Madison Medical Center

All Charges

Charge

Type

Setting

Price

EZ SPECIMAN TRAP

Facility

$70.00

Hospital Charge Code	2819390
Hospital Revenue Code	271
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$49.98
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: UnitedHealthcare Commercial	$46.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.20

EZ SPECIMAN TRAP

Facility

$70.00

Hospital Charge Code	2819390
Hospital Revenue Code	271
Rate for Payer: Cash Price	$63.00

FACET BLOCK C/T SECOND LEVEL

Professional

Both

$470.00

Service Code	CPT 64491
Hospital Charge Code	4164491
Hospital Revenue Code	975
Min. Negotiated Rate	$49.38
Max. Negotiated Rate	$164.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$49.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$73.18
Rate for Payer: Cash Price	$423.00
Rate for Payer: Cash Price	$423.00
Rate for Payer: Cigna Commercial HMO & PPO	$49.38
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$73.18
Rate for Payer: Home State Health Plan Medicaid Managed Care	$80.50
Rate for Payer: Home State Health Plan Medicare Advantage	$49.38
Rate for Payer: Optum Medicare Advantage	$164.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$73.18

FACET BLOCK C/T SINGLE LEVEL

Professional

Both

$900.00

Service Code	CPT 64490
Hospital Charge Code	4164490
Hospital Revenue Code	975
Min. Negotiated Rate	$89.99
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$89.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$145.07
Rate for Payer: Cash Price	$810.00
Rate for Payer: Cash Price	$810.00
Rate for Payer: Cigna Commercial HMO & PPO	$89.99
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$145.07
Rate for Payer: Home State Health Plan Medicaid Managed Care	$159.58
Rate for Payer: Home State Health Plan Medicare Advantage	$89.99
Rate for Payer: Optum Medicare Advantage	$315.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$145.07

FACET BLOCK C/T THIRD LEVEL

Professional

Both

$480.00

Service Code	CPT 64492
Hospital Charge Code	4164492
Hospital Revenue Code	975
Min. Negotiated Rate	$49.60
Max. Negotiated Rate	$168.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$49.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$73.43
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cigna Commercial HMO & PPO	$49.60
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$73.43
Rate for Payer: Home State Health Plan Medicaid Managed Care	$80.77
Rate for Payer: Home State Health Plan Medicare Advantage	$49.60
Rate for Payer: Optum Medicare Advantage	$168.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$73.43

FACET BLOCK LUMBAR SACRAL SECOND LEVEL

Professional

Both

$450.00

Service Code	CPT 64494
Hospital Charge Code	4164494
Hospital Revenue Code	975
Min. Negotiated Rate	$42.53
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$42.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$68.79
Rate for Payer: Cash Price	$405.00
Rate for Payer: Cash Price	$405.00
Rate for Payer: Cigna Commercial HMO & PPO	$42.53
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$68.79
Rate for Payer: Home State Health Plan Medicaid Managed Care	$75.67
Rate for Payer: Home State Health Plan Medicare Advantage	$42.53
Rate for Payer: Optum Medicare Advantage	$157.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$68.79

FACET BLOCK LUMBAR SACRAL SINGLE LEVEL

Professional

Both

$850.00

Service Code	CPT 64493
Hospital Charge Code	4164493
Hospital Revenue Code	975
Min. Negotiated Rate	$77.60
Max. Negotiated Rate	$297.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$77.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$132.86
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cigna Commercial HMO & PPO	$77.60
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$132.86
Rate for Payer: Home State Health Plan Medicaid Managed Care	$146.15
Rate for Payer: Home State Health Plan Medicare Advantage	$77.60
Rate for Payer: Optum Medicare Advantage	$297.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$132.86

FACET BLOCK LUMBAR SACRAL THIRD LEVEL

Professional

Both

$460.00

Service Code	CPT 64495
Hospital Charge Code	4164495
Hospital Revenue Code	975
Min. Negotiated Rate	$43.69
Max. Negotiated Rate	$161.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$43.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$68.54
Rate for Payer: Cash Price	$414.00
Rate for Payer: Cash Price	$414.00
Rate for Payer: Cigna Commercial HMO & PPO	$43.69
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$68.54
Rate for Payer: Home State Health Plan Medicaid Managed Care	$75.39
Rate for Payer: Home State Health Plan Medicare Advantage	$43.69
Rate for Payer: Optum Medicare Advantage	$161.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$68.54

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$36,288.30

Service Code	APR-DRG 0923
Min. Negotiated Rate	$36,288.30
Max. Negotiated Rate	$36,288.30
Rate for Payer: Aetna Better Health Medicaid/QHP	$36,288.30
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$36,288.30
Rate for Payer: Home State Health Plan Medicaid Managed Care	$36,288.30
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$36,288.30

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$54,211.95

Service Code	APR-DRG 0924
Min. Negotiated Rate	$54,211.95
Max. Negotiated Rate	$54,211.95
Rate for Payer: Aetna Better Health Medicaid/QHP	$54,211.95
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$54,211.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$54,211.95
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$54,211.95

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$21,180.73

Service Code	APR-DRG 0922
Min. Negotiated Rate	$21,180.73
Max. Negotiated Rate	$21,180.73
Rate for Payer: Aetna Better Health Medicaid/QHP	$21,180.73
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$21,180.73
Rate for Payer: Home State Health Plan Medicaid Managed Care	$21,180.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$21,180.73

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$17,670.33

Service Code	APR-DRG 0921
Min. Negotiated Rate	$17,670.33
Max. Negotiated Rate	$17,670.33
Rate for Payer: Aetna Better Health Medicaid/QHP	$17,670.33
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$17,670.33
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17,670.33
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17,670.33

FACIAL BONES

Facility

$632.00

Service Code	CPT 70150
Hospital Charge Code	326102
Hospital Revenue Code	320
Rate for Payer: Cash Price	$568.80

FACIAL BONES

Facility

$632.00

Service Code	CPT 70150
Hospital Charge Code	326102
Hospital Revenue Code	320
Min. Negotiated Rate	$94.24
Max. Negotiated Rate	$451.25
Rate for Payer: Aetna Better Health Medicaid/QHP	$94.24
Rate for Payer: Aetna Medicare Advantage	$106.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$374.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$451.25
Rate for Payer: Cash Price	$568.80
Rate for Payer: Cash Price	$568.80
Rate for Payer: Cash Price	$568.80
Rate for Payer: Cigna Commercial HMO & PPO	$106.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$94.24
Rate for Payer: Home State Health Plan Medicaid Managed Care	$100.84
Rate for Payer: Home State Health Plan Medicare Advantage	$106.81
Rate for Payer: Humana Commercial	$213.62
Rate for Payer: Humana Medicare Advantage	$106.81
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$94.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$227.52

FACILITY-CLINIC

Facility

$56.00

Service Code	CPT 99211
Hospital Charge Code	4070001
Hospital Revenue Code	510
Rate for Payer: Cash Price	$50.40

FACILITY-CLINIC

Facility

$56.00

Service Code	CPT 99211
Hospital Charge Code	4070001
Hospital Revenue Code	510
Min. Negotiated Rate	$20.16
Max. Negotiated Rate	$39.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$33.15
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.98
Rate for Payer: Cash Price	$50.40
Rate for Payer: UnitedHealthcare Commercial	$37.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.16

FACTOR II ACTIVITY

Facility

$233.00

Service Code	CPT 85210
Hospital Charge Code	2283002
Hospital Revenue Code	301
Min. Negotiated Rate	$11.68
Max. Negotiated Rate	$166.36
Rate for Payer: Aetna Better Health Medicaid/QHP	$11.68
Rate for Payer: Aetna Medicare Advantage	$12.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$137.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$166.36
Rate for Payer: Cash Price	$209.70
Rate for Payer: Cash Price	$209.70
Rate for Payer: Cash Price	$209.70
Rate for Payer: Cigna Commercial HMO & PPO	$12.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11.68
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12.50
Rate for Payer: Home State Health Plan Medicare Advantage	$12.98
Rate for Payer: Humana Commercial	$25.96
Rate for Payer: Humana Medicare Advantage	$12.98
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$83.88

FACTOR II ACTIVITY

Facility

$233.00

Service Code	CPT 85210
Hospital Charge Code	2283002
Hospital Revenue Code	301
Rate for Payer: Cash Price	$209.70

FACTOR II, DNA ANALYSIS

Facility

$440.00

Service Code	CPT 85240
Hospital Charge Code	2281240
Hospital Revenue Code	305
Rate for Payer: Cash Price	$396.00

FACTOR II, DNA ANALYSIS

Facility

$440.00

Service Code	CPT 85240
Hospital Charge Code	2281240
Hospital Revenue Code	305
Min. Negotiated Rate	$16.11
Max. Negotiated Rate	$314.16
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.11
Rate for Payer: Aetna Medicare Advantage	$17.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$260.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$314.16
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cigna Commercial HMO & PPO	$17.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.11
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.24
Rate for Payer: Home State Health Plan Medicare Advantage	$17.90
Rate for Payer: Humana Commercial	$35.80
Rate for Payer: Humana Medicare Advantage	$17.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$158.40

FACTOR IX ACTIVITY

Facility

$303.00

Service Code	CPT 85250
Hospital Charge Code	2285250
Hospital Revenue Code	301
Min. Negotiated Rate	$17.14
Max. Negotiated Rate	$216.34
Rate for Payer: Aetna Better Health Medicaid/QHP	$17.14
Rate for Payer: Aetna Medicare Advantage	$19.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$179.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$216.34
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial HMO & PPO	$19.04
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$17.14
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18.34
Rate for Payer: Home State Health Plan Medicare Advantage	$19.04
Rate for Payer: Humana Commercial	$38.08
Rate for Payer: Humana Medicare Advantage	$19.04
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$17.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$109.08

FACTOR IX ACTIVITY

Facility

$303.00

Service Code	CPT 85250
Hospital Charge Code	2285250
Hospital Revenue Code	301
Rate for Payer: Cash Price	$272.70

FACTOR V ACTIVITY

Facility

$422.00

Service Code	CPT 85220
Hospital Charge Code	2285210
Hospital Revenue Code	305
Rate for Payer: Cash Price	$379.80

FACTOR V ACTIVITY

Facility

$422.00

Service Code	CPT 85220
Hospital Charge Code	2285210
Hospital Revenue Code	305
Min. Negotiated Rate	$15.89
Max. Negotiated Rate	$301.31
Rate for Payer: Aetna Better Health Medicaid/QHP	$15.89
Rate for Payer: Aetna Medicare Advantage	$17.65
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$249.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$301.31
Rate for Payer: Cash Price	$379.80
Rate for Payer: Cash Price	$379.80
Rate for Payer: Cash Price	$379.80
Rate for Payer: Cigna Commercial HMO & PPO	$17.65
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$15.89
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.00
Rate for Payer: Home State Health Plan Medicare Advantage	$17.65
Rate for Payer: Humana Commercial	$35.30
Rate for Payer: Humana Medicare Advantage	$17.65
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$15.89
Rate for Payer: UnitedHealthcare Medicare Advantage	$151.92

FACTOR VII ACTIVITY

Facility

$118.00

Service Code	CPT 85230
Hospital Charge Code	226143
Hospital Revenue Code	301
Min. Negotiated Rate	$16.11
Max. Negotiated Rate	$84.25
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.11
Rate for Payer: Aetna Medicare Advantage	$17.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$69.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$84.25
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cigna Commercial HMO & PPO	$17.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.11
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.24
Rate for Payer: Home State Health Plan Medicare Advantage	$17.90
Rate for Payer: Humana Commercial	$35.80
Rate for Payer: Humana Medicare Advantage	$17.90
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.11
Rate for Payer: UnitedHealthcare Medicare Advantage	$42.48

Know your out-of-pocket cost for care.

All Charges