Madison Medical Center

All Charges

Charge

Type

Setting

Price

SIMETHICONE DROPS 30ML (20MG/0.3ML) SUSP

Facility

$91.00

Service Code	NDC 4.6287E+10
Hospital Charge Code	2656185
Hospital Revenue Code	250
Rate for Payer: Cash Price	$81.90

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$16,256.36

Service Code	MSDRG 194
Min. Negotiated Rate	$8,128.18
Max. Negotiated Rate	$16,256.36
Rate for Payer: Aetna Medicare Advantage	$8,128.18
Rate for Payer: Cigna Commercial HMO & PPO	$8,128.18
Rate for Payer: Home State Health Plan Medicare Advantage	$8,128.18
Rate for Payer: Humana Commercial	$16,256.36
Rate for Payer: Humana Medicare Advantage	$8,128.18

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$24,214.04

Service Code	MSDRG 193
Min. Negotiated Rate	$12,107.02
Max. Negotiated Rate	$24,214.04
Rate for Payer: Aetna Medicare Advantage	$12,107.02
Rate for Payer: Cigna Commercial HMO & PPO	$12,107.02
Rate for Payer: Home State Health Plan Medicare Advantage	$12,107.02
Rate for Payer: Humana Commercial	$24,214.04
Rate for Payer: Humana Medicare Advantage	$12,107.02

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$13,487.80

Service Code	MSDRG 195
Min. Negotiated Rate	$6,743.90
Max. Negotiated Rate	$13,487.80
Rate for Payer: Aetna Medicare Advantage	$6,743.90
Rate for Payer: Cigna Commercial HMO & PPO	$6,743.90
Rate for Payer: Home State Health Plan Medicare Advantage	$6,743.90
Rate for Payer: Humana Commercial	$13,487.80
Rate for Payer: Humana Medicare Advantage	$6,743.90

SIMPLE REPAIR 10 CM TO 20 CM

Facility

$550.00

Service Code	CPT 12005
Hospital Charge Code	5412005
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	$325.60
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$392.70
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cash Price	$495.00
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	$366.85
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$366.45
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

SIMPLE REPAIR 10 CM TO 20 CM

Facility

$550.00

Service Code	CPT 12005
Hospital Charge Code	5412005
Hospital Revenue Code	521
Rate for Payer: Cash Price	$495.00

SIMPLE REPAIR 2.5CM

Facility

$139.00

Service Code	CPT 12001
Hospital Charge Code	5212001
Hospital Revenue Code	521
Rate for Payer: Cash Price	$125.10

SIMPLE REPAIR 2.5CM

Facility

$139.00

Service Code	CPT 12001
Hospital Charge Code	5212001
Hospital Revenue Code	521
Min. Negotiated Rate	$82.29
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	$82.29
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$99.25
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cash Price	$125.10
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	$92.71
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

SIMPLE REPAIR 7.6CM TO 20CM

Professional

Both

$1,118.00

Service Code	CPT 12016
Hospital Charge Code	1812015
Hospital Revenue Code	981
Min. Negotiated Rate	$119.69
Max. Negotiated Rate	$391.30
Rate for Payer: Aetna Commercial/Medicare Advantage	$119.69
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Medicaid Managed Care	$178.50
Rate for Payer: Cash Price	$1,006.20
Rate for Payer: Cash Price	$1,006.20
Rate for Payer: Cigna Commercial HMO & PPO	$119.69
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$178.50
Rate for Payer: Home State Health Plan Medicaid Managed Care	$196.35
Rate for Payer: Home State Health Plan Medicare Advantage	$119.69
Rate for Payer: Optum Medicare Advantage	$391.30
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$178.50

SIMPLE REPAIR SCALP 2.5 CM OR LESS

Facility

$160.00

Service Code	CPT 12001
Hospital Charge Code	4212001
Hospital Revenue Code	521
Rate for Payer: Cash Price	$144.00

SIMPLE REPAIR SCALP 2.5 CM OR LESS

Facility

$160.00

Service Code	CPT 12001
Hospital Charge Code	4212001
Hospital Revenue Code	521
Min. Negotiated Rate	$94.72
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	$94.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$114.24
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
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	$106.72
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

SIMPLE REPAIR SCALP, NECK FACE <2.5CM

Facility

$200.00

Service Code	CPT 17000
Hospital Charge Code	9812001
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

SIMPLE REPAIR SCALP, NECK FACE <2.5CM

Facility

$200.00

Service Code	CPT 17000
Hospital Charge Code	9812001
Hospital Revenue Code	521
Rate for Payer: Cash Price	$180.00

SIMPLE REPAIR WOUND 2.6CM TO 5.0CM

Facility

$210.00

Service Code	CPT 12013
Hospital Charge Code	5212013
Hospital Revenue Code	521
Rate for Payer: Cash Price	$189.00

SIMPLE REPAIR WOUND 2.6CM TO 5.0CM

Facility

$210.00

Service Code	CPT 12013
Hospital Charge Code	5212013
Hospital Revenue Code	521
Min. Negotiated Rate	$124.32
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	$124.32
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$149.94
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cash Price	$189.00
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	$140.07
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

SIMPLE REPAIR WOUND 2.6 TO 7.5CM SCALP N

Facility

$370.00

Service Code	CPT 12002
Hospital Charge Code	9812002
Hospital Revenue Code	521
Rate for Payer: Cash Price	$333.00

SIMPLE REPAIR WOUND 2.6 TO 7.5CM SCALP N

Facility

$370.00

Service Code	CPT 12002
Hospital Charge Code	9812002
Hospital Revenue Code	521
Min. Negotiated Rate	$162.77
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	$219.04
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$264.18
Rate for Payer: Cash Price	$333.00
Rate for Payer: Cash Price	$333.00
Rate for Payer: Cash Price	$333.00
Rate for Payer: Cash Price	$333.00
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	$246.79
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

SIMPLE REP SUPERF WOUND FACE 2.5 CM OR >

Facility

$375.00

Service Code	CPT 12011
Hospital Charge Code	4212011
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	$222.00
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$267.75
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cash Price	$337.50
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	$250.12
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$180.86
Rate for Payer: UnitedHealthcare Medicare Advantage	$173.53

SIMPLE REP SUPERF WOUND FACE 2.5 CM OR >

Facility

$375.00

Service Code	CPT 12011
Hospital Charge Code	4212011
Hospital Revenue Code	521
Rate for Payer: Cash Price	$337.50

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$92,105.54

Service Code	MSDRG 008
Min. Negotiated Rate	$46,052.77
Max. Negotiated Rate	$92,105.54
Rate for Payer: Aetna Medicare Advantage	$46,052.77
Rate for Payer: Cigna Commercial HMO & PPO	$46,052.77
Rate for Payer: Home State Health Plan Medicare Advantage	$46,052.77
Rate for Payer: Humana Commercial	$92,105.54
Rate for Payer: Humana Medicare Advantage	$46,052.77

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS

Facility

$116,393.80

Service Code	MSDRG 019
Min. Negotiated Rate	$58,196.90
Max. Negotiated Rate	$116,393.80
Rate for Payer: Aetna Medicare Advantage	$58,196.90
Rate for Payer: Cigna Commercial HMO & PPO	$58,196.90
Rate for Payer: Home State Health Plan Medicare Advantage	$58,196.90
Rate for Payer: Humana Commercial	$116,393.80
Rate for Payer: Humana Medicare Advantage	$58,196.90

SIMVASTATIN 20MG TAB EMP

Facility

$40.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2619343
Hospital Revenue Code	250
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$28.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$23.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$28.56
Rate for Payer: Cash Price	$36.00
Rate for Payer: UnitedHealthcare Commercial	$26.68
Rate for Payer: UnitedHealthcare Medicare Advantage	$14.40

SIMVASTATIN 20MG TAB EMP

Facility

$40.00

Service Code	NDC 6.8084E+10
Hospital Charge Code	2619343
Hospital Revenue Code	250
Rate for Payer: Cash Price	$36.00

SIMVASTATIN (ZOCOR) 10MG TAB

Facility

$35.00

Service Code	NDC 6073561
Hospital Charge Code	2656184
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$24.99
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$20.72
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$24.99
Rate for Payer: Cash Price	$31.50
Rate for Payer: UnitedHealthcare Commercial	$23.34
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.60

SIMVASTATIN (ZOCOR) 10MG TAB

Facility

$35.00

Service Code	NDC 6073561
Hospital Charge Code	2656184
Hospital Revenue Code	250
Rate for Payer: Cash Price	$31.50

Know your out-of-pocket cost for care.

All Charges