Madison Medical Center

All Charges

Charge

Type

Setting

Price

SIGMOIDOSCOPY WITH BIOPSY, SINGLE/MULTIP

Professional

Both

$660.00

Service Code	CPT 45331
Hospital Charge Code	9345331
Hospital Revenue Code	975
Min. Negotiated Rate	$63.22
Max. Negotiated Rate	$273.13
Rate for Payer: Aetna Commercial/Medicare Advantage	$63.22
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$248.30
Rate for Payer: Cash Price	$594.00
Rate for Payer: Cash Price	$594.00
Rate for Payer: Cigna Commercial HMO & PPO	$63.22
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$248.30
Rate for Payer: Home State Health Plan Medicaid Managed Care	$273.13
Rate for Payer: Home State Health Plan Medicare Advantage	$63.22
Rate for Payer: Optum Medicare Advantage	$231.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$248.30

SIGMOID, PROCTO

Facility

$81.00

Hospital Charge Code	2819540
Hospital Revenue Code	271
Rate for Payer: Cash Price	$72.90

SIGMOID, PROCTO

Facility

$81.00

Hospital Charge Code	2819540
Hospital Revenue Code	271
Min. Negotiated Rate	$29.16
Max. Negotiated Rate	$57.83
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$47.95
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$57.83
Rate for Payer: Cash Price	$72.90
Rate for Payer: UnitedHealthcare Commercial	$54.03
Rate for Payer: UnitedHealthcare Medicare Advantage	$29.16

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$24,329.84

Service Code	MSDRG 555
Min. Negotiated Rate	$12,164.92
Max. Negotiated Rate	$24,329.84
Rate for Payer: Aetna Medicare Advantage	$12,164.92
Rate for Payer: Cigna Commercial HMO & PPO	$12,164.92
Rate for Payer: Home State Health Plan Medicare Advantage	$12,164.92
Rate for Payer: Humana Commercial	$24,329.84
Rate for Payer: Humana Medicare Advantage	$12,164.92

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$16,642.90

Service Code	MSDRG 556
Min. Negotiated Rate	$8,321.45
Max. Negotiated Rate	$16,642.90
Rate for Payer: Aetna Medicare Advantage	$8,321.45
Rate for Payer: Cigna Commercial HMO & PPO	$8,321.45
Rate for Payer: Home State Health Plan Medicare Advantage	$8,321.45
Rate for Payer: Humana Commercial	$16,642.90
Rate for Payer: Humana Medicare Advantage	$8,321.45

SIGNS AND SYMPTOMS WITH MCC

Facility

$23,509.80

Service Code	MSDRG 947
Min. Negotiated Rate	$11,754.90
Max. Negotiated Rate	$23,509.80
Rate for Payer: Aetna Medicare Advantage	$11,754.90
Rate for Payer: Cigna Commercial HMO & PPO	$11,754.90
Rate for Payer: Home State Health Plan Medicare Advantage	$11,754.90
Rate for Payer: Humana Commercial	$23,509.80
Rate for Payer: Humana Medicare Advantage	$11,754.90

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$16,171.82

Service Code	MSDRG 948
Min. Negotiated Rate	$8,085.91
Max. Negotiated Rate	$16,171.82
Rate for Payer: Aetna Medicare Advantage	$8,085.91
Rate for Payer: Cigna Commercial HMO & PPO	$8,085.91
Rate for Payer: Home State Health Plan Medicare Advantage	$8,085.91
Rate for Payer: Humana Commercial	$16,171.82
Rate for Payer: Humana Medicare Advantage	$8,085.91

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$8,894.46

Service Code	APR-DRG 8612
Min. Negotiated Rate	$8,894.46
Max. Negotiated Rate	$8,894.46
Rate for Payer: Aetna Better Health Medicaid/QHP	$8,894.46
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$8,894.46
Rate for Payer: Home State Health Plan Medicaid Managed Care	$8,894.46
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$8,894.46

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$23,700.41

Service Code	APR-DRG 8614
Min. Negotiated Rate	$23,700.41
Max. Negotiated Rate	$23,700.41
Rate for Payer: Aetna Better Health Medicaid/QHP	$23,700.41
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$23,700.41
Rate for Payer: Home State Health Plan Medicaid Managed Care	$23,700.41
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$23,700.41

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$7,659.12

Service Code	APR-DRG 8611
Min. Negotiated Rate	$7,659.12
Max. Negotiated Rate	$7,659.12
Rate for Payer: Aetna Better Health Medicaid/QHP	$7,659.12
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$7,659.12
Rate for Payer: Home State Health Plan Medicaid Managed Care	$7,659.12
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$7,659.12

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility

$12,955.35

Service Code	APR-DRG 8613
Min. Negotiated Rate	$12,955.35
Max. Negotiated Rate	$12,955.35
Rate for Payer: Aetna Better Health Medicaid/QHP	$12,955.35
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$12,955.35
Rate for Payer: Home State Health Plan Medicaid Managed Care	$12,955.35
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$12,955.35

SI JOINT

Facility

$399.00

Service Code	CPT 72200
Hospital Charge Code	3219106
Hospital Revenue Code	320
Min. Negotiated Rate	$94.24
Max. Negotiated Rate	$284.89
Rate for Payer: Aetna Better Health Medicaid/QHP	$94.24
Rate for Payer: Aetna Medicare Advantage	$106.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$236.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$284.89
Rate for Payer: Cash Price	$359.10
Rate for Payer: Cash Price	$359.10
Rate for Payer: Cash Price	$359.10
Rate for Payer: Cigna Commercial HMO & PPO	$106.81
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$94.24
Rate for Payer: Home State Health Plan Medicaid Managed Care	$100.84
Rate for Payer: Home State Health Plan Medicare Advantage	$106.81
Rate for Payer: Humana Commercial	$213.62
Rate for Payer: Humana Medicare Advantage	$106.81
Rate for Payer: UnitedHealthcare Commercial	$175.00
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$94.24
Rate for Payer: UnitedHealthcare Medicare Advantage	$143.64

SI JOINT

Facility

$399.00

Service Code	CPT 72200
Hospital Charge Code	3219106
Hospital Revenue Code	320
Rate for Payer: Cash Price	$359.10

SILDENAFIL 100MG TAB EMP

Facility

$18.00

Service Code	NDC 69422030
Hospital Charge Code	2624978
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

SILDENAFIL 100MG TAB EMP

Facility

$18.00

Service Code	NDC 69422030
Hospital Charge Code	2624978
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

SILDENAFIL 50MG TAB EMP

Facility

$18.00

Service Code	NDC 69421030
Hospital Charge Code	2622903
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

SILDENAFIL 50MG TAB EMP

Facility

$18.00

Service Code	NDC 69421030
Hospital Charge Code	2622903
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

SILDENAFIL (REVATIO) 20MG TAB EMP

Facility

$207.00

Service Code	NDC 69419068
Hospital Charge Code	2624600
Hospital Revenue Code	250
Rate for Payer: Cash Price	$186.30

SILDENAFIL (REVATIO) 20MG TAB EMP

Facility

$207.00

Service Code	NDC 69419068
Hospital Charge Code	2624600
Hospital Revenue Code	250
Min. Negotiated Rate	$74.52
Max. Negotiated Rate	$147.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$122.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$147.80
Rate for Payer: Cash Price	$186.30
Rate for Payer: UnitedHealthcare Commercial	$138.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$74.52

SILDENAFIL (REVATIO) 20MG TAB HE

Facility

$207.00

Service Code	NDC 6.5162E+10
Hospital Charge Code	2625724
Hospital Revenue Code	250
Rate for Payer: Cash Price	$186.30

SILDENAFIL (REVATIO) 20MG TAB HE

Facility

$207.00

Service Code	NDC 6.5162E+10
Hospital Charge Code	2625724
Hospital Revenue Code	250
Min. Negotiated Rate	$74.52
Max. Negotiated Rate	$147.80
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$122.54
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$147.80
Rate for Payer: Cash Price	$186.30
Rate for Payer: UnitedHealthcare Commercial	$138.07
Rate for Payer: UnitedHealthcare Medicare Advantage	$74.52

SILK

Facility

$28.00

Hospital Charge Code	1269115
Hospital Revenue Code	271
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$19.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$16.58
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$19.99
Rate for Payer: Cash Price	$25.20
Rate for Payer: UnitedHealthcare Commercial	$18.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$10.08

SILK

Facility

$28.00

Hospital Charge Code	1269115
Hospital Revenue Code	271
Rate for Payer: Cash Price	$25.20

SILVADENE 1% CRM 400GM

Facility

$114.00

Service Code	NDC 5.9762E+10
Hospital Charge Code	2626140
Hospital Revenue Code	250
Rate for Payer: Cash Price	$102.60

SILVADENE 1% CRM 400GM

Facility

$114.00

Service Code	NDC 5.9762E+10
Hospital Charge Code	2626140
Hospital Revenue Code	250
Min. Negotiated Rate	$41.04
Max. Negotiated Rate	$81.40
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$67.49
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$81.40
Rate for Payer: Cash Price	$102.60
Rate for Payer: UnitedHealthcare Commercial	$76.04
Rate for Payer: UnitedHealthcare Medicare Advantage	$41.04

Know your out-of-pocket cost for care.

All Charges