Madison Medical Center

All Charges

Charge

Type

Setting

Price

SITAGLIPTIN (JANUVIA) 25MG TAB EMP

Facility

$67.00

Service Code	NDC 6022154
Hospital Charge Code	2623041
Hospital Revenue Code	250
Rate for Payer: Cash Price	$60.30

SITAGLIPTIN (JANUVIA) 25MG TAB EMP

Facility

$67.00

Service Code	NDC 6022154
Hospital Charge Code	2623041
Hospital Revenue Code	250
Min. Negotiated Rate	$24.12
Max. Negotiated Rate	$47.84
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$39.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$47.84
Rate for Payer: Cash Price	$60.30
Rate for Payer: UnitedHealthcare Commercial	$44.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$24.12

SITAGLIPTIN (JANUVIA) 50MG TAB EMP

Facility

$55.00

Service Code	NDC 6011254
Hospital Charge Code	2622592
Hospital Revenue Code	250
Rate for Payer: Cash Price	$49.50

SITAGLIPTIN (JANUVIA) 50MG TAB EMP

Facility

$55.00

Service Code	NDC 6011254
Hospital Charge Code	2622592
Hospital Revenue Code	250
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$39.27
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$32.56
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$39.27
Rate for Payer: Cash Price	$49.50
Rate for Payer: UnitedHealthcare Commercial	$36.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$19.80

SITAGLIPTIN (JANUVIA) 50MG TAB UD

Facility

$70.00

Service Code	NDC 6011201
Hospital Charge Code	2626723
Hospital Revenue Code	250
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$49.98
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$41.44
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$49.98
Rate for Payer: Cash Price	$63.00
Rate for Payer: UnitedHealthcare Commercial	$46.69
Rate for Payer: UnitedHealthcare Medicare Advantage	$25.20

SITAGLIPTIN (JANUVIA) 50MG TAB UD

Facility

$70.00

Service Code	NDC 6011201
Hospital Charge Code	2626723
Hospital Revenue Code	250
Rate for Payer: Cash Price	$63.00

SITZ BATH KIT

Facility

$165.00

Hospital Charge Code	2819445
Hospital Revenue Code	271
Rate for Payer: Cash Price	$148.50

SITZ BATH KIT

Facility

$165.00

Hospital Charge Code	2819445
Hospital Revenue Code	271
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$117.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$97.68
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$117.81
Rate for Payer: Cash Price	$148.50
Rate for Payer: UnitedHealthcare Commercial	$110.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$59.40

SIZER KIT

Facility

$559.00

Hospital Charge Code	123332
Hospital Revenue Code	271
Min. Negotiated Rate	$201.24
Max. Negotiated Rate	$399.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$330.93
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$399.13
Rate for Payer: Cash Price	$503.10
Rate for Payer: UnitedHealthcare Commercial	$372.85
Rate for Payer: UnitedHealthcare Medicare Advantage	$201.24

SIZER KIT

Facility

$559.00

Hospital Charge Code	123332
Hospital Revenue Code	271
Rate for Payer: Cash Price	$503.10

SKELETAL SURVEY

Facility

$2,949.00

Service Code	CPT 77075
Hospital Charge Code	3277075
Hospital Revenue Code	320
Min. Negotiated Rate	$94.24
Max. Negotiated Rate	$2,105.59
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	$1,745.81
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$2,105.59
Rate for Payer: Cash Price	$2,654.10
Rate for Payer: Cash Price	$2,654.10
Rate for Payer: Cash Price	$2,654.10
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	$1,061.64

SKELETAL SURVEY

Facility

$2,949.00

Service Code	CPT 77075
Hospital Charge Code	3277075
Hospital Revenue Code	320
Rate for Payer: Cash Price	$2,654.10

SKIN AFFIX

Facility

$149.00

Hospital Charge Code	284003
Hospital Revenue Code	271
Rate for Payer: Cash Price	$134.10

SKIN AFFIX

Facility

$149.00

Hospital Charge Code	284003
Hospital Revenue Code	271
Min. Negotiated Rate	$53.64
Max. Negotiated Rate	$106.39
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$88.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$106.39
Rate for Payer: Cash Price	$134.10
Rate for Payer: UnitedHealthcare Commercial	$99.38
Rate for Payer: UnitedHealthcare Medicare Advantage	$53.64

SKIN DEBRIDEMENT WITH CC

Facility

$30,107.86

Service Code	MSDRG 571
Min. Negotiated Rate	$15,053.93
Max. Negotiated Rate	$30,107.86
Rate for Payer: Aetna Medicare Advantage	$15,053.93
Rate for Payer: Cigna Commercial HMO & PPO	$15,053.93
Rate for Payer: Home State Health Plan Medicare Advantage	$15,053.93
Rate for Payer: Humana Commercial	$30,107.86
Rate for Payer: Humana Medicare Advantage	$15,053.93

SKIN DEBRIDEMENT WITH MCC

Facility

$49,855.48

Service Code	MSDRG 570
Min. Negotiated Rate	$24,927.74
Max. Negotiated Rate	$49,855.48
Rate for Payer: Aetna Medicare Advantage	$24,927.74
Rate for Payer: Cigna Commercial HMO & PPO	$24,927.74
Rate for Payer: Home State Health Plan Medicare Advantage	$24,927.74
Rate for Payer: Humana Commercial	$49,855.48
Rate for Payer: Humana Medicare Advantage	$24,927.74

SKIN DEBRIDEMENT WITHOUT CC/MCC

Facility

$21,583.40

Service Code	MSDRG 572
Min. Negotiated Rate	$10,791.70
Max. Negotiated Rate	$21,583.40
Rate for Payer: Aetna Medicare Advantage	$10,791.70
Rate for Payer: Cigna Commercial HMO & PPO	$10,791.70
Rate for Payer: Home State Health Plan Medicare Advantage	$10,791.70
Rate for Payer: Humana Commercial	$21,583.40
Rate for Payer: Humana Medicare Advantage	$10,791.70

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$45,261.32

Service Code	MSDRG 577
Min. Negotiated Rate	$22,630.66
Max. Negotiated Rate	$45,261.32
Rate for Payer: Aetna Medicare Advantage	$22,630.66
Rate for Payer: Cigna Commercial HMO & PPO	$22,630.66
Rate for Payer: Home State Health Plan Medicare Advantage	$22,630.66
Rate for Payer: Humana Commercial	$45,261.32
Rate for Payer: Humana Medicare Advantage	$22,630.66

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$80,939.32

Service Code	MSDRG 576
Min. Negotiated Rate	$40,469.66
Max. Negotiated Rate	$80,939.32
Rate for Payer: Aetna Medicare Advantage	$40,469.66
Rate for Payer: Cigna Commercial HMO & PPO	$40,469.66
Rate for Payer: Home State Health Plan Medicare Advantage	$40,469.66
Rate for Payer: Humana Commercial	$80,939.32
Rate for Payer: Humana Medicare Advantage	$40,469.66

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$28,798.74

Service Code	MSDRG 578
Min. Negotiated Rate	$14,399.37
Max. Negotiated Rate	$28,798.74
Rate for Payer: Aetna Medicare Advantage	$14,399.37
Rate for Payer: Cigna Commercial HMO & PPO	$14,399.37
Rate for Payer: Home State Health Plan Medicare Advantage	$14,399.37
Rate for Payer: Humana Commercial	$28,798.74
Rate for Payer: Humana Medicare Advantage	$14,399.37

SKIN GRAFT FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$72,847.47

Service Code	APR-DRG 3124
Min. Negotiated Rate	$72,847.47
Max. Negotiated Rate	$72,847.47
Rate for Payer: Aetna Better Health Medicaid/QHP	$72,847.47
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$72,847.47
Rate for Payer: Home State Health Plan Medicaid Managed Care	$72,847.47
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$72,847.47

SKIN GRAFT FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$46,101.14

Service Code	APR-DRG 3123
Min. Negotiated Rate	$46,101.14
Max. Negotiated Rate	$46,101.14
Rate for Payer: Aetna Better Health Medicaid/QHP	$46,101.14
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$46,101.14
Rate for Payer: Home State Health Plan Medicaid Managed Care	$46,101.14
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$46,101.14

SKIN GRAFT FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$14,671.19

Service Code	APR-DRG 3121
Min. Negotiated Rate	$14,671.19
Max. Negotiated Rate	$14,671.19
Rate for Payer: Aetna Better Health Medicaid/QHP	$14,671.19
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$14,671.19
Rate for Payer: Home State Health Plan Medicaid Managed Care	$14,671.19
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$14,671.19

SKIN GRAFT FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES

Facility

$26,963.60

Service Code	APR-DRG 3122
Min. Negotiated Rate	$26,963.60
Max. Negotiated Rate	$26,963.60
Rate for Payer: Aetna Better Health Medicaid/QHP	$26,963.60
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$26,963.60
Rate for Payer: Home State Health Plan Medicaid Managed Care	$26,963.60
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$26,963.60

SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES

Facility

$29,375.67

Service Code	APR-DRG 3613
Min. Negotiated Rate	$29,375.67
Max. Negotiated Rate	$29,375.67
Rate for Payer: Aetna Better Health Medicaid/QHP	$29,375.67
Rate for Payer: Healthy Blue CHP/Medicaid Managed Care	$29,375.67
Rate for Payer: Home State Health Plan Medicaid Managed Care	$29,375.67
Rate for Payer: UnitedHealthcare Medicaid Managed Care	$29,375.67

Know your out-of-pocket cost for care.

All Charges