Madison Medical Center

All Charges

Charge

Type

Setting

Price

REM FOREIGN BODY UPPER ARM

Facility

$137.00

Service Code	CPT 24200
Hospital Charge Code	4424200
Hospital Revenue Code	521
Min. Negotiated Rate	$81.10
Max. Negotiated Rate	$3,374.74
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,488.83
Rate for Payer: Aetna Medicare Advantage	$1,687.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$97.82
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cigna Commercial HMO & PPO	$1,687.37
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,339.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,593.05
Rate for Payer: Home State Health Plan Medicare Advantage	$1,687.37
Rate for Payer: Humana Commercial	$3,374.74
Rate for Payer: Humana Medicare Advantage	$1,687.37
Rate for Payer: UnitedHealthcare Commercial	$91.38
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,488.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REM FOREIGN BODY UPPER ARM

Facility

$137.00

Service Code	CPT 24200
Hospital Charge Code	4424200
Hospital Revenue Code	521
Rate for Payer: Cash Price	$123.30

REM OF DEV TISSUE FROM WOUND

Facility

$90.00

Service Code	CPT 97602
Hospital Charge Code	9897602
Hospital Revenue Code	521
Rate for Payer: Cash Price	$81.00

REM OF DEV TISSUE FROM WOUND

Facility

$90.00

Service Code	CPT 97602
Hospital Charge Code	9897602
Hospital Revenue Code	521
Min. Negotiated Rate	$53.28
Max. Negotiated Rate	$409.96
Rate for Payer: Aetna Better Health Medicaid/QHP	$180.86
Rate for Payer: Aetna Medicare Advantage	$204.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$53.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$64.26
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$162.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$193.52
Rate for Payer: Home State Health Plan Medicare Advantage	$204.98
Rate for Payer: Humana Commercial	$409.96
Rate for Payer: Humana Medicare Advantage	$204.98
Rate for Payer: UnitedHealthcare Commercial	$60.03
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REM OF FB IN SCROTUM

Professional

Both

$1,250.00

Service Code	CPT 55120
Hospital Charge Code	9355120
Hospital Revenue Code	975
Min. Negotiated Rate	$265.76
Max. Negotiated Rate	$437.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$313.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$265.76
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Cigna Commercial HMO & PPO	$313.99
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$265.76
Rate for Payer: Home State Health Plan Medicaid Managed Care	$292.34
Rate for Payer: Home State Health Plan Medicare Advantage	$313.99
Rate for Payer: Optum Medicare Advantage	$437.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$265.76

REM OF FOREIGN BODY EXT EYE CONJ OR SUPE

Facility

$200.00

Service Code	CPT 65205
Hospital Charge Code	9865205
Hospital Revenue Code	521
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$271.86
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$118.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$142.80
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$107.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$133.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REM OF FOREIGN BODY EXT EYE CONJ OR SUPE

Facility

$200.00

Service Code	CPT 65205
Hospital Charge Code	9865205
Hospital Revenue Code	521
Rate for Payer: Cash Price	$180.00

REMOVAL FB EXTERNAL AUDITORY CANAL

Facility

$300.00

Service Code	CPT 69200
Hospital Charge Code	5469200
Hospital Revenue Code	521
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$271.86
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$177.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$214.20
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$107.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$200.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REMOVAL FB EXTERNAL AUDITORY CANAL

Facility

$300.00

Service Code	CPT 69200
Hospital Charge Code	5469200
Hospital Revenue Code	521
Rate for Payer: Cash Price	$270.00

REMOVAL FB NOSE

Professional

Both

$840.00

Service Code	CPT 30300
Hospital Charge Code	1830300
Hospital Revenue Code	981
Min. Negotiated Rate	$105.10
Max. Negotiated Rate	$294.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$105.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$160.97
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cigna Commercial HMO & PPO	$105.10
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$160.97
Rate for Payer: Home State Health Plan Medicaid Managed Care	$177.07
Rate for Payer: Home State Health Plan Medicare Advantage	$105.10
Rate for Payer: Optum Medicare Advantage	$294.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$160.97

REMOVAL FOREIGN BODY EXT AUDITORY CANAL

Facility

$137.00

Service Code	CPT 69200
Hospital Charge Code	4469200
Hospital Revenue Code	521
Min. Negotiated Rate	$81.10
Max. Negotiated Rate	$271.86
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$81.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$97.82
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$107.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$91.38
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REMOVAL FOREIGN BODY EXT AUDITORY CANAL

Facility

$137.00

Service Code	CPT 69200
Hospital Charge Code	4469200
Hospital Revenue Code	521
Rate for Payer: Cash Price	$123.30

REMOVAL FOREIGN BODY INTRANASAL

Facility

$420.00

Service Code	CPT 30300
Hospital Charge Code	4230300
Hospital Revenue Code	521
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$299.88
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$248.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$299.88
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$107.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$280.14
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REMOVAL FOREIGN BODY INTRANASAL

Facility

$420.00

Service Code	CPT 30300
Hospital Charge Code	4230300
Hospital Revenue Code	521
Rate for Payer: Cash Price	$378.00

REMOVAL FORIGN BODY/NOSE

Professional

Both

$159.00

Service Code	CPT 30300
Hospital Charge Code	4130300
Hospital Revenue Code	975
Min. Negotiated Rate	$55.65
Max. Negotiated Rate	$177.07
Rate for Payer: Aetna Commercial/Medicare Advantage	$105.10
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$160.97
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial HMO & PPO	$105.10
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$160.97
Rate for Payer: Home State Health Plan Medicaid Managed Care	$177.07
Rate for Payer: Home State Health Plan Medicare Advantage	$105.10
Rate for Payer: Optum Medicare Advantage	$55.65
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$160.97

REMOVAL, IMPLANTABLE CONTRACEPT CAPSULES

Facility

$232.00

Service Code	CPT 11976
Hospital Charge Code	5211976
Hospital Revenue Code	521
Min. Negotiated Rate	$137.34
Max. Negotiated Rate	$1,446.94
Rate for Payer: Aetna Better Health Medicaid/QHP	$638.34
Rate for Payer: Aetna Medicare Advantage	$723.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$137.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$165.65
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cigna Commercial HMO & PPO	$723.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$574.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$683.02
Rate for Payer: Home State Health Plan Medicare Advantage	$723.47
Rate for Payer: Humana Commercial	$1,446.94
Rate for Payer: Humana Medicare Advantage	$723.47
Rate for Payer: UnitedHealthcare Commercial	$154.74
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$638.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REMOVAL, IMPLANTABLE CONTRACEPT CAPSULES

Facility

$232.00

Service Code	CPT 11976
Hospital Charge Code	5211976
Hospital Revenue Code	521
Rate for Payer: Cash Price	$208.80

REMOVAL OF F/B DEEP OR COMPLICATED

Professional

Both

$745.00

Service Code	CPT 20525
Hospital Charge Code	4120525
Hospital Revenue Code	975
Min. Negotiated Rate	$219.34
Max. Negotiated Rate	$391.23
Rate for Payer: Aetna Commercial/Medicare Advantage	$219.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$355.66
Rate for Payer: Cash Price	$670.50
Rate for Payer: Cash Price	$670.50
Rate for Payer: Cigna Commercial HMO & PPO	$219.34
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$355.66
Rate for Payer: Home State Health Plan Medicaid Managed Care	$391.23
Rate for Payer: Home State Health Plan Medicare Advantage	$219.34
Rate for Payer: Optum Medicare Advantage	$260.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$355.66

REMOVAL OF F/B EAR

Facility

$185.00

Service Code	CPT 69200
Hospital Charge Code	9769200
Hospital Revenue Code	521
Rate for Payer: Cash Price	$166.50

REMOVAL OF F/B EAR

Facility

$185.00

Service Code	CPT 69200
Hospital Charge Code	9769200
Hospital Revenue Code	521
Min. Negotiated Rate	$107.95
Max. Negotiated Rate	$271.86
Rate for Payer: Aetna Better Health Medicaid/QHP	$119.94
Rate for Payer: Aetna Medicare Advantage	$135.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$109.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$132.09
Rate for Payer: Cash Price	$166.50
Rate for Payer: Cash Price	$166.50
Rate for Payer: Cash Price	$166.50
Rate for Payer: Cash Price	$166.50
Rate for Payer: Cigna Commercial HMO & PPO	$135.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$107.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$128.34
Rate for Payer: Home State Health Plan Medicare Advantage	$135.93
Rate for Payer: Humana Commercial	$271.86
Rate for Payer: Humana Medicare Advantage	$135.93
Rate for Payer: UnitedHealthcare Commercial	$123.39
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.94
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REMOVAL OF F/B IN MUSCLE OR TENDON SIMPL

Facility

$341.00

Service Code	CPT 20520
Hospital Charge Code	4420520
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$3,374.74
Rate for Payer: Aetna Better Health Medicaid/QHP	$1,488.83
Rate for Payer: Aetna Medicare Advantage	$1,687.37
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$201.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$243.47
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial HMO & PPO	$1,687.37
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$1,339.95
Rate for Payer: Home State Health Plan Medicaid Managed Care	$1,593.05
Rate for Payer: Home State Health Plan Medicare Advantage	$1,687.37
Rate for Payer: Humana Commercial	$3,374.74
Rate for Payer: Humana Medicare Advantage	$1,687.37
Rate for Payer: UnitedHealthcare Commercial	$227.45
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$1,488.83
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REMOVAL OF F/B IN MUSCLE OR TENDON SIMPL

Facility

$341.00

Service Code	CPT 20520
Hospital Charge Code	4420520
Hospital Revenue Code	521
Rate for Payer: Cash Price	$306.90

REMOVAL OF F/B (PEG TUBE)

Professional

Both

$1,155.00

Service Code	CPT 43247
Hospital Charge Code	5443247
Hospital Revenue Code	975
Min. Negotiated Rate	$151.00
Max. Negotiated Rate	$404.25
Rate for Payer: Aetna Commercial/Medicare Advantage	$151.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$298.70
Rate for Payer: Cash Price	$1,039.50
Rate for Payer: Cash Price	$1,039.50
Rate for Payer: Cigna Commercial HMO & PPO	$151.00
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$298.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$328.57
Rate for Payer: Home State Health Plan Medicare Advantage	$151.00
Rate for Payer: Optum Medicare Advantage	$404.25
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$298.70

REMOVAL OF F/B SIMPLE

Professional

Both

$276.00

Service Code	CPT 20520
Hospital Charge Code	4120520
Hospital Revenue Code	975
Min. Negotiated Rate	$96.60
Max. Negotiated Rate	$181.75
Rate for Payer: Aetna Commercial/Medicare Advantage	$131.90
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$165.23
Rate for Payer: Cash Price	$248.40
Rate for Payer: Cash Price	$248.40
Rate for Payer: Cigna Commercial HMO & PPO	$131.90
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$165.23
Rate for Payer: Home State Health Plan Medicaid Managed Care	$181.75
Rate for Payer: Home State Health Plan Medicare Advantage	$131.90
Rate for Payer: Optum Medicare Advantage	$96.60
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$165.23

REMOVAL OF F/B SUPERFICIAL EYE

Facility

$105.00

Service Code	CPT 65205
Hospital Charge Code	4465205
Hospital Revenue Code	521
Rate for Payer: Cash Price	$94.50

Know your out-of-pocket cost for care.

All Charges