Madison Medical Center

All Charges

Charge

Type

Setting

Price

OT RE EVALUATION

Facility

$240.00

Service Code	CPT 97004
Hospital Charge Code	5397004
Hospital Revenue Code	434
Rate for Payer: Cash Price	$216.00

OT RESTING HAND SPLINT

Facility

$186.00

Hospital Charge Code	5349039
Hospital Revenue Code	271
Rate for Payer: Cash Price	$167.40

OT RESTING HAND SPLINT

Facility

$186.00

Hospital Charge Code	5349039
Hospital Revenue Code	271
Min. Negotiated Rate	$66.96
Max. Negotiated Rate	$132.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$110.11
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$132.80
Rate for Payer: Cash Price	$167.40
Rate for Payer: UnitedHealthcare Commercial	$124.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$66.96

OT SHOE HORN FLEXIBLE

Facility

$20.00

Hospital Charge Code	5349015
Hospital Revenue Code	271
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

OT SHOE HORN FLEXIBLE

Facility

$20.00

Hospital Charge Code	5349015
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.00

OT SHOE HORN RIGID

Facility

$44.00

Hospital Charge Code	5349003
Hospital Revenue Code	271
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$31.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.05
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$31.42
Rate for Payer: Cash Price	$39.60
Rate for Payer: UnitedHealthcare Commercial	$29.35
Rate for Payer: UnitedHealthcare Medicare Advantage	$15.84

OT SHOE HORN RIGID

Facility

$44.00

Hospital Charge Code	5349003
Hospital Revenue Code	271
Rate for Payer: Cash Price	$39.60

OT SLING SHED

Facility

$165.00

Hospital Charge Code	5349005
Hospital Revenue Code	271
Rate for Payer: Cash Price	$148.50

OT SLING SHED

Facility

$165.00

Hospital Charge Code	5349005
Hospital Revenue Code	271
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$117.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$97.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$117.81
Rate for Payer: Cash Price	$148.50
Rate for Payer: UnitedHealthcare Commercial	$110.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$59.40

OT SOCK AID

Facility

$86.00

Hospital Charge Code	5349013
Hospital Revenue Code	271
Rate for Payer: Cash Price	$77.40

OT SOCK AID

Facility

$86.00

Hospital Charge Code	5349013
Hospital Revenue Code	271
Min. Negotiated Rate	$30.96
Max. Negotiated Rate	$61.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$50.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$61.40
Rate for Payer: Cash Price	$77.40
Rate for Payer: UnitedHealthcare Commercial	$57.36
Rate for Payer: UnitedHealthcare Medicare Advantage	$30.96

OT SOCK AID W CORD

Facility

$20.00

Hospital Charge Code	5349004
Hospital Revenue Code	271
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

OT SOCK AID W CORD

Facility

$20.00

Hospital Charge Code	5349004
Hospital Revenue Code	271
Rate for Payer: Cash Price	$18.00

OT SPLINT HAND RESTING

Facility

$155.00

Hospital Charge Code	5349007
Hospital Revenue Code	271
Rate for Payer: Cash Price	$139.50

OT SPLINT HAND RESTING

Facility

$155.00

Hospital Charge Code	5349007
Hospital Revenue Code	271
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$110.67
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$91.76
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$110.67
Rate for Payer: Cash Price	$139.50
Rate for Payer: UnitedHealthcare Commercial	$103.39
Rate for Payer: UnitedHealthcare Medicare Advantage	$55.80

OT SPLINT SOFT PADDED

Facility

$301.00

Hospital Charge Code	5349009
Hospital Revenue Code	271
Min. Negotiated Rate	$108.36
Max. Negotiated Rate	$214.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$178.19
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$214.91
Rate for Payer: Cash Price	$270.90
Rate for Payer: UnitedHealthcare Commercial	$200.77
Rate for Payer: UnitedHealthcare Medicare Advantage	$108.36

OT SPLINT SOFT PADDED

Facility

$301.00

Hospital Charge Code	5349009
Hospital Revenue Code	271
Rate for Payer: Cash Price	$270.90

OT THERABAND 1 YD

Facility

$22.00

Hospital Charge Code	5349029
Hospital Revenue Code	271
Rate for Payer: Cash Price	$19.80

OT THERABAND 1 YD

Facility

$22.00

Hospital Charge Code	5349029
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

OT THERAPEUTIC ACTIVITIES

Facility

$87.00

Service Code	CPT 97530
Hospital Charge Code	5397530
Hospital Revenue Code	431
Min. Negotiated Rate	$30.70
Max. Negotiated Rate	$136.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$30.70
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	$78.30
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cash Price	$78.30
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$30.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$32.85
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$30.70
Rate for Payer: UnitedHealthcare Medicare Advantage	$31.32

OT THERAPEUTIC ACTIVITIES

Facility

$87.00

Service Code	CPT 97530
Hospital Charge Code	5397530
Hospital Revenue Code	431
Rate for Payer: Cash Price	$78.30

OT THERAPEUTIC EXERCISE 15 MIN

Facility

$121.00

Service Code	CPT 97110
Hospital Charge Code	5397110
Hospital Revenue Code	431
Min. Negotiated Rate	$25.56
Max. Negotiated Rate	$136.00
Rate for Payer: Aetna Better Health Medicaid/QHP	$25.56
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	$108.90
Rate for Payer: Cash Price	$108.90
Rate for Payer: Cash Price	$108.90
Rate for Payer: Cash Price	$108.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$25.56
Rate for Payer: Home State Health Plan Medicaid Managed Care	$27.35
Rate for Payer: UnitedHealthcare Commercial	$82.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$25.56
Rate for Payer: UnitedHealthcare Medicare Advantage	$43.56

OT THERAPEUTIC EXERCISE 15 MIN

Facility

$121.00

Service Code	CPT 97110
Hospital Charge Code	5397110
Hospital Revenue Code	431
Rate for Payer: Cash Price	$108.90

OT THERAPUTTY 2 OZ.

Facility

$35.00

Hospital Charge Code	5349025
Hospital Revenue Code	271
Rate for Payer: Cash Price	$31.50

OT THERAPUTTY 2 OZ.

Facility

$35.00

Hospital Charge Code	5349025
Hospital Revenue Code	271
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$24.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24.99
Rate for Payer: Cash Price	$31.50
Rate for Payer: UnitedHealthcare Commercial	$23.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.60

Know your out-of-pocket cost for care.

All Charges