Madison Medical Center

All Charges

Charge

Type

Setting

Price

REPAIR BLOOD VESSEL

Professional

Both

$3,346.00

Service Code	CPT 35226
Hospital Charge Code	1835226
Hospital Revenue Code	981
Min. Negotiated Rate	$620.72
Max. Negotiated Rate	$1,171.10
Rate for Payer: Aetna Commercial/Medicare Advantage	$734.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$620.72
Rate for Payer: Cash Price	$3,011.40
Rate for Payer: Cash Price	$3,011.40
Rate for Payer: Cigna Commercial HMO & PPO	$734.93
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$620.72
Rate for Payer: Home State Health Plan Medicaid Managed Care	$682.79
Rate for Payer: Home State Health Plan Medicare Advantage	$734.93
Rate for Payer: Optum Medicare Advantage	$1,171.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$620.72

REPAIR COMPLES WOUND

Professional

Both

$617.00

Service Code	CPT 13121
Hospital Charge Code	4113121
Hospital Revenue Code	975
Min. Negotiated Rate	$205.33
Max. Negotiated Rate	$355.86
Rate for Payer: Aetna Commercial/Medicare Advantage	$205.33
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$323.51
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial HMO & PPO	$205.33
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$323.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$355.86
Rate for Payer: Home State Health Plan Medicare Advantage	$205.33
Rate for Payer: Optum Medicare Advantage	$215.95
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$323.51

REPAIR COMPLEX 2.6 TO 7.5CM SCALP ARMS

Facility

$850.00

Service Code	CPT 13121
Hospital Charge Code	4213121
Hospital Revenue Code	521
Rate for Payer: Cash Price	$765.00

REPAIR COMPLEX 2.6 TO 7.5CM SCALP ARMS

Facility

$850.00

Service Code	CPT 13121
Hospital Charge Code	4213121
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$830.64
Rate for Payer: Aetna Better Health Medicaid/QHP	$366.45
Rate for Payer: Aetna Medicare Advantage	$415.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$503.20
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$606.90
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cigna Commercial HMO & PPO	$415.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$329.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$392.10
Rate for Payer: Home State Health Plan Medicare Advantage	$415.32
Rate for Payer: Humana Commercial	$830.64
Rate for Payer: Humana Medicare Advantage	$415.32
Rate for Payer: UnitedHealthcare Commercial	$566.95
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR COMPLEX EA ADD'L 5 CM OR LESS

Facility

$300.00

Service Code	CPT 13122
Hospital Charge Code	4213122
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$214.20
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: UnitedHealthcare Commercial	$200.10
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR COMPLEX EA ADD'L 5 CM OR LESS

Facility

$300.00

Service Code	CPT 13122
Hospital Charge Code	4213122
Hospital Revenue Code	521
Rate for Payer: Cash Price	$270.00

REPAIR, COMPLEX, FACE,HEAD 1.1 TO 2.5CM

Facility

$630.00

Service Code	CPT 13131
Hospital Charge Code	5413131
Hospital Revenue Code	521
Rate for Payer: Cash Price	$567.00

REPAIR, COMPLEX, FACE,HEAD 1.1 TO 2.5CM

Facility

$630.00

Service Code	CPT 13131
Hospital Charge Code	5413131
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$830.64
Rate for Payer: Aetna Better Health Medicaid/QHP	$366.45
Rate for Payer: Aetna Medicare Advantage	$415.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$372.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$449.82
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial HMO & PPO	$415.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$329.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$392.10
Rate for Payer: Home State Health Plan Medicare Advantage	$415.32
Rate for Payer: Humana Commercial	$830.64
Rate for Payer: Humana Medicare Advantage	$415.32
Rate for Payer: UnitedHealthcare Commercial	$420.21
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR COMPLEX-SCALP,ARM,LEG 1.1CM-2.5CM

Professional

Both

$1,229.00

Service Code	CPT 13120
Hospital Charge Code	1813120
Hospital Revenue Code	981
Min. Negotiated Rate	$186.96
Max. Negotiated Rate	$430.15
Rate for Payer: Aetna Commercial/Medicare Advantage	$186.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$270.66
Rate for Payer: Cash Price	$1,106.10
Rate for Payer: Cash Price	$1,106.10
Rate for Payer: Cigna Commercial HMO & PPO	$186.96
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$270.66
Rate for Payer: Home State Health Plan Medicaid Managed Care	$297.73
Rate for Payer: Home State Health Plan Medicare Advantage	$186.96
Rate for Payer: Optum Medicare Advantage	$430.15
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$270.66

REPAIR, COMPLEX, SCALP, ARMS, LEG 2.6-7.

Facility

$814.00

Service Code	CPT 13121
Hospital Charge Code	5413121
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$830.64
Rate for Payer: Aetna Better Health Medicaid/QHP	$366.45
Rate for Payer: Aetna Medicare Advantage	$415.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$481.89
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$581.20
Rate for Payer: Cash Price	$732.60
Rate for Payer: Cash Price	$732.60
Rate for Payer: Cash Price	$732.60
Rate for Payer: Cash Price	$732.60
Rate for Payer: Cigna Commercial HMO & PPO	$415.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$329.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$392.10
Rate for Payer: Home State Health Plan Medicare Advantage	$415.32
Rate for Payer: Humana Commercial	$830.64
Rate for Payer: Humana Medicare Advantage	$415.32
Rate for Payer: UnitedHealthcare Commercial	$542.94
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR, COMPLEX, SCALP, ARMS, LEG 2.6-7.

Facility

$814.00

Service Code	CPT 13121
Hospital Charge Code	5413121
Hospital Revenue Code	521
Rate for Payer: Cash Price	$732.60

REPAIR, COMPLEX, TRUNK 2.6 CM TO 7.5 CM

Facility

$630.00

Service Code	CPT 13101
Hospital Charge Code	5413101
Hospital Revenue Code	521
Rate for Payer: Cash Price	$567.00

REPAIR, COMPLEX, TRUNK 2.6 CM TO 7.5 CM

Facility

$630.00

Service Code	CPT 13101
Hospital Charge Code	5413101
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$1,510.16
Rate for Payer: Aetna Better Health Medicaid/QHP	$666.23
Rate for Payer: Aetna Medicare Advantage	$755.08
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$372.96
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$449.82
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial HMO & PPO	$755.08
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$599.61
Rate for Payer: Home State Health Plan Medicaid Managed Care	$712.87
Rate for Payer: Home State Health Plan Medicare Advantage	$755.08
Rate for Payer: Humana Commercial	$1,510.16
Rate for Payer: Humana Medicare Advantage	$755.08
Rate for Payer: UnitedHealthcare Commercial	$420.21
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$666.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR COMP SCALP,ARM,LEG EA ADDL 5CM

Facility

$289.00

Service Code	CPT 13122
Hospital Charge Code	5413122
Hospital Revenue Code	521
Rate for Payer: Cash Price	$260.10

REPAIR COMP SCALP,ARM,LEG EA ADDL 5CM

Facility

$289.00

Service Code	CPT 13122
Hospital Charge Code	5413122
Hospital Revenue Code	521
Min. Negotiated Rate	$171.09
Max. Negotiated Rate	$206.35
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$171.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$206.35
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cash Price	$260.10
Rate for Payer: UnitedHealthcare Commercial	$192.76
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR INGUINAL HERNIA

Professional

Both

$1,504.00

Service Code	CPT 49500
Hospital Charge Code	4149500
Hospital Revenue Code	975
Min. Negotiated Rate	$315.70
Max. Negotiated Rate	$526.40
Rate for Payer: Aetna Commercial/Medicare Advantage	$387.45
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$315.70
Rate for Payer: Cash Price	$1,353.60
Rate for Payer: Cash Price	$1,353.60
Rate for Payer: Cigna Commercial HMO & PPO	$387.45
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$315.70
Rate for Payer: Home State Health Plan Medicaid Managed Care	$347.27
Rate for Payer: Home State Health Plan Medicare Advantage	$387.45
Rate for Payer: Optum Medicare Advantage	$526.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$315.70

REPAIR INIT FEMORAL HER ALL AGE REDUCIBL

Professional

Both

$1,629.00

Service Code	CPT 49550
Hospital Charge Code	4149550
Hospital Revenue Code	975
Min. Negotiated Rate	$437.86
Max. Negotiated Rate	$570.15
Rate for Payer: Aetna Commercial/Medicare Advantage	$530.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$437.86
Rate for Payer: Cash Price	$1,466.10
Rate for Payer: Cash Price	$1,466.10
Rate for Payer: Cigna Commercial HMO & PPO	$530.42
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$437.86
Rate for Payer: Home State Health Plan Medicaid Managed Care	$481.65
Rate for Payer: Home State Health Plan Medicare Advantage	$530.42
Rate for Payer: Optum Medicare Advantage	$570.15
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$437.86

REPAIR INITIAL FEMORAL HERNIA INCARC

Professional

Both

$1,694.00

Service Code	CPT 49553
Hospital Charge Code	4149553
Hospital Revenue Code	975
Min. Negotiated Rate	$480.68
Max. Negotiated Rate	$592.90
Rate for Payer: Aetna Commercial/Medicare Advantage	$578.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$480.68
Rate for Payer: Cash Price	$1,524.60
Rate for Payer: Cash Price	$1,524.60
Rate for Payer: Cigna Commercial HMO & PPO	$578.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$480.68
Rate for Payer: Home State Health Plan Medicaid Managed Care	$528.75
Rate for Payer: Home State Health Plan Medicare Advantage	$578.87
Rate for Payer: Optum Medicare Advantage	$592.90
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$480.68

REPAIR INIT ING HERNIA >5 AGE REDUCIBLE

Professional

Both

$1,995.00

Service Code	CPT 49505
Hospital Charge Code	5449505
Hospital Revenue Code	975
Min. Negotiated Rate	$397.19
Max. Negotiated Rate	$698.25
Rate for Payer: Aetna Commercial/Medicare Advantage	$481.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$397.19
Rate for Payer: Cash Price	$1,795.50
Rate for Payer: Cash Price	$1,795.50
Rate for Payer: Cigna Commercial HMO & PPO	$481.36
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$397.19
Rate for Payer: Home State Health Plan Medicaid Managed Care	$436.91
Rate for Payer: Home State Health Plan Medicare Advantage	$481.36
Rate for Payer: Optum Medicare Advantage	$698.25
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$397.19

REPAIR INIT ING HERNIA 5 YRS+ INCARC/STR

Professional

Both

$1,586.00

Service Code	CPT 49507
Hospital Charge Code	4149507
Hospital Revenue Code	975
Min. Negotiated Rate	$445.96
Max. Negotiated Rate	$555.10
Rate for Payer: Aetna Commercial/Medicare Advantage	$539.26
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$445.96
Rate for Payer: Cash Price	$1,427.40
Rate for Payer: Cash Price	$1,427.40
Rate for Payer: Cigna Commercial HMO & PPO	$539.26
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$445.96
Rate for Payer: Home State Health Plan Medicaid Managed Care	$490.56
Rate for Payer: Home State Health Plan Medicare Advantage	$539.26
Rate for Payer: Optum Medicare Advantage	$555.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$445.96

REPAIR INIT ING HERNIA 5 YRS+ REDUCIBLE

Professional

Both

$1,586.00

Service Code	CPT 49505
Hospital Charge Code	4149505
Hospital Revenue Code	975
Min. Negotiated Rate	$397.19
Max. Negotiated Rate	$555.10
Rate for Payer: Aetna Commercial/Medicare Advantage	$481.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$397.19
Rate for Payer: Cash Price	$1,427.40
Rate for Payer: Cash Price	$1,427.40
Rate for Payer: Cigna Commercial HMO & PPO	$481.36
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$397.19
Rate for Payer: Home State Health Plan Medicaid Managed Care	$436.91
Rate for Payer: Home State Health Plan Medicare Advantage	$481.36
Rate for Payer: Optum Medicare Advantage	$555.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$397.19

REPAIR INTERMED 2.5 OR LESS NECK,HANDS,

Facility

$368.00

Service Code	CPT 12041
Hospital Charge Code	5412041
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$830.64
Rate for Payer: Aetna Better Health Medicaid/QHP	$366.45
Rate for Payer: Aetna Medicare Advantage	$415.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$217.86
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$262.75
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial HMO & PPO	$415.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$329.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$392.10
Rate for Payer: Home State Health Plan Medicare Advantage	$415.32
Rate for Payer: Humana Commercial	$830.64
Rate for Payer: Humana Medicare Advantage	$415.32
Rate for Payer: UnitedHealthcare Commercial	$245.46
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR INTERMED 2.5 OR LESS NECK,HANDS,

Facility

$368.00

Service Code	CPT 12041
Hospital Charge Code	5412041
Hospital Revenue Code	521
Rate for Payer: Cash Price	$331.20

REPAIR INTERMED 7.6 TO 12.5 CM SCALP,AXI

Facility

$580.00

Service Code	CPT 12034
Hospital Charge Code	9812034
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$830.64
Rate for Payer: Aetna Better Health Medicaid/QHP	$366.45
Rate for Payer: Aetna Medicare Advantage	$415.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$343.36
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$414.12
Rate for Payer: Cash Price	$522.00
Rate for Payer: Cash Price	$522.00
Rate for Payer: Cash Price	$522.00
Rate for Payer: Cash Price	$522.00
Rate for Payer: Cigna Commercial HMO & PPO	$415.32
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$329.81
Rate for Payer: Home State Health Plan Medicaid Managed Care	$392.10
Rate for Payer: Home State Health Plan Medicare Advantage	$415.32
Rate for Payer: Humana Commercial	$830.64
Rate for Payer: Humana Medicare Advantage	$415.32
Rate for Payer: UnitedHealthcare Commercial	$386.86
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR INTERMED 7.6 TO 12.5 CM SCALP,AXI

Facility

$580.00

Service Code	CPT 12034
Hospital Charge Code	9812034
Hospital Revenue Code	521
Rate for Payer: Cash Price	$522.00

Know your out-of-pocket cost for care.

All Charges