Madison Medical Center

All Charges

Charge

Type

Setting

Price

ESR

Facility

$20.00

Service Code	CPT 85651
Hospital Charge Code	4285651
Hospital Revenue Code	521
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$173.53
Rate for Payer: Aetna Better Health Medicaid/QHP	$3.84
Rate for Payer: Aetna Medicare Advantage	$4.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$11.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.28
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial HMO & PPO	$4.27
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$3.46
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4.11
Rate for Payer: Home State Health Plan Medicare Advantage	$4.27
Rate for Payer: Humana Commercial	$8.54
Rate for Payer: Humana Medicare Advantage	$4.27
Rate for Payer: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$3.84
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

ESR

Facility

$20.00

Service Code	CPT 85651
Hospital Charge Code	4285651
Hospital Revenue Code	521
Rate for Payer: Cash Price	$18.00

ESTAB. O/P VISIT (BRIEF)

Facility

$120.00

Service Code	CPT 99212
Hospital Charge Code	4499212
Hospital Revenue Code	521
Min. Negotiated Rate	$71.04
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$71.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$85.68
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: UnitedHealthcare Commercial	$80.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

ESTAB. O/P VISIT (BRIEF)

Facility

$120.00

Service Code	CPT 99212
Hospital Charge Code	4499212
Hospital Revenue Code	521
Rate for Payer: Cash Price	$108.00

ESTAB. O/P VISIT (COMPRE)

Facility

$350.00

Service Code	CPT 99215
Hospital Charge Code	4499215
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$249.90
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: UnitedHealthcare Commercial	$233.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

ESTAB. O/P VISIT (COMPRE)

Facility

$350.00

Service Code	CPT 99215
Hospital Charge Code	4499215
Hospital Revenue Code	521
Rate for Payer: Cash Price	$315.00

ESTAB. O/P VISIT (EXTENDED)

Facility

$250.00

Service Code	CPT 99214
Hospital Charge Code	4499214
Hospital Revenue Code	521
Rate for Payer: Cash Price	$225.00

ESTAB. O/P VISIT (EXTENDED)

Facility

$250.00

Service Code	CPT 99214
Hospital Charge Code	4499214
Hospital Revenue Code	521
Min. Negotiated Rate	$148.00
Max. Negotiated Rate	$178.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$148.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$178.50
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: UnitedHealthcare Commercial	$166.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

ESTAB. O/P VISIT (INTER)

Facility

$160.00

Service Code	CPT 99213
Hospital Charge Code	4499213
Hospital Revenue Code	521
Min. Negotiated Rate	$94.72
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$94.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$114.24
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: UnitedHealthcare Commercial	$106.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

ESTAB. O/P VISIT (INTER)

Facility

$160.00

Service Code	CPT 99213
Hospital Charge Code	4499213
Hospital Revenue Code	521
Rate for Payer: Cash Price	$144.00

ESTAB. O/P VISIT MINIMAL

Facility

$70.00

Service Code	CPT 99211
Hospital Charge Code	4499211
Hospital Revenue Code	521
Min. Negotiated Rate	$41.44
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$41.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$49.98
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: UnitedHealthcare Commercial	$46.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

ESTAB. O/P VISIT MINIMAL

Facility

$70.00

Service Code	CPT 99211
Hospital Charge Code	4499211
Hospital Revenue Code	521
Rate for Payer: Cash Price	$63.00

EST INTERMEDIATE OFFICE VISIT

Facility

$150.00

Service Code	CPT 99213
Hospital Charge Code	9892213
Hospital Revenue Code	521
Rate for Payer: Cash Price	$135.00

EST INTERMEDIATE OFFICE VISIT

Facility

$150.00

Service Code	CPT 99213
Hospital Charge Code	9892213
Hospital Revenue Code	521
Min. Negotiated Rate	$88.80
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$88.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$107.10
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: UnitedHealthcare Commercial	$100.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PATIENT OFFICE VISIT BRIEF

Facility

$120.00

Service Code	CPT 99212
Hospital Charge Code	5499212
Hospital Revenue Code	521
Min. Negotiated Rate	$71.04
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$71.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$85.68
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: UnitedHealthcare Commercial	$80.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PATIENT OFFICE VISIT BRIEF

Facility

$120.00

Service Code	CPT 99212
Hospital Charge Code	5499212
Hospital Revenue Code	521
Rate for Payer: Cash Price	$108.00

EST PATIENT OFFICE VISIT COMPREHENSIVE

Facility

$350.00

Service Code	CPT 99215
Hospital Charge Code	5499215
Hospital Revenue Code	521
Rate for Payer: Cash Price	$315.00

EST PATIENT OFFICE VISIT COMPREHENSIVE

Facility

$350.00

Service Code	CPT 99215
Hospital Charge Code	5499215
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$249.90
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: UnitedHealthcare Commercial	$233.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PATIENT OFFICE VISIT EXTENDED

Facility

$250.00

Service Code	CPT 99214
Hospital Charge Code	5499214
Hospital Revenue Code	521
Rate for Payer: Cash Price	$225.00

EST PATIENT OFFICE VISIT EXTENDED

Facility

$250.00

Service Code	CPT 99214
Hospital Charge Code	5499214
Hospital Revenue Code	521
Min. Negotiated Rate	$148.00
Max. Negotiated Rate	$178.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$148.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$178.50
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: UnitedHealthcare Commercial	$166.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PATIENT OFFICE VISIT INTERMEDIATE

Facility

$160.00

Service Code	CPT 99213
Hospital Charge Code	5499213
Hospital Revenue Code	521
Min. Negotiated Rate	$94.72
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$94.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$114.24
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: UnitedHealthcare Commercial	$106.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PATIENT OFFICE VISIT INTERMEDIATE

Facility

$160.00

Service Code	CPT 99213
Hospital Charge Code	5499213
Hospital Revenue Code	521
Rate for Payer: Cash Price	$144.00

EST PATIENT OFFICE VISIT MINIMAL

Facility

$70.00

Service Code	CPT 99211
Hospital Charge Code	5499211
Hospital Revenue Code	521
Min. Negotiated Rate	$41.44
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$41.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$49.98
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: UnitedHealthcare Commercial	$46.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PATIENT OFFICE VISIT MINIMAL

Facility

$70.00

Service Code	CPT 99211
Hospital Charge Code	5499211
Hospital Revenue Code	521
Rate for Payer: Cash Price	$63.00

EST PT HCY AGE 12 - 17

Facility

$235.00

Service Code	CPT 99394
Hospital Charge Code	9299394
Hospital Revenue Code	521
Min. Negotiated Rate	$139.12
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$139.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$167.79
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cash Price	$211.50
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Know your out-of-pocket cost for care.

All Charges