Madison Medical Center

All Charges

Charge

Type

Setting

Price

INIT INP. CONSULT.(COMPRE)

Facility

$480.00

Service Code	CPT 99255
Hospital Charge Code	4499255
Hospital Revenue Code	525
Rate for Payer: Cash Price	$432.00

INIT INP. CONSULT.(COMPRE)

Facility

$480.00

Service Code	CPT 99255
Hospital Charge Code	4499255
Hospital Revenue Code	525
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$342.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$284.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$342.72
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: UnitedHealthcare Commercial	$320.16
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INIT INP. CONSULT.(EXTENDED)

Facility

$390.00

Service Code	CPT 99254
Hospital Charge Code	4499254
Hospital Revenue Code	525
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$278.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$230.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$278.46
Rate for Payer: Cash Price	$351.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: UnitedHealthcare Commercial	$260.13
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INIT INP. CONSULT.(EXTENDED)

Facility

$390.00

Service Code	CPT 99254
Hospital Charge Code	4499254
Hospital Revenue Code	525
Rate for Payer: Cash Price	$351.00

INIT INP. CONSULT.(INTER)

Facility

$300.00

Service Code	CPT 99253
Hospital Charge Code	4499253
Hospital Revenue Code	525
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$214.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$177.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$214.20
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: UnitedHealthcare Commercial	$200.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INIT INP. CONSULT.(INTER)

Facility

$300.00

Service Code	CPT 99253
Hospital Charge Code	4499253
Hospital Revenue Code	525
Rate for Payer: Cash Price	$270.00

INIT INP. CONSULT.(LIMITED)

Facility

$210.00

Service Code	CPT 99252
Hospital Charge Code	4499252
Hospital Revenue Code	525
Min. Negotiated Rate	$124.32
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$124.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$149.94
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: UnitedHealthcare Commercial	$140.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INIT INP. CONSULT.(LIMITED)

Facility

$210.00

Service Code	CPT 99252
Hospital Charge Code	4499252
Hospital Revenue Code	525
Rate for Payer: Cash Price	$189.00

INIT. I/P CONSUL. 110 MIN.

Facility

$440.00

Service Code	CPT 99255
Hospital Charge Code	4199255
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$314.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$260.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$314.16
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: UnitedHealthcare Commercial	$293.48
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INIT. I/P CONSUL. 110 MIN.

Facility

$440.00

Service Code	CPT 99255
Hospital Charge Code	4199255
Hospital Revenue Code	521
Rate for Payer: Cash Price	$396.00

INIT. I/P CONSUL. 40 MIN.

Facility

$215.00

Service Code	CPT 99252
Hospital Charge Code	4199252
Hospital Revenue Code	521
Rate for Payer: Cash Price	$193.50

INIT. I/P CONSUL. 40 MIN.

Facility

$215.00

Service Code	CPT 99252
Hospital Charge Code	4199252
Hospital Revenue Code	521
Min. Negotiated Rate	$127.28
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$127.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$153.51
Rate for Payer: Cash Price	$193.50
Rate for Payer: Cash Price	$193.50
Rate for Payer: UnitedHealthcare Commercial	$143.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INIT. I/P CONSUL. 55 MIN.

Facility

$270.00

Service Code	CPT 99253
Hospital Charge Code	4199253
Hospital Revenue Code	521
Rate for Payer: Cash Price	$243.00

INIT. I/P CONSUL. 55 MIN.

Facility

$270.00

Service Code	CPT 99253
Hospital Charge Code	4199253
Hospital Revenue Code	521
Min. Negotiated Rate	$159.84
Max. Negotiated Rate	$192.78
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$159.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$192.78
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: UnitedHealthcare Commercial	$180.09
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INIT. I/P CONSUL. 80 MIN.

Facility

$350.00

Service Code	CPT 99254
Hospital Charge Code	4199254
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$249.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$207.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$249.90
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: UnitedHealthcare Commercial	$233.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INIT. I/P CONSUL. 80 MIN.

Facility

$350.00

Service Code	CPT 99254
Hospital Charge Code	4199254
Hospital Revenue Code	521
Rate for Payer: Cash Price	$315.00

INIT. OBSERV/CARE MOD COMPLEX

Professional

Both

$370.00

Service Code	CPT 99222
Hospital Charge Code	5299219
Hospital Revenue Code	987
Min. Negotiated Rate	$110.86
Max. Negotiated Rate	$129.50
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	$333.00
Rate for Payer: Cash Price	$333.00
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	$129.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$110.86

INIT. OBSERV/CARE MOD EXT

Professional

Both

$480.00

Service Code	CPT 99223
Hospital Charge Code	5299220
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	$432.00
Rate for Payer: Cash Price	$432.00
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	$168.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$162.57

INJ ANES AGENT OTHER PERIPHERAL NERVE/BR

Professional

Both

$400.00

Service Code	CPT 64450
Hospital Charge Code	4164450
Hospital Revenue Code	975
Min. Negotiated Rate	$36.74
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$36.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$62.10
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial HMO & PPO	$36.74
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$62.10
Rate for Payer: Home State Health Plan Medicaid Managed Care	$68.31
Rate for Payer: Home State Health Plan Medicare Advantage	$36.74
Rate for Payer: Optum Medicare Advantage	$140.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$62.10

INJ/ASPIRATION INTERMEDIATE JOINT

Facility

$205.00

Service Code	CPT 20605
Hospital Charge Code	5220605
Hospital Revenue Code	521
Min. Negotiated Rate	$121.36
Max. Negotiated Rate	$627.20
Rate for Payer: Aetna Better Health Medicaid/QHP	$276.70
Rate for Payer: Aetna Medicare Advantage	$313.60
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: Cash Price	$184.50
Rate for Payer: Cash Price	$184.50
Rate for Payer: Cigna Commercial HMO & PPO	$313.60
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$249.03
Rate for Payer: Home State Health Plan Medicaid Managed Care	$296.07
Rate for Payer: Home State Health Plan Medicare Advantage	$313.60
Rate for Payer: Humana Commercial	$627.20
Rate for Payer: Humana Medicare Advantage	$313.60
Rate for Payer: UnitedHealthcare Commercial	$136.74
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INJ/ASPIRATION INTERMEDIATE JOINT

Facility

$205.00

Service Code	CPT 20605
Hospital Charge Code	5220605
Hospital Revenue Code	521
Rate for Payer: Cash Price	$184.50

INJECT G-PROBE

Facility

$973.00

Hospital Charge Code	1269111
Hospital Revenue Code	271
Min. Negotiated Rate	$350.28
Max. Negotiated Rate	$694.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$576.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$694.72
Rate for Payer: Cash Price	$875.70
Rate for Payer: UnitedHealthcare Commercial	$648.99
Rate for Payer: UnitedHealthcare Medicare Advantage	$350.28

INJECT G-PROBE

Facility

$973.00

Hospital Charge Code	1269111
Hospital Revenue Code	271
Rate for Payer: Cash Price	$875.70

INJECTION CARPAL TUNNEL

Facility

$255.00

Service Code	CPT 20526
Hospital Charge Code	9320526
Hospital Revenue Code	521
Min. Negotiated Rate	$150.96
Max. Negotiated Rate	$627.20
Rate for Payer: Aetna Better Health Medicaid/QHP	$276.70
Rate for Payer: Aetna Medicare Advantage	$313.60
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: Cash Price	$229.50
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cigna Commercial HMO & PPO	$313.60
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$249.03
Rate for Payer: Home State Health Plan Medicaid Managed Care	$296.07
Rate for Payer: Home State Health Plan Medicare Advantage	$313.60
Rate for Payer: Humana Commercial	$627.20
Rate for Payer: Humana Medicare Advantage	$313.60
Rate for Payer: UnitedHealthcare Commercial	$170.09
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INJECTION CARPAL TUNNEL

Facility

$255.00

Service Code	CPT 20526
Hospital Charge Code	9320526
Hospital Revenue Code	521
Rate for Payer: Cash Price	$229.50

Know your out-of-pocket cost for care.

All Charges