Madison Medical Center

All Charges

Charge

Type

Setting

Price

FX DISTAL RADIAL W/O MANIPULATION

Facility

$368.00

Service Code	CPT 25600
Hospital Charge Code	5225600
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$504.02
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$217.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$262.75
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$245.46
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FX DISTAL RADIAL W/O MANIPULATION

Facility

$368.00

Service Code	CPT 25600
Hospital Charge Code	5225600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$331.20

FX FIBULA OR SHAFT W/O MANIPULATION

Facility

$500.00

Service Code	CPT 27780
Hospital Charge Code	4427780
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$504.02
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$296.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$357.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$333.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FX FIBULA OR SHAFT W/O MANIPULATION

Facility

$500.00

Service Code	CPT 27780
Hospital Charge Code	4427780
Hospital Revenue Code	521
Rate for Payer: Cash Price	$450.00

FX METACARPAL CLOSED SIMPLE

Facility

$368.00

Service Code	CPT 26600
Hospital Charge Code	4426600
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$504.02
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$217.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$262.75
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$245.46
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FX METACARPAL CLOSED SIMPLE

Facility

$368.00

Service Code	CPT 26600
Hospital Charge Code	4426600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$331.20

FX RADIAL SHAFT W/O MANIPULATION CLOSED

Facility

$600.00

Service Code	CPT 25500
Hospital Charge Code	4425500
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$504.02
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$355.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$428.40
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$400.20
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FX RADIAL SHAFT W/O MANIPULATION CLOSED

Facility

$600.00

Service Code	CPT 25500
Hospital Charge Code	4425500
Hospital Revenue Code	521
Rate for Payer: Cash Price	$540.00

FX TRTMT OF CARPAL SCAPHOID CLOSED W/O M

Facility

$840.00

Service Code	CPT 25622
Hospital Charge Code	4225622
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$599.76
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$497.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$599.76
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$560.28
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FX TRTMT OF CARPAL SCAPHOID CLOSED W/O M

Facility

$840.00

Service Code	CPT 25622
Hospital Charge Code	4225622
Hospital Revenue Code	521
Rate for Payer: Cash Price	$756.00

FX ULNAR, PROX END OLECRANON PROCESS

Facility

$500.00

Service Code	CPT 24670
Hospital Charge Code	4424670
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$504.02
Rate for Payer: Aetna Better Health Medicaid/QHP	$222.36
Rate for Payer: Aetna Medicare Advantage	$252.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$296.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$357.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cigna Commercial HMO & PPO	$252.01
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$200.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$237.93
Rate for Payer: Home State Health Plan Medicare Advantage	$252.01
Rate for Payer: Humana Commercial	$504.02
Rate for Payer: Humana Medicare Advantage	$252.01
Rate for Payer: UnitedHealthcare Commercial	$333.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$222.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

FX ULNAR, PROX END OLECRANON PROCESS

Facility

$500.00

Service Code	CPT 24670
Hospital Charge Code	4424670
Hospital Revenue Code	521
Rate for Payer: Cash Price	$450.00

G6PD QUANT

Facility

$81.00

Service Code	CPT 82955
Hospital Charge Code	2282955
Hospital Revenue Code	305
Rate for Payer: Cash Price	$72.90

G6PD QUANT

Facility

$81.00

Service Code	CPT 82955
Hospital Charge Code	2282955
Hospital Revenue Code	305
Min. Negotiated Rate	$8.73
Max. Negotiated Rate	$57.83
Rate for Payer: Aetna Better Health Medicaid/QHP	$8.73
Rate for Payer: Aetna Medicare Advantage	$9.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$47.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$57.83
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial HMO & PPO	$9.70
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8.73
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9.34
Rate for Payer: Home State Health Plan Medicare Advantage	$9.70
Rate for Payer: Humana Commercial	$19.40
Rate for Payer: Humana Medicare Advantage	$9.70
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$29.16

GABAPENTIN

Facility

$166.00

Service Code	CPT 80299
Hospital Charge Code	2280291
Hospital Revenue Code	301
Rate for Payer: Cash Price	$149.40

GABAPENTIN

Facility

$166.00

Service Code	CPT 80299
Hospital Charge Code	2280291
Hospital Revenue Code	301
Min. Negotiated Rate	$16.78
Max. Negotiated Rate	$118.52
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.78
Rate for Payer: Aetna Medicare Advantage	$18.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$98.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$118.52
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cigna Commercial HMO & PPO	$18.64
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.78
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.95
Rate for Payer: Home State Health Plan Medicare Advantage	$18.64
Rate for Payer: Humana Commercial	$37.28
Rate for Payer: Humana Medicare Advantage	$18.64
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$59.76

GABAPENTIN 100MG CAP EMP

Facility

$20.00

Service Code	NDC 6.0505E+10
Hospital Charge Code	2619400
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

GABAPENTIN 100MG CAP EMP

Facility

$20.00

Service Code	NDC 6.0505E+10
Hospital Charge Code	2619400
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

GABAPENTIN 300MG CAP EMP 500

Facility

$21.00

Service Code	NDC 71080524
Hospital Charge Code	2625239
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

GABAPENTIN 300MG CAP EMP 500

Facility

$21.00

Service Code	NDC 71080524
Hospital Charge Code	2625239
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

GABAPENTIN 400MG CAP EMP

Facility

$21.00

Service Code	NDC 6.7877E+10
Hospital Charge Code	2620769
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

GABAPENTIN 400MG CAP EMP

Facility

$21.00

Service Code	NDC 6.7877E+10
Hospital Charge Code	2620769
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

GABAPENTIN 600MG TAB EMP

Facility

$21.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2698230
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

GABAPENTIN 600MG TAB EMP

Facility

$21.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2698230
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.90

GABAPENTIN 800MG TAB EMP

Facility

$21.00

Service Code	NDC 5.0228E+10
Hospital Charge Code	2621384
Hospital Revenue Code	250
Min. Negotiated Rate	$7.56
Max. Negotiated Rate	$14.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$12.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.99
Rate for Payer: Cash Price	$18.90
Rate for Payer: UnitedHealthcare Commercial	$14.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.56

Know your out-of-pocket cost for care.

All Charges