Madison Medical Center

All Charges

Charge

Type

Setting

Price

ORCHIECTOMY, SIMPLE W/WO TEST PROSTHESIS

Professional

Both

$1,108.00

Service Code	CPT 49521
Hospital Charge Code	4154520
Hospital Revenue Code	975
Min. Negotiated Rate	$387.80
Max. Negotiated Rate	$653.02
Rate for Payer: Aetna Commercial/Medicare Advantage	$653.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$543.60
Rate for Payer: Cash Price	$997.20
Rate for Payer: Cash Price	$997.20
Rate for Payer: Cigna Commercial HMO & PPO	$653.02
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$543.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$597.96
Rate for Payer: Home State Health Plan Medicare Advantage	$653.02
Rate for Payer: Optum Medicare Advantage	$387.80
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$543.60

OR CHOLANGIOGRAM

Facility

$613.00

Service Code	CPT 74300
Hospital Charge Code	323190
Hospital Revenue Code	320
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$437.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$362.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$437.68
Rate for Payer: Cash Price	$551.70
Rate for Payer: Cash Price	$551.70
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$220.68

OR CHOLANGIOGRAM

Facility

$613.00

Service Code	CPT 74300
Hospital Charge Code	323190
Hospital Revenue Code	320
Rate for Payer: Cash Price	$551.70

ORGANIC ACIDS URINE

Facility

$235.00

Service Code	CPT 83919
Hospital Charge Code	2283918
Hospital Revenue Code	301
Rate for Payer: Cash Price	$211.50

ORGANIC ACIDS URINE

Facility

$235.00

Service Code	CPT 83919
Hospital Charge Code	2283918
Hospital Revenue Code	301
Min. Negotiated Rate	$14.81
Max. Negotiated Rate	$167.79
Rate for Payer: Aetna Better Health Medicaid/QHP	$14.81
Rate for Payer: Aetna Medicare Advantage	$16.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$139.12
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$167.79
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial HMO & PPO	$16.45
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$15.85
Rate for Payer: Home State Health Plan Medicare Advantage	$16.45
Rate for Payer: Humana Commercial	$32.90
Rate for Payer: Humana Medicare Advantage	$16.45
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14.81
Rate for Payer: UnitedHealthcare Medicare Advantage	$84.60

ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY

Facility

$28,838.12

Service Code	MSDRG 884
Min. Negotiated Rate	$14,419.06
Max. Negotiated Rate	$28,838.12
Rate for Payer: Aetna Medicare Advantage	$14,419.06
Rate for Payer: Cigna Commercial HMO & PPO	$14,419.06
Rate for Payer: Home State Health Plan Medicare Advantage	$14,419.06
Rate for Payer: Humana Commercial	$28,838.12
Rate for Payer: Humana Medicare Advantage	$14,419.06

ORGANIC MENTAL HEALTH CONDITIONS AND DISTURBANCES

Facility

$51,688.45

Service Code	APR-DRG 7574
Min. Negotiated Rate	$51,688.45
Max. Negotiated Rate	$51,688.45
Rate for Payer: Aetna Better Health Medicaid/QHP	$51,688.45
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$51,688.45
Rate for Payer: Home State Health Plan Medicaid Managed Care	$51,688.45
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$51,688.45

ORGANIC MENTAL HEALTH CONDITIONS AND DISTURBANCES

Facility

$16,751.40

Service Code	APR-DRG 7572
Min. Negotiated Rate	$16,751.40
Max. Negotiated Rate	$16,751.40
Rate for Payer: Aetna Better Health Medicaid/QHP	$16,751.40
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16,751.40
Rate for Payer: Home State Health Plan Medicaid Managed Care	$16,751.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16,751.40

ORGANIC MENTAL HEALTH CONDITIONS AND DISTURBANCES

Facility

$14,315.99

Service Code	APR-DRG 7571
Min. Negotiated Rate	$14,315.99
Max. Negotiated Rate	$14,315.99
Rate for Payer: Aetna Better Health Medicaid/QHP	$14,315.99
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14,315.99
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14,315.99
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14,315.99

ORGANIC MENTAL HEALTH CONDITIONS AND DISTURBANCES

Facility

$21,519.25

Service Code	APR-DRG 7573
Min. Negotiated Rate	$21,519.25
Max. Negotiated Rate	$21,519.25
Rate for Payer: Aetna Better Health Medicaid/QHP	$21,519.25
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$21,519.25
Rate for Payer: Home State Health Plan Medicaid Managed Care	$21,519.25
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$21,519.25

ORPHENADRINE 100MG XR EMP

Facility

$20.00

Service Code	NDC 4.3386E+10
Hospital Charge Code	2623311
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

ORPHENADRINE 100MG XR EMP

Facility

$20.00

Service Code	NDC 4.3386E+10
Hospital Charge Code	2623311
Hospital Revenue Code	250
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$11.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$14.28
Rate for Payer: Cash Price	$18.00
Rate for Payer: UnitedHealthcare Commercial	$13.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$7.20

ORPHENADRINE 60MG INJ (IV OR IM) 2ML VL

Facility

$184.00

Service Code	HCPCS J2360
Hospital Charge Code	2626362
Hospital Revenue Code	250
Rate for Payer: Cash Price	$165.60

ORPHENADRINE 60MG INJ (IV OR IM) 2ML VL

Facility

$184.00

Service Code	HCPCS J2360
Hospital Charge Code	2626362
Hospital Revenue Code	250
Min. Negotiated Rate	$66.24
Max. Negotiated Rate	$131.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$108.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$131.38
Rate for Payer: Cash Price	$165.60
Rate for Payer: UnitedHealthcare Commercial	$122.73
Rate for Payer: UnitedHealthcare Medicare Advantage	$66.24

O.R. PROCEDURES FOR OBESITY WITH CC

Facility

$28,702.64

Service Code	MSDRG 620
Min. Negotiated Rate	$14,351.32
Max. Negotiated Rate	$28,702.64
Rate for Payer: Aetna Medicare Advantage	$14,351.32
Rate for Payer: Cigna Commercial HMO & PPO	$14,351.32
Rate for Payer: Home State Health Plan Medicare Advantage	$14,351.32
Rate for Payer: Humana Commercial	$28,702.64
Rate for Payer: Humana Medicare Advantage	$14,351.32

O.R. PROCEDURES FOR OBESITY WITH MCC

Facility

$49,005.94

Service Code	MSDRG 619
Min. Negotiated Rate	$24,502.97
Max. Negotiated Rate	$49,005.94
Rate for Payer: Aetna Medicare Advantage	$24,502.97
Rate for Payer: Cigna Commercial HMO & PPO	$24,502.97
Rate for Payer: Home State Health Plan Medicare Advantage	$24,502.97
Rate for Payer: Humana Commercial	$49,005.94
Rate for Payer: Humana Medicare Advantage	$24,502.97

O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC

Facility

$27,255.96

Service Code	MSDRG 621
Min. Negotiated Rate	$13,627.98
Max. Negotiated Rate	$27,255.96
Rate for Payer: Aetna Medicare Advantage	$13,627.98
Rate for Payer: Cigna Commercial HMO & PPO	$13,627.98
Rate for Payer: Home State Health Plan Medicare Advantage	$13,627.98
Rate for Payer: Humana Commercial	$27,255.96
Rate for Payer: Humana Medicare Advantage	$13,627.98

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC

Facility

$40,306.86

Service Code	MSDRG 940
Min. Negotiated Rate	$20,153.43
Max. Negotiated Rate	$40,306.86
Rate for Payer: Aetna Medicare Advantage	$20,153.43
Rate for Payer: Cigna Commercial HMO & PPO	$20,153.43
Rate for Payer: Home State Health Plan Medicare Advantage	$20,153.43
Rate for Payer: Humana Commercial	$40,306.86
Rate for Payer: Humana Medicare Advantage	$20,153.43

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC

Facility

$60,743.30

Service Code	MSDRG 939
Min. Negotiated Rate	$30,371.65
Max. Negotiated Rate	$60,743.30
Rate for Payer: Aetna Medicare Advantage	$30,371.65
Rate for Payer: Cigna Commercial HMO & PPO	$30,371.65
Rate for Payer: Home State Health Plan Medicare Advantage	$30,371.65
Rate for Payer: Humana Commercial	$60,743.30
Rate for Payer: Humana Medicare Advantage	$30,371.65

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC

Facility

$35,435.80

Service Code	MSDRG 941
Min. Negotiated Rate	$17,717.90
Max. Negotiated Rate	$35,435.80
Rate for Payer: Aetna Medicare Advantage	$17,717.90
Rate for Payer: Cigna Commercial HMO & PPO	$17,717.90
Rate for Payer: Home State Health Plan Medicare Advantage	$17,717.90
Rate for Payer: Humana Commercial	$35,435.80
Rate for Payer: Humana Medicare Advantage	$17,717.90

O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS

Facility

$64,492.76

Service Code	MSDRG 876
Min. Negotiated Rate	$32,246.38
Max. Negotiated Rate	$64,492.76
Rate for Payer: Aetna Medicare Advantage	$32,246.38
Rate for Payer: Cigna Commercial HMO & PPO	$32,246.38
Rate for Payer: Home State Health Plan Medicare Advantage	$32,246.38
Rate for Payer: Humana Commercial	$64,492.76
Rate for Payer: Humana Medicare Advantage	$32,246.38

ORTHOVISC

Facility

$350.00

Service Code	HCPCS J7324
Hospital Charge Code	91007324
Hospital Revenue Code	636
Min. Negotiated Rate	$233.45
Max. Negotiated Rate	$233.45
Rate for Payer: Cash Price	$315.00
Rate for Payer: UnitedHealthcare Commercial	$233.45

ORTHOVISC

Facility

$350.00

Service Code	HCPCS J7324
Hospital Charge Code	91007324
Hospital Revenue Code	636
Min. Negotiated Rate	$100.33
Max. Negotiated Rate	$249.90
Rate for Payer: Aetna Medicare Advantage	$100.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$207.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$249.90
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial HMO & PPO	$100.33
Rate for Payer: Home State Health Plan Medicare Advantage	$100.33
Rate for Payer: Humana Commercial	$200.66
Rate for Payer: Humana Medicare Advantage	$100.33
Rate for Payer: UnitedHealthcare Commercial	$100.33
Rate for Payer: UnitedHealthcare Medicare Advantage	$126.00

ORTHOVISC 30MG INJ 2ML

Facility

$2,374.00

Service Code	HCPCS J7325
Hospital Charge Code	2621597
Hospital Revenue Code	250
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$1,695.04
Rate for Payer: Aetna Medicare Advantage	$6.02
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,405.41
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,695.04
Rate for Payer: Cash Price	$2,136.60
Rate for Payer: Cash Price	$2,136.60
Rate for Payer: Cigna Commercial HMO & PPO	$6.02
Rate for Payer: Home State Health Plan Medicare Advantage	$6.02
Rate for Payer: Humana Commercial	$12.04
Rate for Payer: Humana Medicare Advantage	$6.02
Rate for Payer: UnitedHealthcare Commercial	$1,583.46
Rate for Payer: UnitedHealthcare Medicare Advantage	$854.64

ORTHOVISC 30MG INJ 2ML

Facility

$561.00

Service Code	HCPCS J7325
Hospital Charge Code	9107324
Hospital Revenue Code	521
Rate for Payer: Cash Price	$504.90

Know your out-of-pocket cost for care.

All Charges