Madison Medical Center

All Charges

Charge

Type

Setting

Price

OPO INITIAL, HIGH SEVERITY

Facility

$410.00

Service Code	CPT 99223
Hospital Charge Code	9699220
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$292.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$242.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$292.74
Rate for Payer: Cash Price	$369.00
Rate for Payer: Cash Price	$369.00
Rate for Payer: UnitedHealthcare Commercial	$273.47
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OPO, INITIAL, LOW SEVERITY

Facility

$210.00

Service Code	CPT 99221
Hospital Charge Code	9699218
Hospital Revenue Code	521
Rate for Payer: Cash Price	$189.00

OPO, INITIAL, LOW SEVERITY

Facility

$210.00

Service Code	CPT 99221
Hospital Charge Code	9699218
Hospital Revenue Code	521
Min. Negotiated Rate	$124.32
Max. Negotiated Rate	$173.53
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$124.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$149.94
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: UnitedHealthcare Commercial	$140.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

OPO MODERATE SEVERITY ADMIT

Facility

$240.00

Service Code	CPT 99222
Hospital Charge Code	9699219
Hospital Revenue Code	521
Rate for Payer: Cash Price	$216.00

OPO MODERATE SEVERITY ADMIT

Facility

$240.00

Service Code	CPT 99222
Hospital Charge Code	9699219
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

O/P POST OPER/HRLY

Facility

$424.00

Hospital Charge Code	1269014
Hospital Revenue Code	710
Min. Negotiated Rate	$152.64
Max. Negotiated Rate	$302.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$251.01
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$302.74
Rate for Payer: Cash Price	$381.60
Rate for Payer: UnitedHealthcare Commercial	$282.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$152.64

O/P POST OPER/HRLY

Facility

$424.00

Hospital Charge Code	1269014
Hospital Revenue Code	710
Rate for Payer: Cash Price	$381.60

OP-SITE 10CM X 14CM

Facility

$39.00

Hospital Charge Code	2815336
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

OP-SITE 10CM X 14CM

Facility

$39.00

Hospital Charge Code	2815336
Hospital Revenue Code	271
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

OP-SITE 45CM X 55CM

Facility

$89.00

Hospital Charge Code	2815338
Hospital Revenue Code	271
Rate for Payer: Cash Price	$80.10

OP-SITE 45CM X 55CM

Facility

$89.00

Hospital Charge Code	2815338
Hospital Revenue Code	271
Min. Negotiated Rate	$32.04
Max. Negotiated Rate	$63.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$52.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$63.55
Rate for Payer: Cash Price	$80.10
Rate for Payer: UnitedHealthcare Commercial	$59.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$32.04

OPSITE & PAD

Facility

$39.00

Hospital Charge Code	2815335
Hospital Revenue Code	271
Rate for Payer: Cash Price	$35.10

OPSITE & PAD

Facility

$39.00

Hospital Charge Code	2815335
Hospital Revenue Code	271
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$27.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$27.85
Rate for Payer: Cash Price	$35.10
Rate for Payer: UnitedHealthcare Commercial	$26.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.04

OPSIT I.V. DRESSING

Facility

$22.00

Hospital Charge Code	284575
Hospital Revenue Code	271
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$15.71
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$13.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$15.71
Rate for Payer: Cash Price	$19.80
Rate for Payer: UnitedHealthcare Commercial	$14.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.92

OPSIT I.V. DRESSING

Facility

$22.00

Hospital Charge Code	284575
Hospital Revenue Code	271
Rate for Payer: Cash Price	$19.80

OPTIRAY CONTRAST

Facility

$632.00

Hospital Charge Code	3600142
Hospital Revenue Code	350
Min. Negotiated Rate	$227.52
Max. Negotiated Rate	$853.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$853.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$451.25
Rate for Payer: Cash Price	$568.80
Rate for Payer: Cash Price	$568.80
Rate for Payer: UnitedHealthcare Commercial	$585.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$227.52

OPTIRAY CONTRAST

Facility

$632.00

Hospital Charge Code	3600142
Hospital Revenue Code	350
Rate for Payer: Cash Price	$568.80

ORBITAL PROCEDURES WITH CC/MCC

Facility

$40,530.56

Service Code	MSDRG 113
Min. Negotiated Rate	$20,265.28
Max. Negotiated Rate	$40,530.56
Rate for Payer: Aetna Medicare Advantage	$20,265.28
Rate for Payer: Cigna Commercial HMO & PPO	$20,265.28
Rate for Payer: Home State Health Plan Medicare Advantage	$20,265.28
Rate for Payer: Humana Commercial	$40,530.56
Rate for Payer: Humana Medicare Advantage	$20,265.28

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$24,818.22

Service Code	MSDRG 114
Min. Negotiated Rate	$12,409.11
Max. Negotiated Rate	$24,818.22
Rate for Payer: Aetna Medicare Advantage	$12,409.11
Rate for Payer: Cigna Commercial HMO & PPO	$12,409.11
Rate for Payer: Home State Health Plan Medicare Advantage	$12,409.11
Rate for Payer: Humana Commercial	$24,818.22
Rate for Payer: Humana Medicare Advantage	$12,409.11

ORBIT AND EYE PROCEDURES

Facility

$38,519.16

Service Code	APR-DRG 0734
Min. Negotiated Rate	$38,519.16
Max. Negotiated Rate	$38,519.16
Rate for Payer: Aetna Better Health Medicaid/QHP	$38,519.16
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$38,519.16
Rate for Payer: Home State Health Plan Medicaid Managed Care	$38,519.16
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$38,519.16

ORBIT AND EYE PROCEDURES

Facility

$23,509.59

Service Code	APR-DRG 0733
Min. Negotiated Rate	$23,509.59
Max. Negotiated Rate	$23,509.59
Rate for Payer: Aetna Better Health Medicaid/QHP	$23,509.59
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$23,509.59
Rate for Payer: Home State Health Plan Medicaid Managed Care	$23,509.59
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$23,509.59

ORBIT AND EYE PROCEDURES

Facility

$13,016.30

Service Code	APR-DRG 0731
Min. Negotiated Rate	$13,016.30
Max. Negotiated Rate	$13,016.30
Rate for Payer: Aetna Better Health Medicaid/QHP	$13,016.30
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$13,016.30
Rate for Payer: Home State Health Plan Medicaid Managed Care	$13,016.30
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$13,016.30

ORBIT AND EYE PROCEDURES

Facility

$18,426.59

Service Code	APR-DRG 0732
Min. Negotiated Rate	$18,426.59
Max. Negotiated Rate	$18,426.59
Rate for Payer: Aetna Better Health Medicaid/QHP	$18,426.59
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$18,426.59
Rate for Payer: Home State Health Plan Medicaid Managed Care	$18,426.59
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$18,426.59

ORBIT X-RAY

Facility

$529.00

Service Code	CPT 70200
Hospital Charge Code	3215165
Hospital Revenue Code	320
Rate for Payer: Cash Price	$476.10

ORBIT X-RAY

Facility

$529.00

Service Code	CPT 70200
Hospital Charge Code	3215165
Hospital Revenue Code	320
Min. Negotiated Rate	$94.24
Max. Negotiated Rate	$377.71
Rate for Payer: Aetna Better Health Medicaid/QHP	$94.24
Rate for Payer: Aetna Medicare Advantage	$106.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$313.17
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$377.71
Rate for Payer: Cash Price	$476.10
Rate for Payer: Cash Price	$476.10
Rate for Payer: Cash Price	$476.10
Rate for Payer: Cigna Commercial HMO & PPO	$106.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$94.24
Rate for Payer: Home State Health Plan Medicaid Managed Care	$100.84
Rate for Payer: Home State Health Plan Medicare Advantage	$106.81
Rate for Payer: Humana Commercial	$213.62
Rate for Payer: Humana Medicare Advantage	$106.81
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$94.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$190.44

Know your out-of-pocket cost for care.

All Charges