Madison Medical Center

All Charges

Charge

Type

Setting

Price

HCV VIRAL LOAD RFX TO GEN (LC550090)

Facility

$342.00

Service Code	CPT 87522
Hospital Charge Code	2283895
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$244.19
Rate for Payer: Aetna Better Health Medicaid/QHP	$38.56
Rate for Payer: Aetna Medicare Advantage	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$202.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$244.19
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cigna Commercial HMO & PPO	$42.84
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$38.56
Rate for Payer: Home State Health Plan Medicaid Managed Care	$41.26
Rate for Payer: Home State Health Plan Medicare Advantage	$42.84
Rate for Payer: Humana Commercial	$85.68
Rate for Payer: Humana Medicare Advantage	$42.84
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$38.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$123.12

HCY EST 18 - 39

Facility

$255.00

Service Code	CPT 99395
Hospital Charge Code	9799395
Hospital Revenue Code	521
Rate for Payer: Cash Price	$229.50

HCY EST 18 - 39

Facility

$255.00

Service Code	CPT 99395
Hospital Charge Code	9799395
Hospital Revenue Code	521
Min. Negotiated Rate	$150.96
Max. Negotiated Rate	$182.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$150.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$182.07
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cash Price	$229.50
Rate for Payer: UnitedHealthcare Commercial	$170.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

HCY EST PT AGE 1 - 4

Facility

$220.00

Service Code	CPT 99392
Hospital Charge Code	4299392
Hospital Revenue Code	521
Rate for Payer: Cash Price	$198.00

HCY EST PT AGE 1 - 4

Facility

$220.00

Service Code	CPT 99392
Hospital Charge Code	9799392
Hospital Revenue Code	521
Rate for Payer: Cash Price	$198.00

HCY EST PT AGE 1 - 4

Facility

$220.00

Service Code	CPT 99392
Hospital Charge Code	4299392
Hospital Revenue Code	521
Min. Negotiated Rate	$130.24
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$130.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$157.08
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: UnitedHealthcare Commercial	$146.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

HCY EST PT AGE 1 - 4

Facility

$220.00

Service Code	CPT 99392
Hospital Charge Code	9799392
Hospital Revenue Code	521
Min. Negotiated Rate	$130.24
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$130.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$157.08
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: UnitedHealthcare Commercial	$146.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

HCY EST PT AGE 5 - 11

Facility

$220.00

Service Code	CPT 99393
Hospital Charge Code	4299393
Hospital Revenue Code	521
Rate for Payer: Cash Price	$198.00

HCY EST PT AGE 5 - 11

Facility

$220.00

Service Code	CPT 99393
Hospital Charge Code	4299393
Hospital Revenue Code	521
Min. Negotiated Rate	$130.24
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$130.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$157.08
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: UnitedHealthcare Commercial	$146.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

HCY EST PT NEWBORN

Facility

$205.00

Service Code	CPT 99391
Hospital Charge Code	4299391
Hospital Revenue Code	521
Min. Negotiated Rate	$121.36
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$121.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$146.37
Rate for Payer: Cash Price	$184.50
Rate for Payer: Cash Price	$184.50
Rate for Payer: UnitedHealthcare Commercial	$136.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

HCY EST PT NEWBORN

Facility

$205.00

Service Code	CPT 99391
Hospital Charge Code	4299391
Hospital Revenue Code	521
Rate for Payer: Cash Price	$184.50

HCY EST VISIT AGE 12 - 17

Facility

$235.00

Service Code	CPT 99394
Hospital Charge Code	9799394
Hospital Revenue Code	521
Rate for Payer: Cash Price	$211.50

HCY EST VISIT AGE 12 - 17

Facility

$235.00

Service Code	CPT 99394
Hospital Charge Code	9799394
Hospital Revenue Code	521
Min. Negotiated Rate	$139.12
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$139.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$167.79
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cash Price	$211.50
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

HCY EST VISIT AGE 5 - 11

Facility

$220.00

Service Code	CPT 99393
Hospital Charge Code	9799393
Hospital Revenue Code	521
Min. Negotiated Rate	$130.24
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$130.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$157.08
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: UnitedHealthcare Commercial	$146.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

HCY EST VISIT AGE 5 - 11

Facility

$220.00

Service Code	CPT 99393
Hospital Charge Code	9799393
Hospital Revenue Code	521
Rate for Payer: Cash Price	$198.00

HCY MEDICAID SCREENING

Facility

$81.00

Service Code	CPT W0025
Hospital Charge Code	4100025
Hospital Revenue Code	521
Min. Negotiated Rate	$47.95
Max. Negotiated Rate	$173.53
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: UnitedHealthcare Commercial	$54.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

HCY MEDICAID SCREENING

Facility

$81.00

Service Code	CPT W0025
Hospital Charge Code	4100025
Hospital Revenue Code	521
Rate for Payer: Cash Price	$72.90

HCY NEWBORN EST VISIT

Facility

$205.00

Service Code	CPT 99391
Hospital Charge Code	9799391
Hospital Revenue Code	521
Min. Negotiated Rate	$121.36
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$121.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$146.37
Rate for Payer: Cash Price	$184.50
Rate for Payer: Cash Price	$184.50
Rate for Payer: UnitedHealthcare Commercial	$136.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

HCY NEWBORN EST VISIT

Facility

$205.00

Service Code	CPT 99391
Hospital Charge Code	9799391
Hospital Revenue Code	521
Rate for Payer: Cash Price	$184.50

HCY NEWBORN NEW PATIENT

Facility

$235.00

Service Code	CPT 99381
Hospital Charge Code	9799381
Hospital Revenue Code	521
Min. Negotiated Rate	$139.12
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$139.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$167.79
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cash Price	$211.50
Rate for Payer: UnitedHealthcare Commercial	$156.75
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

HCY NEWBORN NEW PATIENT

Facility

$235.00

Service Code	CPT 99381
Hospital Charge Code	9799381
Hospital Revenue Code	521
Rate for Payer: Cash Price	$211.50

HCY NEW PT PT AGE 1 - 4

Facility

$250.00

Service Code	CPT 99382
Hospital Charge Code	9799382
Hospital Revenue Code	521
Rate for Payer: Cash Price	$225.00

HCY NEW PT PT AGE 1 - 4

Facility

$250.00

Service Code	CPT 99382
Hospital Charge Code	9799382
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

HCY NP 1 - 4

Facility

$250.00

Service Code	CPT 99382
Hospital Charge Code	4299382
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

HCY NP 1 - 4

Facility

$250.00

Service Code	CPT 99382
Hospital Charge Code	4299382
Hospital Revenue Code	521
Rate for Payer: Cash Price	$225.00

Know your out-of-pocket cost for care.

All Charges