Madison Medical Center

All Charges

Charge

Type

Setting

Price

AMPICIL/SULBAC (UNASYN) 3GM IM INJ

Facility

$141.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2656517
Hospital Revenue Code	250
Min. Negotiated Rate	$50.76
Max. Negotiated Rate	$100.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$83.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$100.67
Rate for Payer: Cash Price	$126.90
Rate for Payer: UnitedHealthcare Commercial	$94.05
Rate for Payer: UnitedHealthcare Medicare Advantage	$50.76

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC

Facility

$48,422.16

Service Code	MSDRG 240
Min. Negotiated Rate	$24,211.08
Max. Negotiated Rate	$48,422.16
Rate for Payer: Aetna Medicare Advantage	$24,211.08
Rate for Payer: Cigna Commercial HMO & PPO	$24,211.08
Rate for Payer: Home State Health Plan Medicare Advantage	$24,211.08
Rate for Payer: Humana Commercial	$48,422.16
Rate for Payer: Humana Medicare Advantage	$24,211.08

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC

Facility

$81,264.74

Service Code	MSDRG 239
Min. Negotiated Rate	$40,632.37
Max. Negotiated Rate	$81,264.74
Rate for Payer: Aetna Medicare Advantage	$40,632.37
Rate for Payer: Cigna Commercial HMO & PPO	$40,632.37
Rate for Payer: Home State Health Plan Medicare Advantage	$40,632.37
Rate for Payer: Humana Commercial	$81,264.74
Rate for Payer: Humana Medicare Advantage	$40,632.37

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC

Facility

$25,310.80

Service Code	MSDRG 241
Min. Negotiated Rate	$12,655.40
Max. Negotiated Rate	$25,310.80
Rate for Payer: Aetna Medicare Advantage	$12,655.40
Rate for Payer: Cigna Commercial HMO & PPO	$12,655.40
Rate for Payer: Home State Health Plan Medicare Advantage	$12,655.40
Rate for Payer: Humana Commercial	$25,310.80
Rate for Payer: Humana Medicare Advantage	$12,655.40

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$39,342.74

Service Code	MSDRG 475
Min. Negotiated Rate	$19,671.37
Max. Negotiated Rate	$39,342.74
Rate for Payer: Aetna Medicare Advantage	$19,671.37
Rate for Payer: Cigna Commercial HMO & PPO	$19,671.37
Rate for Payer: Home State Health Plan Medicare Advantage	$19,671.37
Rate for Payer: Humana Commercial	$39,342.74
Rate for Payer: Humana Medicare Advantage	$19,671.37

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$71,282.74

Service Code	MSDRG 474
Min. Negotiated Rate	$35,641.37
Max. Negotiated Rate	$71,282.74
Rate for Payer: Aetna Medicare Advantage	$35,641.37
Rate for Payer: Cigna Commercial HMO & PPO	$35,641.37
Rate for Payer: Home State Health Plan Medicare Advantage	$35,641.37
Rate for Payer: Humana Commercial	$71,282.74
Rate for Payer: Humana Medicare Advantage	$35,641.37

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$22,113.90

Service Code	MSDRG 476
Min. Negotiated Rate	$11,056.95
Max. Negotiated Rate	$22,113.90
Rate for Payer: Aetna Medicare Advantage	$11,056.95
Rate for Payer: Cigna Commercial HMO & PPO	$11,056.95
Rate for Payer: Home State Health Plan Medicare Advantage	$11,056.95
Rate for Payer: Humana Commercial	$22,113.90
Rate for Payer: Humana Medicare Advantage	$11,056.95

AMPUTATION LEG

Professional

Both

$2,431.00

Service Code	CPT 27590
Hospital Charge Code	4127590
Hospital Revenue Code	975
Min. Negotiated Rate	$593.29
Max. Negotiated Rate	$850.85
Rate for Payer: Aetna Commercial/Medicare Advantage	$694.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$593.29
Rate for Payer: Cash Price	$2,187.90
Rate for Payer: Cash Price	$2,187.90
Rate for Payer: Cigna Commercial HMO & PPO	$694.36
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$593.29
Rate for Payer: Home State Health Plan Medicaid Managed Care	$652.62
Rate for Payer: Home State Health Plan Medicare Advantage	$694.36
Rate for Payer: Optum Medicare Advantage	$850.85
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$593.29

AMPUTATION, METATARSAL, WITH TOE, SINGLE

Professional

Both

$1,389.00

Service Code	CPT 28810
Hospital Charge Code	4128810
Hospital Revenue Code	975
Min. Negotiated Rate	$319.43
Max. Negotiated Rate	$486.15
Rate for Payer: Aetna Commercial/Medicare Advantage	$375.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$319.43
Rate for Payer: Cash Price	$1,250.10
Rate for Payer: Cash Price	$1,250.10
Rate for Payer: Cigna Commercial HMO & PPO	$375.46
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$319.43
Rate for Payer: Home State Health Plan Medicaid Managed Care	$351.37
Rate for Payer: Home State Health Plan Medicare Advantage	$375.46
Rate for Payer: Optum Medicare Advantage	$486.15
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$319.43

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$24,074.47

Service Code	APR-DRG 3053
Min. Negotiated Rate	$24,074.47
Max. Negotiated Rate	$24,074.47
Rate for Payer: Aetna Better Health Medicaid/QHP	$24,074.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$24,074.47
Rate for Payer: Home State Health Plan Medicaid Managed Care	$24,074.47
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$24,074.47

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$45,366.15

Service Code	APR-DRG 3054
Min. Negotiated Rate	$45,366.15
Max. Negotiated Rate	$45,366.15
Rate for Payer: Aetna Better Health Medicaid/QHP	$45,366.15
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$45,366.15
Rate for Payer: Home State Health Plan Medicaid Managed Care	$45,366.15
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$45,366.15

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$16,649.66

Service Code	APR-DRG 3052
Min. Negotiated Rate	$16,649.66
Max. Negotiated Rate	$16,649.66
Rate for Payer: Aetna Better Health Medicaid/QHP	$16,649.66
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16,649.66
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16,649.66
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16,649.66

AMPUTATION OF LOWER LIMB EXCEPT TOES

Facility

$9,694.51

Service Code	APR-DRG 3051
Min. Negotiated Rate	$9,694.51
Max. Negotiated Rate	$9,694.51
Rate for Payer: Aetna Better Health Medicaid/QHP	$9,694.51
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$9,694.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$9,694.51
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$9,694.51

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$32,956.16

Service Code	MSDRG 617
Min. Negotiated Rate	$16,478.08
Max. Negotiated Rate	$32,956.16
Rate for Payer: Aetna Medicare Advantage	$16,478.08
Rate for Payer: Cigna Commercial HMO & PPO	$16,478.08
Rate for Payer: Home State Health Plan Medicare Advantage	$16,478.08
Rate for Payer: Humana Commercial	$32,956.16
Rate for Payer: Humana Medicare Advantage	$16,478.08

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$58,505.38

Service Code	MSDRG 616
Min. Negotiated Rate	$29,252.69
Max. Negotiated Rate	$58,505.38
Rate for Payer: Aetna Medicare Advantage	$29,252.69
Rate for Payer: Cigna Commercial HMO & PPO	$29,252.69
Rate for Payer: Home State Health Plan Medicare Advantage	$29,252.69
Rate for Payer: Humana Commercial	$58,505.38
Rate for Payer: Humana Medicare Advantage	$29,252.69

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$25,842.58

Service Code	MSDRG 618
Min. Negotiated Rate	$12,921.29
Max. Negotiated Rate	$25,842.58
Rate for Payer: Aetna Medicare Advantage	$12,921.29
Rate for Payer: Cigna Commercial HMO & PPO	$12,921.29
Rate for Payer: Home State Health Plan Medicare Advantage	$12,921.29
Rate for Payer: Humana Commercial	$25,842.58
Rate for Payer: Humana Medicare Advantage	$12,921.29

AMVISC PLUS

Facility

$184.00

Hospital Charge Code	1269152
Hospital Revenue Code	271
Min. Negotiated Rate	$66.24
Max. Negotiated Rate	$131.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$108.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$131.38
Rate for Payer: Cash Price	$165.60
Rate for Payer: UnitedHealthcare Commercial	$122.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$66.24

AMVISC PLUS

Facility

$184.00

Hospital Charge Code	1269152
Hospital Revenue Code	271
Rate for Payer: Cash Price	$165.60

AMYLASE

Facility

$180.00

Service Code	CPT 82150
Hospital Charge Code	221147
Hospital Revenue Code	301
Rate for Payer: Cash Price	$162.00

AMYLASE

Facility

$180.00

Service Code	CPT 82150
Hospital Charge Code	221147
Hospital Revenue Code	301
Min. Negotiated Rate	$5.83
Max. Negotiated Rate	$128.52
Rate for Payer: Aetna Better Health Medicaid/QHP	$5.83
Rate for Payer: Aetna Medicare Advantage	$6.48
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: Cigna Commercial HMO & PPO	$6.48
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.24
Rate for Payer: Home State Health Plan Medicare Advantage	$6.48
Rate for Payer: Humana Commercial	$12.96
Rate for Payer: Humana Medicare Advantage	$6.48
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$64.80

AMYLASE 2 HR URINE

Facility

$111.00

Service Code	CPT 82150
Hospital Charge Code	221231
Hospital Revenue Code	301
Min. Negotiated Rate	$5.83
Max. Negotiated Rate	$79.25
Rate for Payer: Aetna Better Health Medicaid/QHP	$5.83
Rate for Payer: Aetna Medicare Advantage	$6.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$65.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$79.25
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial HMO & PPO	$6.48
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.24
Rate for Payer: Home State Health Plan Medicare Advantage	$6.48
Rate for Payer: Humana Commercial	$12.96
Rate for Payer: Humana Medicare Advantage	$6.48
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$39.96

AMYLASE 2 HR URINE

Facility

$111.00

Service Code	CPT 82150
Hospital Charge Code	221231
Hospital Revenue Code	301
Rate for Payer: Cash Price	$99.90

AMYLASE BODY FLUID

Facility

$37.00

Service Code	CPT 82150
Hospital Charge Code	221148
Hospital Revenue Code	301
Rate for Payer: Cash Price	$33.30

AMYLASE BODY FLUID

Facility

$37.00

Service Code	CPT 82150
Hospital Charge Code	221148
Hospital Revenue Code	301
Min. Negotiated Rate	$5.83
Max. Negotiated Rate	$26.42
Rate for Payer: Aetna Better Health Medicaid/QHP	$5.83
Rate for Payer: Aetna Medicare Advantage	$6.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$21.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$26.42
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cigna Commercial HMO & PPO	$6.48
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$5.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$6.24
Rate for Payer: Home State Health Plan Medicare Advantage	$6.48
Rate for Payer: Humana Commercial	$12.96
Rate for Payer: Humana Medicare Advantage	$6.48
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$5.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.32

AMYLASE ISOENZYMES

Facility

$185.00

Service Code	CPT 82150
Hospital Charge Code	2284990
Hospital Revenue Code	305
Rate for Payer: Cash Price	$166.50

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All Charges