Madison Medical Center

All Charges

Charge

Type

Setting

Price

NM LIVER IMAGING 3D W/ FLOW

Facility

$1,678.00

Service Code	CPT 78206
Hospital Charge Code	3478206
Hospital Revenue Code	341
Min. Negotiated Rate	$604.08
Max. Negotiated Rate	$1,198.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$993.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,198.09
Rate for Payer: Cash Price	$1,510.20
Rate for Payer: UnitedHealthcare Commercial	$1,119.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$604.08

NM LIVER SPLEEN SCAN

Facility

$1,616.00

Service Code	CPT 78215
Hospital Charge Code	3478215
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,454.40

NM LIVER SPLEEN SCAN

Facility

$1,616.00

Service Code	CPT 78215
Hospital Charge Code	3478215
Hospital Revenue Code	341
Min. Negotiated Rate	$360.38
Max. Negotiated Rate	$1,153.82
Rate for Payer: Cigna Commercial HMO & PPO	$408.43
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: 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 LUNG SCAN ISOTOPE KIT

Facility

$501.00

Service Code	CPT A4641
Hospital Charge Code	3400216
Hospital Revenue Code	342
Min. Negotiated Rate	$180.36
Max. Negotiated Rate	$357.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$296.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$357.71
Rate for Payer: Cash Price	$450.90
Rate for Payer: UnitedHealthcare Commercial	$334.17
Rate for Payer: UnitedHealthcare Medicare Advantage	$180.36

NM LUNG SCAN ISOTOPE KIT

Facility

$501.00

Service Code	CPT A4641
Hospital Charge Code	3400216
Hospital Revenue Code	342
Rate for Payer: Cash Price	$450.90

NM LUNG SCAN PERFUSION

Facility

$2,596.00

Service Code	CPT 78580
Hospital Charge Code	3478580
Hospital Revenue Code	341
Min. Negotiated Rate	$360.38
Max. Negotiated Rate	$1,853.54
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	$1,536.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,853.54
Rate for Payer: Cash Price	$2,336.40
Rate for Payer: Cash Price	$2,336.40
Rate for Payer: Cash Price	$2,336.40
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	$1,731.53
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$360.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$934.56

NM LUNG SCAN PERFUSION

Facility

$2,596.00

Service Code	CPT 78580
Hospital Charge Code	3478580
Hospital Revenue Code	341
Rate for Payer: Cash Price	$2,336.40

NM LUNG VENTILATION W PERFUSION

Facility

$3,490.00

Service Code	CPT 78582
Hospital Charge Code	3478582
Hospital Revenue Code	341
Min. Negotiated Rate	$489.46
Max. Negotiated Rate	$2,491.86
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	$2,066.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,491.86
Rate for Payer: Cash Price	$3,141.00
Rate for Payer: Cash Price	$3,141.00
Rate for Payer: Cash Price	$3,141.00
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	$2,327.83
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$489.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,256.40

NM LUNG VENTILATION W PERFUSION

Facility

$3,490.00

Service Code	CPT 78582
Hospital Charge Code	3478582
Hospital Revenue Code	341
Rate for Payer: Cash Price	$3,141.00

NM MUGA

Facility

$1,046.00

Service Code	CPT 78472
Hospital Charge Code	3478472
Hospital Revenue Code	341
Min. Negotiated Rate	$360.38
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	$619.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$746.84
Rate for Payer: Cash Price	$941.40
Rate for Payer: Cash Price	$941.40
Rate for Payer: Cash Price	$941.40
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	$697.68
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$360.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$376.56

NM MUGA

Facility

$1,046.00

Service Code	CPT 78472
Hospital Charge Code	3478472
Hospital Revenue Code	341
Rate for Payer: Cash Price	$941.40

NM MYOCARDIAC PYP SCAN

Facility

$1,046.00

Service Code	CPT 78466
Hospital Charge Code	3478466
Hospital Revenue Code	341
Min. Negotiated Rate	$360.38
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	$619.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$746.84
Rate for Payer: Cash Price	$941.40
Rate for Payer: Cash Price	$941.40
Rate for Payer: Cash Price	$941.40
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	$697.68
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$360.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$376.56

NM MYOCARDIAC PYP SCAN

Facility

$1,046.00

Service Code	CPT 78466
Hospital Charge Code	3478466
Hospital Revenue Code	341
Rate for Payer: Cash Price	$941.40

NM MYOCARDIAL PERFUSION

Facility

$3,341.00

Service Code	CPT 78452
Hospital Charge Code	3478452
Hospital Revenue Code	341
Min. Negotiated Rate	$1,167.06
Max. Negotiated Rate	$2,645.38
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,167.06
Rate for Payer: Aetna Medicare Advantage	$1,322.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,977.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,385.47
Rate for Payer: Cash Price	$3,006.90
Rate for Payer: Cash Price	$3,006.90
Rate for Payer: Cash Price	$3,006.90
Rate for Payer: Cigna Commercial HMO & PPO	$1,322.69
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,167.06
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,248.75
Rate for Payer: Home State Health Plan Medicare Advantage	$1,322.69
Rate for Payer: Humana Commercial	$2,645.38
Rate for Payer: Humana Medicare Advantage	$1,322.69
Rate for Payer: UnitedHealthcare Commercial	$2,228.45
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,167.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$1,202.76

NM MYOCARDIAL PERFUSION

Facility

$3,341.00

Service Code	CPT 78452
Hospital Charge Code	3478452
Hospital Revenue Code	341
Rate for Payer: Cash Price	$3,006.90

NM PARATHYROID IMAGING

Facility

$1,466.00

Service Code	CPT 78070
Hospital Charge Code	3478070
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,319.40

NM PARATHYROID IMAGING

Facility

$1,466.00

Service Code	CPT 78070
Hospital Charge Code	3478070
Hospital Revenue Code	341
Min. Negotiated Rate	$360.38
Max. Negotiated Rate	$1,046.72
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	$867.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,046.72
Rate for Payer: Cash Price	$1,319.40
Rate for Payer: Cash Price	$1,319.40
Rate for Payer: Cash Price	$1,319.40
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	$977.82
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$360.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$527.76

NM RADIOPHARMACEUTICAL LOCALIZATION

Facility

$2,709.00

Service Code	CPT 78805
Hospital Charge Code	3478805
Hospital Revenue Code	341
Min. Negotiated Rate	$975.24
Max. Negotiated Rate	$1,934.23
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,603.73
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,934.23
Rate for Payer: Cash Price	$2,438.10
Rate for Payer: UnitedHealthcare Commercial	$1,806.90
Rate for Payer: UnitedHealthcare Medicare Advantage	$975.24

NM RADIOPHARMACEUTICAL LOCALIZATION

Facility

$2,709.00

Service Code	CPT 78805
Hospital Charge Code	3478805
Hospital Revenue Code	341
Rate for Payer: Cash Price	$2,438.10

NM RENAL (PHARMA COLOGICAL)

Facility

$1,614.00

Service Code	CPT 78708
Hospital Charge Code	3478708
Hospital Revenue Code	341
Min. Negotiated Rate	$489.46
Max. Negotiated Rate	$1,152.40
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	$955.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,152.40
Rate for Payer: Cash Price	$1,452.60
Rate for Payer: Cash Price	$1,452.60
Rate for Payer: Cash Price	$1,452.60
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	$1,076.54
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$489.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$581.04

NM RENAL (PHARMA COLOGICAL)

Facility

$1,614.00

Service Code	CPT 78708
Hospital Charge Code	3478708
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,452.60

NM RENAL SCAN ISOTOPE KIT

Facility

$312.00

Service Code	CPT A4641
Hospital Charge Code	3400219
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 RENAL SCAN ISOTOPE KIT

Facility

$312.00

Service Code	CPT A4641
Hospital Charge Code	3400219
Hospital Revenue Code	342
Rate for Payer: Cash Price	$280.80

NM RENAL SCAN - STATIC ONLY

Facility

$1,283.00

Service Code	CPT 78700
Hospital Charge Code	3478700
Hospital Revenue Code	341
Rate for Payer: Cash Price	$1,154.70

NM RENAL SCAN - STATIC ONLY

Facility

$1,283.00

Service Code	CPT 78700
Hospital Charge Code	3478700
Hospital Revenue Code	341
Min. Negotiated Rate	$360.38
Max. Negotiated Rate	$916.06
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	$759.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$916.06
Rate for Payer: Cash Price	$1,154.70
Rate for Payer: Cash Price	$1,154.70
Rate for Payer: Cash Price	$1,154.70
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	$855.76
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$360.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$461.88

Know your out-of-pocket cost for care.

All Charges