Madison Medical Center

All Charges

Charge

Type

Setting

Price

OT HIGH EVALUATION

Facility

$264.00

Service Code	CPT 97167GO
Hospital Charge Code	5397167
Hospital Revenue Code	434
Rate for Payer: Cash Price	$237.60

OT HOT COLD PACK

Facility

$55.00

Service Code	CPT 97010
Hospital Charge Code	5397010
Hospital Revenue Code	271
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

OT HOT COLD PACK

Facility

$55.00

Service Code	CPT 97010
Hospital Charge Code	5397010
Hospital Revenue Code	271
Rate for Payer: Cash Price	$49.50

OTIPRIO 60MG OTIC SUSP 1ML VIAL

Facility

$1,787.00

Service Code	NDC 1E+11
Hospital Charge Code	2619995
Hospital Revenue Code	250
Min. Negotiated Rate	$643.32
Max. Negotiated Rate	$1,275.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,057.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,275.92
Rate for Payer: Cash Price	$1,608.30
Rate for Payer: UnitedHealthcare Commercial	$1,191.93
Rate for Payer: UnitedHealthcare Medicare Advantage	$643.32

OTIPRIO 60MG OTIC SUSP 1ML VIAL

Facility

$1,787.00

Service Code	NDC 1E+11
Hospital Charge Code	2619995
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,608.30

OTIPRIO 60MG OTIC SUSP 1ML VIAL

Facility

$1,787.00

Service Code	NDC 6.9251E+10
Hospital Charge Code	2058061
Hospital Revenue Code	250
Rate for Payer: Cash Price	$1,608.30

OTIPRIO 60MG OTIC SUSP 1ML VIAL

Facility

$1,787.00

Service Code	NDC 6.9251E+10
Hospital Charge Code	2058061
Hospital Revenue Code	250
Min. Negotiated Rate	$643.32
Max. Negotiated Rate	$1,275.92
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,057.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$1,275.92
Rate for Payer: Cash Price	$1,608.30
Rate for Payer: UnitedHealthcare Commercial	$1,191.93
Rate for Payer: UnitedHealthcare Medicare Advantage	$643.32

OTITIS MEDIA AND URI WITH MCC

Facility

$22,145.18

Service Code	MSDRG 152
Min. Negotiated Rate	$11,072.59
Max. Negotiated Rate	$22,145.18
Rate for Payer: Aetna Medicare Advantage	$11,072.59
Rate for Payer: Cigna Commercial HMO & PPO	$11,072.59
Rate for Payer: Home State Health Plan Medicare Advantage	$11,072.59
Rate for Payer: Humana Commercial	$22,145.18
Rate for Payer: Humana Medicare Advantage	$11,072.59

OTITIS MEDIA AND URI WITHOUT MCC

Facility

$15,197.16

Service Code	MSDRG 153
Min. Negotiated Rate	$7,598.58
Max. Negotiated Rate	$15,197.16
Rate for Payer: Aetna Medicare Advantage	$7,598.58
Rate for Payer: Cigna Commercial HMO & PPO	$7,598.58
Rate for Payer: Home State Health Plan Medicare Advantage	$7,598.58
Rate for Payer: Humana Commercial	$15,197.16
Rate for Payer: Humana Medicare Advantage	$7,598.58

OT LEG LIFTER

Facility

$101.00

Hospital Charge Code	5349006
Hospital Revenue Code	271
Min. Negotiated Rate	$36.36
Max. Negotiated Rate	$72.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$59.79
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$72.11
Rate for Payer: Cash Price	$90.90
Rate for Payer: UnitedHealthcare Commercial	$67.37
Rate for Payer: UnitedHealthcare Medicare Advantage	$36.36

OT LEG LIFTER

Facility

$101.00

Hospital Charge Code	5349006
Hospital Revenue Code	271
Rate for Payer: Cash Price	$90.90

OT LONG HANDLED SPONGE

Facility

$56.00

Hospital Charge Code	5349002
Hospital Revenue Code	271
Rate for Payer: Cash Price	$50.40

OT LONG HANDLED SPONGE

Facility

$56.00

Hospital Charge Code	5349002
Hospital Revenue Code	271
Min. Negotiated Rate	$20.16
Max. Negotiated Rate	$39.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$33.15
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.98
Rate for Payer: Cash Price	$50.40
Rate for Payer: UnitedHealthcare Commercial	$37.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$20.16

OT LOW EVALUATION

Facility

$264.00

Service Code	CPT 97165GO
Hospital Charge Code	5397165
Hospital Revenue Code	434
Min. Negotiated Rate	$82.00
Max. Negotiated Rate	$136.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$100.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$136.00
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cash Price	$237.60
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$95.04

OT LOW EVALUATION

Facility

$264.00

Service Code	CPT 97165GO
Hospital Charge Code	5397165
Hospital Revenue Code	434
Rate for Payer: Cash Price	$237.60

OT MANUAL THERAPY MYOFACIAL MOBIL MANIP

Facility

$147.00

Service Code	CPT 97140
Hospital Charge Code	5397140
Hospital Revenue Code	430
Rate for Payer: Cash Price	$132.30

OT MANUAL THERAPY MYOFACIAL MOBIL MANIP

Facility

$147.00

Service Code	CPT 97140
Hospital Charge Code	5397140
Hospital Revenue Code	430
Min. Negotiated Rate	$24.39
Max. Negotiated Rate	$136.00
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cash Price	$132.30
Rate for Payer: Aetna Better Health Medicaid/QHP	$24.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$100.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$136.00
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cash Price	$132.30
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$24.39
Rate for Payer: Home State Health Plan Medicaid Managed Care	$26.10
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$24.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$52.92

OT MOBILITY OCCP THERAPY FUNCTION

Facility

$4.00

Hospital Charge Code	538978
Hospital Revenue Code	430
Rate for Payer: Cash Price	$3.60

OT MOBILITY OCCP THERAPY FUNCTION

Facility

$4.00

Hospital Charge Code	538978
Hospital Revenue Code	430
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$136.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$100.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$136.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.60
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1.44

OT MOD EVALUATION

Facility

$264.00

Service Code	CPT 97166GO
Hospital Charge Code	5397166
Hospital Revenue Code	434
Rate for Payer: Cash Price	$237.60

OT MOD EVALUATION

Facility

$264.00

Service Code	CPT 97166GO
Hospital Charge Code	5397166
Hospital Revenue Code	434
Min. Negotiated Rate	$82.00
Max. Negotiated Rate	$136.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$100.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$136.00
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cash Price	$237.60
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$95.04

OT NEUROMUSCULAR RE-EDUC.

Facility

$141.00

Service Code	CPT 97112
Hospital Charge Code	5397112
Hospital Revenue Code	431
Rate for Payer: Cash Price	$126.90

OT NEUROMUSCULAR RE-EDUC.

Facility

$141.00

Service Code	CPT 97112
Hospital Charge Code	5397112
Hospital Revenue Code	431
Min. Negotiated Rate	$28.78
Max. Negotiated Rate	$136.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$28.78
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$100.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$136.00
Rate for Payer: Cash Price	$126.90
Rate for Payer: Cash Price	$126.90
Rate for Payer: Cash Price	$126.90
Rate for Payer: Cash Price	$126.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$28.78
Rate for Payer: Home State Health Plan Medicaid Managed Care	$30.79
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$28.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$50.76

OT OCCUP PRIMARY FUNCT LIMITATION

Facility

$4.00

Hospital Charge Code	538990
Hospital Revenue Code	430
Rate for Payer: Cash Price	$3.60

OT OCCUP PRIMARY FUNCT LIMITATION

Facility

$4.00

Hospital Charge Code	538990
Hospital Revenue Code	430
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$136.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$100.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$136.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cash Price	$3.60
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$1.44

Know your out-of-pocket cost for care.

All Charges