hospital Revenue Code	490
Min. Negotiated Rate	$1,253.00
Max. Negotiated Rate	$3,990.04
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,760.28
Rate for Payer: Aetna Medicare Advantage	$1,995.02
Rate for Payer: Cigna Commercial HMO & PPO	$1,995.02
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,760.28
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,883.50
Rate for Payer: Home State Health Plan Medicare Advantage	$1,995.02
Rate for Payer: Humana Commercial	$3,990.04
Rate for Payer: Humana Medicare Advantage	$1,995.02
Rate for Payer: UnitedHealthcare Commercial	$1,253.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,760.28

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT

Facility

$3,990.04

Service Code	CPT 64635
Hospital Revenue Code	360
Min. Negotiated Rate	$1,253.00
Max. Negotiated Rate	$3,990.04
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,760.28
Rate for Payer: Aetna Medicare Advantage	$1,995.02
Rate for Payer: Cigna Commercial HMO & PPO	$1,995.02
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,760.28
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,883.50
Rate for Payer: Home State Health Plan Medicare Advantage	$1,995.02
Rate for Payer: Humana Commercial	$3,990.04
Rate for Payer: Humana Medicare Advantage	$1,995.02
Rate for Payer: UnitedHealthcare Commercial	$1,253.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,760.28

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT

Facility

$3,990.04

Service Code	CPT 64635
Hospital Revenue Code	490
Min. Negotiated Rate	$1,253.00
Max. Negotiated Rate	$3,990.04
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,760.28
Rate for Payer: Aetna Medicare Advantage	$1,995.02
Rate for Payer: Cigna Commercial HMO & PPO	$1,995.02
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,760.28
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,883.50
Rate for Payer: Home State Health Plan Medicare Advantage	$1,995.02
Rate for Payer: Humana Commercial	$3,990.04
Rate for Payer: Humana Medicare Advantage	$1,995.02
Rate for Payer: UnitedHealthcare Commercial	$1,253.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,760.28

DESTRUCTION LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	4117000
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

DESTRUCTION LESION

Facility

$145.00

Service Code	CPT 17000
Hospital Charge Code	4117000
Hospital Revenue Code	521
Rate for Payer: Cash Price	$130.50

DESTRUCTION LESION-VULVA EXTENSIVE

Facility

$644.00

Service Code	CPT 56515
Hospital Charge Code	4256515
Hospital Revenue Code	521
Rate for Payer: Cash Price	$579.60

DESTRUCTION LESION-VULVA EXTENSIVE

Facility

$644.00

Service Code	CPT 56515
Hospital Charge Code	4256515
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$4,215.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,859.94
Rate for Payer: Aetna Medicare Advantage	$2,107.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$381.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$459.82
Rate for Payer: Cash Price	$579.60
Rate for Payer: Cash Price	$579.60
Rate for Payer: Cash Price	$579.60
Rate for Payer: Cash Price	$579.60
Rate for Payer: Cigna Commercial HMO & PPO	$2,107.97
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,673.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,990.14
Rate for Payer: Home State Health Plan Medicare Advantage	$2,107.97
Rate for Payer: Humana Commercial	$4,215.94
Rate for Payer: Humana Medicare Advantage	$2,107.97
Rate for Payer: UnitedHealthcare Commercial	$429.55
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,859.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DESTRUCTION LESION-VULVA SIMPLE

Facility

$204.00

Service Code	CPT 56501
Hospital Charge Code	4256501
Hospital Revenue Code	521
Rate for Payer: Cash Price	$183.60

DESTRUCTION LESION-VULVA SIMPLE

Facility

$204.00

Service Code	CPT 56501
Hospital Charge Code	4256501
Hospital Revenue Code	521
Min. Negotiated Rate	$120.77
Max. Negotiated Rate	$4,215.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,859.94
Rate for Payer: Aetna Medicare Advantage	$2,107.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$120.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$145.66
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cigna Commercial HMO & PPO	$2,107.97
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,673.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,990.14
Rate for Payer: Home State Health Plan Medicare Advantage	$2,107.97
Rate for Payer: Humana Commercial	$4,215.94
Rate for Payer: Humana Medicare Advantage	$2,107.97
Rate for Payer: UnitedHealthcare Commercial	$136.07
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,859.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DESTRUCTION MALIG LES 6-1.0CM TRUNK, ARM

Facility

$280.00

Service Code	CPT 17261
Hospital Charge Code	4217261
Hospital Revenue Code	521
Rate for Payer: Cash Price	$252.00

DESTRUCTION MALIG LES 6-1.0CM TRUNK, ARM

Facility

$280.00

Service Code	CPT 17261
Hospital Charge Code	4217261
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	$165.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$199.92
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cash Price	$252.00
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	$186.76
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DESTRUCTION MALIG LES .6 TO 1.0 CM

Facility

$375.00

Service Code	CPT 17281
Hospital Charge Code	4217281
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	$222.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$267.75
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cash Price	$337.50
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	$250.12
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

DESTRUCTION MALIG LES .6 TO 1.0 CM

Facility

$375.00

Service Code	CPT 17281
Hospital Charge Code	4217281
Hospital Revenue Code	521
Rate for Payer: Cash Price	$337.50

Know your out-of-pocket cost for care.

All Charges