Madison Medical Center

All Charges

Charge

Type

Setting

Price

REPAIR WOUND

Facility

$403.00

Service Code	CPT 12034
Hospital Charge Code	4112034
Hospital Revenue Code	521
Rate for Payer: Cash Price	$362.70

REPAIR WOUND

Facility

$403.00

Service Code	CPT 12034
Hospital Charge Code	4112034
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	$238.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$287.74
Rate for Payer: Cash Price	$362.70
Rate for Payer: Cash Price	$362.70
Rate for Payer: Cash Price	$362.70
Rate for Payer: Cash Price	$362.70
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	$268.80
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR WOUND

Facility

$400.00

Service Code	CPT 12044
Hospital Charge Code	4112044
Hospital Revenue Code	521
Rate for Payer: Cash Price	$360.00

REPAIR WOUND

Facility

$151.00

Service Code	CPT 12001
Hospital Charge Code	4112001
Hospital Revenue Code	521
Rate for Payer: Cash Price	$135.90

REPAIR WOUND

Facility

$285.00

Service Code	CPT 12051
Hospital Charge Code	4112051
Hospital Revenue Code	521
Rate for Payer: Cash Price	$256.50

REPAIR WOUND

Facility

$151.00

Service Code	CPT 12001
Hospital Charge Code	4112001
Hospital Revenue Code	521
Min. Negotiated Rate	$89.39
Max. Negotiated Rate	$409.96
Rate for Payer: Cigna Commercial HMO & PPO	$204.98
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: Cash Price	$135.90
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	$100.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR WOUND

Facility

$400.00

Service Code	CPT 12044
Hospital Charge Code	4112044
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	$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	$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	$266.80
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$666.23
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR WOUND

Facility

$285.00

Service Code	CPT 12051
Hospital Charge Code	4112051
Hospital Revenue Code	521
Min. Negotiated Rate	$168.72
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	$168.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$203.49
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cash Price	$256.50
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	$190.09
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR WOUND 2.6CM (HAND)

Facility

$883.00

Service Code	CPT 13132
Hospital Charge Code	4113132
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	$522.74
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$630.46
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cash Price	$794.70
Rate for Payer: Cash Price	$794.70
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	$588.96
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR WOUND 2.6CM (HAND)

Facility

$883.00

Service Code	CPT 13132
Hospital Charge Code	4113132
Hospital Revenue Code	521
Rate for Payer: Cash Price	$794.70

REPAIR WOUND FACE 2.0 - 3.0

Facility

$105.00

Service Code	CPT 12013
Hospital Charge Code	4412013
Hospital Revenue Code	521
Rate for Payer: Cash Price	$94.50

REPAIR WOUND FACE 2.0 - 3.0

Facility

$105.00

Service Code	CPT 12013
Hospital Charge Code	4412013
Hospital Revenue Code	521
Min. Negotiated Rate	$62.16
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	$62.16
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$74.97
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cash Price	$94.50
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	$70.03
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR WOUND LAYER INTERMED TRUNK <2.5CM

Facility

$150.00

Service Code	CPT 12031
Hospital Charge Code	4412031
Hospital Revenue Code	521
Min. Negotiated Rate	$88.80
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	$88.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$107.10
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cash Price	$135.00
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	$100.05
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR WOUND LAYER INTERMED TRUNK <2.5CM

Facility

$150.00

Service Code	CPT 12031
Hospital Charge Code	4412031
Hospital Revenue Code	521
Rate for Payer: Cash Price	$135.00

REPAIR WOUND,LIP

Facility

$183.00

Service Code	CPT 12011
Hospital Charge Code	4112011
Hospital Revenue Code	521
Rate for Payer: Cash Price	$164.70

REPAIR WOUND,LIP

Facility

$183.00

Service Code	CPT 12011
Hospital Charge Code	4112011
Hospital Revenue Code	521
Min. Negotiated Rate	$108.34
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	$108.34
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$130.66
Rate for Payer: Cash Price	$164.70
Rate for Payer: Cash Price	$164.70
Rate for Payer: Cash Price	$164.70
Rate for Payer: Cash Price	$164.70
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	$122.06
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR WOUNDS-2.5CM,FACE,EARS

Professional

Both

$630.00

Service Code	CPT 12011
Hospital Charge Code	1812011
Hospital Revenue Code	981
Min. Negotiated Rate	$52.58
Max. Negotiated Rate	$220.50
Rate for Payer: Aetna Commercial/Medicare Advantage	$52.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$92.58
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial HMO & PPO	$52.58
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$92.58
Rate for Payer: Home State Health Plan Medicaid Managed Care	$101.84
Rate for Payer: Home State Health Plan Medicare Advantage	$52.58
Rate for Payer: Optum Medicare Advantage	$220.50
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$92.58

REPAIR WOUNDS-2.6CM TO 5.0CM

Professional

Both

$752.00

Service Code	CPT 12013
Hospital Charge Code	1812013
Hospital Revenue Code	981
Min. Negotiated Rate	$54.58
Max. Negotiated Rate	$263.20
Rate for Payer: Aetna Commercial/Medicare Advantage	$54.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$101.77
Rate for Payer: Cash Price	$676.80
Rate for Payer: Cash Price	$676.80
Rate for Payer: Cigna Commercial HMO & PPO	$54.58
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$101.77
Rate for Payer: Home State Health Plan Medicaid Managed Care	$111.95
Rate for Payer: Home State Health Plan Medicare Advantage	$54.58
Rate for Payer: Optum Medicare Advantage	$263.20
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$101.77

REPAIR WOUNDS-5.1CM TO 7.5CM

Professional

Both

$920.00

Service Code	CPT 12014
Hospital Charge Code	1812014
Hospital Revenue Code	981
Min. Negotiated Rate	$70.59
Max. Negotiated Rate	$322.00
Rate for Payer: Aetna Commercial/Medicare Advantage	$70.59
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$119.74
Rate for Payer: Cash Price	$828.00
Rate for Payer: Cash Price	$828.00
Rate for Payer: Cigna Commercial HMO & PPO	$70.59
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$119.74
Rate for Payer: Home State Health Plan Medicaid Managed Care	$131.71
Rate for Payer: Home State Health Plan Medicare Advantage	$70.59
Rate for Payer: Optum Medicare Advantage	$322.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$119.74

REPAIR WOUND,SCALP

Facility

$461.00

Service Code	CPT 12035
Hospital Charge Code	4112035
Hospital Revenue Code	521
Rate for Payer: Cash Price	$414.90

REPAIR WOUND,SCALP

Facility

$461.00

Service Code	CPT 12035
Hospital Charge Code	4112035
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	$272.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$329.15
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cash Price	$414.90
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	$307.49
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

REPAIR WOUNDS FACE 2.5 CM OR LESS

Facility

$200.00

Service Code	CPT 12011
Hospital Charge Code	9812011
Hospital Revenue Code	521
Rate for Payer: Cash Price	$180.00

REPAIR WOUNDS FACE 2.5 CM OR LESS

Facility

$200.00

Service Code	CPT 12011
Hospital Charge Code	9812011
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 WOUND,SIMPLE

Facility

$77.00

Service Code	CPT 17000
Hospital Charge Code	4117100
Hospital Revenue Code	521
Rate for Payer: Cash Price	$69.30

REPAIR WOUND,SIMPLE

Facility

$194.00

Service Code	CPT 12002
Hospital Charge Code	4112002
Hospital Revenue Code	521
Rate for Payer: Cash Price	$174.60

Know your out-of-pocket cost for care.

All Charges