Madison Medical Center

All Charges

Charge

Type

Setting

Price

REPAIR OF RUPTURED SPLEEN

Facility

$2,928.00

Service Code	CPT 38115
Hospital Charge Code	4138115
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$2,090.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$1,733.38
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,090.59
Rate for Payer: Cash Price	$2,635.20
Rate for Payer: Cash Price	$2,635.20
Rate for Payer: UnitedHealthcare Commercial	$1,952.98
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR OF RUPTURED SPLEEN

Facility

$2,928.00

Service Code	CPT 38115
Hospital Charge Code	4138115
Hospital Revenue Code	521
Rate for Payer: Cash Price	$2,635.20

REPAIR OF WOUND

Facility

$151.00

Service Code	CPT 12001
Hospital Charge Code	4412001
Hospital Revenue Code	250
Min. Negotiated Rate	$54.36
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	$89.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$107.81
Rate for Payer: Cash Price	$135.90
Rate for Payer: Cash Price	$135.90
Rate for Payer: Cash Price	$135.90
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$180.86
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	$100.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$54.36

REPAIR OF WOUND

Facility

$151.00

Service Code	CPT 12001
Hospital Charge Code	4412001
Hospital Revenue Code	250
Rate for Payer: Cash Price	$135.90

REPAIR OF WOUND

Facility

$194.00

Service Code	CPT 12002
Hospital Charge Code	4412002
Hospital Revenue Code	250
Rate for Payer: Cash Price	$174.60

REPAIR OF WOUND

Facility

$194.00

Service Code	CPT 12002
Hospital Charge Code	4412002
Hospital Revenue Code	250
Min. Negotiated Rate	$69.84
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	$114.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$138.52
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$180.86
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	$129.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$69.84

REPAIR/RECONSTRUCTION TENDON (FLEXOR)

Professional

Both

$5,337.00

Service Code	CPT 26350
Hospital Charge Code	1826350
Hospital Revenue Code	981
Min. Negotiated Rate	$575.50
Max. Negotiated Rate	$1,867.95
Rate for Payer: Aetna Commercial/Medicare Advantage	$669.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$575.50
Rate for Payer: Cash Price	$4,803.30
Rate for Payer: Cash Price	$4,803.30
Rate for Payer: Cigna Commercial HMO & PPO	$669.21
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$575.50
Rate for Payer: Home State Health Plan Medicaid Managed Care	$633.05
Rate for Payer: Home State Health Plan Medicare Advantage	$669.21
Rate for Payer: Optum Medicare Advantage	$1,867.95
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$575.50

REPAIR RECUR INGUINAL HERNIA INCARC/STRA

Professional

Both

$2,006.00

Service Code	CPT 49521
Hospital Charge Code	4149521
Hospital Revenue Code	975
Min. Negotiated Rate	$543.60
Max. Negotiated Rate	$702.10
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	$1,805.40
Rate for Payer: Cash Price	$1,805.40
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	$702.10
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$543.60

REPAIR RECURRENT ING HERNIA ANY AGE

Professional

Both

$2,310.00

Service Code	CPT 49520
Hospital Charge Code	5449520
Hospital Revenue Code	975
Min. Negotiated Rate	$481.14
Max. Negotiated Rate	$808.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$578.77
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$481.14
Rate for Payer: Cash Price	$2,079.00
Rate for Payer: Cash Price	$2,079.00
Rate for Payer: Cigna Commercial HMO & PPO	$578.77
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$481.14
Rate for Payer: Home State Health Plan Medicaid Managed Care	$529.25
Rate for Payer: Home State Health Plan Medicare Advantage	$578.77
Rate for Payer: Optum Medicare Advantage	$808.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$481.14

REPAIR SIMPLE 2.6 CM TO 7.5 CM

Facility

$184.00

Service Code	CPT 12002
Hospital Charge Code	4212002
Hospital Revenue Code	521
Rate for Payer: Cash Price	$165.60

REPAIR SIMPLE 2.6 CM TO 7.5 CM

Facility

$184.00

Service Code	CPT 12002
Hospital Charge Code	4212002
Hospital Revenue Code	521
Min. Negotiated Rate	$108.93
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	$108.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$131.38
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$165.60
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	$122.73
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR SIMPLE WOUND 7.6 CM - 12.5 CM

Facility

$232.00

Service Code	CPT 12004
Hospital Charge Code	4112004
Hospital Revenue Code	521
Min. Negotiated Rate	$137.34
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	$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	$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	$154.74
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR SIMPLE WOUND 7.6 CM - 12.5 CM

Facility

$232.00

Service Code	CPT 12004
Hospital Charge Code	4112004
Hospital Revenue Code	521
Rate for Payer: Cash Price	$208.80

REPAIR SIMPLE WOUND 7.6 TO 12.5 CM SCALP

Facility

$400.00

Service Code	CPT 12004
Hospital Charge Code	4212004
Hospital Revenue Code	521
Min. Negotiated Rate	$162.77
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	$236.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$285.60
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
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	$266.80
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR SIMPLE WOUND 7.6 TO 12.5 CM SCALP

Facility

$400.00

Service Code	CPT 12004
Hospital Charge Code	4212004
Hospital Revenue Code	521
Rate for Payer: Cash Price	$360.00

REPAIR SIMPLE WOUND FACE <2.5 CM

Facility

$200.00

Service Code	CPT 12011
Hospital Charge Code	5212011
Hospital Revenue Code	521
Rate for Payer: Cash Price	$180.00

REPAIR SIMPLE WOUND FACE <2.5 CM

Facility

$200.00

Service Code	CPT 12011
Hospital Charge Code	5212011
Hospital Revenue Code	521
Min. Negotiated Rate	$118.40
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	$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	$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	$133.40
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR SIMPLE WOUNDS FACE,EAR 2.6 TO5.0C

Facility

$250.00

Service Code	CPT 12013
Hospital Charge Code	9812013
Hospital Revenue Code	521
Rate for Payer: Cash Price	$225.00

REPAIR SIMPLE WOUNDS FACE,EAR 2.6 TO5.0C

Facility

$250.00

Service Code	CPT 12013
Hospital Charge Code	9812013
Hospital Revenue Code	521
Min. Negotiated Rate	$148.00
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	$148.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$178.50
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cash Price	$225.00
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	$166.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR SUPERFICIAL WOUNDS

Professional

Both

$1,061.00

Service Code	CPT 12005
Hospital Charge Code	1812005
Hospital Revenue Code	981
Min. Negotiated Rate	$87.91
Max. Negotiated Rate	$371.35
Rate for Payer: Aetna Commercial/Medicare Advantage	$87.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$135.69
Rate for Payer: Cash Price	$954.90
Rate for Payer: Cash Price	$954.90
Rate for Payer: Cigna Commercial HMO & PPO	$87.91
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$135.69
Rate for Payer: Home State Health Plan Medicaid Managed Care	$149.26
Rate for Payer: Home State Health Plan Medicare Advantage	$87.91
Rate for Payer: Optum Medicare Advantage	$371.35
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$135.69

REPAIR TENDON

Professional

Both

$4,005.00

Service Code	CPT 26410
Hospital Charge Code	1826410
Hospital Revenue Code	981
Min. Negotiated Rate	$464.51
Max. Negotiated Rate	$1,401.75
Rate for Payer: Aetna Commercial/Medicare Advantage	$540.75
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$464.51
Rate for Payer: Cash Price	$3,604.50
Rate for Payer: Cash Price	$3,604.50
Rate for Payer: Cigna Commercial HMO & PPO	$540.75
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$464.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$510.96
Rate for Payer: Home State Health Plan Medicare Advantage	$540.75
Rate for Payer: Optum Medicare Advantage	$1,401.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$464.51

REPAIR TENDON, FINGER

Professional

Both

$4,005.00

Service Code	CPT 26418
Hospital Charge Code	1826418
Hospital Revenue Code	981
Min. Negotiated Rate	$481.41
Max. Negotiated Rate	$1,401.75
Rate for Payer: Aetna Commercial/Medicare Advantage	$564.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$481.41
Rate for Payer: Cash Price	$3,604.50
Rate for Payer: Cash Price	$3,604.50
Rate for Payer: Cigna Commercial HMO & PPO	$564.27
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$481.41
Rate for Payer: Home State Health Plan Medicaid Managed Care	$529.55
Rate for Payer: Home State Health Plan Medicare Advantage	$564.27
Rate for Payer: Optum Medicare Advantage	$1,401.75
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$481.41

REPAIR TENDON FLEXOR FOOT PRIM EA TENDON

Facility

$1,123.00

Service Code	CPT 28200
Hospital Charge Code	4128200
Hospital Revenue Code	521
Min. Negotiated Rate	$173.53
Max. Negotiated Rate	$6,685.74
Rate for Payer: Aetna Better Health Medicaid/QHP	$2,949.54
Rate for Payer: Aetna Medicare Advantage	$3,342.87
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$664.82
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$801.82
Rate for Payer: Cash Price	$1,010.70
Rate for Payer: Cash Price	$1,010.70
Rate for Payer: Cash Price	$1,010.70
Rate for Payer: Cash Price	$1,010.70
Rate for Payer: Cigna Commercial HMO & PPO	$3,342.87
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$2,654.59
Rate for Payer: Home State Health Plan Medicaid Managed Care	$3,156.01
Rate for Payer: Home State Health Plan Medicare Advantage	$3,342.87
Rate for Payer: Humana Commercial	$6,685.74
Rate for Payer: Humana Medicare Advantage	$3,342.87
Rate for Payer: UnitedHealthcare Commercial	$749.04
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$2,949.54
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR TENDON FLEXOR FOOT PRIM EA TENDON

Facility

$1,123.00

Service Code	CPT 28200
Hospital Charge Code	4128200
Hospital Revenue Code	521
Rate for Payer: Cash Price	$1,010.70

REPAIR UNUSUAL COMPLICATED/OVER 7.5CM

Professional

Both

$1,346.00

Service Code	CPT 11300
Hospital Charge Code	1813300
Hospital Revenue Code	981
Min. Negotiated Rate	$26.84
Max. Negotiated Rate	$471.10
Rate for Payer: Optum Medicare Advantage	$471.10
Rate for Payer: Aetna Commercial/Medicare Advantage	$26.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$77.73
Rate for Payer: Cash Price	$1,211.40
Rate for Payer: Cash Price	$1,211.40
Rate for Payer: Cigna Commercial HMO & PPO	$26.84
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$77.73
Rate for Payer: Home State Health Plan Medicaid Managed Care	$85.50
Rate for Payer: Home State Health Plan Medicare Advantage	$26.84
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$77.73

Know your out-of-pocket cost for care.

All Charges