Madison Medical Center

All Charges

Charge

Type

Setting

Price

EXC BEN LES SCALP,NECK,HANDS <0.6

Facility

$215.00

Service Code	CPT 11420
Hospital Charge Code	5411420
Hospital Revenue Code	521
Rate for Payer: Cash Price	$193.50

EXC BEN LES SCALP,NECK,HANDS 0.6 TO 1.0

Facility

$289.00

Service Code	CPT 11421
Hospital Charge Code	5411421
Hospital Revenue Code	521
Min. Negotiated Rate	$171.09
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$171.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$206.35
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial HMO & PPO	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$192.76
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN LES SCALP,NECK,HANDS 0.6 TO 1.0

Facility

$289.00

Service Code	CPT 11421
Hospital Charge Code	5411421
Hospital Revenue Code	521
Rate for Payer: Cash Price	$260.10

EXC BEN LES SCALP,NECK,HANDS 1.1 TO 2.0

Facility

$336.00

Service Code	CPT 11422
Hospital Charge Code	5411422
Hospital Revenue Code	521
Rate for Payer: Cash Price	$302.40

EXC BEN LES SCALP,NECK,HANDS 1.1 TO 2.0

Facility

$336.00

Service Code	CPT 11422
Hospital Charge Code	5411422
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$3,374.74
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,488.83
Rate for Payer: Aetna Medicare Advantage	$1,687.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$198.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$239.90
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna Commercial HMO & PPO	$1,687.37
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,339.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,593.05
Rate for Payer: Home State Health Plan Medicare Advantage	$1,687.37
Rate for Payer: Humana Commercial	$3,374.74
Rate for Payer: Humana Medicare Advantage	$1,687.37
Rate for Payer: UnitedHealthcare Commercial	$224.11
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,488.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN LES SCALP,NECK,HANDS 2.1 TO 3.0

Facility

$452.00

Service Code	CPT 11423
Hospital Charge Code	5411423
Hospital Revenue Code	521
Rate for Payer: Cash Price	$406.80

EXC BEN LES SCALP,NECK,HANDS 2.1 TO 3.0

Facility

$452.00

Service Code	CPT 11423
Hospital Charge Code	5411423
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$3,374.74
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,488.83
Rate for Payer: Aetna Medicare Advantage	$1,687.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$267.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$322.73
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial HMO & PPO	$1,687.37
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,339.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,593.05
Rate for Payer: Home State Health Plan Medicare Advantage	$1,687.37
Rate for Payer: Humana Commercial	$3,374.74
Rate for Payer: Humana Medicare Advantage	$1,687.37
Rate for Payer: UnitedHealthcare Commercial	$301.48
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,488.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN LES SCALP NECK HANDS .6 TO 1.0CM

Facility

$184.00

Service Code	CPT 11421
Hospital Charge Code	5211421
Hospital Revenue Code	521
Rate for Payer: Cash Price	$165.60

EXC BEN LES SCALP NECK HANDS .6 TO 1.0CM

Facility

$184.00

Service Code	CPT 11421
Hospital Charge Code	5211421
Hospital Revenue Code	521
Min. Negotiated Rate	$108.93
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$108.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$131.38
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cigna Commercial HMO & PPO	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$122.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN LES SCALP,NECK,HANDS,FT,2.1-3.0

Professional

Both

$565.00

Service Code	CPT 11423
Hospital Charge Code	9311423
Hospital Revenue Code	975
Min. Negotiated Rate	$134.08
Max. Negotiated Rate	$197.75
Rate for Payer: Aetna Commercial/Medicare Advantage	$134.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$155.20
Rate for Payer: Cash Price	$508.50
Rate for Payer: Cash Price	$508.50
Rate for Payer: Cigna Commercial HMO & PPO	$134.08
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$155.20
Rate for Payer: Home State Health Plan Medicaid Managed Care	$170.72
Rate for Payer: Home State Health Plan Medicare Advantage	$134.08
Rate for Payer: Optum Medicare Advantage	$197.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$155.20

EXC BEN LES TRUNK ARMS .06 CM - 1CM

Facility

$210.00

Service Code	CPT 11401
Hospital Charge Code	5211401
Hospital Revenue Code	521
Rate for Payer: Cash Price	$189.00

EXC BEN LES TRUNK ARMS .06 CM - 1CM

Facility

$210.00

Service Code	CPT 11401
Hospital Charge Code	5211401
Hospital Revenue Code	521
Min. Negotiated Rate	$124.32
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	$124.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$149.94
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
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	$140.07
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN LES TRUNK, ARMS 1.1 TO 2.0 CM

Facility

$280.00

Service Code	CPT 11402
Hospital Charge Code	9711402
Hospital Revenue Code	521
Rate for Payer: Cash Price	$252.00

EXC BEN LES TRUNK, ARMS 1.1 TO 2.0 CM

Facility

$280.00

Service Code	CPT 11402
Hospital Charge Code	9711402
Hospital Revenue Code	521
Min. Negotiated Rate	$165.76
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
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	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$186.76
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN LES TRUNK ARMS .5 CM OR LESS

Facility

$126.00

Service Code	CPT 11400
Hospital Charge Code	5211400
Hospital Revenue Code	521
Rate for Payer: Cash Price	$113.40

EXC BEN LES TRUNK ARMS .5 CM OR LESS

Facility

$126.00

Service Code	CPT 11400
Hospital Charge Code	5211400
Hospital Revenue Code	521
Min. Negotiated Rate	$74.59
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.96
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cigna Commercial HMO & PPO	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$84.04
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN LES TRUNK ARMS LEGS 1.1 TO 2.0 C

Facility

$420.00

Service Code	CPT 11042
Hospital Charge Code	9311042
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	$248.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$299.88
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cash Price	$378.00
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	$280.14
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN LES TRUNK ARMS LEGS 1.1 TO 2.0 C

Facility

$420.00

Service Code	CPT 11042
Hospital Charge Code	9311042
Hospital Revenue Code	521
Rate for Payer: Cash Price	$378.00

EXC BEN LES TRUNK ARMS LEGS .5CM OR LESS

Facility

$125.00

Service Code	CPT 11400
Hospital Charge Code	4211400
Hospital Revenue Code	521
Min. Negotiated Rate	$74.00
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$74.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$89.25
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial HMO & PPO	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$83.38
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN LES TRUNK ARMS LEGS .5CM OR LESS

Facility

$125.00

Service Code	CPT 11400
Hospital Charge Code	4211400
Hospital Revenue Code	521
Rate for Payer: Cash Price	$112.50

EXC BEN LES TRUNK ARMS LEGS .6 TO 1.0 CM

Facility

$270.00

Service Code	CPT 11401
Hospital Charge Code	4211401
Hospital Revenue Code	521
Rate for Payer: Cash Price	$243.00

EXC BEN LES TRUNK ARMS LEGS .6 TO 1.0 CM

Facility

$270.00

Service Code	CPT 11401
Hospital Charge Code	4211401
Hospital Revenue Code	521
Min. Negotiated Rate	$159.84
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	$159.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$192.78
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cash Price	$243.00
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	$180.09
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN TRK,ARMS,LEGS 1.1 TO 2.0 CM

Facility

$250.00

Service Code	CPT 11402
Hospital Charge Code	9811402
Hospital Revenue Code	521
Rate for Payer: Cash Price	$225.00

EXC BEN TRK,ARMS,LEGS 1.1 TO 2.0 CM

Facility

$250.00

Service Code	CPT 11402
Hospital Charge Code	9811402
Hospital Revenue Code	521
Min. Negotiated Rate	$148.00
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
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: Cash Price	$225.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial HMO & PPO	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$166.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

EXC BEN TRK,ARMS,LEGS 2.1 TO 3.0 CM

Facility

$300.00

Service Code	CPT 11403
Hospital Charge Code	9811403
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$177.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$214.20
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial HMO & PPO	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$200.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Know your out-of-pocket cost for care.

All Charges