Madison Medical Center

All Charges

Charge

Type

Setting

Price

KETOROLAC (TORADOL) 15MG/ML 1 ML INJ SDV

Facility

$100.00

Service Code	HCPCS J1885
Hospital Charge Code	2626333
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$71.40
Rate for Payer: Aetna Medicare Advantage	$0.29
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: Cash Price	$90.00
Rate for Payer: Cigna Commercial HMO & PPO	$0.29
Rate for Payer: Home State Health Plan Medicare Advantage	$0.29
Rate for Payer: Humana Commercial	$0.58
Rate for Payer: Humana Medicare Advantage	$0.29
Rate for Payer: UnitedHealthcare Commercial	$66.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.00

KI-67

Facility

$402.00

Service Code	CPT 88360
Hospital Charge Code	2288301
Hospital Revenue Code	305
Rate for Payer: Cash Price	$361.80

KI-67

Facility

$402.00

Service Code	CPT 88360
Hospital Charge Code	2288301
Hospital Revenue Code	305
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$348.12
Rate for Payer: Aetna Better Health Medicaid/QHP	$153.58
Rate for Payer: Aetna Medicare Advantage	$174.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$237.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$287.03
Rate for Payer: Cash Price	$361.80
Rate for Payer: Cash Price	$361.80
Rate for Payer: Cash Price	$361.80
Rate for Payer: Cigna Commercial HMO & PPO	$174.06
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$153.58
Rate for Payer: Home State Health Plan Medicaid Managed Care	$164.33
Rate for Payer: Home State Health Plan Medicare Advantage	$174.06
Rate for Payer: Humana Commercial	$348.12
Rate for Payer: Humana Medicare Advantage	$174.06
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$153.58
Rate for Payer: UnitedHealthcare Medicare Advantage	$144.72

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC

Facility

$32,321.26

Service Code	MSDRG 657
Min. Negotiated Rate	$16,160.63
Max. Negotiated Rate	$32,321.26
Rate for Payer: Aetna Medicare Advantage	$16,160.63
Rate for Payer: Cigna Commercial HMO & PPO	$16,160.63
Rate for Payer: Home State Health Plan Medicare Advantage	$16,160.63
Rate for Payer: Humana Commercial	$32,321.26
Rate for Payer: Humana Medicare Advantage	$16,160.63

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC

Facility

$53,695.02

Service Code	MSDRG 656
Min. Negotiated Rate	$26,847.51
Max. Negotiated Rate	$53,695.02
Rate for Payer: Aetna Medicare Advantage	$26,847.51
Rate for Payer: Cigna Commercial HMO & PPO	$26,847.51
Rate for Payer: Home State Health Plan Medicare Advantage	$26,847.51
Rate for Payer: Humana Commercial	$53,695.02
Rate for Payer: Humana Medicare Advantage	$26,847.51

KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC

Facility

$27,938.56

Service Code	MSDRG 658
Min. Negotiated Rate	$13,969.28
Max. Negotiated Rate	$27,938.56
Rate for Payer: Aetna Medicare Advantage	$13,969.28
Rate for Payer: Cigna Commercial HMO & PPO	$13,969.28
Rate for Payer: Home State Health Plan Medicare Advantage	$13,969.28
Rate for Payer: Humana Commercial	$27,938.56
Rate for Payer: Humana Medicare Advantage	$13,969.28

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC

Facility

$24,328.28

Service Code	MSDRG 660
Min. Negotiated Rate	$12,164.14
Max. Negotiated Rate	$24,328.28
Rate for Payer: Aetna Medicare Advantage	$12,164.14
Rate for Payer: Cigna Commercial HMO & PPO	$12,164.14
Rate for Payer: Home State Health Plan Medicare Advantage	$12,164.14
Rate for Payer: Humana Commercial	$24,328.28
Rate for Payer: Humana Medicare Advantage	$12,164.14

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC

Facility

$43,524.28

Service Code	MSDRG 659
Min. Negotiated Rate	$21,762.14
Max. Negotiated Rate	$43,524.28
Rate for Payer: Aetna Medicare Advantage	$21,762.14
Rate for Payer: Cigna Commercial HMO & PPO	$21,762.14
Rate for Payer: Home State Health Plan Medicare Advantage	$21,762.14
Rate for Payer: Humana Commercial	$43,524.28
Rate for Payer: Humana Medicare Advantage	$21,762.14

KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC

Facility

$19,847.88

Service Code	MSDRG 661
Min. Negotiated Rate	$9,923.94
Max. Negotiated Rate	$19,847.88
Rate for Payer: Aetna Medicare Advantage	$9,923.94
Rate for Payer: Cigna Commercial HMO & PPO	$9,923.94
Rate for Payer: Home State Health Plan Medicare Advantage	$9,923.94
Rate for Payer: Humana Commercial	$19,847.88
Rate for Payer: Humana Medicare Advantage	$9,923.94

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$19,324.63

Service Code	APR-DRG 4634
Min. Negotiated Rate	$19,324.63
Max. Negotiated Rate	$19,324.63
Rate for Payer: Aetna Better Health Medicaid/QHP	$19,324.63
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$19,324.63
Rate for Payer: Home State Health Plan Medicaid Managed Care	$19,324.63
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$19,324.63

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$12,864.52

Service Code	APR-DRG 4633
Min. Negotiated Rate	$12,864.52
Max. Negotiated Rate	$12,864.52
Rate for Payer: Aetna Better Health Medicaid/QHP	$12,864.52
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12,864.52
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12,864.52
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12,864.52

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$7,564.65

Service Code	APR-DRG 4632
Min. Negotiated Rate	$7,564.65
Max. Negotiated Rate	$7,564.65
Rate for Payer: Aetna Better Health Medicaid/QHP	$7,564.65
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$7,564.65
Rate for Payer: Home State Health Plan Medicaid Managed Care	$7,564.65
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$7,564.65

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$5,877.56

Service Code	APR-DRG 4631
Min. Negotiated Rate	$5,877.56
Max. Negotiated Rate	$5,877.56
Rate for Payer: Aetna Better Health Medicaid/QHP	$5,877.56
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5,877.56
Rate for Payer: Home State Health Plan Medicaid Managed Care	$5,877.56
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5,877.56

KIDNEY AND URINARY TRACT INFECTIONS WITH MCC

Facility

$21,802.48

Service Code	MSDRG 689
Min. Negotiated Rate	$10,901.24
Max. Negotiated Rate	$21,802.48
Rate for Payer: Aetna Medicare Advantage	$10,901.24
Rate for Payer: Cigna Commercial HMO & PPO	$10,901.24
Rate for Payer: Home State Health Plan Medicare Advantage	$10,901.24
Rate for Payer: Humana Commercial	$21,802.48
Rate for Payer: Humana Medicare Advantage	$10,901.24

KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC

Facility

$16,312.72

Service Code	MSDRG 690
Min. Negotiated Rate	$8,156.36
Max. Negotiated Rate	$16,312.72
Rate for Payer: Aetna Medicare Advantage	$8,156.36
Rate for Payer: Cigna Commercial HMO & PPO	$8,156.36
Rate for Payer: Home State Health Plan Medicare Advantage	$8,156.36
Rate for Payer: Humana Commercial	$16,312.72
Rate for Payer: Humana Medicare Advantage	$8,156.36

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$14,720.19

Service Code	APR-DRG 4613
Min. Negotiated Rate	$14,720.19
Max. Negotiated Rate	$14,720.19
Rate for Payer: Aetna Better Health Medicaid/QHP	$14,720.19
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14,720.19
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14,720.19
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14,720.19

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$21,944.38

Service Code	APR-DRG 4614
Min. Negotiated Rate	$21,944.38
Max. Negotiated Rate	$21,944.38
Rate for Payer: Aetna Better Health Medicaid/QHP	$21,944.38
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$21,944.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$21,944.38
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$21,944.38

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$9,285.87

Service Code	APR-DRG 4612
Min. Negotiated Rate	$9,285.87
Max. Negotiated Rate	$9,285.87
Rate for Payer: Aetna Better Health Medicaid/QHP	$9,285.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$9,285.87
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9,285.87
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$9,285.87

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$8,108.96

Service Code	APR-DRG 4611
Min. Negotiated Rate	$8,108.96
Max. Negotiated Rate	$8,108.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$8,108.96
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8,108.96
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8,108.96
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8,108.96

KIDNEY AND URINARY TRACT NEOPLASMS WITH CC

Facility

$20,041.92

Service Code	MSDRG 687
Min. Negotiated Rate	$10,020.96
Max. Negotiated Rate	$20,041.92
Rate for Payer: Aetna Medicare Advantage	$10,020.96
Rate for Payer: Cigna Commercial HMO & PPO	$10,020.96
Rate for Payer: Home State Health Plan Medicare Advantage	$10,020.96
Rate for Payer: Humana Commercial	$20,041.92
Rate for Payer: Humana Medicare Advantage	$10,020.96

KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC

Facility

$31,906.94

Service Code	MSDRG 686
Min. Negotiated Rate	$15,953.47
Max. Negotiated Rate	$31,906.94
Rate for Payer: Aetna Medicare Advantage	$15,953.47
Rate for Payer: Cigna Commercial HMO & PPO	$15,953.47
Rate for Payer: Home State Health Plan Medicare Advantage	$15,953.47
Rate for Payer: Humana Commercial	$31,906.94
Rate for Payer: Humana Medicare Advantage	$15,953.47

KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC

Facility

$16,012.22

Service Code	MSDRG 688
Min. Negotiated Rate	$8,006.11
Max. Negotiated Rate	$16,012.22
Rate for Payer: Aetna Medicare Advantage	$8,006.11
Rate for Payer: Cigna Commercial HMO & PPO	$8,006.11
Rate for Payer: Home State Health Plan Medicare Advantage	$8,006.11
Rate for Payer: Humana Commercial	$16,012.22
Rate for Payer: Humana Medicare Advantage	$8,006.11

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$18,640.15

Service Code	APR-DRG 4422
Min. Negotiated Rate	$18,640.15
Max. Negotiated Rate	$18,640.15
Rate for Payer: Aetna Better Health Medicaid/QHP	$18,640.15
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$18,640.15
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18,640.15
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$18,640.15

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$51,672.29

Service Code	APR-DRG 4424
Min. Negotiated Rate	$51,672.29
Max. Negotiated Rate	$51,672.29
Rate for Payer: Aetna Better Health Medicaid/QHP	$51,672.29
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$51,672.29
Rate for Payer: Home State Health Plan Medicaid Managed Care	$51,672.29
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$51,672.29

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$28,842.22

Service Code	APR-DRG 4423
Min. Negotiated Rate	$28,842.22
Max. Negotiated Rate	$28,842.22
Rate for Payer: Aetna Better Health Medicaid/QHP	$28,842.22
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$28,842.22
Rate for Payer: Home State Health Plan Medicaid Managed Care	$28,842.22
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$28,842.22

Know your out-of-pocket cost for care.

All Charges