Madison Medical Center

All Charges

Charge

Type

Setting

Price

INITIAL HOSP CARE INTERMEDIATE

Facility

$193.50

Service Code	CPT 99222
Hospital Charge Code	3999222
Hospital Revenue Code	521
Min. Negotiated Rate	$114.55
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$114.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$138.16
Rate for Payer: Cash Price	$174.15
Rate for Payer: Cash Price	$174.15
Rate for Payer: UnitedHealthcare Commercial	$129.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INITIAL HOSP CARE INTERMEDIATE

Facility

$193.50

Service Code	CPT 99222
Hospital Charge Code	3999222
Hospital Revenue Code	521
Rate for Payer: Cash Price	$174.15

INITIAL HOSP CARE LOW 30 MIN

Facility

$260.00

Service Code	CPT 99221
Hospital Charge Code	9499221
Hospital Revenue Code	521
Min. Negotiated Rate	$153.92
Max. Negotiated Rate	$185.64
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: UnitedHealthcare Commercial	$173.42
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INITIAL HOSP CARE LOW 30 MIN

Facility

$260.00

Service Code	CPT 99221
Hospital Charge Code	9499221
Hospital Revenue Code	521
Rate for Payer: Cash Price	$234.00

INITIAL HOSP CARE MOD 50 MIN

Facility

$345.00

Service Code	CPT 99222
Hospital Charge Code	9499222
Hospital Revenue Code	521
Rate for Payer: Cash Price	$310.50

INITIAL HOSP CARE MOD 50 MIN

Facility

$345.00

Service Code	CPT 99222
Hospital Charge Code	9499222
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$246.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$204.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$246.33
Rate for Payer: Cash Price	$310.50
Rate for Payer: Cash Price	$310.50
Rate for Payer: UnitedHealthcare Commercial	$230.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INITIAL HOSPITAL CARE

Professional

Both

$345.00

Service Code	CPT 99222
Hospital Charge Code	4199222
Hospital Revenue Code	987
Min. Negotiated Rate	$110.86
Max. Negotiated Rate	$121.95
Rate for Payer: Aetna Commercial/Medicare Advantage	$113.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$110.86
Rate for Payer: Cash Price	$310.50
Rate for Payer: Cash Price	$310.50
Rate for Payer: Cigna Commercial HMO & PPO	$113.62
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$110.86
Rate for Payer: Home State Health Plan Medicaid Managed Care	$121.95
Rate for Payer: Home State Health Plan Medicare Advantage	$113.62
Rate for Payer: Optum Medicare Advantage	$120.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$110.86

INITIAL HOSPITAL CARE (HIGH COMPLEX)

Professional

Both

$471.00

Service Code	CPT 99223
Hospital Charge Code	4199223
Hospital Revenue Code	987
Min. Negotiated Rate	$151.92
Max. Negotiated Rate	$178.83
Rate for Payer: Aetna Commercial/Medicare Advantage	$151.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$162.57
Rate for Payer: Cash Price	$423.90
Rate for Payer: Cash Price	$423.90
Rate for Payer: Cigna Commercial HMO & PPO	$151.92
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$178.83
Rate for Payer: Home State Health Plan Medicare Advantage	$151.92
Rate for Payer: Optum Medicare Advantage	$164.85
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$162.57

INITIAL INCENTIVE SPIROMETRY EDU/ASSESS

Facility

$391.00

Service Code	CPT 94667
Hospital Charge Code	4594011
Hospital Revenue Code	460
Rate for Payer: Cash Price	$351.90

INITIAL INCENTIVE SPIROMETRY EDU/ASSESS

Facility

$391.00

Service Code	CPT 94667
Hospital Charge Code	4594011
Hospital Revenue Code	460
Min. Negotiated Rate	$119.94
Max. Negotiated Rate	$279.17
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	$231.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$279.17
Rate for Payer: Cash Price	$351.90
Rate for Payer: Cash Price	$351.90
Rate for Payer: Cash Price	$351.90
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 Commercial	$260.80
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$140.76

INITIAL INPAT CONS COMP 60 MIN

Facility

$368.00

Service Code	CPT 99254
Hospital Charge Code	5499254
Rate for Payer: Cash Price	$331.20

INITIAL INPATIENT CONSULTATION

Facility

$270.00

Service Code	CPT 99253
Hospital Charge Code	9699253
Rate for Payer: Cash Price	$243.00

INITIAL INPT COMPLEX

Professional

Both

$480.00

Service Code	CPT 99255
Hospital Charge Code	4299255
Hospital Revenue Code	987
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$168.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Optum Medicare Advantage	$168.00

INITIAL INPT COMPREHENSIVE

Professional

Both

$390.00

Service Code	CPT 99254
Hospital Charge Code	4299254
Hospital Revenue Code	987
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$136.50
Rate for Payer: Cash Price	$351.00
Rate for Payer: Optum Medicare Advantage	$136.50

INITIAL INPT CONSULT

Professional

Both

$135.00

Service Code	CPT 99231
Hospital Charge Code	5299251
Hospital Revenue Code	987
Min. Negotiated Rate	$31.75
Max. Negotiated Rate	$47.25
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	$121.50
Rate for Payer: Cash Price	$121.50
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	$47.25
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$31.75

INITIAL INPT CONSULT COMP

Professional

Both

$290.00

Service Code	CPT 99254
Hospital Charge Code	5299254
Hospital Revenue Code	987
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$101.50
Rate for Payer: Cash Price	$261.00
Rate for Payer: Optum Medicare Advantage	$101.50

INITIAL INPT CONSULT COMPLEX

Professional

Both

$365.00

Service Code	CPT 99255
Hospital Charge Code	5299255
Hospital Revenue Code	987
Min. Negotiated Rate	$127.75
Max. Negotiated Rate	$127.75
Rate for Payer: Cash Price	$328.50
Rate for Payer: Optum Medicare Advantage	$127.75

INITIAL INPT CONSULT EXTENDED

Professional

Both

$235.00

Service Code	CPT 99253
Hospital Charge Code	5299253
Hospital Revenue Code	987
Min. Negotiated Rate	$82.25
Max. Negotiated Rate	$82.25
Rate for Payer: Cash Price	$211.50
Rate for Payer: Optum Medicare Advantage	$82.25

INITIAL INPT CONSULT INTERM

Professional

Both

$190.00

Service Code	CPT 99252
Hospital Charge Code	5299252
Hospital Revenue Code	987
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$66.50
Rate for Payer: Cash Price	$171.00
Rate for Payer: Optum Medicare Advantage	$66.50

INITIAL IP HOSP ADMIT 50 MIN

Facility

$260.00

Service Code	CPT 99222
Hospital Charge Code	9699222
Rate for Payer: Cash Price	$234.00

INITIAL IP HOSP VISIT BRIEF

Professional

Both

$270.00

Service Code	CPT 99221
Hospital Charge Code	9799221
Hospital Revenue Code	987
Min. Negotiated Rate	$72.43
Max. Negotiated Rate	$94.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$72.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$82.38
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cigna Commercial HMO & PPO	$72.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$82.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$90.62
Rate for Payer: Home State Health Plan Medicare Advantage	$72.43
Rate for Payer: Optum Medicare Advantage	$94.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$82.38

INITIAL IP HOSP VISIT BRIEF

Professional

Both

$500.00

Service Code	CPT 99223
Hospital Charge Code	9799223
Hospital Revenue Code	987
Min. Negotiated Rate	$151.92
Max. Negotiated Rate	$178.83
Rate for Payer: Aetna Commercial/Medicare Advantage	$151.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$162.57
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cigna Commercial HMO & PPO	$151.92
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.57
Rate for Payer: Home State Health Plan Medicaid Managed Care	$178.83
Rate for Payer: Home State Health Plan Medicare Advantage	$151.92
Rate for Payer: Optum Medicare Advantage	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$162.57

INITIAL IP HOSP VISIT INTERMEDIATE

Professional

Both

$380.00

Service Code	CPT 99222
Hospital Charge Code	9799222
Hospital Revenue Code	987
Min. Negotiated Rate	$110.86
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$113.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$110.86
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial HMO & PPO	$113.62
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$110.86
Rate for Payer: Home State Health Plan Medicaid Managed Care	$121.95
Rate for Payer: Home State Health Plan Medicare Advantage	$113.62
Rate for Payer: Optum Medicare Advantage	$133.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$110.86

INITIAL LOCAL TREATMENT-BURN

Professional

Both

$319.00

Service Code	CPT 16000
Hospital Charge Code	1816000
Hospital Revenue Code	981
Min. Negotiated Rate	$40.85
Max. Negotiated Rate	$111.65
Rate for Payer: Aetna Commercial/Medicare Advantage	$40.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$57.28
Rate for Payer: Cash Price	$287.10
Rate for Payer: Cash Price	$287.10
Rate for Payer: Cigna Commercial HMO & PPO	$40.85
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$57.28
Rate for Payer: Home State Health Plan Medicaid Managed Care	$63.01
Rate for Payer: Home State Health Plan Medicare Advantage	$40.85
Rate for Payer: Optum Medicare Advantage	$111.65
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$57.28

INITIAL NH ADMIT

Facility

$91.00

Service Code	CPT 99304
Hospital Charge Code	5299301
Hospital Revenue Code	525
Min. Negotiated Rate	$53.87
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$53.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$64.97
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: UnitedHealthcare Commercial	$60.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Know your out-of-pocket cost for care.

All Charges