Madison Medical Center

All Charges

Charge

Type

Setting

Price

FOLEY CATHETER

Facility

$610.00

Service Code	CPT 51702
Hospital Charge Code	551702
Hospital Revenue Code	269
Min. Negotiated Rate	$119.94
Max. Negotiated Rate	$435.54
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$361.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$435.54
Rate for Payer: Cash Price	$549.00
Rate for Payer: Cash Price	$549.00
Rate for Payer: Cash Price	$549.00
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$119.94
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$219.60

FOLEY CATHETER

Facility

$610.00

Service Code	CPT 51702
Hospital Charge Code	551702
Hospital Revenue Code	269
Rate for Payer: Cash Price	$549.00

FOLEY CATHETER

Professional

Both

$610.00

Service Code	CPT 51702
Hospital Charge Code	1851702
Hospital Revenue Code	981
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$213.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$22.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$55.69
Rate for Payer: Cash Price	$549.00
Rate for Payer: Cash Price	$549.00
Rate for Payer: Cigna Commercial HMO & PPO	$22.10
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$55.69
Rate for Payer: Home State Health Plan Medicaid Managed Care	$61.26
Rate for Payer: Home State Health Plan Medicare Advantage	$22.10
Rate for Payer: Optum Medicare Advantage	$213.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$55.69

FOLIC ACID

Facility

$324.00

Service Code	CPT 82746
Hospital Charge Code	2282746
Hospital Revenue Code	301
Rate for Payer: Cash Price	$291.60

FOLIC ACID

Facility

$324.00

Service Code	CPT 82746
Hospital Charge Code	2282746
Hospital Revenue Code	301
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$231.34
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.23
Rate for Payer: Aetna Medicare Advantage	$14.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$191.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$231.34
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial HMO & PPO	$14.70
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.23
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.16
Rate for Payer: Home State Health Plan Medicare Advantage	$14.70
Rate for Payer: Humana Commercial	$29.40
Rate for Payer: Humana Medicare Advantage	$14.70
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$116.64

FOLIC ACID 1MG TAB EMP

Facility

$20.00

Service Code	NDC 6.3739E+10
Hospital Charge Code	2622291
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
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: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

FOLIC ACID 1MG TAB EMP

Facility

$20.00

Service Code	NDC 6.3739E+10
Hospital Charge Code	2622291
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

FOLIC ACID (FOLVITE) 1MG TAB UD

Facility

$20.00

Service Code	NDC 6.2584E+10
Hospital Charge Code	2655040
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
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: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

FOLIC ACID (FOLVITE) 1MG TAB UD

Facility

$20.00

Service Code	NDC 6.2584E+10
Hospital Charge Code	2655040
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

FOLIC ACID (LAB CORP)

Facility

$324.00

Service Code	CPT 82746
Hospital Charge Code	2282748
Hospital Revenue Code	301
Rate for Payer: Cash Price	$291.60

FOLIC ACID (LAB CORP)

Facility

$324.00

Service Code	CPT 82746
Hospital Charge Code	2282748
Hospital Revenue Code	301
Min. Negotiated Rate	$13.23
Max. Negotiated Rate	$231.34
Rate for Payer: Aetna Better Health Medicaid/QHP	$13.23
Rate for Payer: Aetna Medicare Advantage	$14.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$191.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$231.34
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial HMO & PPO	$14.70
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13.23
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14.16
Rate for Payer: Home State Health Plan Medicare Advantage	$14.70
Rate for Payer: Humana Commercial	$29.40
Rate for Payer: Humana Medicare Advantage	$14.70
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$116.64

FOLLOW-UP DETAIL HIGH COMPLEX

Professional

Both

$282.00

Service Code	CPT 99233
Hospital Charge Code	4199233
Hospital Revenue Code	987
Min. Negotiated Rate	$84.01
Max. Negotiated Rate	$103.87
Rate for Payer: Aetna Commercial/Medicare Advantage	$103.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$84.01
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cigna Commercial HMO & PPO	$103.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$84.01
Rate for Payer: Home State Health Plan Medicaid Managed Care	$92.41
Rate for Payer: Home State Health Plan Medicare Advantage	$103.87
Rate for Payer: Optum Medicare Advantage	$98.70
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$84.01

FOLLOW-UP LOW/COMPLEX 15.MIN

Professional

Both

$128.00

Service Code	CPT 99231
Hospital Charge Code	4199231
Hospital Revenue Code	987
Min. Negotiated Rate	$31.75
Max. Negotiated Rate	$44.80
Rate for Payer: Aetna Commercial/Medicare Advantage	$42.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$31.75
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cigna Commercial HMO & PPO	$42.91
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$31.75
Rate for Payer: Home State Health Plan Medicaid Managed Care	$34.92
Rate for Payer: Home State Health Plan Medicare Advantage	$42.91
Rate for Payer: Optum Medicare Advantage	$44.80
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$31.75

FOOT AND TOE PROCEDURES

Facility

$36,807.87

Service Code	APR-DRG 3144
Min. Negotiated Rate	$36,807.87
Max. Negotiated Rate	$36,807.87
Rate for Payer: Aetna Better Health Medicaid/QHP	$36,807.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$36,807.87
Rate for Payer: Home State Health Plan Medicaid Managed Care	$36,807.87
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$36,807.87

FOOT AND TOE PROCEDURES

Facility

$19,207.81

Service Code	APR-DRG 3143
Min. Negotiated Rate	$19,207.81
Max. Negotiated Rate	$19,207.81
Rate for Payer: Aetna Better Health Medicaid/QHP	$19,207.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$19,207.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$19,207.81
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$19,207.81

FOOT AND TOE PROCEDURES

Facility

$12,664.06

Service Code	APR-DRG 3142
Min. Negotiated Rate	$12,664.06
Max. Negotiated Rate	$12,664.06
Rate for Payer: Aetna Better Health Medicaid/QHP	$12,664.06
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12,664.06
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12,664.06
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12,664.06

FOOT AND TOE PROCEDURES

Facility

$9,834.11

Service Code	APR-DRG 3141
Min. Negotiated Rate	$9,834.11
Max. Negotiated Rate	$9,834.11
Rate for Payer: Aetna Better Health Medicaid/QHP	$9,834.11
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$9,834.11
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9,834.11
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$9,834.11

FOOT DISLOCATION REDUCTION

Professional

Both

$670.00

Service Code	CPT 28660
Hospital Charge Code	1828660
Hospital Revenue Code	981
Min. Negotiated Rate	$92.74
Max. Negotiated Rate	$234.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$93.65
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$92.74
Rate for Payer: Cash Price	$603.00
Rate for Payer: Cash Price	$603.00
Rate for Payer: Cigna Commercial HMO & PPO	$93.65
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$92.74
Rate for Payer: Home State Health Plan Medicaid Managed Care	$102.01
Rate for Payer: Home State Health Plan Medicare Advantage	$93.65
Rate for Payer: Optum Medicare Advantage	$234.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$92.74

FOOT INSERT REMOV MOLDED TO PT

Facility

$250.00

Service Code	CPT L3000
Hospital Charge Code	9303000
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

FOOT INSERT REMOV MOLDED TO PT

Facility

$250.00

Service Code	CPT L3000
Hospital Charge Code	9303000
Hospital Revenue Code	521
Rate for Payer: Cash Price	$225.00

FOOT PROCEDURES WITH CC

Facility

$32,938.82

Service Code	MSDRG 504
Min. Negotiated Rate	$16,469.41
Max. Negotiated Rate	$32,938.82
Rate for Payer: Aetna Medicare Advantage	$16,469.41
Rate for Payer: Cigna Commercial HMO & PPO	$16,469.41
Rate for Payer: Home State Health Plan Medicare Advantage	$16,469.41
Rate for Payer: Humana Commercial	$32,938.82
Rate for Payer: Humana Medicare Advantage	$16,469.41

FOOT PROCEDURES WITH MCC

Facility

$47,482.46

Service Code	MSDRG 503
Min. Negotiated Rate	$23,741.23
Max. Negotiated Rate	$47,482.46
Rate for Payer: Aetna Medicare Advantage	$23,741.23
Rate for Payer: Cigna Commercial HMO & PPO	$23,741.23
Rate for Payer: Home State Health Plan Medicare Advantage	$23,741.23
Rate for Payer: Humana Commercial	$47,482.46
Rate for Payer: Humana Medicare Advantage	$23,741.23

FOOT PROCEDURES WITHOUT CC/MCC

Facility

$31,735.24

Service Code	MSDRG 505
Min. Negotiated Rate	$15,867.62
Max. Negotiated Rate	$31,735.24
Rate for Payer: Aetna Medicare Advantage	$15,867.62
Rate for Payer: Cigna Commercial HMO & PPO	$15,867.62
Rate for Payer: Home State Health Plan Medicare Advantage	$15,867.62
Rate for Payer: Humana Commercial	$31,735.24
Rate for Payer: Humana Medicare Advantage	$15,867.62

FOOT STRAPPING TAPE

Facility

$20.00

Hospital Charge Code	4002237
Hospital Revenue Code	510
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
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: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

FOOT STRAPPING TAPE

Facility

$20.00

Hospital Charge Code	4002237
Hospital Revenue Code	510
Rate for Payer: Cash Price	$18.00

Know your out-of-pocket cost for care.

All Charges