Madison Medical Center

All Charges

Charge

Type

Setting

Price

INJECTION MAJOR JOINT US GUIDED

Facility

$371.00

Service Code	CPT 20611
Hospital Charge Code	9120611
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
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	$219.63
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$264.89
Rate for Payer: Cash Price	$333.90
Rate for Payer: Cash Price	$333.90
Rate for Payer: Cash Price	$333.90
Rate for Payer: Cash Price	$333.90
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	$247.46
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INJECTION MAJOR JOINT US GUIDED

Facility

$371.00

Service Code	CPT 20611
Hospital Charge Code	9120611
Hospital Revenue Code	521
Rate for Payer: Cash Price	$333.90

Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

Facility

$135.00

Service Code	CPT 27096
Hospital Revenue Code	360
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$135.00
Rate for Payer: UnitedHealthcare Commercial	$135.00

Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level

Facility

$1,807.26

Service Code	CPT 64483
Hospital Revenue Code	490
Min. Negotiated Rate	$797.31
Max. Negotiated Rate	$1,807.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$797.31
Rate for Payer: Aetna Medicare Advantage	$903.63
Rate for Payer: Cigna Commercial HMO & PPO	$903.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$797.31
Rate for Payer: Home State Health Plan Medicaid Managed Care	$853.12
Rate for Payer: Home State Health Plan Medicare Advantage	$903.63
Rate for Payer: Humana Commercial	$1,807.26
Rate for Payer: Humana Medicare Advantage	$903.63
Rate for Payer: UnitedHealthcare Commercial	$947.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$797.31

Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level

Facility

$1,807.26

Service Code	CPT 64483
Hospital Revenue Code	360
Min. Negotiated Rate	$797.31
Max. Negotiated Rate	$1,807.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$797.31
Rate for Payer: Aetna Medicare Advantage	$903.63
Rate for Payer: Cigna Commercial HMO & PPO	$903.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$797.31
Rate for Payer: Home State Health Plan Medicaid Managed Care	$853.12
Rate for Payer: Home State Health Plan Medicare Advantage	$903.63
Rate for Payer: Humana Commercial	$1,807.26
Rate for Payer: Humana Medicare Advantage	$903.63
Rate for Payer: UnitedHealthcare Commercial	$947.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$797.31

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

Facility

$1,807.26

Service Code	CPT 64490
Hospital Revenue Code	360
Min. Negotiated Rate	$797.31
Max. Negotiated Rate	$1,807.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$797.31
Rate for Payer: Aetna Medicare Advantage	$903.63
Rate for Payer: Cigna Commercial HMO & PPO	$903.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$797.31
Rate for Payer: Home State Health Plan Medicaid Managed Care	$853.12
Rate for Payer: Home State Health Plan Medicare Advantage	$903.63
Rate for Payer: Humana Commercial	$1,807.26
Rate for Payer: Humana Medicare Advantage	$903.63
Rate for Payer: UnitedHealthcare Commercial	$947.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$797.31

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

Facility

$1,807.26

Service Code	CPT 64493
Hospital Revenue Code	490
Min. Negotiated Rate	$797.31
Max. Negotiated Rate	$1,807.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$797.31
Rate for Payer: Aetna Medicare Advantage	$903.63
Rate for Payer: Cigna Commercial HMO & PPO	$903.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$797.31
Rate for Payer: Home State Health Plan Medicaid Managed Care	$853.12
Rate for Payer: Home State Health Plan Medicare Advantage	$903.63
Rate for Payer: Humana Commercial	$1,807.26
Rate for Payer: Humana Medicare Advantage	$903.63
Rate for Payer: UnitedHealthcare Commercial	$947.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$797.31

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

Facility

$1,807.26

Service Code	CPT 64493
Hospital Revenue Code	360
Min. Negotiated Rate	$797.31
Max. Negotiated Rate	$1,807.26
Rate for Payer: Aetna Better Health Medicaid/QHP	$797.31
Rate for Payer: Aetna Medicare Advantage	$903.63
Rate for Payer: Cigna Commercial HMO & PPO	$903.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$797.31
Rate for Payer: Home State Health Plan Medicaid Managed Care	$853.12
Rate for Payer: Home State Health Plan Medicare Advantage	$903.63
Rate for Payer: Humana Commercial	$1,807.26
Rate for Payer: Humana Medicare Advantage	$903.63
Rate for Payer: UnitedHealthcare Commercial	$947.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$797.31

INJECTION SINGLE TENDON

Professional

Both

$190.00

Service Code	CPT 20551
Hospital Charge Code	4120551
Hospital Revenue Code	975
Min. Negotiated Rate	$32.17
Max. Negotiated Rate	$66.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$32.17
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$43.84
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cigna Commercial HMO & PPO	$32.17
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$43.84
Rate for Payer: Home State Health Plan Medicaid Managed Care	$48.22
Rate for Payer: Home State Health Plan Medicare Advantage	$32.17
Rate for Payer: Optum Medicare Advantage	$66.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$43.84

INJECTION SINGLE TENDON ORIGIN/INSERTION

Facility

$180.00

Service Code	CPT 20551
Hospital Charge Code	9820551
Hospital Revenue Code	521
Rate for Payer: Cash Price	$162.00

INJECTION SINGLE TENDON ORIGIN/INSERTION

Facility

$180.00

Service Code	CPT 20551
Hospital Charge Code	9820551
Hospital Revenue Code	521
Min. Negotiated Rate	$106.56
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	$106.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$128.52
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cash Price	$162.00
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	$120.06
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	3920600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$171.00

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	4220600
Hospital Revenue Code	521
Min. Negotiated Rate	$112.48
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	$112.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$135.66
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
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	$126.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	9520600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$171.00

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	9320600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$171.00

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	5220600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$171.00

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	9820600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$171.00

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	5220600
Hospital Revenue Code	521
Min. Negotiated Rate	$112.48
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	$112.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$135.66
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
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	$126.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	4220600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$171.00

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	3920600
Hospital Revenue Code	521
Min. Negotiated Rate	$112.48
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	$112.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$135.66
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
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	$126.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	9420600
Hospital Revenue Code	521
Rate for Payer: Cash Price	$171.00

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	9820600
Hospital Revenue Code	521
Min. Negotiated Rate	$112.48
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	$112.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$135.66
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
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	$126.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	9520600
Hospital Revenue Code	521
Min. Negotiated Rate	$112.48
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	$112.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$135.66
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
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	$126.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	9320600
Hospital Revenue Code	521
Min. Negotiated Rate	$112.48
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	$112.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$135.66
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
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	$126.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

INJECTION SMALL JOINT

Facility

$190.00

Service Code	CPT 20600
Hospital Charge Code	9220600
Hospital Revenue Code	521
Min. Negotiated Rate	$112.48
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	$112.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$135.66
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cash Price	$171.00
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	$126.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$276.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Know your out-of-pocket cost for care.

All Charges