Madison Medical Center

All Charges

Charge

Type

Setting

Price

EST PT OZARK VISIT LEVEL 2

Facility

$130.00

Service Code	CPT 99348
Hospital Charge Code	9299335
Hospital Revenue Code	521
Min. Negotiated Rate	$76.96
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.82
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: UnitedHealthcare Commercial	$86.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT OZARK VISIT LEVEL 2

Facility

$130.00

Service Code	CPT 99348
Hospital Charge Code	9499335
Hospital Revenue Code	521
Min. Negotiated Rate	$76.96
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$76.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$92.82
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: UnitedHealthcare Commercial	$86.71
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT OZARK VISIT LEVEL 2

Facility

$130.00

Service Code	CPT 99348
Hospital Charge Code	9499335
Hospital Revenue Code	521
Rate for Payer: Cash Price	$117.00

EST PT OZARK VISIT LEVEL 3

Facility

$190.00

Service Code	CPT 99349
Hospital Charge Code	9499336
Hospital Revenue Code	521
Rate for Payer: Cash Price	$171.00

EST PT OZARK VISIT LEVEL 3

Facility

$190.00

Service Code	CPT 99349
Hospital Charge Code	9299336
Hospital Revenue Code	521
Min. Negotiated Rate	$112.48
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$112.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$135.66
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: UnitedHealthcare Commercial	$126.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT OZARK VISIT LEVEL 3

Facility

$190.00

Service Code	CPT 99349
Hospital Charge Code	9499336
Hospital Revenue Code	521
Min. Negotiated Rate	$112.48
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$112.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$135.66
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: UnitedHealthcare Commercial	$126.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT OZARK VISIT LEVEL 3

Facility

$190.00

Service Code	CPT 99349
Hospital Charge Code	9299336
Hospital Revenue Code	521
Rate for Payer: Cash Price	$171.00

EST PT OZARK VISIT LEVEL 4

Facility

$280.00

Service Code	CPT 99350
Hospital Charge Code	9499337
Hospital Revenue Code	521
Min. Negotiated Rate	$165.76
Max. Negotiated Rate	$199.92
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: UnitedHealthcare Commercial	$186.76
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT OZARK VISIT LEVEL 4

Facility

$280.00

Service Code	CPT 99350
Hospital Charge Code	9499337
Hospital Revenue Code	521
Rate for Payer: Cash Price	$252.00

EST PT OZARK VISIT LEVEL 4

Facility

$280.00

Service Code	CPT 99350
Hospital Charge Code	9299337
Hospital Revenue Code	521
Min. Negotiated Rate	$165.76
Max. Negotiated Rate	$199.92
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: UnitedHealthcare Commercial	$186.76
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT OZARK VISIT LEVEL 4

Facility

$280.00

Service Code	CPT 99350
Hospital Charge Code	9299337
Hospital Revenue Code	521
Rate for Payer: Cash Price	$252.00

EST PT PHYSICAL AGE 18 - 39

Facility

$255.00

Service Code	CPT 99395
Hospital Charge Code	9499395
Hospital Revenue Code	521
Min. Negotiated Rate	$150.96
Max. Negotiated Rate	$182.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$150.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$182.07
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cash Price	$229.50
Rate for Payer: UnitedHealthcare Commercial	$170.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT PHYSICAL AGE 18 - 39

Facility

$255.00

Service Code	CPT 99395
Hospital Charge Code	9299395
Hospital Revenue Code	521
Rate for Payer: Cash Price	$229.50

EST PT PHYSICAL AGE 18 - 39

Facility

$255.00

Service Code	CPT 99395
Hospital Charge Code	9299395
Hospital Revenue Code	521
Min. Negotiated Rate	$150.96
Max. Negotiated Rate	$182.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$150.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$182.07
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cash Price	$229.50
Rate for Payer: UnitedHealthcare Commercial	$170.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT PHYSICAL AGE 18 - 39

Facility

$255.00

Service Code	CPT 99395
Hospital Charge Code	9499395
Hospital Revenue Code	521
Rate for Payer: Cash Price	$229.50

EST PT PHYSICAL AGE 40 - 64

Facility

$285.00

Service Code	CPT 99396
Hospital Charge Code	9299396
Hospital Revenue Code	521
Min. Negotiated Rate	$168.72
Max. Negotiated Rate	$203.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$168.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$203.49
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cash Price	$256.50
Rate for Payer: UnitedHealthcare Commercial	$190.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT PHYSICAL AGE 40 - 64

Facility

$285.00

Service Code	CPT 99396
Hospital Charge Code	9299396
Hospital Revenue Code	521
Rate for Payer: Cash Price	$256.50

EST PT PHYSICAL AGE 40 - 64

Facility

$285.00

Service Code	CPT 99396
Hospital Charge Code	9499396
Hospital Revenue Code	521
Rate for Payer: Cash Price	$256.50

EST PT PHYSICAL AGE 40 - 64

Facility

$285.00

Service Code	CPT 99396
Hospital Charge Code	9499396
Hospital Revenue Code	521
Min. Negotiated Rate	$168.72
Max. Negotiated Rate	$203.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$168.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$203.49
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cash Price	$256.50
Rate for Payer: UnitedHealthcare Commercial	$190.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT PHYSICAL AGE 65 AND OLDER

Facility

$330.00

Service Code	CPT 99397
Hospital Charge Code	9299397
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$235.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$195.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$235.62
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: UnitedHealthcare Commercial	$220.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT PHYSICAL AGE 65 AND OLDER

Facility

$330.00

Service Code	CPT 99397
Hospital Charge Code	9499397
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$235.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$195.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$235.62
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: UnitedHealthcare Commercial	$220.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT PHYSICAL AGE 65 AND OLDER

Facility

$330.00

Service Code	CPT 99397
Hospital Charge Code	9299397
Hospital Revenue Code	521
Rate for Payer: Cash Price	$297.00

EST PT PHYSICAL AGE 65 AND OLDER

Facility

$330.00

Service Code	CPT 99397
Hospital Charge Code	9499397
Hospital Revenue Code	521
Rate for Payer: Cash Price	$297.00

EST PT PREVENTATIVE EXAM 18 - 39

Facility

$255.00

Service Code	CPT 99395
Hospital Charge Code	9899395
Hospital Revenue Code	521
Min. Negotiated Rate	$150.96
Max. Negotiated Rate	$182.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$150.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$182.07
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cash Price	$229.50
Rate for Payer: UnitedHealthcare Commercial	$170.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EST PT PREVENTATIVE EXAM 18 - 39

Facility

$255.00

Service Code	CPT 99395
Hospital Charge Code	9899395
Hospital Revenue Code	521
Rate for Payer: Cash Price	$229.50

Know your out-of-pocket cost for care.

All Charges