Madison Medical Center

All Charges

Charge

Type

Setting

Price

RUBEOLA IGM

Facility

$66.00

Service Code	CPT 86765
Hospital Charge Code	2286762
Hospital Revenue Code	301
Rate for Payer: Cash Price	$59.40

RUBEOLA IGM

Facility

$66.00

Service Code	CPT 86765
Hospital Charge Code	2286762
Hospital Revenue Code	301
Min. Negotiated Rate	$11.59
Max. Negotiated Rate	$47.12
Rate for Payer: Aetna Better Health Medicaid/QHP	$11.59
Rate for Payer: Aetna Medicare Advantage	$12.88
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.07
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.12
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial HMO & PPO	$12.88
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11.59
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12.40
Rate for Payer: Home State Health Plan Medicare Advantage	$12.88
Rate for Payer: Humana Commercial	$25.76
Rate for Payer: Humana Medicare Advantage	$12.88
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11.59
Rate for Payer: UnitedHealthcare Medicare Advantage	$23.76

RX EPI N (TW)

Facility

$75.00

Hospital Charge Code	2824476
Hospital Revenue Code	270
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$53.55
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$44.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$53.55
Rate for Payer: Cash Price	$67.50
Rate for Payer: UnitedHealthcare Commercial	$50.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$27.00

RX EPI N (TW)

Facility

$75.00

Hospital Charge Code	2824476
Hospital Revenue Code	270
Rate for Payer: Cash Price	$67.50

SA02 OXIMETER

Facility

$63.00

Hospital Charge Code	2024474
Hospital Revenue Code	271
Rate for Payer: Cash Price	$56.70

SA02 OXIMETER

Facility

$63.00

Hospital Charge Code	2024474
Hospital Revenue Code	271
Min. Negotiated Rate	$22.68
Max. Negotiated Rate	$44.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$37.30
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$44.98
Rate for Payer: Cash Price	$56.70
Rate for Payer: UnitedHealthcare Commercial	$42.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$22.68

SACCHAROMYCES IGA

Facility

$220.00

Service Code	CPT 86671
Hospital Charge Code	2286672
Hospital Revenue Code	301
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$157.08
Rate for Payer: Aetna Better Health Medicaid/QHP	$11.03
Rate for Payer: Aetna Medicare Advantage	$12.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$130.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$157.08
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cigna Commercial HMO & PPO	$12.25
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11.03
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11.80
Rate for Payer: Home State Health Plan Medicare Advantage	$12.25
Rate for Payer: Humana Commercial	$24.50
Rate for Payer: Humana Medicare Advantage	$12.25
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$79.20

SACCHAROMYCES IGA

Facility

$220.00

Service Code	CPT 86671
Hospital Charge Code	2286672
Hospital Revenue Code	301
Rate for Payer: Cash Price	$198.00

SACCHAROMYCES IGG

Facility

$220.00

Service Code	CPT 86671
Hospital Charge Code	2286671
Hospital Revenue Code	301
Rate for Payer: Cash Price	$198.00

SACCHAROMYCES IGG

Facility

$220.00

Service Code	CPT 86671
Hospital Charge Code	2286671
Hospital Revenue Code	301
Min. Negotiated Rate	$11.03
Max. Negotiated Rate	$157.08
Rate for Payer: Aetna Better Health Medicaid/QHP	$11.03
Rate for Payer: Aetna Medicare Advantage	$12.25
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$130.24
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$157.08
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cigna Commercial HMO & PPO	$12.25
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$11.03
Rate for Payer: Home State Health Plan Medicaid Managed Care	$11.80
Rate for Payer: Home State Health Plan Medicare Advantage	$12.25
Rate for Payer: Humana Commercial	$24.50
Rate for Payer: Humana Medicare Advantage	$12.25
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$11.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$79.20

SACROILIAC JOINT INJ.

Professional

Both

$1,341.00

Service Code	CPT 27096
Hospital Charge Code	1827096
Hospital Revenue Code	981
Min. Negotiated Rate	$70.79
Max. Negotiated Rate	$469.35
Rate for Payer: Aetna Commercial/Medicare Advantage	$70.79
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$123.51
Rate for Payer: Cash Price	$1,206.90
Rate for Payer: Cash Price	$1,206.90
Rate for Payer: Cigna Commercial HMO & PPO	$70.79
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$123.51
Rate for Payer: Home State Health Plan Medicaid Managed Care	$135.86
Rate for Payer: Home State Health Plan Medicare Advantage	$70.79
Rate for Payer: Optum Medicare Advantage	$469.35
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$123.51

SACRUM

Facility

$577.00

Service Code	CPT 72220
Hospital Charge Code	3219125
Hospital Revenue Code	320
Min. Negotiated Rate	$78.45
Max. Negotiated Rate	$411.98
Rate for Payer: Aetna Better Health Medicaid/QHP	$78.45
Rate for Payer: Aetna Medicare Advantage	$88.91
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$341.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$411.98
Rate for Payer: Cash Price	$519.30
Rate for Payer: Cash Price	$519.30
Rate for Payer: Cash Price	$519.30
Rate for Payer: Cigna Commercial HMO & PPO	$88.91
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$78.45
Rate for Payer: Home State Health Plan Medicaid Managed Care	$83.94
Rate for Payer: Home State Health Plan Medicare Advantage	$88.91
Rate for Payer: Humana Commercial	$177.82
Rate for Payer: Humana Medicare Advantage	$88.91
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$78.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$207.72

SACRUM

Facility

$577.00

Service Code	CPT 72220
Hospital Charge Code	3219125
Hospital Revenue Code	320
Rate for Payer: Cash Price	$519.30

SACUBIT/VALSART 49/51MG TAB EMP

Facility

$24.00

Service Code	NDC 378580793
Hospital Charge Code	2627108
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$17.14
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$14.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$17.14
Rate for Payer: Cash Price	$21.60
Rate for Payer: UnitedHealthcare Commercial	$16.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$8.64

SACUBIT/VALSART 49/51MG TAB EMP

Facility

$24.00

Service Code	NDC 378580793
Hospital Charge Code	2627108
Hospital Revenue Code	250
Rate for Payer: Cash Price	$21.60

SADDLE BLOC

Facility

$60.00

Hospital Charge Code	202028
Hospital Revenue Code	370
Rate for Payer: Cash Price	$54.00

SADDLE BLOC

Facility

$60.00

Hospital Charge Code	202028
Hospital Revenue Code	370
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$42.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$35.52
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$42.84
Rate for Payer: Cash Price	$54.00
Rate for Payer: UnitedHealthcare Commercial	$40.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$21.60

SAFETY PINS

Facility

$13.00

Hospital Charge Code	1216025
Hospital Revenue Code	271
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$9.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$7.70
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$9.28
Rate for Payer: Cash Price	$11.70
Rate for Payer: UnitedHealthcare Commercial	$8.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$4.68

SAFETY PINS

Facility

$13.00

Hospital Charge Code	1216025
Hospital Revenue Code	271
Rate for Payer: Cash Price	$11.70

SALEM SUMP ANTI-REFLEX VALVE

Facility

$48.00

Hospital Charge Code	28266197
Hospital Revenue Code	271
Rate for Payer: Cash Price	$43.20

SALEM SUMP ANTI-REFLEX VALVE

Facility

$48.00

Hospital Charge Code	28266197
Hospital Revenue Code	271
Min. Negotiated Rate	$17.28
Max. Negotiated Rate	$34.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$28.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$34.27
Rate for Payer: Cash Price	$43.20
Rate for Payer: UnitedHealthcare Commercial	$32.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$17.28

SALICYLATE

Facility

$142.00

Service Code	CPT 80299
Hospital Charge Code	2219214
Hospital Revenue Code	301
Min. Negotiated Rate	$16.78
Max. Negotiated Rate	$101.39
Rate for Payer: Aetna Better Health Medicaid/QHP	$16.78
Rate for Payer: Aetna Medicare Advantage	$18.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$84.06
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$101.39
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial HMO & PPO	$18.64
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$16.78
Rate for Payer: Home State Health Plan Medicaid Managed Care	$17.95
Rate for Payer: Home State Health Plan Medicare Advantage	$18.64
Rate for Payer: Humana Commercial	$37.28
Rate for Payer: Humana Medicare Advantage	$18.64
Rate for Payer: UnitedHealthcare Commercial	$21.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$16.78
Rate for Payer: UnitedHealthcare Medicare Advantage	$51.12

SALICYLATE

Facility

$142.00

Service Code	CPT 80299
Hospital Charge Code	2219214
Hospital Revenue Code	301
Rate for Payer: Cash Price	$127.80

SALIVARY GLAND PROCEDURES

Facility

$22,982.42

Service Code	MSDRG 139
Min. Negotiated Rate	$11,491.21
Max. Negotiated Rate	$22,982.42
Rate for Payer: Aetna Medicare Advantage	$11,491.21
Rate for Payer: Cigna Commercial HMO & PPO	$11,491.21
Rate for Payer: Home State Health Plan Medicare Advantage	$11,491.21
Rate for Payer: Humana Commercial	$22,982.42
Rate for Payer: Humana Medicare Advantage	$11,491.21

.SALIVARY PROTEIN 1 IGA

Facility

$30.00

Service Code	CPT 83520
Hospital Charge Code	22816832
Hospital Revenue Code	302
Rate for Payer: Cash Price	$27.00

Know your out-of-pocket cost for care.

All Charges