Madison Medical Center

All Charges

Charge

Type

Setting

Price

INC & REMOVAL F/B SUBCUT TISSUE SIMPLE

Facility

$260.00

Service Code	CPT 10120
Hospital Charge Code	5410120
Hospital Revenue Code	521
Rate for Payer: Cash Price	$234.00

INC & REMOVAL F/B SUBCUT TISSUE SIMPLE

Facility

$260.00

Service Code	CPT 10120
Hospital Charge Code	5410120
Hospital Revenue Code	521
Min. Negotiated Rate	$153.92
Max. Negotiated Rate	$830.64
Rate for Payer: Aetna Better Health Medicaid/QHP	$366.45
Rate for Payer: Aetna Medicare Advantage	$415.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$153.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$185.64
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial HMO & PPO	$415.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$329.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$392.10
Rate for Payer: Home State Health Plan Medicare Advantage	$415.32
Rate for Payer: Humana Commercial	$830.64
Rate for Payer: Humana Medicare Advantage	$415.32
Rate for Payer: UnitedHealthcare Commercial	$173.42
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INDIA INK (SURGERY) 1ML

Facility

$100.00

Service Code	NDC 1E+11
Hospital Charge Code	2698216
Hospital Revenue Code	250
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$71.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$59.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$71.40
Rate for Payer: Cash Price	$90.00
Rate for Payer: UnitedHealthcare Commercial	$66.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.00

INDIA INK (SURGERY) 1ML

Facility

$100.00

Service Code	NDC 1E+11
Hospital Charge Code	2698216
Hospital Revenue Code	250
Rate for Payer: Cash Price	$90.00

INDIGO CARMINE SOL.

Facility

$40.00

Hospital Charge Code	129107
Hospital Revenue Code	271
Rate for Payer: Cash Price	$36.00

INDIGO CARMINE SOL.

Facility

$40.00

Hospital Charge Code	129107
Hospital Revenue Code	271
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$28.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$28.56
Rate for Payer: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

INDOMETHACIN 25MG CAPS EMP

Facility

$9.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2622713
Hospital Revenue Code	250
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$6.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$5.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$6.43
Rate for Payer: Cash Price	$8.10
Rate for Payer: UnitedHealthcare Commercial	$6.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.24

INDOMETHACIN 25MG CAPS EMP

Facility

$9.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2622713
Hospital Revenue Code	250
Rate for Payer: Cash Price	$8.10

INDOMETHACIN 50MG CAP EMP

Facility

$9.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2622927
Hospital Revenue Code	250
Rate for Payer: Cash Price	$8.10

INDOMETHACIN 50MG CAP EMP

Facility

$9.00

Service Code	NDC 3.1722E+10
Hospital Charge Code	2622927
Hospital Revenue Code	250
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$6.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$5.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$6.43
Rate for Payer: Cash Price	$8.10
Rate for Payer: UnitedHealthcare Commercial	$6.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$3.24

INFANT AMBU BAG

Facility

$62.00

Hospital Charge Code	4500227
Hospital Revenue Code	271
Min. Negotiated Rate	$22.32
Max. Negotiated Rate	$44.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$36.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$44.27
Rate for Payer: Cash Price	$55.80
Rate for Payer: UnitedHealthcare Commercial	$41.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$22.32

INFANT AMBU BAG

Facility

$62.00

Hospital Charge Code	4500227
Hospital Revenue Code	271
Rate for Payer: Cash Price	$55.80

INFANT CATH KIT

Facility

$21.00

Hospital Charge Code	2835630
Hospital Revenue Code	271
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

INFANT CATH KIT

Facility

$21.00

Hospital Charge Code	2835630
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

INFANT MASK (OXYGEN)

Facility

$21.00

Hospital Charge Code	4500444
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.90

INFANT MASK (OXYGEN)

Facility

$21.00

Hospital Charge Code	4500444
Hospital Revenue Code	271
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

INF., BUTTERFLY

Facility

$28.00

Hospital Charge Code	289163
Hospital Revenue Code	271
Rate for Payer: Cash Price	$25.20

INF., BUTTERFLY

Facility

$28.00

Hospital Charge Code	289163
Hospital Revenue Code	271
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$18,965.26

Service Code	MSDRG 758
Min. Negotiated Rate	$9,482.63
Max. Negotiated Rate	$18,965.26
Rate for Payer: Aetna Medicare Advantage	$9,482.63
Rate for Payer: Cigna Commercial HMO & PPO	$9,482.63
Rate for Payer: Home State Health Plan Medicare Advantage	$9,482.63
Rate for Payer: Humana Commercial	$18,965.26
Rate for Payer: Humana Medicare Advantage	$9,482.63

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$26,055.92

Service Code	MSDRG 757
Min. Negotiated Rate	$13,027.96
Max. Negotiated Rate	$26,055.92
Rate for Payer: Aetna Medicare Advantage	$13,027.96
Rate for Payer: Cigna Commercial HMO & PPO	$13,027.96
Rate for Payer: Home State Health Plan Medicare Advantage	$13,027.96
Rate for Payer: Humana Commercial	$26,055.92
Rate for Payer: Humana Medicare Advantage	$13,027.96

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$14,034.60

Service Code	MSDRG 759
Min. Negotiated Rate	$7,017.30
Max. Negotiated Rate	$14,034.60
Rate for Payer: Aetna Medicare Advantage	$7,017.30
Rate for Payer: Cigna Commercial HMO & PPO	$7,017.30
Rate for Payer: Home State Health Plan Medicare Advantage	$7,017.30
Rate for Payer: Humana Commercial	$14,034.60
Rate for Payer: Humana Medicare Advantage	$7,017.30

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$6,484.34

Service Code	APR-DRG 1132
Min. Negotiated Rate	$6,484.34
Max. Negotiated Rate	$6,484.34
Rate for Payer: Aetna Better Health Medicaid/QHP	$6,484.34
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$6,484.34
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6,484.34
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$6,484.34

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$12,101.51

Service Code	APR-DRG 1133
Min. Negotiated Rate	$12,101.51
Max. Negotiated Rate	$12,101.51
Rate for Payer: Aetna Better Health Medicaid/QHP	$12,101.51
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12,101.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12,101.51
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12,101.51

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$22,290.66

Service Code	APR-DRG 1134
Min. Negotiated Rate	$22,290.66
Max. Negotiated Rate	$22,290.66
Rate for Payer: Aetna Better Health Medicaid/QHP	$22,290.66
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$22,290.66
Rate for Payer: Home State Health Plan Medicaid Managed Care	$22,290.66
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$22,290.66

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$4,062.10

Service Code	APR-DRG 1131
Min. Negotiated Rate	$4,062.10
Max. Negotiated Rate	$4,062.10
Rate for Payer: Aetna Better Health Medicaid/QHP	$4,062.10
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$4,062.10
Rate for Payer: Home State Health Plan Medicaid Managed Care	$4,062.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$4,062.10

Know your out-of-pocket cost for care.

All Charges