Madison Medical Center

All Charges

Charge

Type

Setting

Price

.F TULEREMIA AB, IGM

Facility

$190.00

Service Code	CPT 86668
Hospital Charge Code	2286669
Hospital Revenue Code	302
Min. Negotiated Rate	$12.74
Max. Negotiated Rate	$135.66
Rate for Payer: Aetna Better Health Medicaid/QHP	$12.74
Rate for Payer: Aetna Medicare Advantage	$14.16
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: Cash Price	$171.00
Rate for Payer: Cigna Commercial HMO & PPO	$14.16
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12.74
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13.63
Rate for Payer: Home State Health Plan Medicare Advantage	$14.16
Rate for Payer: Humana Commercial	$28.32
Rate for Payer: Humana Medicare Advantage	$14.16
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$68.40

FULL BODY BLANKET

Facility

$152.00

Hospital Charge Code	122249
Hospital Revenue Code	271
Rate for Payer: Cash Price	$136.80

FULL BODY BLANKET

Facility

$152.00

Hospital Charge Code	122249
Hospital Revenue Code	271
Min. Negotiated Rate	$54.72
Max. Negotiated Rate	$108.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$89.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$108.53
Rate for Payer: Cash Price	$136.80
Rate for Payer: UnitedHealthcare Commercial	$101.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$54.72

FULL MASK W/HEAD GEAR C/BI PAP LARGE

Facility

$178.00

Hospital Charge Code	4500447
Hospital Revenue Code	271
Rate for Payer: Cash Price	$160.20

FULL MASK W/HEAD GEAR C/BI PAP LARGE

Facility

$178.00

Hospital Charge Code	4500447
Hospital Revenue Code	271
Min. Negotiated Rate	$64.08
Max. Negotiated Rate	$127.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$105.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$127.09
Rate for Payer: Cash Price	$160.20
Rate for Payer: UnitedHealthcare Commercial	$118.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$64.08

FULL MASK W/HEAD GEAR C/BI PAP MEDIUM

Facility

$178.00

Hospital Charge Code	4500446
Hospital Revenue Code	271
Rate for Payer: Cash Price	$160.20

FULL MASK W/HEAD GEAR C/BI PAP MEDIUM

Facility

$178.00

Hospital Charge Code	4500446
Hospital Revenue Code	271
Min. Negotiated Rate	$64.08
Max. Negotiated Rate	$127.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$105.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$127.09
Rate for Payer: Cash Price	$160.20
Rate for Payer: UnitedHealthcare Commercial	$118.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$64.08

FULL MASK W/ HEAD GEAR C/BI PAP SMALL

Facility

$178.00

Hospital Charge Code	4500441
Hospital Revenue Code	271
Min. Negotiated Rate	$64.08
Max. Negotiated Rate	$127.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$105.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$127.09
Rate for Payer: Cash Price	$160.20
Rate for Payer: UnitedHealthcare Commercial	$118.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$64.08

FULL MASK W/ HEAD GEAR C/BI PAP SMALL

Facility

$178.00

Hospital Charge Code	4500441
Hospital Revenue Code	271
Rate for Payer: Cash Price	$160.20

FULL TERM NEONATE WITH MAJOR PROBLEMS

Facility

$69,325.46

Service Code	MSDRG 793
Min. Negotiated Rate	$351.00
Max. Negotiated Rate	$69,325.46
Rate for Payer: Aetna Medicare Advantage	$34,662.73
Rate for Payer: Cigna Commercial HMO & PPO	$34,662.73
Rate for Payer: Home State Health Plan Medicare Advantage	$34,662.73
Rate for Payer: Humana Commercial	$69,325.46
Rate for Payer: Humana Medicare Advantage	$34,662.73
Rate for Payer: UnitedHealthcare Commercial	$351.00

FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY

Facility

$38,317.14

Service Code	MSDRG 934
Min. Negotiated Rate	$19,158.57
Max. Negotiated Rate	$38,317.14
Rate for Payer: Aetna Medicare Advantage	$19,158.57
Rate for Payer: Cigna Commercial HMO & PPO	$19,158.57
Rate for Payer: Home State Health Plan Medicare Advantage	$19,158.57
Rate for Payer: Humana Commercial	$38,317.14
Rate for Payer: Humana Medicare Advantage	$19,158.57

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC

Facility

$116,998.62

Service Code	MSDRG 928
Min. Negotiated Rate	$58,499.31
Max. Negotiated Rate	$116,998.62
Rate for Payer: Aetna Medicare Advantage	$58,499.31
Rate for Payer: Cigna Commercial HMO & PPO	$58,499.31
Rate for Payer: Home State Health Plan Medicare Advantage	$58,499.31
Rate for Payer: Humana Commercial	$116,998.62
Rate for Payer: Humana Medicare Advantage	$58,499.31

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC

Facility

$54,280.36

Service Code	MSDRG 929
Min. Negotiated Rate	$27,140.18
Max. Negotiated Rate	$54,280.36
Rate for Payer: Aetna Medicare Advantage	$27,140.18
Rate for Payer: Cigna Commercial HMO & PPO	$27,140.18
Rate for Payer: Home State Health Plan Medicare Advantage	$27,140.18
Rate for Payer: Humana Commercial	$54,280.36
Rate for Payer: Humana Medicare Advantage	$27,140.18

FULL THICKNESS GRAFT 20 SQ CM FACE

Facility

$2,095.00

Service Code	CPT 15260
Hospital Charge Code	4115260
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$4,215.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,859.94
Rate for Payer: Aetna Medicare Advantage	$2,107.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,240.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,495.83
Rate for Payer: Cash Price	$1,885.50
Rate for Payer: Cash Price	$1,885.50
Rate for Payer: Cash Price	$1,885.50
Rate for Payer: Cash Price	$1,885.50
Rate for Payer: Cigna Commercial HMO & PPO	$2,107.97
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,673.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,990.14
Rate for Payer: Home State Health Plan Medicare Advantage	$2,107.97
Rate for Payer: Humana Commercial	$4,215.94
Rate for Payer: Humana Medicare Advantage	$2,107.97
Rate for Payer: UnitedHealthcare Commercial	$1,397.37
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,859.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FULL THICKNESS GRAFT 20 SQ CM FACE

Facility

$2,095.00

Service Code	CPT 15260
Hospital Charge Code	4115260
Hospital Revenue Code	521
Rate for Payer: Cash Price	$1,885.50

FULL THICKNESS GRAFT EA ADD'L 20 SQ CM

Facility

$910.00

Service Code	CPT 15261
Hospital Charge Code	4115261
Hospital Revenue Code	521
Rate for Payer: Cash Price	$819.00

FULL THICKNESS GRAFT EA ADD'L 20 SQ CM

Facility

$910.00

Service Code	CPT 15261
Hospital Charge Code	4115261
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$649.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$538.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$649.74
Rate for Payer: Cash Price	$819.00
Rate for Payer: Cash Price	$819.00
Rate for Payer: UnitedHealthcare Commercial	$606.97
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FUNGAL CULTURE

Facility

$387.00

Service Code	CPT 87107
Hospital Charge Code	3087107
Hospital Revenue Code	306
Min. Negotiated Rate	$9.29
Max. Negotiated Rate	$276.32
Rate for Payer: Aetna Better Health Medicaid/QHP	$9.29
Rate for Payer: Aetna Medicare Advantage	$10.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$229.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$276.32
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial HMO & PPO	$10.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$9.29
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9.94
Rate for Payer: Home State Health Plan Medicare Advantage	$10.32
Rate for Payer: Humana Commercial	$20.64
Rate for Payer: Humana Medicare Advantage	$10.32
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$9.29
Rate for Payer: UnitedHealthcare Medicare Advantage	$139.32

FUNGAL CULTURE

Facility

$387.00

Service Code	CPT 87107
Hospital Charge Code	3087107
Hospital Revenue Code	306
Rate for Payer: Cash Price	$348.30

FUNGAL STAIN

Facility

$80.00

Service Code	CPT 87206
Hospital Charge Code	308015
Hospital Revenue Code	306
Min. Negotiated Rate	$4.85
Max. Negotiated Rate	$57.12
Rate for Payer: Aetna Better Health Medicaid/QHP	$4.85
Rate for Payer: Aetna Medicare Advantage	$5.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$47.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$57.12
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial HMO & PPO	$5.39
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4.85
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5.19
Rate for Payer: Home State Health Plan Medicare Advantage	$5.39
Rate for Payer: Humana Commercial	$10.78
Rate for Payer: Humana Medicare Advantage	$5.39
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$28.80

FUNGAL STAIN

Facility

$80.00

Service Code	CPT 87206
Hospital Charge Code	308015
Hospital Revenue Code	306
Rate for Payer: Cash Price	$72.00

FUNGITELL

Facility

$284.00

Service Code	CPT 87449
Hospital Charge Code	2287450
Hospital Revenue Code	302
Rate for Payer: Cash Price	$255.60

FUNGITELL

Facility

$284.00

Service Code	CPT 87449
Hospital Charge Code	2287450
Hospital Revenue Code	302
Min. Negotiated Rate	$10.78
Max. Negotiated Rate	$202.78
Rate for Payer: Aetna Better Health Medicaid/QHP	$10.78
Rate for Payer: Aetna Medicare Advantage	$11.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$168.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$202.78
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial HMO & PPO	$11.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$10.78
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11.53
Rate for Payer: Home State Health Plan Medicare Advantage	$11.98
Rate for Payer: Humana Commercial	$23.96
Rate for Payer: Humana Medicare Advantage	$11.98
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$10.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$102.24

FUROSEMIDE 20MG TAB EMP

Facility

$20.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2698226
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

FUROSEMIDE 20MG TAB EMP

Facility

$20.00

Service Code	NDC 5.1079E+10
Hospital Charge Code	2698226
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

Know your out-of-pocket cost for care.

All Charges