Madison Medical Center

All Charges

Charge

Type

Setting

Price

NM BRAIN SCAN ISOTOPE KIT

Facility

$312.00

Service Code	CPT A4641
Hospital Charge Code	3400204
Hospital Revenue Code	342
Rate for Payer: Cash Price	$280.80

NM BRAIN SCAN ISOTOPE KIT

Facility

$312.00

Service Code	CPT A4641
Hospital Charge Code	3400204
Hospital Revenue Code	342
Min. Negotiated Rate	$112.32
Max. Negotiated Rate	$222.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$184.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$222.77
Rate for Payer: Cash Price	$280.80
Rate for Payer: UnitedHealthcare Commercial	$208.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$112.32

NM BRAIN SCAN WFLOW

Facility

$1,660.00

Service Code	CPT 78601
Hospital Charge Code	3478601
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,494.00

NM BRAIN SCAN WFLOW

Facility

$1,660.00

Service Code	CPT 78601
Hospital Charge Code	3478601
Hospital Revenue Code	341
Min. Negotiated Rate	$360.38
Max. Negotiated Rate	$1,185.24
Rate for Payer: Aetna Better Health Medicaid/QHP	$360.38
Rate for Payer: Aetna Medicare Advantage	$408.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$982.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,185.24
Rate for Payer: Cash Price	$1,494.00
Rate for Payer: Cash Price	$1,494.00
Rate for Payer: Cash Price	$1,494.00
Rate for Payer: Cigna Commercial HMO & PPO	$408.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$360.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$385.61
Rate for Payer: Home State Health Plan Medicare Advantage	$408.43
Rate for Payer: Humana Commercial	$816.86
Rate for Payer: Humana Medicare Advantage	$408.43
Rate for Payer: UnitedHealthcare Commercial	$1,107.22
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$360.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$597.60

NM BRAIN SCAN WO FLOW

Facility

$1,616.00

Service Code	CPT 78600
Hospital Charge Code	3478600
Hospital Revenue Code	341
Min. Negotiated Rate	$360.38
Max. Negotiated Rate	$1,153.82
Rate for Payer: Aetna Better Health Medicaid/QHP	$360.38
Rate for Payer: Aetna Medicare Advantage	$408.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$956.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,153.82
Rate for Payer: Cash Price	$1,454.40
Rate for Payer: Cash Price	$1,454.40
Rate for Payer: Cash Price	$1,454.40
Rate for Payer: Cigna Commercial HMO & PPO	$408.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$360.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$385.61
Rate for Payer: Home State Health Plan Medicare Advantage	$408.43
Rate for Payer: Humana Commercial	$816.86
Rate for Payer: Humana Medicare Advantage	$408.43
Rate for Payer: UnitedHealthcare Commercial	$1,077.87
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$360.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$581.76

NM BRAIN SCAN WO FLOW

Facility

$1,616.00

Service Code	CPT 78600
Hospital Charge Code	3478600
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,454.40

NM CARDIOLITE ISO

Facility

$414.00

Service Code	CPT A9500
Hospital Charge Code	3400020
Hospital Revenue Code	342
Min. Negotiated Rate	$149.04
Max. Negotiated Rate	$295.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$245.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$295.60
Rate for Payer: Cash Price	$372.60
Rate for Payer: UnitedHealthcare Commercial	$276.14
Rate for Payer: UnitedHealthcare Medicare Advantage	$149.04

NM CARDIOLITE ISO

Facility

$414.00

Service Code	CPT A9500
Hospital Charge Code	3400020
Hospital Revenue Code	342
Rate for Payer: Cash Price	$372.60

NM CARD SCAN ISOTOPE KIT

Facility

$381.00

Service Code	CPT A4641
Hospital Charge Code	3400207
Hospital Revenue Code	342
Rate for Payer: Cash Price	$342.90

NM CARD SCAN ISOTOPE KIT

Facility

$381.00

Service Code	CPT A4641
Hospital Charge Code	3400207
Hospital Revenue Code	342
Min. Negotiated Rate	$137.16
Max. Negotiated Rate	$272.03
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$225.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$272.03
Rate for Payer: Cash Price	$342.90
Rate for Payer: UnitedHealthcare Commercial	$254.13
Rate for Payer: UnitedHealthcare Medicare Advantage	$137.16

.N-METHYLHISTAMINE, URINE R CPT 82542

Facility

$346.00

Service Code	CPT 82542
Hospital Charge Code	22282542
Hospital Revenue Code	307
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$247.04
Rate for Payer: Aetna Better Health Medicaid/QHP	$21.68
Rate for Payer: Aetna Medicare Advantage	$24.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$204.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$247.04
Rate for Payer: Cash Price	$311.40
Rate for Payer: Cash Price	$311.40
Rate for Payer: Cash Price	$311.40
Rate for Payer: Cigna Commercial HMO & PPO	$24.09
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$21.68
Rate for Payer: Home State Health Plan Medicaid Managed Care	$23.20
Rate for Payer: Home State Health Plan Medicare Advantage	$24.09
Rate for Payer: Humana Commercial	$48.18
Rate for Payer: Humana Medicare Advantage	$24.09
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$21.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$124.56

.N-METHYLHISTAMINE, URINE R CPT 82542

Facility

$346.00

Service Code	CPT 82542
Hospital Charge Code	22282542
Hospital Revenue Code	307
Rate for Payer: Cash Price	$311.40

NM GASTRIC EMPTYING STUDY

Facility

$1,967.00

Service Code	CPT 78264
Hospital Charge Code	3478264
Hospital Revenue Code	341
Min. Negotiated Rate	$360.38
Max. Negotiated Rate	$1,404.44
Rate for Payer: Aetna Better Health Medicaid/QHP	$360.38
Rate for Payer: Aetna Medicare Advantage	$408.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,164.46
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,404.44
Rate for Payer: Cash Price	$1,770.30
Rate for Payer: Cash Price	$1,770.30
Rate for Payer: Cash Price	$1,770.30
Rate for Payer: Cigna Commercial HMO & PPO	$408.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$360.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$385.61
Rate for Payer: Home State Health Plan Medicare Advantage	$408.43
Rate for Payer: Humana Commercial	$816.86
Rate for Payer: Humana Medicare Advantage	$408.43
Rate for Payer: UnitedHealthcare Commercial	$1,311.99
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$360.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$708.12

NM GASTRIC EMPTYING STUDY

Facility

$1,967.00

Service Code	CPT 78264
Hospital Charge Code	3478264
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,770.30

NM HEP-HIDA SCAN ISOTOPE KIT

Facility

$388.00

Service Code	CPT A4641
Hospital Charge Code	3400210
Hospital Revenue Code	342
Rate for Payer: Cash Price	$349.20

NM HEP-HIDA SCAN ISOTOPE KIT

Facility

$388.00

Service Code	CPT A4641
Hospital Charge Code	3400210
Hospital Revenue Code	342
Min. Negotiated Rate	$139.68
Max. Negotiated Rate	$277.03
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$229.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$277.03
Rate for Payer: Cash Price	$349.20
Rate for Payer: UnitedHealthcare Commercial	$258.80
Rate for Payer: UnitedHealthcare Medicare Advantage	$139.68

NM HIDA SCAN W CCK

Facility

$1,962.00

Service Code	CPT 78227
Hospital Charge Code	3478227
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,765.80

NM HIDA SCAN W CCK

Facility

$1,962.00

Service Code	CPT 78227
Hospital Charge Code	3478227
Hospital Revenue Code	341
Min. Negotiated Rate	$489.46
Max. Negotiated Rate	$1,400.87
Rate for Payer: Aetna Better Health Medicaid/QHP	$489.46
Rate for Payer: Aetna Medicare Advantage	$554.73
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,161.50
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,400.87
Rate for Payer: Cash Price	$1,765.80
Rate for Payer: Cash Price	$1,765.80
Rate for Payer: Cash Price	$1,765.80
Rate for Payer: Cigna Commercial HMO & PPO	$554.73
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$489.46
Rate for Payer: Home State Health Plan Medicaid Managed Care	$523.72
Rate for Payer: Home State Health Plan Medicare Advantage	$554.73
Rate for Payer: Humana Commercial	$1,109.46
Rate for Payer: Humana Medicare Advantage	$554.73
Rate for Payer: UnitedHealthcare Commercial	$1,308.65
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$489.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$706.32

NM HIDA SCAN WO CCK

Facility

$1,856.00

Service Code	CPT 78226
Hospital Charge Code	3478226
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,670.40

NM HIDA SCAN WO CCK

Facility

$1,856.00

Service Code	CPT 78226
Hospital Charge Code	3478226
Hospital Revenue Code	341
Min. Negotiated Rate	$360.38
Max. Negotiated Rate	$1,325.18
Rate for Payer: Aetna Better Health Medicaid/QHP	$360.38
Rate for Payer: Aetna Medicare Advantage	$408.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,098.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,325.18
Rate for Payer: Cash Price	$1,670.40
Rate for Payer: Cash Price	$1,670.40
Rate for Payer: Cash Price	$1,670.40
Rate for Payer: Cigna Commercial HMO & PPO	$408.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$360.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$385.61
Rate for Payer: Home State Health Plan Medicare Advantage	$408.43
Rate for Payer: Humana Commercial	$816.86
Rate for Payer: Humana Medicare Advantage	$408.43
Rate for Payer: UnitedHealthcare Commercial	$1,237.95
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$360.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$668.16

NM I-123 SODIUM IODIDE CAP 200 UCI

Facility

$355.00

Hospital Charge Code	3478990
Hospital Revenue Code	341
Min. Negotiated Rate	$127.80
Max. Negotiated Rate	$253.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$210.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$253.47
Rate for Payer: Cash Price	$319.50
Rate for Payer: UnitedHealthcare Commercial	$236.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$127.80

NM I-123 SODIUM IODIDE CAP 200 UCI

Facility

$355.00

Hospital Charge Code	3478990
Hospital Revenue Code	341
Rate for Payer: Cash Price	$319.50

NM LIMITED BONE SCAN

Facility

$849.00

Service Code	CPT 78300
Hospital Charge Code	3478300
Hospital Revenue Code	341
Rate for Payer: Cash Price	$764.10

NM LIMITED BONE SCAN

Facility

$849.00

Service Code	CPT 78300
Hospital Charge Code	3478300
Hospital Revenue Code	341
Min. Negotiated Rate	$305.64
Max. Negotiated Rate	$816.86
Rate for Payer: Aetna Better Health Medicaid/QHP	$360.38
Rate for Payer: Aetna Medicare Advantage	$408.43
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$502.61
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$606.19
Rate for Payer: Cash Price	$764.10
Rate for Payer: Cash Price	$764.10
Rate for Payer: Cash Price	$764.10
Rate for Payer: Cigna Commercial HMO & PPO	$408.43
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$360.38
Rate for Payer: Home State Health Plan Medicaid Managed Care	$385.61
Rate for Payer: Home State Health Plan Medicare Advantage	$408.43
Rate for Payer: Humana Commercial	$816.86
Rate for Payer: Humana Medicare Advantage	$408.43
Rate for Payer: UnitedHealthcare Commercial	$566.28
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$360.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$305.64

NM LIVER IMAGING 3D W/ FLOW

Facility

$1,678.00

Service Code	CPT 78206
Hospital Charge Code	3478206
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,510.20

Know your out-of-pocket cost for care.

All Charges