Madison Medical Center

All Charges

Charge

Type

Setting

Price

MOBILITY EVALUATION

Facility

$50.00

Service Code	CPT G0372
Hospital Charge Code	9700372
Hospital Revenue Code	521
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

MOBILITY (POWER) EVALUATION

Facility

$50.00

Service Code	CPT G0372
Hospital Charge Code	9800372
Hospital Revenue Code	521
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

MOBILITY (POWER) EVALUATION

Facility

$50.00

Service Code	CPT G0372
Hospital Charge Code	9800372
Hospital Revenue Code	521
Rate for Payer: Cash Price	$45.00

MOBILITY (POWER) EVALUATION

Facility

$50.00

Service Code	CPT G0372
Hospital Charge Code	4200372
Hospital Revenue Code	521
Rate for Payer: Cash Price	$45.00

MOBILITY (POWER) EVALUATION

Facility

$50.00

Service Code	CPT G0372
Hospital Charge Code	4200372
Hospital Revenue Code	521
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$29.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$35.70
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: UnitedHealthcare Commercial	$33.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

MOBILIZATION OF SPLENIC FLEXURE

Professional

Both

$402.00

Service Code	CPT 44139
Hospital Charge Code	4144139
Hospital Revenue Code	975
Min. Negotiated Rate	$90.70
Max. Negotiated Rate	$140.70
Rate for Payer: Aetna Commercial/Medicare Advantage	$103.97
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$90.70
Rate for Payer: Cash Price	$361.80
Rate for Payer: Cash Price	$361.80
Rate for Payer: Cigna Commercial HMO & PPO	$103.97
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$90.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$99.77
Rate for Payer: Home State Health Plan Medicare Advantage	$103.97
Rate for Payer: Optum Medicare Advantage	$140.70
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$90.70

MO COBALT EXPOSURE PNL (LABCORP 251075)

Facility

$323.00

Hospital Charge Code	2212277
Hospital Revenue Code	301
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$230.62
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$191.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$230.62
Rate for Payer: Cash Price	$290.70
Rate for Payer: Cash Price	$290.70
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$116.28

MO COBALT EXPOSURE PNL (LABCORP 251075)

Facility

$323.00

Hospital Charge Code	2212277
Hospital Revenue Code	301
Rate for Payer: Cash Price	$290.70

MODAFINIL 200MG TAB EMP C5

Facility

$67.00

Service Code	NDC 2.3155E+10
Hospital Charge Code	2624874
Hospital Revenue Code	250
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$47.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.84
Rate for Payer: Cash Price	$60.30
Rate for Payer: UnitedHealthcare Commercial	$44.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.12

MODAFINIL 200MG TAB EMP C5

Facility

$67.00

Service Code	NDC 2.3155E+10
Hospital Charge Code	2624874
Hospital Revenue Code	250
Rate for Payer: Cash Price	$60.30

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$23,650.12

Service Code	APR-DRG 7933
Min. Negotiated Rate	$23,650.12
Max. Negotiated Rate	$23,650.12
Rate for Payer: Aetna Better Health Medicaid/QHP	$23,650.12
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$23,650.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$23,650.12
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$23,650.12

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$52,103.12

Service Code	APR-DRG 7934
Min. Negotiated Rate	$52,103.12
Max. Negotiated Rate	$52,103.12
Rate for Payer: Aetna Better Health Medicaid/QHP	$52,103.12
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$52,103.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$52,103.12
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$52,103.12

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$16,919.62

Service Code	APR-DRG 7932
Min. Negotiated Rate	$16,919.62
Max. Negotiated Rate	$16,919.62
Rate for Payer: Aetna Better Health Medicaid/QHP	$16,919.62
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16,919.62
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16,919.62
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16,919.62

MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT

Facility

$13,069.00

Service Code	APR-DRG 7931
Min. Negotiated Rate	$13,069.00
Max. Negotiated Rate	$13,069.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$13,069.00
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13,069.00
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13,069.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13,069.00

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$25,410.40

Service Code	APR-DRG 9513
Min. Negotiated Rate	$25,410.40
Max. Negotiated Rate	$25,410.40
Rate for Payer: Aetna Better Health Medicaid/QHP	$25,410.40
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$25,410.40
Rate for Payer: Home State Health Plan Medicaid Managed Care	$25,410.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$25,410.40

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$18,595.78

Service Code	APR-DRG 9512
Min. Negotiated Rate	$18,595.78
Max. Negotiated Rate	$18,595.78
Rate for Payer: Aetna Better Health Medicaid/QHP	$18,595.78
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$18,595.78
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18,595.78
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$18,595.78

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$8,724.69

Service Code	APR-DRG 9511
Min. Negotiated Rate	$8,724.69
Max. Negotiated Rate	$8,724.69
Rate for Payer: Aetna Better Health Medicaid/QHP	$8,724.69
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8,724.69
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8,724.69
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8,724.69

MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS

Facility

$48,909.83

Service Code	APR-DRG 9514
Min. Negotiated Rate	$48,909.83
Max. Negotiated Rate	$48,909.83
Rate for Payer: Aetna Better Health Medicaid/QHP	$48,909.83
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$48,909.83
Rate for Payer: Home State Health Plan Medicaid Managed Care	$48,909.83
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$48,909.83

MODIFIED BA SWALLOW

Facility

$502.00

Service Code	CPT 74210
Hospital Charge Code	3274210
Hospital Revenue Code	320
Rate for Payer: Cash Price	$451.80

MODIFIED BA SWALLOW

Facility

$502.00

Service Code	CPT 74210
Hospital Charge Code	3274210
Hospital Revenue Code	320
Min. Negotiated Rate	$158.12
Max. Negotiated Rate	$358.43
Rate for Payer: Aetna Better Health Medicaid/QHP	$158.12
Rate for Payer: Aetna Medicare Advantage	$179.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$297.18
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$358.43
Rate for Payer: Cash Price	$451.80
Rate for Payer: Cash Price	$451.80
Rate for Payer: Cash Price	$451.80
Rate for Payer: Cigna Commercial HMO & PPO	$179.20
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$158.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$169.19
Rate for Payer: Home State Health Plan Medicare Advantage	$179.20
Rate for Payer: Humana Commercial	$358.40
Rate for Payer: Humana Medicare Advantage	$179.20
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$158.12
Rate for Payer: UnitedHealthcare Medicare Advantage	$180.72

MODIFIED T TUBES - ULTRASIL

Facility

$245.00

Hospital Charge Code	1220730
Hospital Revenue Code	272
Rate for Payer: Cash Price	$220.50

MODIFIED T TUBES - ULTRASIL

Facility

$245.00

Hospital Charge Code	1220730
Hospital Revenue Code	272
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$174.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$145.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$174.93
Rate for Payer: Cash Price	$220.50
Rate for Payer: UnitedHealthcare Commercial	$163.41
Rate for Payer: UnitedHealthcare Medicare Advantage	$88.20

MOMETASONE (NASONEX) NASAL SPRAY EMP

Facility

$698.00

Service Code	NDC 85128801
Hospital Charge Code	2626350
Hospital Revenue Code	250
Min. Negotiated Rate	$251.28
Max. Negotiated Rate	$498.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$413.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$498.37
Rate for Payer: Cash Price	$628.20
Rate for Payer: UnitedHealthcare Commercial	$465.57
Rate for Payer: UnitedHealthcare Medicare Advantage	$251.28

MOMETASONE (NASONEX) NASAL SPRAY EMP

Facility

$698.00

Service Code	NDC 85128801
Hospital Charge Code	2626350
Hospital Revenue Code	250
Rate for Payer: Cash Price	$628.20

MONITOR O.R.

Facility

$217.00

Hospital Charge Code	2813035
Hospital Revenue Code	271
Min. Negotiated Rate	$78.12
Max. Negotiated Rate	$154.94
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$128.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$154.94
Rate for Payer: Cash Price	$195.30
Rate for Payer: UnitedHealthcare Commercial	$144.74
Rate for Payer: UnitedHealthcare Medicare Advantage	$78.12

Know your out-of-pocket cost for care.

All Charges