Madison Medical Center

All Charges

Charge

Type

Setting

Price

NEUROSES EXCEPT DEPRESSIVE

Facility

$20,448.80

Service Code	MSDRG 882
Min. Negotiated Rate	$10,224.40
Max. Negotiated Rate	$20,448.80
Rate for Payer: Aetna Medicare Advantage	$10,224.40
Rate for Payer: Cigna Commercial HMO & PPO	$10,224.40
Rate for Payer: Home State Health Plan Medicare Advantage	$10,224.40
Rate for Payer: Humana Commercial	$20,448.80
Rate for Payer: Humana Medicare Advantage	$10,224.40

NEVYUS

Facility

$24.00

Hospital Charge Code	1269090
Hospital Revenue Code	271
Rate for Payer: Cash Price	$21.60

NEVYUS

Facility

$24.00

Hospital Charge Code	1269090
Hospital Revenue Code	271
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.14
Rate for Payer: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

NEVYUS DRAPE

Facility

$65.00

Hospital Charge Code	1239090
Hospital Revenue Code	272
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$46.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$38.48
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$46.41
Rate for Payer: Cash Price	$58.50
Rate for Payer: UnitedHealthcare Commercial	$43.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$23.40

NEVYUS DRAPE

Facility

$65.00

Hospital Charge Code	1239090
Hospital Revenue Code	272
Rate for Payer: Cash Price	$58.50

NEW PATIENT LEVEL 4 VISIT

Facility

$385.00

Service Code	CPT 99204
Hospital Charge Code	9199204
Hospital Revenue Code	521
Rate for Payer: Cash Price	$346.50

NEW PATIENT LEVEL 4 VISIT

Facility

$385.00

Service Code	CPT 99204
Hospital Charge Code	9199204
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$274.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$227.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$274.89
Rate for Payer: Cash Price	$346.50
Rate for Payer: Cash Price	$346.50
Rate for Payer: UnitedHealthcare Commercial	$256.80
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

NEW PATIENT OFFICE VISIT

Facility

$120.00

Service Code	CPT 99202
Hospital Charge Code	9699201
Hospital Revenue Code	521
Min. Negotiated Rate	$71.04
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$71.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$85.68
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: UnitedHealthcare Commercial	$80.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

NEW PATIENT OFFICE VISIT

Facility

$120.00

Service Code	CPT 99202
Hospital Charge Code	9699201
Hospital Revenue Code	521
Rate for Payer: Cash Price	$108.00

NEW PATIENT OFFICE VISIT INTERMEDIATE

Facility

$240.00

Service Code	CPT 99203
Hospital Charge Code	5499203
Hospital Revenue Code	521
Min. Negotiated Rate	$142.08
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$142.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$171.36
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: UnitedHealthcare Commercial	$160.08
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

NEW PATIENT OFFICE VISIT INTERMEDIATE

Facility

$240.00

Service Code	CPT 99203
Hospital Charge Code	5499203
Hospital Revenue Code	521
Rate for Payer: Cash Price	$216.00

NEW PT BRIEF 20 MIN VISIT

Facility

$175.00

Service Code	CPT 99202
Hospital Charge Code	5499202
Hospital Revenue Code	521
Rate for Payer: Cash Price	$157.50

NEW PT BRIEF 20 MIN VISIT

Facility

$175.00

Service Code	CPT 99202
Hospital Charge Code	5499202
Hospital Revenue Code	521
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$103.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$124.95
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cash Price	$157.50
Rate for Payer: UnitedHealthcare Commercial	$116.72
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

NEW PT MINIMAL 10 MIN VISIT

Facility

$120.00

Service Code	CPT 99202
Hospital Charge Code	5499201
Hospital Revenue Code	521
Min. Negotiated Rate	$71.04
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$71.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$85.68
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: UnitedHealthcare Commercial	$80.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

NEW PT MINIMAL 10 MIN VISIT

Facility

$120.00

Service Code	CPT 99202
Hospital Charge Code	5499201
Hospital Revenue Code	521
Rate for Payer: Cash Price	$108.00

NEXIUM 20MG 24HR-OTC CAP 42

Facility

$12.00

Service Code	NDC 1E+11
Hospital Charge Code	2619473
Hospital Revenue Code	250
Rate for Payer: Cash Price	$10.80

NEXIUM 20MG 24HR-OTC CAP 42

Facility

$12.00

Service Code	NDC 1E+11
Hospital Charge Code	2619473
Hospital Revenue Code	250
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$8.57
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$8.57
Rate for Payer: Cash Price	$10.80
Rate for Payer: UnitedHealthcare Commercial	$8.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.32

NEXPLANNON INSERTION

Facility

$480.00

Service Code	CPT 11981
Hospital Charge Code	9211981
Hospital Revenue Code	521
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$342.72
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
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: Cash Price	$432.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$107.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$320.16
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

NEXPLANNON INSERTION

Facility

$480.00

Service Code	CPT 11981
Hospital Charge Code	9211981
Hospital Revenue Code	521
Rate for Payer: Cash Price	$432.00

NEXPLANNON PLACEMENT

Facility

$480.00

Service Code	CPT 11981
Hospital Charge Code	3911981
Hospital Revenue Code	521
Rate for Payer: Cash Price	$432.00

NEXPLANNON PLACEMENT

Facility

$480.00

Service Code	CPT 11981
Hospital Charge Code	3911981
Hospital Revenue Code	521
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$342.72
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
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: Cash Price	$432.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$107.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$320.16
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

NEXPLANNON PRODUCT

Facility

$900.00

Service Code	HCPCS J7307
Hospital Charge Code	9207307
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$642.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$532.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$642.60
Rate for Payer: Cash Price	$810.00
Rate for Payer: Cash Price	$810.00
Rate for Payer: UnitedHealthcare Commercial	$600.30
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

NEXPLANNON PRODUCT

Facility

$900.00

Service Code	HCPCS J7307
Hospital Charge Code	9207307
Hospital Revenue Code	521
Rate for Payer: Cash Price	$810.00

NEXPLANNON REMOVAL

Facility

$500.00

Service Code	CPT 11982
Hospital Charge Code	9811982
Hospital Revenue Code	521
Rate for Payer: Cash Price	$450.00

NEXPLANNON REMOVAL

Facility

$500.00

Service Code	CPT 11982
Hospital Charge Code	9811982
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$912.80
Rate for Payer: Aetna Better Health Medicaid/QHP	$402.70
Rate for Payer: Aetna Medicare Advantage	$456.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$296.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$357.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cigna Commercial HMO & PPO	$456.40
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$362.43
Rate for Payer: Home State Health Plan Medicaid Managed Care	$430.89
Rate for Payer: Home State Health Plan Medicare Advantage	$456.40
Rate for Payer: Humana Commercial	$912.80
Rate for Payer: Humana Medicare Advantage	$456.40
Rate for Payer: UnitedHealthcare Commercial	$333.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$402.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

Know your out-of-pocket cost for care.

All Charges